Grand rounds presented to the Saskatoon Health Region emergency medicine faculty on Musculoskeletal ultrasound applications in the emergency room.

1. MSK US applications in the ER
September 25, 2013
Patrick Ling, MD

2. Goals
 Improve overall management of selected acute
musculoskeletal conditions using ultrasound

3. Objectives
 Review US guided knee arthrocentesis (diagnosis)
 Review use of US for evaluation of lateral ankle stabilizing
ligaments (prognosis)
 Review use of US for evaluation of trochanteric bursitis
(treatment)

4. Knee Arthrocentesis

5. Accuracy Rates
 Definition of Accuracy – no uniformity
 Studies use cadaveric model (non clinical setting)
 No account for number of attempts

7. Accuracy Rates
 Via palpation (Cadaver): 40 – 100% accurate
 Via palpation (clinical): 25 – 100% accurate
 US guided (cadaver): 90 – 100% accurate
 US guided (clinical): 79 – 100%
 Hall 2013 The Accuracy and Efficacy of Palpation versus Image-Guided Peripheral
Injections in Sports Medicine, Current Sports Medicine Reports, 12(5), 2013

8. Traditional Landmark Guided
Approach
 Knee: Parapatellar,
 Suprapatellar
 infrapatellar

11. Role of x-ray
 Ottawa knee rules
 Criticism: most knee injuries are ligamentous
 Radiographs give clues to the diagnosis

12. Bursa
Suprapatellar
bursa is in
direct communication
with joint

15. Musculoskeletal Ultrasound
Standardized Examination
 ARDMS – American Registry of Diagnostic Medical
Sonographers
 ESSR – European Society of Musculoskeletal Radiology

23. Imaging Lateral Ankle Ligaments

24. Lateral Ankle Sprain
 2/3rds are isolated anterior talofibular ligament (ATFL)
 20% associated calcaneofibular ligament (CFL)
 Comparing diagnostic accuracy of MRI, US and stress radiograph to
arthroscopic surgery found:
 MRI 97%
 US 91%
 Stress xrays 67%

25. Traditional Approach

26. Management
 (P)RICE, tensor +/- crutches
 Follow-up with family physician
 ?PT
 ?prognosis
 How long will it take to improve?
 Impact on ADLs?
 Recommendations for work, return to sport etc

28. Ankle US

29. AITF – ‘High Ankle Sprain’

30. CFL

34. Prognosis
 Ankle laxity improved over a period of 6 weeks to 1 year
 Most patients return to activity within 4 wks
 30% have mechanical laxity and instability at 1 year

35. Prognosis
 Determined by extent and degree of ligament injury
 Radiographic stress views not done
 MRI – good but costly/limited access
 Clinical stress testing - variable
 Ultrasound imaging
 Dynamic testing – anterior drawer test, laxity

36. Stages of Rehabilitation
 Stage 1: acute stage (1 – 3 days)
 Stage 2: sub-acute stage (3 – 14 days)
 Stage 3: early rehab (week 3)
 Stage 4: late rehab (week 4)
 Stage 5: functional rehab (week 5+)

37. Prevention
 Rehabilitation
 Neuromuscular training
 Education programs

39. Ultrasound Lateral Hip

40. Greater Trochanteric Bursitis
 Common
 Based on clinical diagnosis
 Risk factors: gait abnormalities, previous THR, leg length
discrepancy, obesity, runners
 Female to male ratio – 4:1

51. Tips
 Needle long enough?
 Get use to using your left hand for imaging and right hand for
the procedure
 In MSK US, orientation does not matter, labelling matters
 If in doubt, do comparison fields, sonopalpation

52. Summary
 MSK US can significantly enhance ER practice
 Value added applications
 Diagnosis
 Prognosis
 treatment