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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5779_Библиотеки_им_академика_М_И_Перельмана
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Shoulder
Mohini Rawat, DPT, MS, ECS, OCS, RMSK
Contents
• Anterior Shoulder and Rotator Cuff
Long Head of the Biceps Tendon
º
Subscapularis
º
Supraspinatus
º
Infraspinatus
º
Teres Minor
º
Anterior Joint
º
Coracoid Process Attachments
º
Pectoralis Major
º
• Posterior Shoulder
Posterior Joint
º
Suprascapular Nerve at the Spinoglenoid Notch
º
• Acromioclavicular Joint
• Sternoclavicular Joint
• Ligaments
Coracohumeral Ligament
º
Coracoacromial Ligament
º
• Rotator Interval
• Rotator Cable
4
- 81 -
Atlas of Musculoskeletal Ultrasound of the E xtremities (pp 81-114).
Rawat M.
© 2021 SLACK Incorporated.
82 Chapter 4
ANTERIOR SHOULDER AND ROTATOR CUFF
Long Head of the Biceps Tendon
1. Patient position: Sitting with shoulder in neutral position with elbow flexed and resting on a
leg or pillow with no active supination or pronation of the forearm
2. Probe/transducer position: The probe is placed transversely on the anterior aspect of the shoul-
der to visualize the long head of the biceps tendon in the short axis (SX) view in the bicipital
groove. The probe is then rotated 90 degrees to visualize the tendon in the long axis (LX) view
(Figures 4-1 and 4-2).
A
Figure 4-1. SX view of the long head of
the biceps tendon . (A) Probe placement.
(B) SX view of the long head of the
biceps tendon (white arrow) between
the greater tuberosity (GT) and
lesser tuberosity (LT), with overlying
transverse humeral ligament (white
triangle). Also shown is the anterior
circumflex artery (red arrow). (C) SX of
the long head of the biceps tendon
with color Doppler to show color signal
in the anterior circumflex artery.
B
C
Shoulder 83
AB
Figure 4-2. LX view of the long head of the biceps tendon. (A) Probe placement. (B) LX view of the long head of the
biceps tendon (white arrow) overlying the hyperechoic bony interface of the humerus.
84 Chapter 4
3. Relevant anatomy: The long head of the biceps tendon originates from the supraglenoid
tubercle and superior labrum. From its origin, the tendon courses obliquely toward the bicipital groove or intertubercular groove. The tendon is stabilized by the medial sling formed by
the coracohumeral ligament and superior glenohumeral ligament. It is intra-articular and
extrasynovial. After it exits the bicipital groove, it joins the short head of the biceps tendon in
the upper arm. After joining the short head of the biceps tendon, both tendons transition into
muscle bellies, continue distally, and form the distal biceps tendon (Figure 4-3).
1,2
Figure 4 -3. Anterior shoulder anatomy showing the long head of the biceps (LHB) tendon between the intertubercular
groove, covered by the transverse humeral ligament. Distally, the long head of the biceps tendon joins the short head
of the biceps (SHB) and coracobrachialis to form the common biceps brachii muscle belly. The short head of the biceps
and coracobrachialis originate from the coracoid process (CP). The pectoralis minor (PM) attaches to the medial aspect
of the coracoid process. Also shown is the coracoacromial ligament (CAL). (Pec Major = pectoralis major.)
4. Points to remember: The long head of the biceps exhibits anisotropy in the SX and LX views,
which results in a hypoechoic appearance of the tendon. The probe should be placed parallel to
the long head of the biceps to minimize anisotropy in the LX view. In the SX view, a tilting or
fanning movement of the probe can help visualization of the tendon. The anterior circumflex
artery can be seen lateral to the long head of the biceps tendon in the intertubercular groove.
Shoulder 85
Subscapularis
1. Patient position: Sitting with the elbow flexed to 90 degrees and the shoulder in neutral, then
externally rotated
2. Probe/transducer position: The probe is first positioned over the long head of the biceps ten-
don in the SX view. The patient is then asked to externally rotate the shoulder to bring the
subscapularis into view. In neutral position, the subscapularis tendon is under the coracoid
process and therefore cannot be visualized. With external rotation, the tendon moves laterally and is accessible for sonographic visualization. For the SX view of the tendon, the probe
is rotated 90 degrees from the LX view (Figures 4-4 and 4-5).
A
Figure 4-4. LX view of the
subscapularis. (A) Probe placement. (B)
LX view of the subscapularis tendon
(white arrow) attaching to the lesser
tuberosity (LT).
A
B
B
Figure 4 -5. SX view of the subscapularis.
(A) Probe placement. (B) SX view of
the subscapularis tendon (white arrow).
Also shown is the lesser tuberosity (LT).
86 Chapter 4
3. Relevant anatomy: The subscapularis originates from the anterior surface of the scapula and
courses laterally, passing under the coracoid process to insert on the lesser tuberosity where
the tendinous portion blends with the fibers of the joint capsule.3 Subscapularis insertion on
the lesser tuberosity is divided into the tendinous insertion on the superior two-thirds and
the thin membranous muscular insertion on the inferior one-third.
4
The footprint of the subscapularis is about 4 cm in length (superior to inferior) and 1.6 cm in width (medial to lateral)
(Figures 4-6 and 4-7).
3,4
Figure 4-6. Relevant anatomy of the subscapularis tendon and approximate dimensions of the footprint, which is
about 4 cm in length (superior to inferior) and 1.6 cm in width (medial to lateral).
Shoulder 87
A
B
Figure 4-7. (A) Panoramic SX view of the subscapularis tendon. (B) Focused
view showing the wide tendon insertion comprising the hyperechoic
tendinous insertion on the superior two-thirds (between double-headed
blue arrow) and hypoechoic thin membranous muscular insertion on the
inferior one-third (between double-headed white arrow).
4. Points to remember: In the SX view of the tendon, tendinous tissue (hyperechoic) is seen inter-
digitating with muscular tissue (hypoechoic); therefore, the SX view is only used to confirm
tendon defects visualized in the LX view of the tendon.
88 Chapter 4
Supraspinatus
1. Patient position: Sitting with the shoulder in internal rotation and hyperextension, with the
elbow flexed and the dorsal aspect of hand on the lower back midline (Crass position) or the
hand on the posterior aspect of the iliac crest or in the back pocket (Middleton or modified
Crass position).
sonographic visualization (Figure 4-8).
5,6
These positions bring the supraspinatus out from beneath the acromion for
AB
Figure 4-8. Patient position for supraspinatus scanning. (A) Crass position.
(B) Middleton or modified Crass position.
2. Probe/transducer position: The probe is placed in the oblique LX along the LX of the supra-
spinatus tendon with the proximal end of the probe pointing toward the ipsilateral ear. For
SX visualization, the probe is oriented transversely across the tendon (Figures 4-9 and 4-10).
AB
Figure 4-9. LX view of the supraspinatus tendon. (A) Probe placement. (B) LX view of the supraspinatus (white arrow)
attaching to the superior facet of the greater tuberosity (GT). Just above the supraspinatus tendon, the hyperechoic
subacromial bursa (white triangle) is seen. Overlying the muscle is the deltoid above the bursa. The head of the
humerus is lined by anechoic cartilage (blue arrow).
Shoulder 89
A
Figure 4-10. SX view of the
supraspinatus tendon. (A) Probe
placement. (B) SX view of the
supraspinatus tendon (white arrow).
B
3. Relevant anatomy: The supraspinatus originates from the supraspinous fossa of the scapula
and then courses laterally, passing beneath the acromion to insert on the superior facet of
the greater tuberosity. Posterior fibers of the supraspinatus interdigitate, or blend, with the
infraspinatus tendon. The footprint of the supraspinatus is about 0.6 cm in width (medial to
lateral), 2 cm in medial length (anterior to posterior), and 0.6 cm in lateral length (anterior to
posterior; Figures 4-11 and 4-12).
7
Figure 4-11. Relevant anatomy of the rotator cuff showing the supraspinatus, infraspinatus, and teres minor tendons
attaching to the greater tuberosity. Posterior fibers of the supraspinatus blend with the infraspinatus tendon (green
triangle). (ACR = acromion; CL = clavicle; CP = coracoid process; LHB = long head of the biceps.)
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