Ultrasonography of Muscles and Tendons: Examination Technique and Atlas of Normal Anatomy of the Extremities

233 Pages·1989·10.31 MB·English

by  Bruno D. Fornage M.D. (auth.)

Ultrasonography of
Muscles and Tendons
Bruno D. Fomage
Ultrasonography of
Muscles and Tendons
Examination Technique and
Atlas of Normal Anatomy
of the Extremities
With 612 Illustrations
Springer-Verlag
New York Berlin Heidelberg
London Paris Tokyo
Bruno D. Fornage, M.D.
Associate Professor of Radiology
Division of Diagnostic Radiology
Chief, Section of Ultrasound
The University of Texas
M.D. Anderson Cancer Center
Houston, Texas, USA
Associate Professor of Radiology
Institut Jean-Godinot, Reims, France
Translation of Echographie du systeme musculo-tendineux des membreslAtlas d'anatomie ultrasonore normale,
Vigot, Paris, 1987.
Translation by the author.
Library of Congress Cataloging-in-Publication Data
Fornage, Bruno.
Ultrasonography of muscles and tendons.
Translation of: Echographie du systeme musculo
tendineux des membres.
Includes bibliographies and index.
1. Muscles-Imaging. 2. Tendons-Imaging.
3. Ultrasonic imaging. 4. Muscles-Atlases.
5. Tendons-Atlases. I. Title. [DNLM: 1. Muscles
anatomy & histology-atlases. 2. Tendons-anatomy &
histology-atlases. 3. Ultrasonic Diagnosis-methods
atlases. WE 17 F727e]
QM151.F6713 1988 611'.73 88-4657
Printed on acid-free paper
© 1989 by Springer-Verlag New York Inc.
Softcover reprint of tbe hardcover 1s t edition 1989
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ISBN-13: 978-1-4612-8119-1 e-ISBN-13: 978-1-4612-3482-1
DOl: 10.1007/978-1-4612-3482-1
Introduction
Muscles, tendons, and the other soft tissues of the extremities have historically been
neglected by radiology, in the main because of the lack of an effective imaging technique.
Yet it is surprising that until recently sonography has not received much attention in this
application, since, even with conventional equipment, it readily evaluates superficial tis
sues. In this setting, there is no obstacle from gas or bone to the propagation of sound. Fur
ther, sonography permits both depiction in any orientation and real-time dynamic study.
I was induced to undertake ultrasound examinations of muscles and tendons by physi
cians specializing in sports medicine. Before this specialty emerged, physicians had
limited interest in the traumatic and inflammatory disorders of muscles and tendons, given
the questionable severity of the lesions, the paucity of late sequelae impairing normal
activity, and the absence of life-threatening complications. Now, however, athletics is a
major social activity and sonography is used more and more frequently.
In the domain of muscular sonography, a dual expertise is required. First, precise
knowledge of the regional anatomy is a prerequisite to any ultrasound examination.
Second, the sonologist must be familiar with the clinical evaluation of patients with
muscle trauma, in whom physical examination is often equivocal.
In this book, the technical fundamentals of the sonographic examination of muscles and
tendons and the normal ultrasound anatomy of the extremities are presented.
Note to the Reader
In this atlas, sonograms are oriented according to the international standards for imaging
techniques. All scans have been performed on right extremities. With few exceptions,
which are noted, transverse sonograms are "seen from below;' whereas longitudinally
oriented scans, whether sagittal or coronal, are shown with the proximal part of the
extremity on the left and the distal part on the right.
Acknowledgments. The author is indebted to Veronique Dupuis who prepared the
manuscript, and Suzanne Simpson of the Department of Scientific Publications, The
University of Texas M.D. Anderson Cancer Center, for her valuable editorial assistance.
Contents
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Note to the Reader. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VI
Part I. Technique of Sonographic Examination and General Considerations
on Ultrasound Normal Anatomy
Anatomic Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Skeletal Muscles .......................................... . . . . . . . . 3
Tendons. . . .. . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . .. . .. . . . . . . . . . . .. . . . . . 3
Synovial Bursae. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Joints ........................................................... 5
Fatty Tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
2 Technique for Sonography of Muscles and Tendons
of the Extremities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Type of Sonographic Equipment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Probe Frequency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Standoff Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Orthogonal Views . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Examination of the Contralateral Segment ............................. 11
Real-Time Dynamic Study .......................................... 11
Palpation Under Sonoscopy ......................................... 11
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
3 Normal Ultrasound Anatomy of Muscles .............................. 13
Longitudinal Sonograms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Transverse Sonograms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Dynamic Examination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
4 Normal Ultrasound Anatomy of Tendons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Longitudinal Sonograms ........................................... 20
Transverse Sonograms ...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Dynamic Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
5 Artifacts and Pitfalls in Sonography of Muscles and Tendons. . . . . . . . . . . . . . 26
Muscles. .. . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Tendons. . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Internal Fixation Devices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
6 Sonographic Patterns of the Other Anatomic Components of the Extremities. 40
Bones........................................................... 40
Joints. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Surrounding Soft Tissues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
7 Other Imaging Techniques for Muscles and Tendons. . . . . . . . . . . . . . . . . . . . . 45
Plain Radiography ................................................ 45
Low-Kilovoltage Radiography ....................................... 45
Xeroradiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Computed Tomography ............................................ 46
Magnetic Resonance Imaging ....................................... 46
Angiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Tenography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Radionuclide Imaging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Thermography ................................................... 49
Prospects in Ultrasonography ....................................... 49
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Part II. Atlas of Ultrasound Scans of the Extremities
List of Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
A Upper Extremity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Shoulder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Arm, Upper Third. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Arm, Midthird ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Arm, Lower Third . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Elbow. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Forearm, Upper Third. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Forearm, Midthird . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Forearm, Lower Third. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 101
Wrist. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 104
Hand. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 118
VlIl Contents
B Lower Extremity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 131
Thigh, Upper Third ............................................... 133
Thigh, Midthird .................................................. 143
Thigh, Lower Third. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 154
Knee, Patellar Tendon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 163
Knee, Popliteal Fossa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 171
Knee, Other Scans ................................................ 178
Leg, Upper Third. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 180
Leg, Midthird . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 189
Leg, Lower Third . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 196
Leg, Achilles Tendon .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 201
Foot. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 211
Index. . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . .. 229
Contents IX
Part I
Technique of Sonographic Examination
and General Considerations
on Ultrasound Normal Anatomy
1
Anatomic Considerations
Skeletal Muscles triphosphate (ATP). Accordingly, the muscle fiber
is rich in mitochondria, which lie in contact with
Skeletal muscles consist of juxtaposed bundles of the outer membrane (the sarcolemma), and glyco
parallel muscle fibers with ensheathing connective lytic and respiratory enzymes. It also contains
tissue. Each fiber is several centimeters in length large amounts of glycogen, ATP and phosphocrea
with a diameter of 10 to 100 ~m. The fibers are tine, and myoglobin.
arranged in fascicles separated by septa of con The over 650 muscles account for 45% of the
nective tissue, the perimysia, that extend inward total weight of the body. There is significant
from an external sheath of dense connective tissue, individual variation in the shape and size of mus
called the epimysium, that surrounds the whole cles. Athletic or occupational activities may result
muscle. This perimuscular aponeurosis, or fascia, in muscular hypertrophy. Conversely, disuse may
separates the various muscles (Fig. 1.1). In the fas be associated with a relative hypotrophy, whereas
cicles, muscle fibers are separated by the endo total immobilization may lead to atrophy. Such var
mysium. The general orientation of muscle fibers iations in muscle size develop fairly quickly and
in relation to the overall axis of the muscle depends are reversible. Supernumerary (or accessory) mus
on the degree of muscular contraction. The striated cles have been described, particularly in the hand
muscle contains a significant amount of water and (extensor digitorum brevis) and the lower calf
connective tissue. (accessorius ad quadratum plantae) [2], and other
A rich vasculature enables dramatic variations muscles may be absent (plantaris).
in blood flow. The blood vessels and the nerve
form a neurovascular bundle to enter the muscle.
Blood vessels run longitudinally in the perimysium
Tendons
between fascicles. During intense contraction,
blood vessels may be squeezed so that the muscle
has to function anaerobically. Tendons are elongated structures made of dense,
The nerve fibers of motor neurons enter the mus regular connective tissue whose role is to attach
cle at the motor end plate. Each axon innervates the striated muscle to bone. They cannot be
several muscle fibers. The motor unit comprises stretched and are extremely resistant to traction
one motor neuron and all the innervated muscle forces (up to 400 kg for the Achilles tendon).
fibers. McMaster [1] has shown that one half of the
Histologically, the muscle fiber is a highly fibers of the tendon of the gastrocnemius muscle
differentiated syncytial cell that contains longitu in the rabbit must be injured before the tendon
dinally oriented contractile filaments of actin and ruptures under violent tension, while the preser
myosin. The contractile filaments are responsible vation of as little as one fourth of the fibers can
for muscle contraction; they slide past one another prevent rupture during a muscular contraction of
when energy is provided in the form of adenosine normal intensity.