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قالو سُبحانك ل ا ع لام لنا 
ا ل اما ع لامتنا انك انت العليمُ الحكيم 
Surah Al Baqarah verse 32
Basics of MSK 
Ultrasound 
By: Dr. Raham Bacha 
MD, MSc Sonology. 
Lecturer of Ultrasound (UIRSMIT) 
The university of 
La...
• “ULTRASOUND IMAGING IS NOT A PASSIVE 
PUSH-BUTTON ACTIVITY; RATHER IT IS AN 
INTERACTIVE PROCESS INVOLVING A 
SKILLED CL...
By; Dr. Raham Bacha
By; Dr. Raham Bacha
By; Dr. Raham Bacha 
MSK US appearing on the horizon, is the more 
frequent application of diagnostic ultrasound to 
image...
EQUIPMENT SELECTION 
Musculoskeletal structures are long, striated and 
many times layered tissues. Due to the striated 
m...
PROBE PLACEMENT 
It is very important to maintain accurate 
transducers placement in musculoskeletal 
sonography. Due to t...
IMAGE ORIENTATION 
Regardless of right or left 
Longitudinal views: 
left side of the image is CEPHALAD. 
Transverse views...
3 STEPS TO SUCCESSFUL 
IMAGING 
1. Image GENERATION 
Patient & probe position, grayscale settings 
2. Image RECOGNITION 
I...
BASIC NORMAL MUSCULOSKELETAL 
ULTRASOUND ANATOMY 
Skeletal Muscle 
On longitudinal views, the muscle septae appear as 
ech...
Subcutaneous Tissue 
Subcutaneous tissue is isoechoic with skeletal 
muscle. The difference between subcutaneous 
tissue a...
Cortical Bone 
On ultrasound examination, normal cortical 
bone appears as a continuous echogenic (bright) 
line with post...
Fascia 
Fascia is a collagenous structure that usually 
surrounds the musculotendinous areas of the 
extremities. The fasc...
Periosteum 
Occasionally, a thin echogenic line running 
parallel with the cortical bone is 
demonstrated on ultrasound, t...
Tendons 
A normal tendon on ultrasound examination is a 
bright/echogenic linear band that can vary in 
thickness accordin...
Ligaments 
On ultrasound examination, a normal ligament is 
also a bright echogenic linear structure. However 
ligaments h...
Bursae 
In a normal joint, the bursa is a thin 
black/ anechoic line no more than 2 mm 
thick. The bursa fills with fluid ...
Peripheral Nerves 
High-frequency transducers allow the visualization 
of peripheral nerves that pass close to the skin 
s...
ANISOTROPY 
An / iso / tropy. 
To not have equal properties 
/characteristics/ appearances on all axes. 
The property of b...
Current, developing and potential indications for MSUS
EFFUSION 
Proven indication: 
Diagnosis of joint, tendon sheath and bursal effusion. Aspiration of 
effusion. Differentiat...
SYNOVIUM 
Proven indication: 
Diagnosis of synovial proliferation and synovitis 
Developing Indication: 
Diagnosis of less...
Proven indication: 
Diagnosis of superficial and deep bursitis. Bursal aspiration and 
injection 
Developing Indication: 
...
BONE 
Proven indication: 
Demonstration of joint erosion 
Developing Indication: 
Diagnosis of fractures, bone tumors, per...
TENDON/LIGAMENT 
Proven indication: 
Diagnosis of tendon damage, rupture, tendonitis or tenosynovitis. 
Diagnosis of ligam...
SKIN 
Proven indication: 
Measure skin thickness in scleroderma. Detect subcutaneous 
oedema. Detect subcutaneous hypertro...
CARTILAGE 
Proven indication: 
Imaging of local and generalized cartilage defects and calcification 
Developing Indication...
VASCULATURE 
Proven indication: 
Detection of inflammation with power Doppler. Imaging of location 
and morphology of vasc...
SALIVARY GLANDS 
Proven indication: 
Demonstration of salivary gland size and morphology 
Developing Indication: 
Correlat...
INDICATIONS FOR MSK 
ULTRASOUND IN EMERGENCY 
DEPARTMENT 
Clinical Suspicion for: 
Fracture 
Joint Dislocation 
Joint Effu...
• Wrist 
• Mass Tenosynovitis 
• Tendon rupture 
• Joint synovitis Pulley 
rupture 
• Sagittal band injury 
• Central slip...
• Elbow 
• Lateral epicondylitis 
• Medial epicondylitis 
• Radial nerve 
compression 
• Median nerve 
entrapment, pronato...
• Shoulder 
• Bursitis 
• Full thickness cuff 
tears 
• Calcific tendonitis 
• LHB: rupture 
• LHB: dislocation 
• Septic ...
• Ankle/Foot 
• Tendinopathy 
• Tears 
• Sheath effusions 
• Peroneal dislocation 
• Calcific tendinitis 
• Retrocalcaneal...
• Knee 
• Patellar 
tendinopathy/tear 
• Quadriceps 
tendinosis/tear 
• Pes anserinus 
tendinobursitis 
• Baker´s cyst 
• ...
• Hip 
• Fluid detection 
• Extra-articular 
snapping hip 
• Synovitis/effusion/ 
synovial cysts 
• Sports hernias 
• More...
TENDONS 
• Critical biomechanical units in the musculoskeletal system 
• transmit the muscular tension to mobile skeletal ...
TENDONS 
• The primary bundles are assembled to form 
secondary bundles which are clustered in 
tertiary bundles surrounde...
Anchor or supporting tendons (such 
as the Achilles and the patellar tendon) are 
typically bigger and stronger than slidi...
Sliding tendons are; 
• wrapped in a covering sheath (tenosynovial sheath) 
whose function is to guarantee better sliding ...
Tendons may present with less vascularized zones, 
named critical areas, which are extremely 
important in the pathogenesi...
The point of union between the tendons and 
the muscle is called myotendinous junction 
and that of bone and tendon is nam...
In contrast The osteotendinous junction has a more 
complicated structure: its nature may be either fibrous 
or fibrocarti...
Retinaculum is a transversal thickening of 
the deep fascia attached to a bone’s eminence. 
The biomechanical function of ...
• Some of the important retinaculum 
are; 
• The transverse carpal ligament 
• the ankle retinacula 
• flexor annular pull...
Ligaments are analogous structures to 
that of tendons; however, they are thinner 
and they contain a higher amount of ela...
There are two types of ligaments: 
• The intrinsic capsular ligaments, which 
appear as localized thickenings within the 
...
TENDON 
Nowadays US represents the gold standard technique for the 
assessment of tendons. 
With the advent, for clinical ...
DISEASED STATE 
Normally there is a slight difference between 
sliding and anchor tendons. There is a small amount 
of syn...
Supporting tendon: 
On the other hand, anchor tendons are 
surrounded by the peritenon, a layer of dense 
connective tissu...
The gray-scale ultrasound technique is still not 
able to recognize indirect signs of inflammation. 
By implementing Power...
Several conditions such as 
inflammatory, posttraumatic and 
infectious, are responsible for the 
activation of vascular h...
RETINACULA 
Appear on ultrasound as thin 
hyperechoic structures located more 
superficially than the sliding tendons, 
in...
Transverse US scan of the medial 
compartment of the ankle
LIGAMENTS 
The structure of ligamentsis very similar to 
that of tendons; the main differences are 
reduced thickness and ...
The US examination of ligaments, unlike 
tendons, is mainly performed using long 
axis views, the transducer being aligned...
• The most common ligaments to assess 
with US are; 
• Ligaments of the medial and lateral 
compartments of the ankle (del...
Transverse US scan of the lateral compartment of the ankle.The 
anterior talo-fibular ligament (*) is tight between the an...
Longitudinal US scan of flexor digitorum tendons at the 
metacarpophalangeal joint.The first (A1) out of five pulleys is 
...
• The MCL is a flattened, large structure 
extending from the medial femoral 
condyle to the medial condyle of the tibia 
...
• Sonographically the MCL appears as a 
• trilaminar structure consisting of two 
hyperechoic layers, separated by a centr...
Longitudinal US scan of the medial compartment of the knee. The 
complex structure of medial collateral ligament is shown....
MUSCLES 
Muscle is made of bundles of contractile 
striated muscle fibers with their 
major axis lying along the contracti...
Muscular fibers are arranged parallel to 
one another and they are supported by a 
matrix of connective tissue. 
Muscle is...
Muscular fibers are arranged parallel to one 
another and they are supported by a matrix of 
connective tissue. 
Muscle is...
The epimysial, perimysial and endomysial 
coverings come together where muscles 
connect to adjacent structures like a ten...
The internal structure of muscles can be 
easily assessed by ultrasound imaging. The 
epimysium appears hyperechoic extern...
The typical pennate structure of muscles can 
be easily assessed in longitudinal axis views 
where the hyperechoic fibro-a...
NERVES 
From an anatomical point of view, 
nerves are characterized by a 
complex internal structure made of 
nervous fibe...
Nerves are externally surrounded by a sheath 
called the epineurium; several septa invigilate 
from it to form the perineu...
With the current generation of high-fequency 
“small parts” transducers and compound 
technology, US has become a well-acc...
Apart from the availability of high resolution 
transcucers, nerve US requires indepth 
knowledge of anatomy and close cor...
With these credentials, US provides low-cost 
and non-invasive imaging, speed of 
performance, and other important advanta...
On long axis planes, nerves typically assume 
an elongated appearance with multiple 
hypoechoic parallel linear areas, whi...
The number of fascicles in a nerve may vary 
depending on the occurrence of nerve 
branching. In nerve bifurcations, the n...
Generally speaking, nerves are compressible 
structures and alter their shape depending on 
the volume of the anatomical s...
The floor of these tunnels consists of bone, 
whereas the roof is made of focal thickenings 
of the fascia, the so-called ...
Careful scanning technique of nerves based on the 
precise knowledge of their position and analysis of 
their anatomical r...
In the event of intrinsic or extrinsic nerve 
abnormalities, the US examination is more 
appropriately focused on the area...
In fact, most cranial nerves, the nerve roots 
exiting the dorsal, lumbar and sacral spine, 
the sympathetic chains and th...
Dermis and hypodermis 
From an anatomical point of view, 
nerves are characterized by a 
complex internal structure made o...
The skin represents the external 
covering of the whole body. Its 
thickness varies according to different 
body regions, ...
The epidermis; consisting of 
squamous multi-stratified epithelium 
that continues deeply with the dermis, 
The dermis; a ...
The hypodermis is found even more 
deeply and it is made of a tissue rich in 
collagen fibers and connected to the 
dermis...
Detailed US exploration of the skin is 
now possible due to high frequency 
and high resolution transducers. The 
skin app...
The hypodermis, on the contrary, is 
easily identifiable: it appears as a deep 
hypoechoic layer, characterized by 
inters...
The hypodermis is separated 
from the underlying muscular layer by 
the superficial aponeurotic fascia, 
appearing as a do...
To diagnose skin disease, the main 
investigation tends to be clinical 
examination, eventually supported by 
histological...
Subcutaneous tissue ultrasound 
examination can also be useful in the 
diagnosis and staging of some 
neoplastic lesions s...
epidermis-dermis (E), hypodermis (H) and superficial 
aponeurotic fascia (A)
THANK YOU!
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
Basics of msk ultrasound  By Dr. Raham Bacha
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Basics of msk ultrasound By Dr. Raham Bacha

  1. 1. قالو سُبحانك ل ا ع لام لنا ا ل اما ع لامتنا انك انت العليمُ الحكيم Surah Al Baqarah verse 32
  2. 2. Basics of MSK Ultrasound By: Dr. Raham Bacha MD, MSc Sonology. Lecturer of Ultrasound (UIRSMIT) The university of Lahore
  3. 3. • “ULTRASOUND IMAGING IS NOT A PASSIVE PUSH-BUTTON ACTIVITY; RATHER IT IS AN INTERACTIVE PROCESS INVOLVING A SKILLED CLINICIAN, PATIENT, TRANSDUCER, INSTRUMENT, AND EXPERIENCED INTERPRETER. UNDERSTANDING THE PHYSICAL PRINCIPLES INVOLVED CONTRIBUTES TO THE QUALITY OF MEDICAL CARE INVOLVING DIAGNOSTIC SONOGRAPHY” {ULTRASOUND SEES THE FIRE – AS WELL AS THE SMOKE} By; Dr. Raham Bacha
  4. 4. By; Dr. Raham Bacha
  5. 5. By; Dr. Raham Bacha
  6. 6. By; Dr. Raham Bacha MSK US appearing on the horizon, is the more frequent application of diagnostic ultrasound to image musculoskeletal structures and the extremities of the body. Sonography’s unique real-time capability, which permits examination during movement, and allows guidance of biopsy needles, combined with the exquisite resolution of state-of-the-art scanners and high-frequency transducers, makes musculoskeletal sonography a powerful tool for diagnosing abnormalities of the soft tissues.
  7. 7. EQUIPMENT SELECTION Musculoskeletal structures are long, striated and many times layered tissues. Due to the striated morphology of these tissues and their superficial location, high frequency, linear array transducers are best suited for this application. It is recommended that no less than 7.5 MHz transducers be used for musculoskeletal examinations of the extremities. Ideally, 8.0 MHz and above provide the highest resolution.
  8. 8. PROBE PLACEMENT It is very important to maintain accurate transducers placement in musculoskeletal sonography. Due to the close proximity of several distinct structures in a small area, a slight displacement of the probe can produce inaccurate images. If the image states it is a “midline” image be sure to be as close to midline as possible.
  9. 9. IMAGE ORIENTATION Regardless of right or left Longitudinal views: left side of the image is CEPHALAD. Transverse views: left side of the image is the PATIENT’S RIGHT
  10. 10. 3 STEPS TO SUCCESSFUL IMAGING 1. Image GENERATION Patient & probe position, grayscale settings 2. Image RECOGNITION Identify Individual Interfaces from the bony cortex UP to the skin surface! 3. Image INTERPRETATION Determine abnormal findings by knowing normal!
  11. 11. BASIC NORMAL MUSCULOSKELETAL ULTRASOUND ANATOMY Skeletal Muscle On longitudinal views, the muscle septae appear as echogenic structures, and are seen as thin bright linear bands. On transverse views, the muscle bundles appear as speckled echoes with short, curvilinear bright lines dispersed throughout the hypoechoic background.
  12. 12. Subcutaneous Tissue Subcutaneous tissue is isoechoic with skeletal muscle. The difference between subcutaneous tissue and skeletal muscle visualized on ultrasound is the septa do not lay in lines or layers. More conspicuously; a thick, continuous, hyperechoic band usually separates subcutaneous fat from muscle.
  13. 13. Cortical Bone On ultrasound examination, normal cortical bone appears as a continuous echogenic (bright) line with posterior acoustic shadowing (black).
  14. 14. Fascia Fascia is a collagenous structure that usually surrounds the musculotendinous areas of the extremities. The fascia is then encompassed by subcutaneous tissue. Many times, the fascia is seen inserting onto bone, and blending with the periosteum. Normal fascia appears as a fibrous, bright/hyperechoic structure
  15. 15. Periosteum Occasionally, a thin echogenic line running parallel with the cortical bone is demonstrated on ultrasound, this is likely the periosteum. However, in normal situations, the periosteum is not visualized by ultrasound. Injuries to the bone, especially those damaging the cortex, periosseous soft tissues, and periosteum will produce a periosteal reaction, which is visible
  16. 16. Tendons A normal tendon on ultrasound examination is a bright/echogenic linear band that can vary in thickness according to its location. The internal echoes are described characteristically as having a fibrillar echotexture on longitudinal views. On ultrasound the parallel series of collagen fibers are hyperechoic, separated by hypoechoic surrounding connective tissue. The fibers will be continuous and intact. Interruptions in tendon fibers are visualized as anechoic areas within the tendon. Tendons are known to be anisotropic structures.
  17. 17. Ligaments On ultrasound examination, a normal ligament is also a bright echogenic linear structure. However ligaments have a more compact fibrillar echotexture. Individual strands / fibers of the ligaments are more 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.
  18. 18. Bursae In a normal joint, the bursa is a thin black/ anechoic line no more than 2 mm thick. The bursa fills with fluid due to irritation or infection. Depending on the extent of effusion, the bursa will distend and enlarge; internal brightness echoes are inflammatory debris.
  19. 19. Peripheral Nerves High-frequency transducers allow the visualization of peripheral nerves that pass close to the skin surface. Peripheral nerves appear as parallel hyperechoic lines with hypoechoic separations between them. On longitudinal views, their appearance is similar to tendons, but less echogenic. On transverse views, the peripheral nerves’ individual fibers, and fibrous matrix, present with multiple, punctate echogenicities (bright dots) within an ovoid, well-defined nerve sheath.
  20. 20. ANISOTROPY An / iso / tropy. To not have equal properties /characteristics/ appearances on all axes. The property of being directionally dependent. Produced when the probe is not perpendicular with the structure being evaluated. Most common artifact in musculoskeletal ultrasound.
  21. 21. Current, developing and potential indications for MSUS
  22. 22. EFFUSION Proven indication: Diagnosis of joint, tendon sheath and bursal effusion. Aspiration of effusion. Differentiation of cystic from solid masses, detection of cyst rupture, sinus and fistula. Diagnosis of vascular and nerve compression syndromes by fluid collections Developing Indication: Role of MSUS in improving efficacy of joint and bursal injection Potential Indication: Differentiation of type of effusion: US microscopy of synovial Fluid
  23. 23. SYNOVIUM Proven indication: Diagnosis of synovial proliferation and synovitis Developing Indication: Diagnosis of lesser degrees of synovitis. Differentiate active from inactive synovitis Potential Indication: US used as standardized outcome measure for synovitis in RA trials. US used to classify joint involvement (oligoarticular, polyarticular). Development of tissue specific and immunospecific contrast agents. US synovectomy (high-intensity focused US)
  24. 24. Proven indication: Diagnosis of superficial and deep bursitis. Bursal aspiration and injection Developing Indication: Differential diagnosis of true effusive bursitis from soft tissue inflammation (greater trochanter bursitis vs. greater trochanter enthesitis without effusion) Potential Indication: Improve understanding of bursal function and pathology
  25. 25. BONE Proven indication: Demonstration of joint erosion Developing Indication: Diagnosis of fractures, bone tumors, periosteal disease Potential Indication: US erosion included in diagnostic criteriafor RA.US erosion used as standardizedoutcome measure in RA trials.Differentiate active vascularized erosionfrom inactive erosion
  26. 26. TENDON/LIGAMENT Proven indication: Diagnosis of tendon damage, rupture, tendonitis or tenosynovitis. Diagnosis of ligament injury or enthesitis. Improve assessment of indication for surgery Developing Indication: Monitoring of response to therapy, surgery. Role of MSUS in improving efficacy of tendon sheath and soft tissue injection Potential Indication: Differentiate active from inactiveenthesitis. Quantitative score of peripheralenthesitis. Improve understanding ofpathogenesis of mechanical andinflammatory enthesitis
  27. 27. SKIN Proven indication: Measure skin thickness in scleroderma. Detect subcutaneous oedema. Detect subcutaneous hypertrophy and atrophy, abscess, calcification, foreign body, nodule or tumors Developing Indication: Application of skin thickness as a standard measure of outcome in, scleroderma. Objective monitoring of oedema after therapy. Monitoring of subcutaneous hypertrophy and atrophy, abscess, calcification, foreign body, nodule or tumor Potential Indication: Diagnosis of scleroderma. Differentialdiagnosis of cellulitis, necrotizing fasciitis,subcutaneous pathology
  28. 28. CARTILAGE Proven indication: Imaging of local and generalized cartilage defects and calcification Developing Indication: Monitoring of cartilage thickness homogeneity cartilage disease Potential Indication: Diagnosis of osteoarthritis and othercartilage disease
  29. 29. VASCULATURE Proven indication: Detection of inflammation with power Doppler. Imaging of location and morphology of vascular structures Developing Indication: Objective and reproducible quantification of inflammation with power Doppler. Correlation of MSUS with histological diagnosis of temporal arteritis and vasculitis Potential Indication: Imaging of ‘normal ’blood flow in joints. Diagnosis of temporal arteritis without recourse to biopsy. Diagnosis of medium and large vessel vasculitis. Diagnosis and monitoring of Raynaud ’s disease
  30. 30. SALIVARY GLANDS Proven indication: Demonstration of salivary gland size and morphology Developing Indication: Correlation of MSUS findings with labial gland histology Potential Indication: Diagnosis of Sjogren’s syndrome
  31. 31. INDICATIONS FOR MSK ULTRASOUND IN EMERGENCY DEPARTMENT Clinical Suspicion for: Fracture Joint Dislocation Joint Effusion Tendon Tear/Laceration Ligament Injury Procedure Guidance for: Fracture and Joint Relocation Arthrocentesis Fracture Hematoma Block
  32. 32. • Wrist • Mass Tenosynovitis • Tendon rupture • Joint synovitis Pulley rupture • Sagittal band injury • Central slip injury • Trigger finger • Pulley ganglion • Rugby/jersey finger • Foreign body • FCU/FCR • ECU • UCL • Hammer hand • Ganglion • De Quervains Knee • FCR • CTS • Guyons canal • Wartenbergs syndrome
  33. 33. • Elbow • Lateral epicondylitis • Medial epicondylitis • Radial nerve compression • Median nerve entrapment, pronator syndrome • Triceps tendon injury • Snapping triceps syndrome • Ulnar nerve neuropathy • Ulnar nerve subluxation • Olecranon bursitis • Synovitis • Septic arthritis / effusion
  34. 34. • Shoulder • Bursitis • Full thickness cuff tears • Calcific tendonitis • LHB: rupture • LHB: dislocation • Septic arthritis • Rotator cuff tears • • Subdeltoid-subacromial bursitis (SD- SA) • • Biceps tendonitis/tenosynov itis • • Gleno-humeral effusion
  35. 35. • Ankle/Foot • Tendinopathy • Tears • Sheath effusions • Peroneal dislocation • Calcific tendinitis • Retrocalcaneal bursitis • Postoperative tendon tear • ATF ligament • CF ligament • Ant tibiofibular ligament • Joint effusions • Synovitis • Nerve entrapment • Plantar fasciitis • Retinacula • Ganglion cysts
  36. 36. • Knee • Patellar tendinopathy/tear • Quadriceps tendinosis/tear • Pes anserinus tendinobursitis • Baker´s cyst • Periarticular bursitis • Periarticular ganglion • Synovitis, effusion • Septic arthritis • Nerve pathology • Osgood-Schlatter, SindingLarsen
  37. 37. • Hip • Fluid detection • Extra-articular snapping hip • Synovitis/effusion/ synovial cysts • Sports hernias • Morel-Lavallee lesions • High-grade muscle injuries • Lateral femoral cutaneous nerve • Femoral nerve
  38. 38. TENDONS • Critical biomechanical units in the musculoskeletal system • transmit the muscular tension to mobile skeletal segments • extremely resistant to traction • extremely variable shape and dimensions, characterized by the presence of dense fibrous tissue arranged in parallel bundles • consist of about 70% of type I collagen fibers • fibrocytes endowed with large laminar protrusions, named tenocytes or alar cells Among the primary bundles • elastic fibers (about 4%) can also be found; acts as “shock absorber”
  39. 39. TENDONS • The primary bundles are assembled to form secondary bundles which are clustered in tertiary bundles surrounded by The endotenon • the whole tendon is surrounded by epindotenon. • Tendon may either be • Supporting or • Sliding tendon.
  40. 40. Anchor or supporting tendons (such as the Achilles and the patellar tendon) are typically bigger and stronger than sliding tendons, they are not provided with a synovial sheath, but they are surrounded by a connective lamina external to the epitenon, called peritenon; the two connective sheaths (epitenon and peritenon) form the paratenon together with highly vascularized adipose and areolar tissue
  41. 41. Sliding tendons are; • wrapped in a covering sheath (tenosynovial sheath) whose function is to guarantee better sliding and protection to the tendons when they run adjacent to irregular osseous surfaces, sites of potential friction. The teno-synovial sheath consists of two layers: • Visceral layer, strictly contiguous to the epitenon, and • Parietal, more external, layer; the two layers come together to form • a synovial “fold” named mesotenon. A closed cavity, containing a very small amount of synovial fluid
  42. 42. Tendons may present with less vascularized zones, named critical areas, which are extremely important in the pathogenesis of several tendon diseases. Examples include the pre-insertional area of the supraspinatus tendon of the shoulder, or the central part of the Achilles tendon, which typically constitute highly susceptible sites of degenerative disease and tendon rupture.
  43. 43. The point of union between the tendons and the muscle is called myotendinous junction and that of bone and tendon is named as osteotendinous junction (enthesis). At The level myotendinous junctionis usually the tendon fibers are intertwined with the myofibers.
  44. 44. In contrast The osteotendinous junction has a more complicated structure: its nature may be either fibrous or fibrocartilaginous according to the tendon mobility, the angle formed between the tendon fibers and the bone, and the presence of an underlying retinaculum. The tendons moving in a single spatial plan and whose insertion on the bone occurs with an acute angle (for example, the flexor tendons of the toes), have a fibrous enthesis. The same situation occurs for tendons whose course is modified and kept in position by a retinaculum – for example the peroneal tendons – and whose insertion on the bone once again forms an acute angle.
  45. 45. Retinaculum is a transversal thickening of the deep fascia attached to a bone’s eminence. The biomechanical function of a retinaculum is to keep the tendons in position as they pass underneath it, in order to avoid their dislocation during muscular action. Retinacula therefore guarantee that tendons are correctly deviated and kept in position in their respective osteofibrous canals. Retinacula are typically found in the wrist and ankle
  46. 46. • Some of the important retinaculum are; • The transverse carpal ligament • the ankle retinacula • flexor annular pulleys
  47. 47. Ligaments are analogous structures to that of tendons; however, they are thinner and they contain a higher amount of elastin, which is a necessary element to supply these structures with some degree of elasticity for their very important biomechanical role in the stabilization of joints.
  48. 48. There are two types of ligaments: • The intrinsic capsular ligaments, which appear as localized thickenings within the capsule with a strengthening function, and • The extrinsic ligaments, which are independent from the fibrous capsule and can be further classified as; • Extra-capsular and • Intra-capsular ligaments
  49. 49. TENDON Nowadays US represents the gold standard technique for the assessment of tendons. With the advent, for clinical purposes, of high resolution transducers and specific image processing software, it became possible to make detailed analysis of the shape and structure of tendons. In addition, US is the only technique that allows the sonologist to perform a dynamic study of tendons, which is extremely important for the diagnosis of tendon pathology. In longitudinal ultrasound views (long axis), the tendons appear as echoic ribbon-like bands, defined by a marginal hyperechoic line corresponding to the paratenon and characterized by a fibrillar internal structure. The fibrillar echotexture is represented by a succession of thin hyperechoic parallel bands, slightly wavy, which tend to grow apart from one another when the tendon is released and to move closer when the tendon is tense.
  50. 50. DISEASED STATE Normally there is a slight difference between sliding and anchor tendons. There is a small amount of synovial fluid around the sliding tendons and can be appreciated by meticulous examination. An increase in the amount of fluid in the mesotenon around the tendon can be examined in tenosynovitis.
  51. 51. Supporting tendon: On the other hand, anchor tendons are surrounded by the peritenon, a layer of dense connective tissue leaning on the epitenon, which contributes to constitute the paratenon. The paratenon appears as an echogenic line surrounding the tendon, without the possibility of distinguishing, in normal conditions, between peritenon and epitenon
  52. 52. The gray-scale ultrasound technique is still not able to recognize indirect signs of inflammation. By implementing Power Doppler techniques with the information obtained from grayscale image make the examiner able to identify the hemodynamic state of the tendon. Normally the tendon have low metabolic activity and the blood supply is given by high resistance arteries and small veins, too thin to be studied with the Doppler technique.
  53. 53. Several conditions such as inflammatory, posttraumatic and infectious, are responsible for the activation of vascular hyperemia with an increase in blood flow and a drop in vascular resistance
  54. 54. RETINACULA Appear on ultrasound as thin hyperechoic structures located more superficially than the sliding tendons, in very critical areas from a biomechanical point of view Dynamic Scanning and high amount of gel is used as a spacer in order to avoid any pressure on the tissue, for the evaluation of retinacula.
  55. 55. Transverse US scan of the medial compartment of the ankle
  56. 56. LIGAMENTS The structure of ligamentsis very similar to that of tendons; the main differences are reduced thickness and a less regular arrangement of structural elements; for this reason, it is harder to study ligaments with US than tendons.
  57. 57. The US examination of ligaments, unlike tendons, is mainly performed using long axis views, the transducer being aligned on the ligament’s major axis. Transverse views (short axis) have poor diagnostic value. With US, ligaments appear as homogeneous, hyperechoic bands, 2-3 mm thick, lying close to the bone
  58. 58. • The most common ligaments to assess with US are; • Ligaments of the medial and lateral compartments of the ankle (deltoid, anterior talofibular and fibulocalcaneal) • The collateral ligaments of the knee, • The collateral and annular ligaments of the elbow, • The coraco-acromial and coraco-humeral ligaments of the shoulder and the ulnar collateral ligament of the thumb
  59. 59. Transverse US scan of the lateral compartment of the ankle.The anterior talo-fibular ligament (*) is tight between the anterior part of the lateral malleolus (P) and the talus (A)
  60. 60. Longitudinal US scan of flexor digitorum tendons at the metacarpophalangeal joint.The first (A1) out of five pulleys is clearly shown over the tendons.FP= flexor digitorum profundus;FS= flexor digitorum superficialis;PH= proximal phalanx;H= metacarpal head;P= palmar plate;C= cartilage
  61. 61. • The MCL is a flattened, large structure extending from the medial femoral condyle to the medial condyle of the tibia • it is about 9 cm long and it is divided into two components, deep and superficial, which are separated by a thin layer of loose connective tissue. The deep component is then divided into • menisco-femoral ligament • menisco-tibial ligament.
  62. 62. • Sonographically the MCL appears as a • trilaminar structure consisting of two hyperechoic layers, separated by a central interleaved hypoechoic area. The hyperechoic bands correspond to deep and superficial fiber bundles; whereas the loose areolar tissue constitutes the hypoechoic central area that divides the superficial component from the deep one
  63. 63. Longitudinal US scan of the medial compartment of the knee. The complex structure of medial collateral ligament is shown.* = superficial portion,MF= meniscofemoral deep portion,MT= menisco-tibial deep portion;C=femoral condyle;T= tibial plateau; M= meniscus
  64. 64. MUSCLES Muscle is made of bundles of contractile striated muscle fibers with their major axis lying along the contraction direction. The fibers have a cylindrical or polyhedral shape. These muscle fibers have a considerable length, varying from a few millimeters to several centimeters, and a width between 10 and 100 mm.
  65. 65. Muscular fibers are arranged parallel to one another and they are supported by a matrix of connective tissue. Muscle is externally surrounded by a thick connective sheath called the epimysium; from the internal aspect of this sheath several septa invigilate to form the perimysium, which surrounds diverse bundles of muscular fibers, named fascicles (bundle of fibers) ) .)گھچا
  66. 66. Muscular fibers are arranged parallel to one another and they are supported by a matrix of connective tissue. Muscle is externally surrounded by a thick connective tissue sheath called the epimysium; from the internal aspect of this sheath several septa invigilate to form the perimysium, which surrounds diverse bundles of muscular fibers, named fascicles (bundle of fibers) ) .)گھچا Very light and thin septa arising from the perymysium spread into the fascicles to surround every single muscular fiber and thus form the endomysium.
  67. 67. The epimysial, perimysial and endomysial coverings come together where muscles connect to adjacent structures like a tendon, periosteum, aponeurosis or the dermis. at the endpoints of the muscular fiber, the myofibrils are attached to the sarcolemma. By means of these devices, the muscular fibers are strongly connected to the terminal insertion.
  68. 68. The internal structure of muscles can be easily assessed by ultrasound imaging. The epimysium appears hyperechoic external band measuring a maximum of 2-3 mm of thickness and, on longitudinal US sections, continues without interruption along the corresponding tendon profile. The perimysia are seen as hyperechoic lines separating the contiguous hypoechoic muscular fascicles from one another
  69. 69. The typical pennate structure of muscles can be easily assessed in longitudinal axis views where the hyperechoic fibro-adipose septa converge, with a mainly parallel course, on a central aponeurosis, appearing as a thin, highly reflective band pennation angle; is the angle measured between the muscular fibers direction and the central aponeurosis axis
  70. 70. NERVES From an anatomical point of view, nerves are characterized by a complex internal structure made of nervous fibers (containing axons, myelin sheaths and Schwann cells) grouped to form fascicles, and loose connective tissue (containing elastic fibers and vessels)
  71. 71. Nerves are externally surrounded by a sheath called the epineurium; several septa invigilate from it to form the perineurium, which surrounds bundles of neurve fibers, named fascicles (bundle of fibers) ) .)گھچا Very light and thin septa arising from the peryneurium spread into the fascicles to surround every single neurve fiber and thus form the endoneurium. The connective tissue intervening between the outer nerve sheath and the fascicles is commonly referred to as the interfascicular epineuriumand houses the nerve vasculature.
  72. 72. With the current generation of high-fequency “small parts” transducers and compound technology, US has become a well-accepted and widespread imaging modality for evaluation of peripheral nerves. The improved performance of these transducers has made it possible to recognize subtle anatomical details with US at least equal to or even better than surface-coil magnetic resonance (MR) imaging for the assessment of wide range of pathological conditions affecting nerves
  73. 73. Apart from the availability of high resolution transcucers, nerve US requires indepth knowledge of anatomy and close correlation of imaging findings with the patient’s clinical history and the results of electrophysiological studies.
  74. 74. With these credentials, US provides low-cost and non-invasive imaging, speed of performance, and other important advantages over MR imaging, including a higher spatial resolution and the ability to explore long segments of nerve trunks in a single study and to examine nerves in both static and dynamic states with real time scanning.
  75. 75. On long axis planes, nerves typically assume an elongated appearance with multiple hypoechoic parallel linear areas, which correspond to the neuronal fascicles that run longitudinally within the nerve, separated by hyperechoic bands. On short axis planes, high-resolution US demonstrates nerves as honeycomb-like structures. Hypoechoic fascicles embedded in a hyperechoic interfascicular epineurium.
  76. 76. The number of fascicles in a nerve may vary depending on the occurrence of nerve branching. In nerve bifurcations, the nerve trunk divides into two or more secondary nerve bundles, whereas each fascicle enters only one of the divisional branches without splitting. The outer boundaries of nerves are usually undefined due to the similar hyperechoic appearance of both the superficial epineurium and the surrounding fat.
  77. 77. Generally speaking, nerves are compressible structures and alter their shape depending on the volume of the anatomical spaces within which they run, as well as on the bulk and conformation of the perineural structures. Across synovial joints, they pass through narrow anatomical passageways – the osteofibrous tunnels – that redirect their course.
  78. 78. The floor of these tunnels consists of bone, whereas the roof is made of focal thickenings of the fascia, the so-called “retinacula”, which prevent dislocation and traumatic damage of the structures contained in the tunnel during joint activity. In normal states, color and power Doppler US are able to depict blood flow signals from perineural and interfascicular vessels only occasionally and in large nerve trunks.
  79. 79. Careful scanning technique of nerves based on the precise knowledge of their position and analysis of their anatomical relationships with surrounding structures is essential. Systematic scanning on short axis planes is preferred to follow the nerves contiguously throughout the limbs. Once detected, the nerve is followed proximally and distally shifting the transducer up or down according to its course. With this technique – called the “lift technique” – the examiner is able to explore long segments of a nerve in a few seconds throughout the limbs and extremities.
  80. 80. In the event of intrinsic or extrinsic nerve abnormalities, the US examination is more appropriately focused on the area-of-interest using oblique and longitudinal scanning planes. all main nerves can readily be displayed in the extremities due to their superficial position and absence of intervening bone, depiction of the peripheral nervous system is not possible verywhere with US.
  81. 81. In fact, most cranial nerves, the nerve roots exiting the dorsal, lumbar and sacral spine, the sympathetic chains and the splanchnic (visceral) nerves in the abdomen cannot be visualized due to their course being too deep or interposition of bony structures.
  82. 82. Dermis and hypodermis From an anatomical point of view, nerves are characterized by a complex internal structure made of nervous fibers (containing axons, myelin sheaths and Schwann cells) grouped to form fascicles, and loose connective tissue (containing elastic fibers and vessels)
  83. 83. The skin represents the external covering of the whole body. Its thickness varies according to different body regions, reaching a maximum thickness at the palm of the hand and the sole of the foot. The skin is divided into two ifferent layers; • The external layer is the epidermis • The internal layer the dermis
  84. 84. The epidermis; consisting of squamous multi-stratified epithelium that continues deeply with the dermis, The dermis; a layer of connective tissue made of cells and collagen fibers lying in an amorphous (without shape) interstitial substance. The dermis contains blood vessels, nerves, lymphatics, hair follicles and glands.
  85. 85. The hypodermis is found even more deeply and it is made of a tissue rich in collagen fibers and connected to the dermis by fibrous branches. The hypodermis has a complicated structure containing adipose storage inside the subcutaneous adipose tissue. The hypodermal thickness varies according to the examined region and to the patient’s personal constitution
  86. 86. Detailed US exploration of the skin is now possible due to high frequency and high resolution transducers. The skin appears as a hyperechoic superficial band of variable thickness and homogeneous structure where it is not possible to differentiate the epidermis from the dermis by ultrasound.
  87. 87. The hypodermis, on the contrary, is easily identifiable: it appears as a deep hypoechoic layer, characterized by intersecting curvilinear septa, that correspond to supporting fibrous branches, containing blood vessels well-depicted by color Doppler techniques.
  88. 88. The hypodermis is separated from the underlying muscular layer by the superficial aponeurotic fascia, appearing as a double hyperechoic line. Dynamic examination is useful to differentiate adipose from muscular tissue
  89. 89. To diagnose skin disease, the main investigation tends to be clinical examination, eventually supported by histological analysis; US can be useful as a follow-up examination when assessing systemic diseases with skin involvement, such as systemic sclerosis (scleroderma).
  90. 90. Subcutaneous tissue ultrasound examination can also be useful in the diagnosis and staging of some neoplastic lesions such as melanoma, glomus tumours and hemangiomas. It is also used for anthropometric studies in sports medicine to calculate the fat-free mass, which represents an important indicator of physical condition for athletes.
  91. 91. epidermis-dermis (E), hypodermis (H) and superficial aponeurotic fascia (A)
  92. 92. THANK YOU!

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