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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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90 Chapter 4
Figure 4-12. Footprint of the supraspinatus (Supra), infraspinatus (Infra), and teres (T) minor on the greater tuberosity
showing the inferior (I), middle (M), and superior (S) facets of the greater tuberosity. (LT = lesser tuberosity.)
4. Points to remember: The Crass or modified Crass position helps bring the tendon out from
beneath the acromion. In neutral position, a limited view of the distal portion of the tendon
is visible. The posterior portion of the tendon can appear disorganized or may lack normal
parallel fibrillary echotexture due to the transition zone or interdigitating infraspinatus and
supraspinatus fibers. This zone should not be confused with tendon pathology.
Shoulder 91
Infraspinatus
1. Patient position: Sitting with a neutral shoulder or holding the opposite arm to stretch the
tendon for better visualization
2. Probe/transducer position:
a. LX view: The probe is placed transversely on the posterior aspect of the scapula over the
infraspinatus muscle belly, just under the spine of the scapula, and then the infraspinatus
is followed laterally as it crosses the glenohumeral joint to insert on the middle facet of the
greater tuberosity of the humerus.
b. SX view: The probe is rotated 90 degrees to visualize the tendon (Figures 4-13 and 4-14).
A
Figure 4 -13. LX view of the infraspinatus
tendon. (A) Probe placement. (B) LX
view of the infraspinatus (Infra) muscle
belly overlying the posterior shoulder
joint. (HH = humeral head.) (C) LX view
of the infraspinatus tendon (white
arrow) attaching to the middle facet of
the greater tuberosity (GT).
B
C
92 Chapter 4
AB
Figure 4-14. SX view of the infraspinatus tendon. (A) Probe placement. (B) SX view of the infraspinatus tendon (white
arrow). (GT = greater tuberosity.)
3. Relevant anatomy: The infraspinatus originates from the infraspinous fossa of the scapula and
then courses superiorly and laterally to insert on the greater tuberosity. The footprint of the
infraspinatus is about 1.2 cm in width (medial to lateral), 2.3 cm in medial length (anterior to
posterior), and 2.6 cm in lateral length (anterior to posterior).7
4. Points to remember: Some cortical irregularities under the infraspinatus at the level just proximal to the greater tuberosity is a normal finding and should not be confused with erosions.
Shoulder 93
Teres Minor
1. Patient position: Same as for the infraspinatus
2. Probe/transducer position: After obtaining the infraspinatus LX view, the probe is moved
inferiorly to scan the teres minor tendon, which is immediately inferior to the infraspinatus
tendon. The SX view is obtained by rotating the probe 90 degrees from the LX view (Figures
4-15 and 4-16).
A
Figure 4-15. LX view of the teres minor
tendon. (A) Probe placement. (B) LX
view of the teres minor tendon (white
arrow) attaching to the inferior facet of
the greater tuberosity (GT).
B
94 Chapter 4
A
Figure 4-16. SX view of the teres minor tendon. (A) Probe placement. (B) SX view of the teres minor tendon (white
arrow). (GT = greater tuberosity.)
B
3. Relevant anatomy: The teres minor originates from the dorsal aspect of the lateral border of
the scapula and courses laterally to attach to the inferior facet of the greater tuberosity. It is the
most posterior tendon of the rotator cuff and functions to externally rotate the humerus.6 It
has muscular attachment to the posterior capsule and the humerus with a smaller tendinous
insertion. Unlike the supraspinatus and infraspinatus, the teres minor does not blend with
infraspinatus fibers posteriorly.8 The teres minor has a triangular footprint with a tapered
inferior end. The footprint of the teres minor is about 2.9 cm in length (superior to inferior)
and 2.1 cm in width (medial to lateral).
9
4. Points to remember: The teres minor is about half the size of the infraspinatus tendon. An
intact teres minor is important for activities of daily living when there is a massive irreparable
rotator cuff tear.
8
Shoulder 95
Anterior Joint
1. Patient position: Supine or sitting with external rotation of the shoulder
2. Probe/transducer position: The probe is placed transversely on the anterior aspect of the shoul-
der, distal to the coracoid process, to visualize the anterior joint area (Figure 4-17).
AB
Figure 4-17. Anterior shoulder joint. (A) Probe placement. (B) Anterior glenohumeral joint (white star), glenoid (white
arrow), cartilage lining the humeral head (HH; yellow arrow), and subscapularis muscle tendon complex (red arrow).
3. Relevant anatomy: The anterior joint is visualized deep to the subscapularis muscle-tendon
complex.
4. Points to remember: Ultrasound gives a limited view of the anterior joint and is therefore not
the first choice for imaging intra-articular pathology.
96 Chapter 4
Coracoid Process Attachments
1. Patient position: Seated with neutral shoulder
2. Probe/transducer position: The probe is placed transversely over the coracoid process and
moved just distal enough to lose the view of the coracoid process to visualize the tendon
attachments in the SX view. For the LX view, the probe is aligned along the structure of interest with the coracoid process as a bony landmark (Figures 4-18 and 4-19).
A
Figure 4-18. Short head of the biceps
and coracobrachialis attachment at the
coracoid process. (A) Probe placement.
(B) SX view of the hyperechoic
tendinous portion of the short head
of the biceps (white arrow) and hypoechoic muscular portion of the coracobrachialis (red arrow). Laterally, the
subscapularis can be seen (white triangle).
B
Shoulder 97
A
Figure 4-19. LX view of the pectoralis
minor. (A) Probe placement. (B) LX view
of the pectoralis minor (white arrows)
attaching to the coracoid process (CP).
B
3. Relevant anatomy: The short head of the biceps and coracobrachialis originate from the ante-
rior aspect of the tip of the coracoid process. The pectoralis minor originates from the medial
aspect of the coracoid process.
4. Points to remember: The coracoid process gives attachment to multiple structures. It is impor-
tant to note that very little movement of the probe is required to scan structures attaching to
the coracoid process.
98 Chapter 4
Pectoralis Major
1. Patient position: Sitting
2. Probe position: The probe is placed transversely over the anterior shoulder to visualize the
long head of the biceps in the SX in the groove. The long head of the biceps is then followed
distally until the hyperechoic tendon of the pectoralis major is seen crossing over the long
head of the biceps. The SX view is obtained by rotating the probe 90 degrees from the LX view
(Figures 4-20 and 4-21).
A
Figure 4-20. LX view of the pectoralis
major. (A) Probe placement. The long
head of the biceps is first identified
at the intertubercular groove, then
followed distally until the LX of the
pectoralis tendon is visualized crossing
above the long head of the biceps in a perpendicular direction. (B) LX view of the pectoralis major (white arrow). The
muscle-tendon complex of the long head of the biceps (yellow arrow) is seen under the pectoralis major tendon.
A
B
B
Figure 4-21. SX view of the pectoralis major. (A) Probe placement. (B) SX view of the pectoralis major tendon (white
arrow).
3. Relevant anatomy: The pectoralis major is attached to the lateral lip of the intertubercular
groove.
Shoulder 99
POSTERIOR SHOULDER
Posterior Joint
1. Patient position: Sitting
2. Probe/transducer position: The probe is placed transversely on the posterior aspect of the gle-
nohumeral joint at the level of the infraspinatus muscle-tendon complex. Initially, the probe
is placed on the posterior aspect of the scapula just below the spine of the scapula to visualize
the infraspinatus muscle, and then the muscle is followed laterally as it crosses the posterior
glenohumeral joint (Figure 4-22).
A
Figure 4-22. Posterior glenohumeral
joint showing the glenoid (GL), glenoid
labrum (white arrow), and anechoic
cartilage lining the humeral head (red
arrow) and overlying infraspinatus (Inf).
3. Relevant anatomy: The infraspinatus muscle-tendon complex overlies the posterior joint.
4. Points to remember: To widen the joint space for better visualization, the patient is asked to
reach across and hold the opposite arm.
B
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