General Principles of Musculoskeletal Ultrasound

Alice Chiu SPT DKCH 3 July 2012

Basic considerations

Equipment Selection High Frequency, linear array transducers are best for tissues with striated morphology of tissues e.g mm, ligt in superficial location. (5-14MHz) (7.5MHz) Adequate greyscale is necessary for accurate diagnostic interpretation-optimal image settings.

Probe Placement
If the image states is a midline image, be sure to be as close to midline as possible

Image Orientation Longitudinal view: left side of image is CEPHALAD Transverse view: left side of the image is the PATIENTs RIGHT

Suggested Exam Protocol

Bilateral studies not absolute necessary Not necessary to perform all images for each extremity: selection Usually perform images in the area of complaint Usual practice: no less than 6 images per exam with 3 transverses and 3 longitudinal images

Identification of bony landmarks during imaging is key success for accurate soft tissue labeling.

Reflectivity-echogenicity
High reflective pattern: whiter and brighterhyperechoic Low reflective pattern: darker and less bright-hypoechoic No reflectivity-clear fluid-anechoic Same reflectivity surrounding tissueisoechoic

Hypoechoic Hyperechoic

Anechoic

Isoechic

Basic Normal Musculoskeletal Ultrasound Anatomy

Skeletal Muscle
Long view: muscle septae appear as bright/echogenic structures and are seen as thin bright linear band. Transverse views: muscle bundles appear as speckled echos with short curvilinear bright lines dispersed throughout the darker/hypoechoic background

Subcutaneous Tissue
Isoechoic( equal brightness) with skeletal muscle. Main difference: septa do not lay in lines or layers. It usually appears as a thick continuous, hyperechoic band usually separate subcutaneous fat from muscle.

Cortical Bone
Appears as a continuous echogenic ( bright ) line with posterior acoustic shadowing ( black)

Fascia
Collagenous structure that usually surrounds the musculotendinous areas of the extremities. The fascia is encompassed by subcutaneous tissue. Fascia is seen inserting into bone, blending with periosteum. Appears as a fibrous, bright/hyperechoic structure.

Periosteum
A thin echogenic line running parallel with the cortical bone. Not usually not visualized by US except after cortex damages, periosseous soft tissues and periosteum will produce a perisoteal reaction visible by US.

Tendons
A bright/echogenic linear band that can vary in thickness according to its location. Tendons are known to be anisotropic structures in US nomenclature. On Longitudinal views: fibrillar echotexture. The parallel series of collagen fibers are hyperechoic, separated by darker/hypoechoic surrounding connective tissues. The fibres will be continuous/intact. Interruptions in tendon fibres are visualised as anechoic /black areas within the tendon.

Anisotropy
The physical characteristic of muscle, tendons and nerves to vary in their ultrasound appearances depending upon the angle of insonation of the incident sound beam. Produced when the probe is not perpendicular with the structure being evaluated. The apparent change in echogenicity within the structure may mimic the appearance of fluid or lead to loss of visulisation of the structure. Thus angulation of probe is important for beam to insonates at 90 degree

Most common artifact in MS US

Anisotropy artifact. Transverse sonograms of the extensor surface of the wrist show the extensor digitorum (ED) and extensor pollicis longus (EPL) tendons, clearly and without artifact on the image obtained with the probe held exactly perpendicular to the tendons

but with a significant loss of echogenicity on the image obtained with the probe held at an oblique angle to the tendons

Tendon pathology
Tendonitis: acute Tendinoses/tendinosis : chronic, may have ischemia in critical zones followed by myxoid degeneration
Caused by degenerative process, overuse, steriod injection, systemic disease etc

Ligaments
Bright echogenic linear structure. Have more compact fibrillar echotexture. Individual strands/fibers of the ligaments are closely aligned. Ligaments are composed of dense connective tissue, like tendons, but there is much variability in the amounts of collagen, elastin and fibrocartilage within a ligament, which makes its ultrasound appearance more variable than tendons.

ATFL- lat malleolus with talus

CFL- lat malleoulus with calcaneous

Ultrasound grading of ligt injury

Grade I: mild stretching-normal Grade II: partial tear-thickened hypoechoic Grade III: complete tear-complete disruption

II

III

Bursae
Thin black/anechoic line no more than 2 mm thick. Will fill with fluid due to irritation or infection and become distend and enlarge. Internal brightness echoes are inflammatory debris.

Longitudinal sonogram shows 30-year-old man with knee pain. Fluid is visible in deep infrapatellar bursa (solid arrow), indicating deep infrapatellar bursitis. Patellar tendon is normal (open arrow), but overlying soft tissues appear swollen (arrowhead).

Peripheral Nerves
Appear a parallel hyperechoic lines with hypoechoic separations between them. Longitudinal view: appearance similar to tendons but less bright/echogenic. Transverse view: the peripheral nerve individual fibers and fibrous matrix, present with multiple punctate echogenicities( bright dots) within an ovid well defined nerve sheath.

Longitudinal sonogram of the median nerve shows parallel hypoechoic groups of nerve fascicles and the median nerve, which lies deep to the flexor digitorum superficialis (FDS) muscle in the distal forearm.

Sequel

References

Introduction to Musculoskeletal Ultrasound Imaging Randy E Moore DC RDMS www.mskmasters.com John Lin at el, An illustrated Tutorial of Musculoskeletal sonography AJR:175, Sept 2000

www.essr.org/ Real Time Ultrasound in Physiotherapy Practice AIU