Download MSK Ultrasound Shoulder DR C Gandhi

MSK Ultrasound Shoulder
DR C Gandhi
27-3-2015
Palm Hotel
• It has sensitivities and specificities in
assessment of the rotator cuff that are
comparable to MRI
• Assessing for subluxation of the biceps
tendon or impingement syndromes, e.g.,
supraspinatus or subcoracoid impingement.
Clinical Indications
• Assessment of rotator cuff and biceps tendon
pathology, including tendinosis, partial and full
thickness tears, and impingement syndromes.
• Nerve impingement, e.g., suprascapular nerve
impingement and potential secondary findings
such as atrophy and fatty infiltration of the
supplied muscles.
• Labral injuries, particularly posterior labral tears
with paralabral cyst formation
• Ultrasound -guided biopsy of soft tissue
masses, arthrograms (e.g., in patients
requiring MRI but who are allergic to iodine
used in fluoroscopically guided injections),
• Direct joint or tendon injections,
• Joint aspiration
• Aspiration and dissolution of calcific
tendinosis
• Aspiration and injection of bursae and
paralabral cysts.
The surface anatomy of the shoulder: (a)
anterior and (b) posterior views.
The important shoulder bony landmarks: (a) anterior
and (b) posterior views.
The muscle origin (red) and insertion (blue) points of the shoulder girdle
muscles: (a) anterior and (b) posterior views.
The ligaments around the anterior
shoulder joint.
Position
• The examiner can either sit or stand in front or
behind the patient.
• The patient sits on a stool with the shoulder
exposed;
• “Longitudinal” and “axial” refer to the axis of
the structure being imaged.
• Examine in the longitudinal and transverse
planes to identify tears, calcification, fluid
Bicipital tendon
• Long head – O - supraglenoid tubercle, I radial tuberosity
• Short head - O - coracoid process, I - radial
tuberosity
• Flexion and supination forearm
Long head biceps
• Elbow flexed to 90°, arm supinated and hand resting on
ipsilateral thigh
• Transverse scan, - locate bicipital tendon within the bicipital
groove
• Medially the subscapularis tendon and laterally the
supraspinatus tendon are present
• Minimal amount of fluid may be present
• Longitudinal scan – rotate the probe 90°
• Apply more pressure on the distal end of the probe ( heel–
toe effect)
transverse
longitudinal
Biceps tendon
Transverse -- hyperechoic oval LHBT (arrowhead) within the bicipital
groove
Longitudinal
Subscapularis tendon; supraspinatus tendon; long
head of the biceps tendon
SubS
SupraS
Subscapularis
• O - subscapular fossa scapula, I - lesser
tuberosity
• Internal rotation
• Multipennate tendon
Subscapularis
• Elbow flexed to 90°, arm supinated resting on
ipsilateral thigh,
• Medial to bicipital groove
• Probe positioned obliquely and transversely to the axis
of body and longitudinally to the tendons of the
rotator cuff
• For full length examination internal and external rotate
the arm
• On longitudinal scan is beak shaped at insertion
subscapularis
longitudinal
subscapularis
longitudinal ultrasound image
transverse - normal appearance of the multipennate
hyperechoic tendons
Supraspinatus
Crass position
Middleton position
supraspinatus
• O - supraspinous fossa scapula, I - greater
tuberosity
• Shoulder/arm abduction
• Overlying is subacromial-subdeltoid (SASD) bursa
visible as a thin hypoechoic layer
• Tendon is seen beak shaped structure
Supraspinatus transverse
Arrows - supraspinatus tendon;
GT - greater tuberosity;
B - long head biceps tendon;
arrowhead - subscapularis.
Supraspinatus longitudinal
GT - greater tuberosity;
black arrow - articular cartilage;
curved arrow - hypoechoic bursa and adjacent hyperechoic capsule
and peribursal fat
Acromioclavicular Joint
• Arm in a neutral position by the patient’s side
• In the coronal position, the clavicle usually lies at
a slightly higher position than the acromion.
• If acromioclavicular instability is suspected
clinically, measurement of acromioclavicular
separation
• Common pathology is osteoarthritis, common in
person aged > 50 years
A C joint
Infraspinatus
• Ipsilateral hand on contralateral arm/shoulder
• O - infraspinous fossa, I - greater tuberosity
• External rotation
infraspinatus
Infraspinatus longitudinal
infraspinatus tendon (arrowheads)
musculotendinous junction (arrow)
Infraspinatus transverse
junction of the inferior border infraspinatus (arrow)
superior border teres minor (arrowhead) muscles.
GT - greater tuberosity
Teres minor
• Ipsilateral hand on contralateral arm/shoulder
• O - dorsal surface axillary border scapula
• I - greater tuberosity, posterior facet
• External rotation, stabilizer
Teres minor
teres minor (curved arrows).
1 - infraspinatus;
2 - teres minor
short hyperechoic tendon of the teres minor, which can
be used to differentiate from the infraspinatus.
Posterior Labrum
• The transducer is moved transversely,
perpendicular to the glenoid, and medially to
overlie the posterior aspect of the
glenohumeral joint
• Triangular shaped hyperechoic hyaline
cartilage
Posterior Labrum
hyperechoic triangular labrum (arrow) between the humeral head
(H) and glenoid (G).
Subacromial Impingement
• The shoulder is adducted in internal rotation, and
the transducer is placed over the lateral margin
of the acromion in a coronal plane
• Movement of the supraspinatus tendon and
overlying bursa is assessed during abduction
• The supraspinatus tendon and the bursa normally
move smoothly under the acromion, without
bunching of the fibers of the tendon or lateral
distention of the bursa.
Impingement
Impingement
neutral position - longitudinal plane of the tendon
abduction. - supraspinatus tendon should move smoothly under the
acromion without bunching of its fibers, lateral distention of the
overlying bursa, or superior translation of the humeral head.
TENOSYNOVITIS, LONG BICEPS TENDON
DISLOCATION OF LONG BICEPS TENDON
Subdeltoid bursitis
Tear of supraspinatus
Chondrocalcinosis, Supraspinatus tendon
tear
T Q