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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