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2.1 Abdominal Sonography
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
n
Left midabdominal transverse scan:
Fig. 33 While still over the kidney, the probe is rotated to a transverse position
and is angled, rotated, and slid to a midabdominal transverse scan that displays the
renal hilum with its vascular pedicle and may define the proximal ureter. The probe
is then moved slowly down the kidney (K) from its upper to lower pole to survey
the organ in transverse sections. Vr = renal vein
n
Left subcostal oblique scan:
2
The Ultrasound Examination
Fig. 34 From the midabdominal transverse scan, the probe is slid to a position
below the left costal arch to obtain a left subcostal oblique scan. The liver (L) is
visible on the left side of the image. The spleen (S) appears posterolaterally on the
right side of the image, displaying its true width and a foreshortened longitudinal
diameter
27
2.1 Abdominal Sonography
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
2
n
Diagram of the major abdominal vessels:
The Ultrasound Examination
Fig. 35 Diagram of the arterial vessels arising from the aorta and the tributaries of
the vena cava. These vessels can be distinguished sonographically and can provide
useful landmarks for intra-abdominal scanning
28
n
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
Upper abdominal longitudinal scan:
Fig. 36 The following
structures can be identified from anterior to posterior: liver (L), pancreas
(P), superior mesenteric
vein (Vms), celiac trunk
(Tc), and superior mesenteric artery (Ams), the
latter two arising from the
aorta (AO). The spinal
column (Sc) is visible
posteriorly
n
Diagram of the female genital organs:
2.1 Abdominal Sonography
2
The Ultrasound Examination
Fig. 37 Relationships of the lower abdominal organs in the female. This diagram
aids in understanding how the ultrasound probe should be directed during the
examination. The uterus lies posterior and superior to the bladder. The following
structures appear in sagittal section from anterior to posterior: pubic symphysis
(sound does not penetrate bone, so the probe must be placed above the symphysis), bladder, uterus, and rectum. The probe can be angled downward to
demonstrate the vagina
29
2.1 Abdominal Sonography
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
2
n
Diagram of the male genital organs:
The Ultrasound Examination
Fig. 38 The male pelvis has a similar structure. It is important to note that the
prostate is inferior to the bladder, and the seminal vesicles are posteroinferior
n
Lower abdominal transverse scan:
Fig. 39 The following structures are defined from anterior to posterior: abdominal
wall, bladder (B), and uterus (U), which is flanked by the fallopian tubes (T)
30
2.2 Ultrasound Imaging of Joints (Arthrosonography)
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
n
Lower abdominal longitudinal scan:
2
Fig. 40 From anterior to
posterior: abdominal wall,
bladder (B), and uterus
(U), which is bounded by
the fundus above and the
vagina (V) below
Examination of Specific Organs: See Blue Part
..............................................................................................................
Arteries and veins, p. 188; cervical vessels, p. 214; liver, p. 231; kidney, p. 262; adrenal glands, p. 292; pancreas, p. 293; spleen, p. 312; bile ducts, p. 322; gallbladder,
p. 334; gastrointestinal tract, p. 352; urogenital organs, p. 375; pleura and lung,
p. 400; thyroid gland, p. 412; salivary glands, p. 425.
2.2 Ultrasound Imaging of Joints (Arthrosonography)
Basic Principles
..............................................................................................................
n
Clinical importance: In recent years, ultrasonography of the musculoskeletal sys-
tem has developed into a recognized and clinically important imaging modality.
For investigations in rheumatology, ultrasound imaging is the next step in the
diagnostic algorithm following the history and physical examination. The intraand periarticular soft-tissue changes that are typical of inflammatory joint diseases can be detected much earlier by sonography than by physical examination
or radiography. Sonography can make an important contribution to diagnosis
(e.g., detecting clinically asymptomatic synovitis) as well as management (e.g.,
the prompt initiation of basic treatment for early destructive joint changes).
n
Capabilities of arthrosonography:
x
Detection of exudative or proliferative articular syn ovitis
x
Detection of exudative or proliferative tenosynovitis
x
Detection of synovial cysts
x
Early detection of erosive defects in bone and joint margins
x
Detection of degenerative articular and soft-tissue changes such as marginal
osteophytes, bursitis, periarticular ossification, and tendon lesions
n
Limitations of arthrosonography:
x
Limited ability to image superficial joint structures, depending on individual
anatomy
The Ultrasound Examination
31
2.2 Ultrasound Imaging of Joints (Arthrosonography)
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
2
x
Poor visualization of deeper joint structures, with an inability to evaluate intraarticular or subchondral lesions
x
Limited ability to discriminate synovitis (“inflammatory substrates”) in the
B-mode image
n
Normal findings (Table 5):
Table 5.Normal sonographic findings
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Structure Sonographic appearance
yyyyyyyyyyyyyyyyyyyyyyyy
Synovial membrane
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Echogenic, normally difficult to delineate from connective tissue
Cartilage Anechoic, parallel to bone surface
Bone Very echogenic with an associated acoustic shadow
The Ultrasound Examination
Tendons Echogenic when scanned at a perpendicular angle, but may appear
hypoechoic (Fig. 41) when scanned at certain angles (acoustic anisotropism; compare with muscle)
Muscle Hypoechoic; typical pennate pattern in longitudinal section; mottled
echo pattern in transverse section
ab
Fig. 41a, b Anterior transverse scan of the shoulder. a When the long biceps
tendon is perpendicular to the beam, it appears as a bright round echo (p).
b When the long biceps tendon is scanned at a different angle, the sound waves
are not reflected and the tendon groove (p) appears empty.
!
Caution: Do not interpret this as a tendon rupture
32
2.2 Ultrasound Imaging of Joints (Arthrosonography)
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
n
Typical abnormal findings (Table 6):
Table 6.Typical abnormal findings
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Structure Sonographic appearance
yyyyyyyyyyyyyyyyyyyyyy
Joint effusion
“True” bone
erosion
yyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Anechoic or hypoechoic (Fig. 42)
Constant surface discontinuity with echoes from the base of the erosion
(Fig. 43)
Pseudoerosion Apparent defect caused by beam obliquity relative to the bone surface;
no base echoes
Pannus Erosive changes in articular surfaces with infiltration of tendons (Fig. 44)
Synovitis
(“inflammatory
substrate”)
B-mode image: hypoechoic thickening of the joint capsule (the proliferative and exudative components cannot be positively distinguished in
most cases)
Color or power Doppler: increased vascularity (Fig. 45)
Tenosynovitis Anechoic or hypoechoic margin surrounding an echogenic tendon
(Fig. 46)
Pannus = inflammatory exudate that can destroy articular cartilage and bone as well as
tendons.
Synovitis (“inflammatory substrate”) = synovial proliferation (proliferative component),
usually associated with intra-articular effusion (exudative component) p joint swelling.
2
The Ultrasound Examination
ab
Fig. 42a, b Anechoic effusion in exudative coxitis. Ultrasound demonstrates
convex widening of the joint capsule. a Longitudinal scan, b transverse scan
33
2.2 Ultrasound Imaging of Joints (Arthrosonography)
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
2
Fig. 43 Echogenic base of an erosion: circumscribed erosive defect at the base of
the first proximal phalanx (arrow) in erosive psoriatic arthritis
The Ultrasound Examination
ab
cd
Fig. 44a–d Pannus. a, b Hypoechoic infiltration of the tendon by pannus tissue
(arrows) due to pannous flexor tenosynovitis in a patient with chronic rheumatoid
arthritis. a Survey image, b zoom image. c, d Fifth MTP joint with pannus in the
right foot (c); compare with the same joint without pannus in the left foot (d)
34
2.2 Ultrasound Imaging of Joints (Arthrosonography)
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
2
ab
Fig. 45a–c Synovitis in an arthritic knee.
a Transverse B-mode image.
b CDS demonstrates areas of boggy
synovial thickening with increased
vascularity.
c Doppler spectrum shows a typical
increase in diastolic flow
ab
Fig. 46a, b Tendovaginitis appears as a hypoechoic rim around the tendon of
the extensor carpi ulnaris. a Transverse scan, b longitudinal scan over the distal
ulna
c
The Ultrasound Examination
35
2.2 Ultrasound Imaging of Joints (Arthrosonography)
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
2
General Scanning Guidelines
..............................................................................................................
n
Transducers:
x
High-frequency linear transducer (7.5–15 MHz) : Used for examining superficial
structures (e.g., tendons and ligaments) and small joints in the hands or feet.
x
Low-frequency linear transducer (5 MHz): Used for scanning deeper joints (e.g.,
the hip and shoulder joints).
x
Convex 3.5 MHz transducer: Necessary only in rare cases, as in very obese
patients.
n
Scanning tips :
x
Use standard anatomical landmarks for orientation.
x
Locate the static transverse and longitudinal scan planes.
x
Use the RES function on the machine to zoom selected regions of interest while
The Ultrasound Examination
maintaining high resolution.
x
For dynamic scanning, move the transducer continuously during active or passive motion of the scanned structures. Joint motion is often necessary in order
to detect subtle abnormalities (e.g., mild degrees of exudation).
x
Always compare the findings with the contralateral joint.
Sonography of the Shoulder
..............................................................................................................
n
The patient is examined in a sitting position with the arm hanging at the side, the
elbow flexed 90h, and the forearm supinated. Dynamic scans are obtained with
internal/external rotation and abduction of the shoulder joint.
n
Scan planes :
x
Anterior longitudinal scan:
ab
b normal findings. The humerus appears below the long biceps tendon, and above
36