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2.2 Ultrasound Imaging of Joints (Arthrosonography)
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
x
Anterior transverse scan:
ab
b normal findings. The greater tuberosity is on the left side of the image (2),
x
Posterior longitudinal scan:
2
The Ultrasound Examination
ab
b normal findings. 1 = Supraspinatus muscle, 2 = infraspinatus muscle, 3 = teres
37
2.2 Ultrasound Imaging of Joints (Arthrosonography)
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
2
x
Posterior transverse scan:
The Ultrasound Examination
ab
Fig. 50a, b Sonography of the shoulder: posterior transverse scan. a Scan plane,
b normal findings. The humerus appears on the right side of the image. To the left
of it is the scapular border, and above that is the infraspinatus. The deltoid muscle
is visible above the humerus
x
Lateral longitudinal scan:
ab
Fig. 51a, b Lateral longitudinal scan of the rotator cuff. a Scan plane, b normal
findings. The image in this place resembles a bird’s head and beak. The acromion is
on the left, the humerus is at lower right. Between them is the supraspinatus
muscle, and above that is the deltoid
38
x
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
Lateral transverse scan:
2.2 Ultrasound Imaging of Joints (Arthrosonography)
2
ab
Fig. 52a, b Lateral transverse scan of the rotator cuff. a Scan plane, b normal
findings. The image in this plane resembles a tire on a wheel. The humerus appears
at the bottom of the image, with the rotator cuff above it. Above the rotator cuff
are the deltoid muscle and subcutaneous tissue
x
Axillary longitudinal scan (Fig. 53): Can detect small effusions.
!
Caution: Do not press too hard with the transducer, as this could mask small
effusion volumes.
ab
Fig. 53a, b Axillary longitudinal scan. a demonstrates the axillary recess of
the joint capsule, which is concave and parallel to the neck of the humerus.
b Major vascular structures (axillary artery) appear hypoechoic on CDS
The Ultrasound Examination
39
2.2 Ultrasound Imaging of Joints (Arthrosonography)
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
2
Sonography of the Elbow
..............................................................................................................
n
The patient is examined in a standing position.
n
Scan planes: Posterior scans with the elbow flexed, anterior scans with the elbow
extended.
x
Anterior humeroradial scan:
The Ultrasound Examination
ab
Fig. 54a, b Sonography of the elbow: anterior humeroradial longitudinal scan.
a Scan plane, b normal findings. 1 = Capitellum of the humerus, 2 = head of the
radius
x
Anterior humeroulnar scan:
ab
Fig. 55a, b Sonography of the elbow: anterior humeroulnar longitudinal scan.
a Scan plane, b normal findings. 1 = Coronoid fossa, 2 = humeral trochlea,
3 = coronoid process of the ulna, with the brachialis muscle above
40
2.2 Ultrasound Imaging of Joints (Arthrosonography)
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
x
Posterior longitudinal scan:
ab
Fig. 56a, b Sonography of the elbow: posterior longitudinal scan. a Scan plane,
b normal findings. 1 = Olecranon fossa, 2 = humeral trochlea, 3 = olecranon,
with the triceps muscle above
Sonography of the Carpal Joints, Fingers, and Toes
..............................................................................................................
n
The small joints in particular are easily accessible to ultrasound examination.
n
Scan planes : Posterior and anterior transverse and longitudinal scans.
Sonography of the Hip
..............................................................................................................
n
5–7.5 MHz transducer.
n
The patient is examined in the supine or lateral position.
n
Scan planes :
x
Anterior scan along the neck of the femur (Fig. 57); 90h transverse scan in the
neutral (0h) joint position; may also obtain dynamic scans with the hip joint in
slight flexion (10–20h) and rotation.
2
The Ultrasound Examination
a
Fig. 57a, b Sonography of the hip:
anterior longitudinal scan. a Scan plane,
b normal findings. 1 = Head of femur,
2 = joint capsule, 3 = iliopsoas muscle
b
41
2.2 Ultrasound Imaging of Joints (Arthrosonography)
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
2
x
Posterior scan along the neck of the femur; 90h transverse scan with the hip
joint in 90h flexion (Fig.
a
The Ultrasound Examination
58).
Fig. 58a, b Sonography of the hip:
lateral longitudinal scan over the
greater trochanter.
a Scan plane, b normal findings.
Above the greater trochanter are the
insertions of the gluteal muscles, and
above that are layers of subcutaneous
connective tissue and fat
x
Lateral longitudinal scan over the greater trochanter (to check for trochanteric
b
bursitis).
Sonography of the Knee
..............................................................................................................
n
The patient is examined in the supine position. The prone position is used for
scanning the popliteal fossa.
n
Flexion of the knee makes more areas of the joint accessible to scanning.
n
Scan planes :
x
Anterior longitudinal and transverse scans for evaluating the supra-, para- and
infrapatellar recesses (Figs.
x
Posterior longitudinal and transverse scans for evaluating the popliteal recess
or a popliteal cyst (Baker cyst) and blood vessels (Fig.
x
Supplementary medial and lateral longitudinal scans.
59 and 60).
61).
42
2.2 Ultrasound Imaging of Joints (Arthrosonography)
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
a
Fig. 59a, b Sonography of the knee:
suprapatellar longitudinal scan.
a Scan plane. b Normal sonographic
appearance of the patella, femoral shaft,
and quadriceps tendon
a
Fig. 60a, b Sonography of the knee:
suprapatellar transverse scan with the
knee in flexion. a Scan plane, b normal
findings. Concavity = hyaline cartilage.
The medial condyle is on the left, the lateral condyle on the right. Above that is the
quadriceps tendon, imaged in cross-section
b
b
2
The Ultrasound Examination
a
Fig. 61a, b Sonography of the knee:
posterior (medial) longitudinal scan of
the right knee. a Scan plane, b normal
findings. 1 = Medial femoral condyle,
2 = joint space, 3 = tibia
b
43
2.2 Ultrasound Imaging of Joints (Arthrosonography)
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
2
Sonography of the Malleolar Region
..............................................................................................................
n
The patient is examined in the supine position. The prone position is used for posterior scanning. The ankle joint should be unconstrained, to allow passive movement.
n
Ankle joint:
x
Anterior and posterior longitudinal and transverse scans (Fig. 62).
The Ultrasound Examination
ab
Fig. 62a, b Sonography of the ankle joint: anterior longitudinal scan. a Scan plane,
b normal findings. 1 = Extensor digitorum longus, 2 = ankle joint space
x
Medial and lateral longitudinal scans.
x
Dynamic examination: Flexion and extension of the talocrural joint.
n
Achilles tendo n : Longitudinal scan over the Achilles tendon (Fig. 63).
ab
Fig. 63a, b Sonography of the Achilles tendon. a Scan plane, b normal findings.
1 = Achilles tendon, 2 = connective tissue or Karger’s triangle, 3 = calcaneus
44
2.2 Ultrasound Imaging of Joints (Arthrosonography)
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
Normal and Abnormal Distance Values in Arthrosonography
..............................................................................................................
Table 7.Normal and abnormal distance values in arthrosonography
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Joint Scan plane Measurement Mean value
yyyyyyyyyyyyyyyyyyy
Shoulder
Rotator cuff
(supraspinatus
yyyyyyyyyyyyyyyyyyyyyyyyyyyy
Axillary recess,
longitudinal
Lateral transverse,
60h internal rotation
yyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Distance from bone
to joint capsule
Sagittal diameter 4.6 I 3.0
(mm)
yyyyyyyyyyyyyyyy
2.2
Abnormal
(mm)
yyyyyyyyyyyyyyy
i 3.5
muscle)
Elbow Anterior longitudinal Distance from bone
1.8 i 3.0
to joint capsule
Wrist Posterior (dorsal)
longitudinal
Metacarpo-
Volar longitudinal Distance from bone
phalangeal joint
Hip Anterior longitudinal Distance from bone
Distance from bone
to joint capsule
to joint capsule
1.5 i 3.0
0.9 i 2.0
5.2 i 8.0
to joint capsule
Knee Anterior longitudinal
midline
Ankle joint Anterior longitudinal Distance from bone
Maximum clearance in
suprapatellar pouch
2.4 i 5.0
1.7 i 3.0
to joint capsule
Achilles tendon Posterior longitudinal Sagittal diameter 2 cm
4.3 i 6.0
proximal to calcaneus
Metatarsophalangeal joint
Anterior longitudinal Distance from bone
to joint capsule
1.6 i 3.0
Note: The numerical data are intended as reference values and may vary as a function of various parameters. Besides noting the absolute value, the examiner should directly compare
the findings with the opposite side in order to make an accurate interpretation. A difference
between the sides i 1 mm is suggestive of capsular thickening, and a difference i 2mmisa
definite sign of capsular thickening (e.g., due to effusion or synovial proliferation).
2
The Ultrasound Examination
45
3.2 Guideline-Oriented Documentation
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
3
3 Documentation and Reporting
n
The written ultrasound report should be concise and should cover all relevant
findings (normal and abnormal).
n
The report may be freely dictated, or the findings may be entered on standard
preprinted forms.
n
Computer-based systems are increasingly used in ultrasound reporting as they are
faster, more precise, and more objective than traditional methods. Computer
records also make it easier to compare sonographic findings, and provide an efficient database for quality control.
n
Written reports should always be supplemented by image documentation and
archiving.
Documentation and Reporting
3.1 Requirements for Documentation
n
Written documentation:
x
Patient identification
x
Place and date of the examination
x
Clinical problem that prompted the examination; presumptive diagnosis
x
Description of the sonographic findings
x
Final sonographic diagnosis and its relevance to the clinical problem
x
Signature of the examining physician
n
Image documentation:
x
Patient identification
x
Place and date of the examination
x
Documentation of the scan direction (pictogram)
x
Acceptable image quality
x
Abnormal findings documented in two planes
3.2 Guideline-Oriented Documentation
n
Documentation should follow guidelines such as those of the German Society for
Ultrasound in Medicine.
n
The image documentation for each organ should include as many scans as needed
to display essential organ structures and should include information on significant
environmental factors.
n
The documentation should include representative images for the following
regions:
x
Pancreas: 3 scans (head of pancreas with uncinate process, body of pancreas
with pancreatic duct, tail of pancreas)
x
Liver: 4 scans (termination of hepatic veins, portal vein, right and left hepatic
lobes)
x
Gallbladder and bile ducts : 3 scans (gallbladder longitudinal and transverse, bile
duct longitudinal)
x
Spleen: 1 scan
x
Kidneys: 2 scans each (longitudinal and transverse)
x
Retroperitoneum: 4 scans (aorta, may include major branches; vena cava, may
include tributaries; iliac vessels on both sides)
x
Thyroid gland: 4 scans (both lobes longitudinal and transverse)
46