MusculoSkeletal
UltraSonography
J. Antonio Bouffard, MD
Henry Ford Hospital
Detroit, Michigan
Evaluation of the Patient
Clinical
Evaluation
X-Ray
Ultrasound
MRI
CT
Arthrogram
MSk Ultrasound: Target Regions
• Shoulder
• Elbow
• Hand & Wrist
• Hip
• Knee
• Foot & Ankle
• Spine
MSk Ultrasound: Target Regions
• Shoulder
• Arm
• Elbow
• Forearm
• Hand & Wrist
• Fingers
• Hip
• Thigh
• Knee
• Leg
• Foot & Ankle
• Toes
• Spine
• Sacroiliac Joint
MSk Ultrasound: Indications
• Tendons
• Ligaments
• Muscles
• Bursae
• Nerves
MSk Ultrasound: Indications
• Tendons
• Joints
• Ligaments
• Synovia
• Muscles
• Cartilage
• Bursae
• Cortex
• Nerves
• Vessels
• Intervention
Linear Array Transducer
• 7.5 MHz (13 – 8MHz)
• High frequency
• High resolution
• Average penetration
Curved Linear Array Transducer
• 3.5 MHz (8 – 3 MHz)
• Lower frequency
• Lower resolution
• Better penetration
(depth)
Linear Probe
Curve Probe
Compact Linear Transducer
•Very High Frequency
•Very High Resolution
•Very Superficial
Compact Linear Transducer
Long Axis: flexor tendon
MSk Ultrasound: Protocols
MSk Ultrasound: Protocols
Orthogonal Planes
Long Axis
Short Axis
Non-Orthogonal Planes
Long Axis Rt FPL
MSk Imaging: Foreign Bodies
MSk Imaging: Foreign Bodies
FPL
MSk Ultrasound: Techniques
• Spatial Resolution
• Focused Field of View
• Dynamic Maneuvers
– Compression
– Range of motion
– Translation
• Right – Left Comparisons
• Doppler
Spatial Resolution
Focused Field of View
Achilles Tendon: LNX
Soleus
Calcaneus
Kager
FHL
Focused Field of View
Achilles Tendon: SAX
Paratenon
Plantaris
Med
Med
Lat
Lat
Achilles Tendinosis
Long Axis
Hypoechoic Fusiform Enlargement
Widened Interfibrillar Distances
Achilles Tendinosis
Long Axis
Doppler Positive
Short Axis
Achilles Paratendinosis
Long Axis
Adherent Tendon Sheath
Asymp Contralateral
Short Axis
Achilles Tear: Small
Sag T2W
Ax PD
Achilles Tear: Small
Sag T2W
Calc
Calc
Post Malleolus
Achilles Tear: Small
Long
Short
Axis
Calc
Post Malleolus
Axis
Achilles Tear: Discontinuous
MSk Ultrasound: Techniques
• Spatial Resolution
• Focused Field of View
• Dynamic Maneuvers
– Compression
– Range of motion
– Translation
• Right – Left Comparisons
• Doppler
SUBSCAP
NEUTRAL
POSITION
ERNAL
ROTATION
Subscapularis: Dynamic Maneuver
Intact Inferior Subscapularis
Torn Superior Subscapularis
Comparison
Note: asymmetry R>L
Preop – Dynamic Images
MRI Correlation: Axial
Note: Biceps
Normal - Inferior
Abnormal - Superior
MRI Correlation: Coronal
Acromion
Coracoid
Subscap,
edema
Intraop – Bony Avulsion
11 months later, “hit the
boards” again and c/o pain
Looks good, but what is this?
Comparison
Postop – Dynamic Images
Ulnar Collateral Lig.: MRI
The ‘T’ Sign:
on MRI
The ‘T’ Sign:
on MRI
Scanning the Anterior
Band
Scanning the Anterior Band
Torn Ulnar Collat. Lig.
Left – Right Comparison
Complete Tear: Anterior
Band
Valgus Stress
Ulnar Collateral Dynamics
MSk Ultrasound: Indications
• Tendons
• Joints
• Ligaments
• Synovia
• Muscles
• Cartilage
• Bursae
• Cortex
• Nerves
• Vessels
• Intervention
Median Nerve: Long Axis
Nerve
Tendons
Radius
Lunate
Capitate
Median Nerve: Short Axis
N
Tendons
Lunate
Median Nerve: Size
MN
MN
Long Axis
Short Axis
Medial Ankle: Tendons
Tarsal Tunnel: Tibial Nerve
Tarsal Tunnel Syndrome
TN
Ganglion
FHL
Long Axis
Long Axis with Doppler
Tarsal Tunnel: Ganglion
TN
Long Axis
Short Axis
MSk Ultrasound: Indications
• Tendons
• Joints
• Ligaments
• Synovia
• Muscles
• Bursae
• Nerves
• Cartilage
• Cortex
• Vessels
• INTERVENTIONAL
Normal Hip Ultrasound
Hip Effusion
Hip Effusion
Calcific Tendinosis
Interventional MSUS
Calcific Tendinosis
MSUS in Space
Dr. Scott Dulchavsky
and Wyle Team
USA Hockey
Professional Hockey
Player
Women’s US Olympic
Hockey Player
MusculoSkeletal UltraSound
• Portability
• High-Resolution Images
• Accessibility
• Prompt Diagnosis
• Intervention
MSUS Portability
S Dulchavsky 2008
US of Fractures: Dynamic
Amponsah 2010
A.D.U.M. Cue Cards
USOC TRAINING CENTERS
•Colorado Springs
•Chula Vista
•Lake Placid
Remote guidance exams consisted of hockey groin
hernia, knee, ankle, elbow, or shoulder evaluations.
Ultrasound video streaming set up
Compact U/S system
in the stadium
Virtual video image
review… anywhere
VGA to Web
Remote guidance & diagnosis via
video streaming…
Sports arena or locker room
Remote expert support
Real-time ultrasound
imaging & communication
Athletic Trainer or Physician
Physician with MSK expertise
Bringing the latest advantage in medical imaging to
the athletes…
CONCLUSIONS
• MSk Ultrasonography
• Tendons/Ligaments
• Joints/Bone Surface
• Intervention
• Portable
• Diagnostic