Download Anatomy Guide - Ultrasound Haemophilia

Haemophilia Early Arthropathy
Detection with UltraSound
Anatomy Guide
A baseline understanding of joint anatomy is beneficial to treaters who are less
familiar with the routine use of ultrasound in practice, as it can help users to
identify bony landmarks within patient joints during examination. Carlo Martinoli
and his colleague Maribel Miguel Perez from University of Barcelona, Spain, have
developed brief descriptions of the complex anatomy of the elbow, knee and ankle
to refresh understanding in this area. Emphasis has been given to the anatomic
features amenable to ultrasound examination, including bone and joint surfaces.
REFEU385
Date of preparation: March 2014
This educational programme is supported by Pfizer
REFEUxxx
Date of preparation:
This programme
is supported byMay
Pfizer2013
with the aim to improve education and practice in the context of haemophilia departments as well as to establish the use of ultrasound as
a diagnostic modality to assess the status of joints in haemophilia patients. The HEAD-US scheme does not enable examiners to perform a comprehensive diagnostic ultrasound
evaluation of the musculoskeletal system in these patients and cannot be applied in a clinical setting other than haemophilia
Haemophilia Early Arthropathy
Detection with UltraSound
Bone Anatomy
The bones within the elbow joint include the proximal ends
of the ulna and radius and the distal end of the humerus.
The radial head articulates with the humeral capitellum in a
pivotal mode and the ulna with the humeral trochlea in a
hinge mode. The proximal radioulnar articulation is made of
the radial head which revolves within the sigmoid (radial)
notch of the ulna allowing pronation–supination
movements. These articulations cooperate during complex
joint movements allowing a wide degree of flexion,
extension and axial rotation. The humeral trochlea and
capitellum, the trochlear notch of the ulna and the radial
head, with the exception of its anterolateral portion, are
covered by articular cartilage which is approximately 2mm
thick. The elbow is one of the most stable joints of the
body. In normal states, elbow joint motion ranges
approximately from 0° to 150° of flexion and from 75° in
pronation to 85° in supination.
Elbow
Joint Anatomy
The joint capsule invests the entire elbow. Anteriorly, it is attached to the humeral shaft just above the coronoid
and the radial fossae, to the anterior aspect of the coronoid process and to the annular ligament. It is taut in elbow
extension and lax in elbow flexion. Posteriorly, the capsule inserts on the posterior aspect of the humerus above
the olecranon fossa, and to the upper margin of the olecranon. The anterior bulk of the brachialis muscle, the
posterior bulk of the triceps and, on each side, the collateral ligaments reinforce the capsule. Two main fat pads lie
between the fibrous capsule and the synovial membrane in an extrasynovial intra-articular location: the anterior fat
pad filling the radial and the coronoid fossa underneath the brachialis muscle and the posterior fat pad filling the
olecranon fossa.
This educational programme is supported by Pfizer
REFEUxxx
Date of preparation:
This programme
is supported byMay
Pfizer2013
with the aim to improve education and practice in the context of haemophilia departments as well as to establish the use of ultrasound as
This meeting
is organised
and funded
by Pfizer
a diagnostic modality to assess the status of joints in haemophilia patients. The HEAD-US scheme does not enable examiners
to perform
a comprehensive
diagnostic
ultrasound
evaluation of the musculoskeletal system in these patients and cannot be applied in a clinical setting other than haemophilia
Haemophilia Early Arthropathy
Detection with UltraSound
Synovial Space
Elbow
The synovial membrane of the elbow joint envelops the inner surface of the fat pads, the capsule and the annular
ligament. It infolds between the radius and ulna, separating the joint into humero–ulnar and humero–radial
portions and delimits three main synovial recesses on the anterior elbow: the radial recess (laterally), the coronoid
recess (medially) and the annular recess (inferiorly). The radial and coronoid recesses are distensible spaces located
in the supracondylar area underneath the anterior fat pad and the brachialis muscle. The olecranon recess lies
posteriorly on the floor of the olecranon fossa, underneath the posterior fat pad and the triceps muscle. Any
intrasynovial expansible process, such as effusion and synovitis, causes bulging of the recess (inducing recess shape
change from concavity to convexity), as well as displacement and elevation of the fat pads. The most distal recess is
the annular, located at the level of the radial neck. This recess is delimited superiorly by the annular ligament – a
stiff fibrous band which circumscribes the radial head and stabilises the proximal radioulnar joint. The joint space
cannot distend at the level of the radial head unless the annular ligament is torn.
This educational programme is supported by Pfizer
REFEUxxx
Date of preparation:
This programme
is supported byMay
Pfizer2013
with the aim to improve education and practice in the context of haemophilia departments as well as to establish the use of ultrasound as
a diagnostic modality to assess the status of joints in haemophilia patients. The HEAD-US scheme does not enable examiners to perform a comprehensive diagnostic ultrasound
evaluation of the musculoskeletal system in these patients and cannot be applied in a clinical setting other than haemophilia
Haemophilia Early Arthropathy
Detection with UltraSound
Growing skeleton in children
At birth the distal humeral, proximal radial and ulnar epiphyses are entirely chondral. Six ossification centres (four
in the distal humerus, one each in the radius and ulna) develop in an orderly sequence. "CRITOE" can be used as a
memo to remember the sequence in which the ossification centres appear:
1. Capitellum (6 months–2 years)
2. Radial head (3–6 years)
3. Internal (medial) epicondyle (4–7 years)
4. Trochlea (7–10 years)
5. Olecranon (6–12 years)
6. External (lateral) epicondyle (10–14 years)
As a rule, the ossification centres appear earlier in girls. The ossification centres are usually ovoid and smooth with
the exception of the trochlea, which can be fragmented and irregular. The knowledge of the ossification sequence
with age is helpful to avoid confusion with osteochondral damage patterns. As a memo, one can associate CRITOE
to the odd numbers "1-3-5-7-9-11" which are the ages in years that the ossification centres appear.
Elbow
Elbow ossification centres
This educational programme is supported by Pfizer
REFEUxxx
Date of preparation:
This programme
is supported byMay
Pfizer2013
with the aim to improve education and practice in the context of haemophilia departments as well as to establish the use of ultrasound as
This meeting
is organised
and funded
by Pfizer
a diagnostic modality to assess the status of joints in haemophilia patients. The HEAD-US scheme does not enable examiners
to perform
a comprehensive
diagnostic
ultrasound
evaluation of the musculoskeletal system in these patients and cannot be applied in a clinical setting other than haemophilia
Haemophilia Early Arthropathy
Detection with UltraSound
Supratrochlear Foramen
Elbow
A thin plate of bone separates the olecranon and coronoid fossa, which may become perforated to give rise to a
foramen known as "supratrochlear foramen" or "epitrochlear foramen". The incidence of foramen ranges from 6 to
60% in different races. Generally, the shapes of supratrochlear foramen are oval, round, triangular and some are
with sieve-like apertures. The break in the bone septum allows the anterior and the posterior fat pads to contact
each other. It doesn't, however, affect the position of the joint recesses.
This educational programme is supported by Pfizer
REFEUxxx
Date of preparation:
This programme
is supported byMay
Pfizer2013
with the aim to improve education and practice in the context of haemophilia departments as well as to establish the use of ultrasound as
This meeting
is organised
and funded
by Pfizer
a diagnostic modality to assess the status of joints in haemophilia patients. The HEAD-US scheme does not enable examiners
to perform
a comprehensive
diagnostic
ultrasound
evaluation of the musculoskeletal system in these patients and cannot be applied in a clinical setting other than haemophilia
Haemophilia Early Arthropathy
Detection with UltraSound
Bone Anatomy
Knee
In the knee, the femoral (medial and lateral) condyles project posteriorly and are separated by a deep U-shaped
intercondylar notch. The superior surface of the tibia is flat and consists of the medial and lateral tibial plateaux,
which are separated by the intercondylar eminence. Anterior to the femorotibial joint, the patella has a slightly
convex anterior surface and a posterior surface covered by hyaline cartilage. A vertical ridge divides its posterior
surface into lateral and medial facets, the lateral one being larger and more concave. The articular surfaces of the
patella are in front of the corresponding facets of the femoral trochlea, whereas its vertical ridge is opposed to the
trochlea groove. At birth, the patella is entirely cartilaginous. More distally, the tibia articulates with the fibula
through a small facet. From the functional point of view, the knee is an intrinsically unstable joint, the main
stabilisers being represented by powerful ligaments and muscles that bind the femur and the tibia together. Its
movements include flexion and extension, but also mild degrees of internal and external rotation, abduction and
adduction.
Femorotibial Joint Anatomy
The femorotibial joint consists of two compartments: medial and lateral. The medial compartment gives stability to
the joint, whereas the lateral one allows mobility. The lateral and medial fibrocartilaginous menisci help to increase
the congruity between the convex femoral condyles and the relatively flat tibial surfaces. In addition, they greatly
enhance joint stability, transmitting nearly 60% of the forces applied during axial loading to the bones. Stability of
the femorotibial joint is essentially maintained by the articular capsule, a thick fibrous structure inserting into the
bones and periosteum at the edges of the articular cartilages, by several powerful ligaments and by the action of
regional muscles. The most important ligaments of the knee are the collaterals and the cruciate ligaments.
This educational programme is supported by Pfizer
REFEUxxx
Date of preparation:
This programme
is supported byMay
Pfizer2013
with the aim to improve education and practice in the context of haemophilia departments as well as to establish the use of ultrasound as
This meeting
is organised
and funded
by Pfizer
a diagnostic modality to assess the status of joints in haemophilia patients. The HEAD-US scheme does not enable examiners
to perform
a comprehensive
diagnostic
ultrasound
evaluation of the musculoskeletal system in these patients and cannot be applied in a clinical setting other than haemophilia
Haemophilia Early Arthropathy
Detection with UltraSound
Patellofemoral Joint Anatomy
Knee
The patellofemoral joint is formed by the groove of the femoral trochlea and the V-shaped articular facet of the
patella. The orientation of the articular surfaces varies from cranial to caudal with the groove of the trochlea less
pronounced in the upper portion and deeper inferiorly. During flexion and extension movements of the
femorotibial joint, the patella is stabilised by its convex shape that matches the corresponding concave trochlea.
Additional stabilisers are the lateral and medial patellar retinacula, fibrous bands which arise from the lateral and
medial edges of the patella and insert into the femoral condyles. From the biomechanical point of view, the patella
reduces the stress on the quadriceps and patellar tendons during contraction of the quadriceps muscle and
increases the efficacy of muscle contraction by displacing the vector forces transmitted by these tendons more
anteriorly.
Tibiofibular Joint Anatomy
The superior tibiofibular joint consists of the articulation between the medial articular facet of the fibular head and
the corresponding facet of the tibia. It is a small synovial joint located inferolateral to the femorotibial joint.
This educational programme is supported by Pfizer
REFEUxxx
Date of preparation:
This programme
is supported byMay
Pfizer2013
with the aim to improve education and practice in the context of haemophilia departments as well as to establish the use of ultrasound as
This meeting
is organised
and funded
by Pfizer
a diagnostic modality to assess the status of joints in haemophilia patients. The HEAD-US scheme does not enable examiners
to perform
a comprehensive
diagnostic
ultrasound
evaluation of the musculoskeletal system in these patients and cannot be applied in a clinical setting other than haemophilia
Haemophilia Early Arthropathy
Detection with UltraSound
Synovial Space
Knee
The main recesses of the femorotibial joint are the
suprapatellar recess, which is also referred to as the
subquadriceps recess and the parapatellar recesses,
located medial and lateral to the patella. The
suprapatellar synovial recess is the widest recess of
the knee joint. It derives from the fusion of the
subquadriceps bursa with the joint cavity, a process
which occurs during intrauterine life. In normal
states, this recess contains a small amount of fluid.
The suprapatellar recess lies just deep to the
quadriceps tendon and the suprapatellar fat pad and
superficial to the prefemoral fat pads. The
suprapatellar fat pad is a small triangular space
located cranial to the patella and posterior to the
distal third of the quadriceps tendon. Immediately
superficial to the femur, the prefemoral fat pad
appears as a large fatty space.
In normal conditions, the suprapatellar recess
appears as a thin hypoechoic space which results
from a collapsed anterior and posterior synovial
membrane. Occasionally, small amounts of synovial
fluid and synovial tissue accumulate in the most
dependent lateral and medial parapatellar recesses,
rather than in the suprapatellar one. This would
suggest obtaining scanning not only in the midline
but also along the lateral and medial sides of the
patella.
This educational programme is supported by Pfizer
REFEUxxx
Date of preparation:
This programme
is supported byMay
Pfizer2013
with the aim to improve education and practice in the context of haemophilia departments as well as to establish the use of ultrasound as
This meeting
is organised
and funded
by Pfizer
a diagnostic modality to assess the status of joints in haemophilia patients. The HEAD-US scheme does not enable examiners
to perform
a comprehensive
diagnostic
ultrasound
evaluation of the musculoskeletal system in these patients and cannot be applied in a clinical setting other than haemophilia
Haemophilia Early Arthropathy
Detection with UltraSound
Synovial Mimickers
Knee
Focal bulging of the hyperechoic prefemoral fat within the inferolateral aspect of the suprapatellar recess is a
common finding at ultrasound and can occasionally mimic a synovial mass. This image should not be confused with
hypertrophied synovium. It has clear-cut boundaries and may assume a nodular appearance. Gradual compression
with the probe reveals a soft compressible nature.
This educational programme is supported by Pfizer
REFEUxxx
Date of preparation:
This programme
is supported byMay
Pfizer2013
with the aim to improve education and practice in the context of haemophilia departments as well as to establish the use of ultrasound as
This meeting
is organised
and funded
by Pfizer
a diagnostic modality to assess the status of joints in haemophilia patients. The HEAD-US scheme does not enable examiners
to perform
a comprehensive
diagnostic
ultrasound
evaluation of the musculoskeletal system in these patients and cannot be applied in a clinical setting other than haemophilia
Haemophilia Early Arthropathy
Detection with UltraSound
Bone Anatomy
The ankle is composed of two main articulations that are amenable to ultrasound examination: the tibiotalar
(talocrural or ankle joint) and the subtalar (talocalcaneal).
The tibiotalar joint is formed by the articular surfaces of the talar dome and the distal ends of the tibia and fibula
covered by hyaline cartilage. It is a hinge-type synovial joint that allows dorsiflexion (up to 30°) and plantar flexion
(down to 50°) with respect to the neutral position (90° between foot and calf). The supporting structures of this
joint include the fibrous capsule and the medial and lateral collateral ligaments. Proximally, the capsule is attached
to the medial and lateral malleoli and the acetabular margins of the tibia. Distally, it inserts into the talar neck at
some distance from the articular space. A large anterior and a small posterior fat pad lie underneath the capsule in
an intraarticular position.
Ankle
The subtalar joint is a plane synovial joint that permits movements of inversion and eversion of the foot. It takes
place between the inferior surface of body of talus and the facet on the middle of the upper surface of calcaneus.
More specifically, the subtalar joint comprises three articulations between talus and calcaneus:
1. Anterior, the smallest, between the head of the talus and anterior facet of calcaneus
2. Middle, between medial facet of the talus and sustentaculum tali
3. Posterior, the largest, between posterior facet of talus and posterior facet of calcaneus
It is supported by a fibrous capsule that is attached to the margins of the articular facets and is reinforced by
ligaments. In approximately 10–20% of patients, its synovial cavity communicates with the ankle joint. The tibiotalar
and subtalar joints exhibit two main recesses each, anterior and posterior.
This educational programme is supported by Pfizer
REFEUxxx
Date of preparation:
This programme
is supported byMay
Pfizer2013
with the aim to improve education and practice in the context of haemophilia departments as well as to establish the use of ultrasound as
This meeting
is organised
and funded
by Pfizer
a diagnostic modality to assess the status of joints in haemophilia patients. The HEAD-US scheme does not enable examiners
to perform
a comprehensive
diagnostic
ultrasound
evaluation of the musculoskeletal system in these patients and cannot be applied in a clinical setting other than haemophilia
Haemophilia Early Arthropathy
Detection with UltraSound
Bone Anatomy
In the tibiotalar joint, the anterior recess overlies the anterior aspect of the talar dome, which is invested by a thin
layer of articular cartilage, and extends distally until the end of the talar neck, deep to the intra-articular anterior fat
pad. In this recess, a small amount of fluid may accumulate at the level of the talar neck, which is the area of least
resistance to synovial distension. The posterior recess of the tibiotalar joint is smaller and lies underneath the
posterior fat pad, a small triangular structure located between the posterior malleolus and the posterior talus.
Ankle
Similar to the tibiotalar, the subtalar joint exhibits anterior and posterior recesses. The anterior recess lies in the
sinus tarsi, a deep groove located between the talus and calcaneus. The distension of this recess typically induces
displacement of the fat content of the groove. The posterior recess is small and located between the posterior
process of the talus and the calcaneus. The flexor hallucis longus tendon runs alongside the posterior recess. During
ultrasound examination, care should be taken not to confuse this tendon, which may appear hypoechoic as a result
of anisotropy, for a distended posterior recess.
This educational programme is supported by Pfizer
REFEUxxx
Date of preparation:
This programme
is supported byMay
Pfizer2013
with the aim to improve education and practice in the context of haemophilia departments as well as to establish the use of ultrasound as
This meeting
is organised
and funded
by Pfizer
a diagnostic modality to assess the status of joints in haemophilia patients. The HEAD-US scheme does not enable examiners
to perform
a comprehensive
diagnostic
ultrasound
evaluation of the musculoskeletal system in these patients and cannot be applied in a clinical setting other than haemophilia
Haemophilia Early Arthropathy
Detection with UltraSound
Tibiotalar and Subtalar Joint Spaces
In the tibiotalar joint, the anterior recess overlies the anterior aspect of the talar dome, which is invested by a thin
layer of articular cartilage, and extends distally until the end of the talar neck, deep to the intra-articular anterior fat
pad. In this recess, a small amount of fluid may accumulate at the level of the talar neck, which is the area of least
resistance to synovial distension. The posterior recess of the tibiotalar joint is smaller and lies underneath the
posterior fat pad, a small triangular structure located between the posterior malleolus and the posterior talus.
Ankle
Similar to the tibiotalar, the subtalar joint exhibits anterior and posterior recesses. The anterior recess lies in the
sinus tarsi, a deep groove located between the talus and calcaneus. The distension of this recess typically induces
displacement of the fat content of the groove. The posterior recess is small and located between the posterior
process of the talus and the calcaneus. The flexor hallucis longus tendon runs alongside the posterior recess. During
ultrasound examination, care should be taken not to confuse this tendon, which may appear hypoechoic as a result
of anisotropy, for a distended posterior recess.
This educational programme is supported by Pfizer
REFEUxxx
Date of preparation:
This programme
is supported byMay
Pfizer2013
with the aim to improve education and practice in the context of haemophilia departments as well as to establish the use of ultrasound as
This meeting
is organised
and funded
by Pfizer
a diagnostic modality to assess the status of joints in haemophilia patients. The HEAD-US scheme does not enable examiners
to perform
a comprehensive
diagnostic
ultrasound
evaluation of the musculoskeletal system in these patients and cannot be applied in a clinical setting other than haemophilia
Haemophilia Early Arthropathy
Detection with UltraSound
Talar Dome
Ankle
On its dorsal aspect, the talus is formed by three parts. From posterior to anterior, these are: the dome, the neck
and the head. The dome is convex, invested by a uniform layer of articular cartilage. The neck is surfaced by bare
bone without any cartilage cover and starts when the convexity of the dome ends. The talar head is a prominent
process for the articulation with the navicular. The dome and neck form the floor of the synovial recess of the
tibiotalar joint. The osteochondral surface of the talar dome can be examined with ultrasound selecting an anterior
access for the probe while keeping the foot plantar-flexed and a posterior access while the foot is dorsi-flexed.
Nonetheless, part of the weight-bearing area located around the top of the dome cannot be examined owing to
problems of access. Similarly, the osteochondral facets investing the distal tibia and the malleoli cannot be
evaluated with ultrasound.
This educational programme is supported by Pfizer
REFEUxxx
Date of preparation:
This programme
is supported byMay
Pfizer2013
with the aim to improve education and practice in the context of haemophilia departments as well as to establish the use of ultrasound as
This meeting
is organised
and funded
by Pfizer
a diagnostic modality to assess the status of joints in haemophilia patients. The HEAD-US scheme does not enable examiners
to perform
a comprehensive
diagnostic
ultrasound
evaluation of the musculoskeletal system in these patients and cannot be applied in a clinical setting other than haemophilia