The document provides an overview of the role of ultrasound in orthopedics. It begins with a description of normal sonographic appearances of structures like tendons, bones, cartilage and ligaments. It then discusses various sonographic artifacts and basic pathology concepts for evaluating musculoskeletal injuries and conditions like muscle/tendon injuries, bone injuries, infections, arthritis and soft tissue foreign bodies. Specific applications of ultrasound for assessing conditions in different body regions like shoulder, elbow, wrist, hip, knee, ankle and foot are covered. The document highlights advantages of ultrasound for diagnosis, interventions and treatments in orthopedics.

1. ROLE OF USG IN
ORTHOPEDICS
Presenter : Dr. Karthik S J
Moderator: Dr Arun H S sir

2. TABLE OF CONTENTS
Introduction
Normal structure : Sonographic
appearance
Sonographic artifacts
Basic pathology concepts
Muscle and Tendon injuries
Bone injury
Infection
Arthritis
Soft tissue foreign body
Peripheral neve entrapment
Shoulder Ultrasound
Rotator cuff tears
Tendinosis
Tendinitis
Rotator cuff atrophy
Subluxation and Dislocation
Elbow Ultrasound
Common flexor and extensor
origin pathology

3. TABLE OF CONTENTS
Ultrasound of wrist and Hand
Joint abnormalities
Dequervain disease
Tendon tear
Peripheral nerve Abnormalities
Dupytren contracture
Hip
DDH
Other Pathologies
Knee
Baker cyst
Patellar tendon injury
Ligament injury
Ankle and Foot
Achilles Tendon tear
Plantar fasciitis
Lisfranc Injuries
Advantages of Ultrasound
Antenatal diagnosis
Interventional techniques
Therapeutic techniques
Conclusion

4. INTRODUCTION
• Ultrasound is sound above the audibly perceptible range of
frequencies (20 Hz–20 kHz).
• Ultrasound waves are produced by piezoelectric crystals
• The ultrasonography identifies changes in tissue based on physical
characteristics
• Peizo electric effect : It is defined as change in physical dimensions of
certain materials, when subjected to an electric field
Orthopedic Ultrasound Is Often Referred To As The
“Orthopedic Surgeon’s Stethoscope”

5. NORMAL STRUCTURES: SONOGRAPHIC
APPEARANCE
• Normal tendon appears hyper echoic with fibrillar echotexture
• Continuous tendons are better appreciated when they are images
along the long axis of the tendon
Ultrasound image of flexor
tendons of the finger in long axis shows
normal tendon hyper echogenicity
becoming more hypoechoic as the
tendon becomes oblique relative to
the sound beam

6. Bone:
• The surface of bone or calcification is typically very hyperechoic, with
posterior acoustic shadowing if the surface of the bone is smooth and
flat
Ultrasound image of brachialis and
biceps brachii muscles in long axis
shows hypoechoic muscle and
hyperechoic fibroadipose septa

7. Hyaline cartilage:
• The hyaline cartilage covering the articular surface of bone is
hypoechoic and uniform where labrum of the hip and shoulder, and
the knee menisci are hyperechoic.

8. Ligaments:
• Ligaments have a hyperechoic, striated appearance that is more
compact compared with tendons
• In addition, ligaments are also identified in that they connect two
osseous structures

9. PERIPHERAL NERVES
• Normal peripheral nerves have a fascicular appearance in which the
individual nerve fascicles are hypoechoic, surrounded by hyperechoic
connective tissue epineurium
Ultrasound image of median nerve shows
individual hypoechoic nerve fascicles and
the adjacent hyperechoic flexor carpi
radialis tendon

10. OTHER STRUCTURES:
NORMAL STRUCTURES SONOGRAPHIC APPEARANCE
Air/Gas Comet tail artefacts
Fat Hypoechoic
Fascia Hyperechoic
Muscle Hyperechoic
Synovium / Capsule Both appears hypoechoic similar to Joint fluid

11. SONOGRAPHIC ARTIFACTS:
• Anisotropy : A tissue is anisotropic if its properties change when
measured from different directions (When a tendon is seen at an
angle 2 to 3 degree of the long axis, its hyperechoic architecture is
lost)

12. • Shadowing : This occurs when the ultrasound beam is reflected,
absorbed, or refracted.
• The resulting image shows an anechoic area that extends deep from
the involved interface

13. Posterior acoustic enhancement / Increased through-transmission:
• Deeper soft tissues will appear relatively hyperechoic compared with
the adjacent soft tissues
• This occurs during imaging of fluid and some solid soft tissue tumors,
such as peripheral nerve sheath tumors

14. Posterior reverberation:
• This occurs when the surface of an object is smooth and flat, such as a
metal object or the surface of bone
• The transducer and produces a series of linear reflective echoes that
extend deep to the structure

15. BASIC PATHOLOGY CONCEPTS
Muscle and Tendon injury:
Morel-Lavallée lesion
• Hemorrhage located between the subcutaneous fat and the adjacent
hip musculature can occur with trauma as a degloving-type injury
Ultrasound image over lateral hip shows
anechoic fluid at the site of prior hemorrhage
between subcutaneous fat
(F) and musculature (M).

16. Myositis ossificans:
An area of damaged muscle may ossify, termed myositis ossificans and
ultrasound can show early mineralization before visualization on
radiography

17. • After surgery, misplaced hardware or screw-tip penetration beyond
the bone cortex may cause excessive wear of an adjacent tendon.
• Ultrasound is helpful in this diagnosis because artifact from metal
hardware does not obscure overlying soft tissues

18. BONE INJURY:
• The hallmark of an acute fracture is discontinuity of the bone cortex
with possible step-off deformity. Adjacent mixed echogenicity
hemorrhage may also be present.

19. • A stress fracture involving a metatarsal, may initially appear as an
abnormal focal hypoechoic area adjacent to bone, which may
progress to fracture step-off deformity or hyperechoic callus
formation

20. • In case of avulsion of bone at tendon and ligament attachments, a
small fragment of bone with variable shadowing is seen attached to
the involved tendon or ligament

21. Ultrasound application in Bone :
• The indication for the examination is often to evaluate a bone or joint
abnormality after a “negative” radiograph
• In case of suboptimal positioning or suboptimal radiographs, greater
tuberosity fracture of humerus might be missed. Ultrasound
examination will reveal a step off sign
• Ultrasound helps in better diagnosis of the rib fractures
• It can also be applied to limb-lengthening procedures, in which
ultrasound can detect new bone prior to being seen at radiography

22. • It is also used in the diagnosis of tibial fracture nonunion with static
interlocked nail placement
• It can detect healing before radiography, whereas visualization of the
hyperechoic nail indicates no overlying callus formation
Ultrasound image shows hyperechoic
intramedullary nail with posterior reverberation
artifact indicating incomplete healing of the tibial
fracture

23. INFECTION:
Cellulitis
• Cellulitis appears as hyperechoic and
thickened subcutaneous tissue.
• Later, hypoechoic or anechoic
branching channels are visualized, with
distortion of the soft tissues
• Such branching channels can coalesce
as purulent fluid and can progress to
frank abscess, where ultrasound-
guided aspiration may be of benefit

24. ABCESS
• The ultrasound appearance of abscess is variable but commonly
appears as well-defined hypoechoic heterogeneous fluid collection
with posterior through-transmission
Ultrasound image shows
isoechoic abscess adjacent to metal
side plate and screws

25. • Soft tissue infection may also involve a bursa, which can produce
complex fluid and synovitis, and possibly gas, which appears
hyperechoic with comet-tail artifact

26. Osteomyelitis:
• If an area of soft tissue infection is
identified adjacent to bone, then
osteomyelitis should be considered
• In the presence of cortical irregularity
resulting from erosions or
destruction, osteomyelitis is likely,
although confirmation with magnetic
resonance imaging (MRI) is typically
required to fully assess the extent of
infection

27. Septic Arthritis
• May be isolated abnormality or secondary to infection in adjacent
soft tissue or bone
• Fluid is seen as anechoic or hypoechoic areas
• Doppler can demonstrate increased flow in capsule (infection causes
hyperemia)
• Absence of hyperemia doesn’t exclude septic arthritis
• Ultrasonography guided, joint fluid aspiration can be done

28. RHEUMATOID ARTHRITIS
• The characteristic features of rheumatoid
arthritis at ultrasound include synovial
hypertrophy and erosions.
• Ultrasound can be used for early
diagnosis, assessment of response to
therapy, and can guide injections or
aspirations
• Synovial hypertrophy appears as
hypoechoic

29. • Synovial hypertrophy may be seen
in the dorsal recesses of the wrist,
the volar and dorsal recesses of the
MCP and IP joints of the hand, and
the MTP and IP joints of the feet
• Erosions begin in the marginal
regions of a joint, where the bone
cortex is not covered with hyaline
cartilage
• A rheumatoid nodule typically
appears as a hypoechoic nodule at
ultrasound

30. PSORIATIC ARTHRITIS
• It involves synovial articulations,
which can cause joint effusion,
synovial hypertrophy, and erosions
• One distinguishing feature of
psoriatic arthritis is the presence
of bone proliferation at tendon
and ligament attachments
• The presence of hyperemia, often
seen in psoriatic arthritis, is
another feature

31. GOUT
• The ultrasound findings of gout include joint
effusion, erosions, and tophi.
• Crystal deposition on the surface of the
cartilage will appear hyperechoic, also called
the double contour sign
• Tendon and tendon sheath involvement are
also possible

32. OSTEOARTHRITIS
• The hallmark of osteoarthritis is
cartilage loss and osteophyte formation,
related to wear-and-tear of a joint
• Ultrasound can detect findings of
osteoarthritis, especially in accessible
peripheral joints
• Osteophytes appear as a well-defined
bone excrescence at a margin of an
involved joint
• Joint effusion may also be present

33. SOFT TISSUE FOREIGN BODIES
• All foreign bodies are initially
hyperechoic although organic or plant
material may become less echogenic
over time
• A hypoechoic halo with possible
hyperemia may be present, representing
hemorrhage, granulation tissue, or
abscess

34. PERIPHERAL NERVE ENTRAPMENT
• Median nerve in the carpal tunnel (carpal tunnel syndrome)
• Ulnar nerve in the Guyon canal (ulnar canal syndrome)
• Ulnar nerve in the cubital tunnel of the elbow (cubital tunnel
syndrome)
• Tibial nerve at the ankle (cubital tunnel syndrome)
• Plantar digital nerve in the distal foot (Motor neuroma)

36. SHOULDER ULTRASOUND

37. ROTATOR CUFF TEARS
PARTIAL THICKNESS TEARS :
• Partial-thickness supraspinatus tendon tears are characterized by a
well-defined hypoechoic or anechoic abnormality that disrupts the
tendon fibers, which may be articular-side or bursal-side
• An intra-substance or interstitial tear is a form of partial-thickness
tear, but it does not extend to the articular or bursal surface.

38. • Bursal-side partial-thickness supraspinatus tendon tear is also
hypoechoic or anechoic, but it is localized to the bursal surface
• Tear extension from the bursal surface to the greater tuberosity
surface without extension to the articular surface is a bursal-side
partial-thickness tear

39. Full thickness tears :
Full-thickness supraspinatus tendon tear is characterized by a well-
defined hypoechoic or anechoic defect that disrupts the tendon fibers
and extends from the articular to bursal surfaces of the tendon

40. TENDIOSIS:
• The term tendinosis is used rather than tendinitis because active
inflammatory cells are absent.
• Degenerative process is present with eosinophilic, fibrillar, and
mucoid degeneration
• In tendinosis a normal convex superior surface of the tendon is seen

41. TENDINITIS:
• Thickening of tendon with inflammatory features (edema, blurred
margins)
• Decreased echogenicity
• Increased vascularity on Doppler imaging
• Calcification can be detected in chronic tendinitis

42. INDIRECT SIGNS OF TENDON TEAR
• Tendon thinning
• Cortical Irregularity
• Joint effusion
• Cartilage interface sign

43. Wiener and Seitz classification
TEAR CATEGORY IMAGING FEATURES
Normal Normal
Partial thickness Hypoechoic areas
Small full thickness < 1cm
Large full thickness 1-3 cm
Massive With or without rotator cuff
arthropathy

44. CRITERIA FOR DIAGNOSING ROTATOR CUFF
TEARS
MAJOR CRITERIA MINOR CRITERIA OTHER OBSERVATIONS
Non visualization of the cuff Intra- and extraarticular
effusions
Cuff thickening
Focal non visualization or
discontinuity
Concave subdeltoid bursal
contour
Blood flow characteristic
Abnormal echogenicity Humeral head elevation
Thickening of subdeltoid bursa

45. Rotator Cuff Atrophy
• In case of a full-thickness rotator cuff
tear, the supraspinatus and
infraspinatus may undergo fatty
degeneration or infiltration and
possible atrophy
• The degree of rotator cuff atrophy
relates to size, location, and chronicity
of the rotator cuff tear
• In ultrasound, fatty degeneration or
infiltration and muscle atrophy will
appear as increased echogenicity of
the muscle

46. Postoperative Shoulder
• Ultrasound has been shown to be effective in the evaluation of the
postoperative cuff with more accuracy
• Low-grade partial-thickness tear is commonly debrided, whereas a
high-grade partial thickness tear is converted to a full-thickness tear
and repaired
• Transosseous suture or suture anchors may be used for the repair
• After rotator cuff repair, the tendon may appear thin and
heterogeneous

47. • Repaired cuff begins to appear as normal tendon by 6 months after
surgery
• Recurrent rotator cuff tear after repair, visualization of a defined
tendon defect is important
Recurrent tear with
displaced suture anchor

48. TEAR TENDINOSIS
Anechoic Hypoechoic
Well defined Ill defined
Homogenous Heterogenous
Thin Increased thickness
Bone irregularity Smooth cortex

49. • Tendon calcification
• Impingement syndrome
• Adhesive capsulitis
• Labral cyst
are the other pathologies that can be visualized under Ultrasound

50. SUBLUXATION
• When the biceps brachii long head tendon is not normally identified
in the bicipital groove medial subluxation or dislocation is considered
• Medial dislocation of the long head of biceps brachii tendon over the
lesser tuberosity in neutral shoulder position may relocate into the
bicipital groove with shoulder internal rotation associated with a
painful snap

51. ULTRASOUND OF ELBOW

52. PATHOLOGIES AROUND ELBOW
• Septic elbow Joint
• Rheumatoid arthritis
• Nerve compression due to RA
• Intra articular osteoid osteoma
• Synovial chondromatosis
• Intra articular bodies
• Radius neck fractures
• Synovial fold syndrome
• Epitrochlear lymph node
pathology
• Radial groove syndrome
• Ligament injuries around elbow

53. Common flexor and Extensor Tendon:
Pathology
• Golfer’s elbow : Abnormalities of common flexor origin at medial
epicondyle (Medial epicondylitis)
• Tennis elbow : Abnormalities of common extensor origin at lateral
epicondyle (Lateral epicondylitis)
• Abnormality consists of degeneration, tendinosis, and possible
tendon tear rather than true active inflammation
• Extensor carpi radialis brevis is commonly affected

54. common extensor tendon show abnormal hypoechoic
tendinosis (arrows), with superimposed anechoic interstitial
tear

55. ULTRASOUND OF WRIST AND HAND

56. JOINT ABNORMALITIES
Joint effusion

57. Synovial hypertrophy : RA
Synovial hypertrophy distending the dorsal recess
of the distal radioulnar joint erosion

58. DEQUERVAIN DISEASE
• Tenosynovitis involving the extensor
pollicis brevis and abductor pollicis
longus tendons in the first extensor
wrist compartment
• Thickening of extensor retinaculum over
the involved tendons, with possible
hyperemia, tendinosis, and cortical
irregularity of the radius

59. TENDON TEARS AND AVULSION FRACTURES
Torn and retracted flexor digitorum superficialis
Retracted fracture fragment avulsed from
the distal phalanx along with FDP

60. PERIPHERAL NERVE ABNORMALITIES
• Carpal Tunnel Syndrome : Most
common entrapment of upper limb
involving median nerve at the level of
wrist
• Decrease in the size of the carpal
tunnel or increase in the volume of its
contents can cause nerve compression
• Increase in size > 2mm comparing
proximal with distal

61. Ulnar tunnel syndrome :
• Entrapment of Ulnar nerve in Guyon
canal
• Hook of the hamate bone is directly
deep to the ulnar nerve direct impact on
the ulnar aspect of the hand can cause
peripheral nerve or vascular injury
• Hypothenar hammer syndrome: Direct
trauma over hypothenar area result in
thrombosis of Ulnar artery leading to
vascular insufficiency of digits

62. DUPUYTREN CONTRACTURE
• It is caused due to the thickening of the palmar aponeurosis and
present as a palpable mass
• In ultrasound, nodular or cord-like hypoechoic masses are seen
superficial and parallel to one or more of the flexor tendons

63. ULTRASOUND OF HIP

64. DEVELOPMENTAL DYSPLASIA OF HIP
• Clinical assessment of the neonatal hip is performed routinely in the
first day of life
• Clinically: Barlow and Ortolani maneuvers

65. Ultrasound protocol
1st position: coronal view with the
hip in neutral position
α angle : angle between the lateral
ilium (baseline) and the acetabular
roof line
β angle : angle between the lateral
ilium baseline and a line drawn
through the hyperechoic labral tip
from the lateral acetabulum

66. The line drawn from the flat ilium covers at least 50% of the head and
an acetabular α angle is greater than 60 degrees

67. • 2nd position : coronal plane with the
hip flexed
• The transducer is moved posteriorly
over the triradiate cartilage, stress
is applied posteriorly to evaluate for
posterior subluxation of the femoral
head

68. • 3rd position: hip remains flexed,
and the transducer is turned to the
transverse plane
• Dynamic hip adduction with stress
applied posteriorly (the Barlow
test) evaluates for hip subluxation
• Hip abduction with anteriorly
directed stress (the Ortolani test)
evaluates for relocation

70. SIMPILIFIED GRAF CLASSIFICATION
TYPE ALPHA ANGLE BETA ANGLE DESCRIPTION
1 > 60° < 55° Normal
2 43° - 59° 55° - 77° Unstable hip
3 < 43° > 77° Lateralisation/
subluxation
4 Unmeasurable Unmeasurable Dislocated

71. Other Pathologies
• Joint Effusion
• Synovial Hypertrophy
• Infection
• Rheumatoid arthritis
• Pigmented Villo nodular Synovitis
• Labral tears
• Paralabral cysts
• Chondrocalcinosis
• Osteoarthritis
• Femoroacetabular impingement
• Pseudo hypertropy of Tensor
Fascia Lata
• Inguinal lymph node pathologies

72. ULTRASOUND OF KNEE

73. BAKERS CYST (popliteal cyst)
• It is the most common cyst due to distention
of the gastrocnemio-semimembranosus
bursa
• It becomes distended with joint fluid through
communication with the knee joint
• Present in 50% of adults who are older than
50 years
• It is due combination of degenerative
weakening of the intervening capsule, and
increased intra-articular pressure

74. PATELLAR TENDON INJURY
• Jumper’s knee: Tendinosis and partial-
thickness tears may also involve the
proximal patellar tendon
• Abnormal hypoechogenicity with
possible tendon enlargement is seen in
Ultrasound
• Full thickness Tendon tears: Complete
tendon fiber discontinuity and
refraction shadowing at the retracted
torn tendon stumps

75. LIGAMENT INJURIES
• Ultrasound is most effective for the superficially located ligament
such as the medial collateral and lateral collateral ligaments
Medial Joint space widening on Valgus
stress
< 5mm Grade 1
5 -10 mm Grade 2
>10 mm Grade 3
• Shadowing calcification or ossification at the proximal aspect of
the medial collateral ligament indicates Pelligrini-Stieda lesion

76. ULTRASOUND OF ANKLE AND FOOT

77. ACHILLES TENDON TEAR
Partial Achilles tendon tear
• It appears as more defined hypoechoic or anechoic
area or cleft within the tendon that partially
disrupts tendon fibers
• Achilles tendon enlargement greater than 1 cm
indicate a partial-thickness tear
• Dynamic evaluation with ankle dorsiflexion and
plantar flexion is used to demonstrate tendon fiber
continuity to exclude full-thickness tendon tear

78. Full Thickness Tendon tear
• Full-thickness tears of the Achilles tendon
are characterized by complete tendon fiber
disruption and tendon retraction,
commonly 2 to 6 cm proximal to the
calcaneal attachment

79. PLANTAR FASCIITIS
• Hypoechoic thickening (>4 mm)
of the proximal plantar fascia at
the calcaneal origin
• It may occur due to repetitive
micro trauma, degeneration or
edema

80. Lisfranc ligament disruption
• Tear of the dorsal tarsometatarsal
ligament between the medial
cuneiform and second metatarsal base
• Abnormal widening and hypoechoic
hemorrhage between the medial
cuneiform and second metatarsal base

81. ULTRASOUND OF NECK

82. • Cervical rib
• Congenital muscular torticollis
• Fracture of clavicle in newborn
• Congenital pseudo arthrosis of clavicle

83. ADVANTAGE :
• Advantage of ultrasound over other static imaging methods is the
dynamic capability
• Ultrasound evaluation can be directly guided by a patient’s history,
symptoms, and findings at physical examination.
• Once ultrasound examination is begun, the patient can directly
provide feedback with regard to pain or other symptoms with
transducer pressure over an ultrasound abnormality

84. • In case of a rotator cuff tear, compression can help to demonstrate
the volume loss associated with a full-thickness tear
• Transducer pressure over a stump neuroma is also used to determine
if a neuroma is causing symptom
• If the muscle or tendon stumps that move away from each other
during this dynamic maneuver at the site of the tear indicates full-
thickness extent

85. • Safety is the foremost advantage with no known deleterious somatic
or genetic effect reported.
• The examination can be multiply repeated
• Low cost
• Easy accessibility
• Portability
• Noninvasiveness and no ionizing radiation are imparted to the patient

86. ANTENATAL DIAGNOSIS
• Osteochondrodysplasia
• Club foot
• Arthrogryposis
• Limb abnormalities associated with syndromes

87. INTERVENTIONAL PROCEDURES
• Localized aspiration of fluid/abscess
• Injection of drugs into subtle spaces
• Localization of masses and guided biopsy
• Localization of foreign body for placing incision for extraction
• The size, site and nature of foreign body can be identified.

88. THERAPEUTIC : LIPUS
• The application of low intensity pulsed ultrasound on stress fractures,
delayed or nonunion or postsurgical intervention has the positive
effect
• It can also be used to diagnose stress fractures effectively
• Therapeutic effect diminishes with the concomitant use of
nonsteroidal anti-inflammatory drugs (NSAIDs) and calcium channel
blockers.

89. • The effect could very well be similar to Wolff ’s law
• Wolff ’s law : Stress related bone remodeling in normal osseous
structures
• LIPUS : Stress generated potential may play a similar role
• It is used to regenerate consolidation in distraction osteogenesis,
postspinal fusion and improving the osteogenesis
• Tendinopathies like the tennis elbow, plantar fasciitis, tendoachilles
inflammation : Due to its heating effect

90. CONCLUSION
• Use of ultrasonography in orthopedic practice is under evolution with
newer findings constantly introduced in the literature
• It is highly user dependent and has steep learning curve
• Therapeutic use of sonography is controversial
• Future of sonography appears bright with better delineation of the
pathologies and greater description of the modality

91. THANK YOU