Normal Ultrasound Anatomy of the Musculoskeletal System: A pratical guide

140 Pages·2012·8.22 MB·English

by  Enzo Silvestri

Normal Ultrasound Anatomy
of the Musculoskeletal System
Enzo Silvestri • Alessandro Muda •
Luca Maria Sconfienza
Editors
Normal Ultrasound
Anatomy of the
Musculoskeletal
System
A pratical guide
Presentazione di
Lisa Licitra, Patrizia Olmi
123
Editors
Enzo Silvestri Luca Maria Sconfienza
Ospedale Evangelico Internazionale IRCCS Policlinico San Donato
Unit of Radiology Unit of Radiology
Genoa, Italy San Donato Milanese (MI), Italy
Alessandro Muda
University Hospital “San Martino”
Unit of Radiology
Genoa, Italy
Contributors
Emanuele Fabbro, MD
Giulio Ferrero, MD
Chiara Martini, MD
Davide Orlandi, MD
Post Graduate School of Radiodiagnostic
University of Genoa
Genoa, Italy
ISBN 978-88-470-2456-4 ISBN 978-88-470-2457-1 (eBook)
DOI 10.1007/978-88-470-2457-1
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Preface
The use of Ultrasound has become widely accepted as an imaging modal-
ity in assessment of the musculoskeletal system, as it is quick, cheap, and
readily available. Also, recent technological improvements in this field have
demonstrated that this imaging modality can provide extremely useful infor-
mation to diagnose and treat musculoskeletal diseases.
When first approaching musculoskeletal ultrasound, many obstacles may
be encountered: for example, it may be difficult at first to position the probe
correctly, or the ultrasound images may not be correctly interpreted. Also,
the high number of artifacts and pitfalls that can be encountered in clinical
practice may further complicate the approach to this imaging modality. Fi-
nally, most medical professionals find it difficult to remember the normal
anatomy of the musculoskeletal system.
For these reasons, we decided to prepare this handbook, which aims to
be a quick and practical reference in daily routine. It is based on a distance-
learning project, prepared in 2010 for Italian radiologists, orthopedists, and
rheumatologists. We wanted to keep the text as concise as possible, to allow
plenty of space for anatomical schemes, pictures of anatomical landmarks
for a better understanding of the correct placement of the probe, and ultra-
sound images, highlighting the most relevant anatomical structures of the
main joints: shoulder, elbow, hand and wrist, hip, knee, ankle and foot. In
addition, an initial chapter dealing with basic principles of musculoskeletal
ultrasound is included.
Finally, we acknowledge the hard work of our colleagues Emanuele Fab-
bro, Giulio Ferrero, Chiara Martini, and Davide Orlandi, whose help with
drawing most anatomical schemes and acting as models for anatomical pic-
tures made an invaluable contribution to this book.
Genoa, November 2011 Enzo Silvestri
Alessandro Muda
Luca Maria Sconfienza
v
Contents
01 Basic Principles of Musculosketal Ultrasound . . . . . . . . . . 1
1.1 Tendons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Ligaments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.3 Peripheral nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.4 Cartilage and bone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.5 Muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
02 Shoulder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.1 Long Head of Biceps Brachii Tendon (LHBBT) . . . . . . 9
2.2 Subscapularis Tendon . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2.3 Supraspinatus Tendon and Subacromial-Subdeltoid
Bursa (SASD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
2.4 Coracoacromial Ligament . . . . . . . . . . . . . . . . . . . . . . . 20
2.5 Infraspinatus and Teres Minor Tendons . . . . . . . . . . . . . 21
2.6 Acromion-Clavicular Joint . . . . . . . . . . . . . . . . . . . . . . 21
03 Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
3.1 Anterior Compartment . . . . . . . . . . . . . . . . . . . . . . . . . . 27
3.1.1 Distal Tendon of Biceps Brachii . . . . . . . . . . . . . . 27
3.1.2. Anterior Joint Recess . . . . . . . . . . . . . . . . . . . . . . 30
3.1.3 Median Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
3.1.4 Radial and Posterior Interosseous Nerves . . . . . . 30
3.2 Lateral Compartment . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
3.2.1 Common Extensor Tendon . . . . . . . . . . . . . . . . . . 35
3.2.2 Humeral-Radial Joint . . . . . . . . . . . . . . . . . . . . . . 35
3.3 Medial Compartment . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
3.3.1 Common Flexor Tendon . . . . . . . . . . . . . . . . . . . . 38
3.3.2 Medial Collateral Ligament . . . . . . . . . . . . . . . . . 38
3.4 Posterior Compartment . . . . . . . . . . . . . . . . . . . . . . . . . 41
3.4.1 Triceps Brachii Muscle and Tendon . . . . . . . . . . . 41
3.4.2 Olecranon Fossa and Posterior Olecranon Recess 41
3.4.3 Cubital Tunnel and Ulnar Nerve . . . . . . . . . . . . . . 41
04 Wrist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
4.1 Palmar Side . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
4.1.1 Carpal Tunnel and Median nerve . . . . . . . . . . . . . 45
vii
viii Contents
4.1.2 Guyon Tunnel and Ulnar Nerve . . . . . . . . . . . . . . 50
4.2 Dorsal Side . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
4.2.1 Extensor Tendon Compartments . . . . . . . . . . . . . . 51
4.2.1.1 First Compartment . . . . . . . . . . . . . . . . . . . . . 51
4.2.1.2 Second Compartment . . . . . . . . . . . . . . . . . . . 54
4.2.1.3 Third Compartment . . . . . . . . . . . . . . . . . . . . . 56
4.2.1.4 Fourth and Fifth Compartment . . . . . . . . . . . . 58
4.2.1.5 Sixth Compartment . . . . . . . . . . . . . . . . . . . . . 60
4.2.2 Distal Radio-Ulnar Joint . . . . . . . . . . . . . . . . . . . . 60
05 Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
5.1 Ventral Side . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
5.1.1 Palmar Aponeurosis . . . . . . . . . . . . . . . . . . . . . . . 63
5.1.2 Flexor Digitorum Tendons . . . . . . . . . . . . . . . . . . 64
5.1.3 Metacarpophalangeal and Interphalangeal Joints . 68
5.2 Dorsal Side . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
5.2.1 Extensor Digitorum Tendons . . . . . . . . . . . . . . . . 71
06 Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
6.1 Anterior Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
6.1.1 Sartorius and Tensor Fasciae Latae . . . . . . . . . . . . 76
6.1.2 Rectus Femoris . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
6.1.3 Iliopsoas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
6.1.4 Femoral Neurovascular Bundle . . . . . . . . . . . . . . 82
6.1.5 Hip Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
6.2 Medial Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
6.2.1 Adductor Tendons and Muscles . . . . . . . . . . . . . . 85
6.3 Lateral Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
6.3.1 Gluteus Tendons and Muscles . . . . . . . . . . . . . . . 86
6.4 Posterior Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
6.4.1 Ischiocrural Tendons (Hamstrings) . . . . . . . . . . . . 89
6.4.2 Sciatic Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
07 Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
7.1 Anterior Compartment . . . . . . . . . . . . . . . . . . . . . . . . . . 93
7.1.1 Quadriceps Tendon . . . . . . . . . . . . . . . . . . . . . . . . 93
7.1.2 Suprapatellar and Paracondylar Recesses . . . . . . . 96
7.1.3 Femoral Trochlea . . . . . . . . . . . . . . . . . . . . . . . . . 96
7.1.4 Patellar Retinacula . . . . . . . . . . . . . . . . . . . . . . . . 96
7.1.5 Patellar Tendon or Ligament . . . . . . . . . . . . . . . . . 100
7.2 Medial Compartment . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
7.2.1 Medial Collateral Ligament . . . . . . . . . . . . . . . . . 102
7.2.2 Goose’s Foot Tendons . . . . . . . . . . . . . . . . . . . . . . 102
7.3 Lateral Compartment . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
7.3.1 Iliotibial Tract . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
7.3.2 Lateral Collateral Ligament . . . . . . . . . . . . . . . . . 105
7.4 Posterior Compartment . . . . . . . . . . . . . . . . . . . . . . . . . 108
Contents ix
7.4.1 Medial Tendons . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
7.4.2 Semimembranosus Bursa . . . . . . . . . . . . . . . . . . . 108
7.4.3 Popliteal Neurovascular Bundle . . . . . . . . . . . . . . 110
7.4.4 Posterolateral Corner and Biceps Femoris Tendon 111
7.4.5 Peroneal Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
0
08 Ankle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
8.1 Lateral Compartment . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
8.1.1 Anterior Talo-Fibular Ligament . . . . . . . . . . . . . . 116
8.1.2 Anterior Tibio-Fibular Ligament . . . . . . . . . . . . . 118
8.1.3 Calcaneo-Fibular Ligament . . . . . . . . . . . . . . . . . 119
8.1.4 Peroneal Tendons . . . . . . . . . . . . . . . . . . . . . . . . . 119
8.2 Medial Compartment . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
8.2.1 Deltoid Ligament . . . . . . . . . . . . . . . . . . . . . . . . . 122
8.2.2 Tarsal Tunnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
8.3 Posterior Compartment . . . . . . . . . . . . . . . . . . . . . . . . . 127
8.3.1 Achilles Tendon . . . . . . . . . . . . . . . . . . . . . . . . . . 127
8.3.2 Posterior Tibio-Talar Recess . . . . . . . . . . . . . . . . . 129
8.4 Anterior Compartment . . . . . . . . . . . . . . . . . . . . . . . . . . 130
8.4.1 Anterior Tendons and Deep Peroneal Nerve . . . . 130
8.4.2 Anterior Tibio-Talar Recess . . . . . . . . . . . . . . . . . 132
09 Foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
9.1 Hindfoot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
9.1.1 Plantar Aponeurosis . . . . . . . . . . . . . . . . . . . . . . . 133
9.2 Forefoot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
9.2.1 Plantar Side . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
9.2.2 Dorsal Side . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Recommended Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
1
Basic Principles of Musculosketal
Ultrasound
Contents
1.1 Tendons
1.2 Ligaments
1.3 Peripheral Nerves
1.4 Cartilage and Bone
1.5 Muscles
1.1 Tendons that envelops the whole tendon (Fig. 1.1).
From a functional and anatomical point of
Tendons are critical biomechanical units in view, tendons can be divided into two types:
the musculoskeletal system, the function of supporting(or anchor) and sliding tendons.
which is to transmit muscular strength to Anchor tendons (such as the Achilles and the
mobile skeletal segments. Tendons are patellar tendon) are typically bigger and
extremely resistant to traction, almost like stronger than sliding tendons, they are not
bone, being able to bear up to 1000 kg per 10 provided with a synovial sheath, but they are
mm2 transverse section. Conversely, tendons surrounded by a connective lamina external
are not very elastic, being only able to toler- to the epitenon, called the peritenon. Sliding
ate a maximum elongation of 6% before tendons are wrapped in a covering sheath
being damaged. Tendons have very slow (teno-synovial sheath) whose function is to
metabolism, even during action, and it can guarantee better sliding and protection to the
only be significantly increased by inflamma- tendons when they run adjacent to irregular
tory conditions and traumas. Tendons macro- osseous surfaces, sites of potential friction.
scopically appear as ribbon-like structures, The sites of union between tendon and mus-
with extremely variable shape and dimen- cle or tendon and bone are named myotendi-
sions, characterized by the presence of dense nous or osteotendinous junctions, respec-
fibrous tissue arranged in parallel bundles. tively. This latter is also called enthesis. The
Primary bundles are assembled to form sec- myotendinous junction is usually well-
ondary bundles (representing the tendon’s defined: at this level the tendon fibers are
functional unit), which are in turn clustered in interspersed with the endomysial fibers.
tertiary bundles. The endotenonis a thin con- Conversely, the enthesis has a more compli-
nective strip surrounding the primary, sec- cated structure, as it can be either fibrous or
ondary and tertiary bundles, and also sepa- fibrocartilaginous according to the tendon
rates them. Small vessels and nerves run mobility, the angle formed between the ten-
within the endotenon thickness. The epitenon don fibers and the bone, and the presence of
is a thin band of stronger connective tissue an underlying retinaculum.
E. Silvestri, A. Muda, L. M. Sconfienza, Normal Ultrasound Anatomy of the Musculoskeletal System, 1
© Springer-Verlag Italia 2012
2 1 Basic Principles of Musculosketal Ultrasound
Fig. 1.1Anatomical drawing of a tendon. I, primary
bundle; II, secondary bundle; III, tertiary bundle; E,
epitenon; e, endotenon
Fig. 1.2The fibrillar echotexture of a nor mal
tendon is created by the interfaces between
collagen fibers and endotenon septa (long axis
scan). Arrowheads, tendon
Ultrasonography (US) represents the gold
er when the tendon is tense. This fibrillar
standard technique for tendon assessment.
echotexture is caused by the specular reflec-
With the advent of high resolution transducers
tions within the tendon, determined by the
and specific image processing software, eval-
existing acoustic interface between the
uation of the inner structure of tendons was
endotenon septa. The tendon is surrounded by
made easier. Also, US is the only imaging
hyperechoic bands that correspond to the
modality that allows for a dynamic evaluation
paratenon (Fig. 1.2).
of tendons and joints. When imaged on a lon-
In a transverse view (short axis), the ten-
gitudinal view (long axis), the tendon appears
dons appear as round- or oval-shaped struc-
as a hyperechoic ribbon-like structure. The
tures, characterized by several homogeneously-
tendon has an inner fibrillar echotexture that
scattered spotty echoes (Fig. 1.3).
can be appreciated as a succession of thin
Transverse scans are optimal to measure
hyperechoic fibrillar bands, slight ly wavy,
tendon thickness, as it can be overestimated
which tend to grow apart from one anothe r
when measured on longitudinal scans.
when the tendon is released and to move clos -
In clinical practice, ultrasound evaluation