Download Agnes Kaweme-Knee Ultrasound

KNEE ULTRASOUND INTERESTING CASE
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Student:
Student Number:
Email Address:
School:
Workplace:
Lecturer:
Due Date:
Agnes Kaweme
17324438
[email protected]
Science and Engineering
My Radiology Centre (MRC) Perth
Le-Anne Grimshaw
26/05/2014
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I declare that this assignment is my own work and has not been
submitted in any form for another unit, degree or diploma at any
university or other institute of tertiary education. Information derived
from the published or unpublished work of others has been
acknowledged in the text and a list of references is given. I warrant that
any disks and or computer files submitted as part of this assignment have
been checked for viruses and reported clean.
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Student Signature: akaweme
Date: 30/05/2014
INTRODUCTION
Ultrasound remains an imaging modality of choice (useful tool) in
musculoskeletal investigations of all body parts because it’s readily
available, non invasive and economic. The knee is one of the body parts
where ultrasound remains useful in assessing pathology. It has a complex
anatomy with attachments of numerous tendons, ligaments and bursae.
Due to high incidence of over use most injuries occur to the extra articular
soft tissues of the joint (Ronald Ptasznik 1999).
Patient’s history
A 35-year-old man presented for an ultrasound appointment with a
request to scan the knee. The patient had a clinical history of swollen
knee, and acknowledged that he was a sports man and has spent the past
six months renorvating his house, however did not recall any acute injury
to the knee. Over a period of three weeks, the swelling had increased and
he consulted his General Practitioner.
BACKGROUND INFORMATION ON THE KNEE
Below is a summary of how the structures relate to one another within the knee:
Bony structures
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The intercondylar notch separates the medial and lateral condyles
of the femur articulate with the tibial plateau-and posteriorly
The medial and lateral articular surfaces are firmly fitted by the
triangular shaped menisci – cartilaginous structures
The anterior tibia has a prominent apophysis and tibial tuberosity
Proximal metaphysis of the tibia where the patella tendon inserts.
The largest body sessamoid bone (patella) lies anteriorly to the
femoro-tibial joint
The lateral tibia condyle has a small articular surface with the
fibula (tibiofibula joint).
The medial femoral condyle and the concave part of the medial
tibial plateau (Bianchi and Martinoli 2007).
Ligament structures
 Anterior cruciate ligament- strong and thicker-intra and extra
capsular synovial –originates from the postero-medial of the
lateral femoral condyle- inserting anterior to the tibial spine.
 Medial collateral ligament (MCL) –is the most commonly injured
superficial ligament. It is found in the intermediate layer that
blends with the crural fascia to form the medial patellar
retinaculum (which originates from the medial femoral
epicondyle). The MCL is 5 centimeters above the joint and inserts
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on the medial aspect of the tibia 6-7centimeters below the knee
joint behind the pes anserinus
The iliotibial band and the biceps tendon are housed in the most
superficial layer.
The intermediate layer houses the lateral patellar retinaculum,
patellofemoral ligaments and lateral collateral ligament (Bianchi
and Martinoli 2007).
Quadrants
The four quadrants within the knee are known as anterior, medial, lateral and
posterior.
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Anterior kneeThe quadriceps tendon is made up of the following muscles, whose main
action is the extension of the leg and knee joint
-The rectus femoris- lies superficially, originates from the anterior
inferior iliac spine above the acetabulum and attaches the quadriceps
tendon to the base of the patella and onto tibial tuberosity via patella
ligament
-The vastus lateralis-is located mid and laterally, is the largest of the
quadriceps in the anterior compartment, originates from the greater
trochanter and upper lateral surface of the linear aspera and inserts on
the patella via the quadriceps tendon-on the tibial tuberosity via the
patellar ligament
-The vastus medialis-located medially, (it’s a medial quadriceps in the
anterior compartment)-originates from the intertronchanteric line and
medial lip of the linear aspera, inserting on the patella via the quadriceps
tendon-on the tibial tuberosity via the patella ligament
-The vastus intermedius-lies deep to the rectus femoris, originates from
the upper third of the anterior lateral surfaces of the femur and inserts as
a common tendon of the quadriceps enclosing the patella and then
inserting on the tibial tuberosity (Bianchi and Martinoli 2007).
MEDIAL KNEE
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The following are found within the medial knee:
Medial Collateral Ligament (MCL)
Pes anserinus (comprises of the Graciis, Sartorius and Semitendinosus
tendons) insertion is onto tibial metaphysis 5-6 centimeters below the
knee joint.
Anserinus bursa.
LATERAL KNEE
There are two groups of knee stabilisers found within the lateral knee
1) Anterolateral- Iliotibial tract which extends from the fascia lata and
inserts on Gerdy's tubercle on the tibia
The anterolateral ligament forms part of the posterior cruciate ligament,
originates from the anterior and distal lateral collateral ligamentinserting on the posterior horn of the lateral meniscus and proximal tibia
between Gerdy’s tubercle and fibular head.
2) Posterolateral- arcuate ligament complex; there are 6 Ligaments-LCL,
Popliteal fibular, Popliteal meniscal, Oblique Popliteal, arcuate and
Fabellofibula. 3 muscle group- Popliteus, Biceps, and lateral
Gastrocnemius (Bianchi and Martinoli 2007)
POSTERIOR KNEE
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Popliteal Fossa- forms a hollow space when the knee is flexed.
The posterior knee tendons are flexors of the joint and also help with
extension of the hip joint.
Medially the following tendons are found: Semitendinosus,
semimembranosus,
Laterally- Biceps femoris
Distally- medial and lateral heads of the Gastrocnemius
Posterior compartment-contains - Semimembranosus and
Gastrocnemius bursa with neurovascular bundle comprising of the –
Popliteal artery, Popliteal vein and Tibial nerve which lies quite
superficially.
Posterior cruciate ligament
COMMON PATHOLOGY
Patellofemoral syndrome, patella tendinopathy, patellofemoral instability
(Ronald Ptasznik 1999
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Synovial effusions- Baker’s cyst, found at the medial border of the
Gastrocnemius muscle and Semimembranosus tendon.
Ganglions- could be intra articular located in the cruciate ligament. extra
articular found in the superior tibiofibula joint, extra neural causes
Peroneal nerve compression, intramural-located within the nerve sheath
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Snapping knee syndrome.
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Bursitis – e.g. Suprapatella, Prepatella ( subcutaneous in location) Deep
infrapatella, Superficial infrapatella, Pes anserinus , Semimambranosusgastrocnemius,
Os good – Schlatter disease –
Knee locking-usually due to meniscal lesions.
Jumpers knee
Runners knee (Bianchi S, C martinoli
Sinding Larsen- Johansson syndrome- juvenile osteochondrosis
Degeneration- could be due to-Osteochondrol defects-Articular cartilage
injuries-loose bodies-marginal erosions.
Rheumatoid arthritis
Vascular insufficiency, due to-compression of the popliteal artery
secondary to abnormal anatomical relationship of the medial head of the
gastrocnemius and popliteus muscle.
INDICATIONS FOR THE EXAMINATION
Trauma- mainly sport injuries
Acute and chronic knee pain-rheumatological
disorders
Swelling- could be due to-masses and effusion
SCANNING TECHNIQUE-ANTERIOR KNEE
The patient was examined in a supine position with the left knee flexed
and the planter aspect of the foot flat on the couch. A form pad was placed
under the knee (in the popliteal space) to support and maintain the
position and for patient's comfort as well as avoiding anisotropy.
The transducer was placed longitudinally in the midline with the distal
end of the transducer over the patella. Scanning the entire anterior knee
from medial to the lateral aspect in longitudinal and transverse planes.
Assessing the quadriceps in its superficial position to the bursa, then
proximally from the muscle bellies to the distal union of the three muscles
to a common tendon inserting on the patella and the tibial tuberosity. The
quadriceps was assessed for tendinopathy with colour Doppler,
enthesopathy, rupture, partial thickness tears or chronic stress tears. The
bursa was assessed for possible effusion and loose bodies. Hoffa’s fat pad
was also assessed. The prepatella bursa was showed a large fluid
collection (Beggs et al 2010)
Fluid in the knee joint would be due to the presence of intra-articular pathology,
an MRI is useful in the investigation of such.
Prepatellar bursa- It is a thin synovial lining, located in the subcutaneous tissue
between the skin and bone (patella), anterior to the lower half of the patella and
proximal patellar tendon. The bursa is also known as popeye knee, house maid’s
knee, carpet layer’s knee, coal miner’s knee nun’s knee. The function is to reduce
friction between the skin and the patella.
Superficial infrapatella bursa- It is a small fluid filled sac , located between the
tibial tuberosity and the skin- reduces friction between the skin and tibial
tuberosity
Deep Infrapatellar bursa- It is a mall fluid filled sac, lies deep to the patella –
located between the deep boundary of the distal patellar tendon and the
anterior tibia.
The function of the bursa is to reduce friction between the distal patellar tendon
and the anterior aspect of the tibia.
Causes of bursitis: Pressure from kneeling, trauma, bacterial inflammation,,
complications from osteoarthritis, knee gout.
Risk factors: Osteoarthritis and obesity, sport activities such as wrestling ,
runners, football and volley ball .
LEFT KNEE- MEDIAL
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The medial aspect of the knee was assessed in the same position as
anterior knee with a slight external rotation. Displaying the medial
meniscus, medial collateral ligament assessing these structures in long
and axial planes for possible tears and any other pathology such as cysts.
LATERAL KNEE
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The patient’s knee was slightly medially rotated-maintaining the flexed
position, the lateral aspect of the knee was examined in longitudinal and
lateral planes
Assessing the Iliotibial band, the lateral meniscus and the lateral
collateral ligament
POSTERIOR KNEE
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The patient was asked to roll over into a prone position, with the knee
extended
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With the transducer in transverse position- postero-medial aspect-the
sartorius muscle , the graciis, the semitendinosus and semmembranosus
tendons were assessed, carefully looking for possible baker’s cyst.
Sliding the transducer towards the mid and postero lateral the medial and
lateral head of the gastrocnemius, the posterior cruciate ligament were
assessed in long and transverse planes.
Moving the transducer up and down in the popliteal fossa the
neurovascular bundle was assessed –the tibial nerve, popliteal artery,
popliteal vein checking for patency and compressibility to rule out deep
vein thrombosis
Image 1:Left knee shows normal quadriceps tendon at its insertion
Image 2:Left knee shows normal quadriceps in transverse view
Image 3:Left knee- shows prepatellar effusion in longitudinal
Image 4: Left knee- shows- shows prepatellar effusion in transverse view
Image 5: shows normal patella tendon at insertion on the tibial tuberosity
note fluid collection in that superficial-infrapatella bursa
Image 6:Left knee shows patella tendon inserting on the tibial tubercle
Image 7: Left knee –shows superficial infrapatellar bursa
Image 8: Left knee –shows the medial-meniscus (medial collateral ligament)
LEFT KNEE- PES ANSERINUS
Image 9: shows –normal pes anserinus
Image 10: Left knee shows fluid in the lateral meniscus recess
Image 11:Left knee shows lateral meniscus with
Image 12: Left knee –shows normal lateral iliotibial band
Image 13: Left knee shows Left Collateral ligament
Image 14: Left knee
Image 15:Left knee shows posterior knee in transverse with the medial head of
gastrocnemius
Image 16 left knee shows –posterior knee ganglion
Image 17 Left Knee shows compressible popliteal vein
Image 18-Left posterior knee –shows a normal artery
REFERENCES
Bianchi,S., and C. Martinoli. 2007. Ultrasound of the Musculoskeletal
System:
New York: Springer
http://www.curtin.eblib.com.au.dbgw.lis.curtin.edu.au/patron
/SearchResults.aspx?q=Bianchi%2CS.%2C+and+C.+Martinoli.+
2007+ultrasound+of+the+musculoskeletal+system%3ASpring
er&t=quick
Ptasznik, Ronald.1999. “Ultrasound in acute and chronic knee injury” Radiologic
Clinics of North America 37(4):797-830.
Beggs Ian Stefano, Bianchi Michel Cohen, Michel Court-Payen, Andrew Grainger,
Franz Kainberger, Andrea Klauser, Carlo Martinoli, Eugene McNally,
Philip J. O’Connor, Monique Reijnierse Philip and Remplik Enzo
Silvestri.2010. “Musculoskeletal Ultrasound: Technical Guidelines”
Insights into Imaging 1:99-141.