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Transcript
Patrick R Meyers, BS, RDMS, RVT, RDCS
Musculoskeletal Ultrasound of SE Wisconsin, LLC
the shoulder
what’s included
• palpable landmarks
• anterior, anteriolateral, superior & posterior views
• anatomic relationships
• dynamic maneuvers
• patient positions
• bone landmarks
• ipsilateral to contralateral comparisons
• manual techniques to adjust for anisotropy
anatomic structures
• Biceps Tendon (BT) and muscle
• Subscapularis Tendon (SCT) and muscle
• Supraspinatus Tendon (SST) and muscle
• Acromio-Clavciular Joint (AC Joint)
• Infraspinatus Tendon (IST) and muscle
• Posterior Labrum (Lab)
• Spinoglenoid groove or notch
• Superior Labrum (optional)
anatomic structures – insonation angles
anterior
anatomic structures
Biceps Tendon
• attached to the supraglenoid
tubercle
• lies between the greater and lesser
tuberosity of the humeral head
• covered by transverse humeral
ligament at tuberosities
Sonography
• tendon is evaluate in SAX & LAX
• follow biceps tendon from the
intracapsular segment through the
insertion of the pectoralis on humerus
• clip in SAX from intracapsular segment
through pectoralis insertion
• clip from medial to lesser tuberosity
through bicipital groove through greater
tuberosity
sonography – biceps tendon
Technique
• elbow bent 900 arm rests on thigh
• palm up
• may use some internal or external
rotation depending on patient
• stills of LAX with clip
• stills in SAX with clip
• LAX sweep from groove to M/T
junction
• use power Doppler hypoechoic
areas
sonography – biceps tendon
Technique
• elbow bent 900 arm rests on thigh
• palm up
• LAX sweep from medial to lesser
tuberosity to lateral to the greater
tuberosity
• LAX sweep from intracapsular
segment to MT junction
• SAX sweep from intracapsular
segment to insertion of the
pectoralis muscle
anatomic structures - subscapularis tendon
Subscapularis Tendon/Muscle
• tendon insertion on lesser tuberosity of humerus and
anterior scapula proximally
• bone landmarks lesser tuberosity and coracoid
process of scapula
Sonography
• tendon is evaluate in SAX & LAX
• dynamic maneuver with elbow tucked and arm
externally rotated
• evaluate tendon, bursa and lesser tuberosity
slip
• SAX of tendon from coracoid to tendon insertion on
lesser tuberosity
• LAX superior to inferior
sonography – subscapularis tendon
Subscapularis tendon and muscle
• tendon insertion on lesser tuberosity of humerus and
anterior scapula proximally
• bone landmarks lesser tuberosity and coracoid
process of scapula
Technique
• tendon is evaluate in LAX
• superior, middle and inferior segment
• note any loss of mass between segments
sonography – subscapularis tendon
Technique
• tendon is evaluate in SAX with arm
externally rotated
• stills from coracoid process to tendon
insertion on the lesser tuberosity
• make note of fluid collections or loss
tendon segment bulk
sonography - subscapularis
Technique
• externally rotate arm with elbow
tucked
• stills evaluating superior, mid and
inferior sections
• capture clip of arm in FULL internal
and external rotations
anatomic structures – Acromio-Clavciular joint
Anatomy
• lateral end of the clavicle and
acromion process of scapula
• cart ligneous intra articular disk
• joint is wider anteriorly then
posteriorly
sonography – Acromio-Clavciular (AC) joint
Sonography
• LAX only
• evaluated in neutral and internal rotation
• if instability is suspected dynamic
maneuver bilaterally
• ipsilateral to contralateral comparison in
neutral position is routine
Sonography – internal rotation AC joint
Sonography
• AC joint space closes
• slight superior bulging of capsule
• no fluid “fountain” should appear
• minimal caudal/cephalid translation
Sonography – internal rotation AC joint
Sonography
• AC joint space closes
• slight superior bulging of capsule
• no fluid “fountain” should appear
• minimal caudal/cephalid translation
Sonography – internal rotation AC joint
Sonography
• AC joint space closes
• slight superior bulging of capsule
• no fluid “fountain” should appear
• minimal caudal/cephalid translation
anatomic structures -supraspinatus
Supraspinatus Tendon/Muscle
• muscle arises from the supraspinatus fossa of the
scapula
• passes beneath the acromion and attaches to the
greater tuberosity of the humerus
• slides beneath the subdeltoid subacromial bursa
(SDSA)
• responsible for abduction of the arm
Crass
Sonography
Crass
Modified Crass
Middleton
• tendon is evaluate in SAX & LAX
• two positions Crass and modified Crass or Middleton
•SAX & LAX of tendon and muscle sweeps from M/T
junction through insertion point in both Crass and
Middleton position
• superior margin is the coracoacromial ligament
sonography – supraspinatus SAX
Technique
• SAX and LAX in both positions
• Middleton position demonstrates
cuff interval best
• capture stills and clips from
coracoacromial ligament through
insertion on the greater tuberosity
• always adjust for anisotropy!
sonography – supraspinatus LAX
Technique
• SAX and LAX in both positions
• Middleton position demonstrates
cuff interval best
• capture stills and clips from
coracoacromial ligament through
insertion on the greater tuberosity
• always adjust for anisotropy!
modifications to Crass position
Technique
• patients with rotator cuff disease
have trouble with Crass position
• minimal position is to get arm with
dorsal hand resting on lower back