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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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110 Chapter 4
3. Relevant anatomy: The rotator interval is located in the anterosuperior aspect of the shoulder
in a triangular area. The base of the triangle is medially at the coracoid process, the superior
border of the subscapularis forms the inferior border, the anterior margin of the supraspinatus
forms the superior border, and the transverse humeral ligament between the intertubercular
groove forms the apex. The rotator interval is the anterosuperior aspect of the capsule, which is
reinforced externally by the coracohumeral ligament and reinforced internally by the superior
glenohumeral ligament and capsular fibers, which blend together and insert medially and laterally to the bicipital groove. The contents of the rotator interval include the coracohumeral ligament, superior glenohumeral ligament, glenohumeral capsule, and long head of the biceps.
The rotator interval plays an important role in the stability of the glenohumeral joint and
biceps tendon. Injury or pathology of the rotator interval can lead to contractures, instability,
or pathological conditions of the glenohumeral joint and biceps tendon (Figure 4-34).
20,21
19
Figure 4-34. Relevant anatomy of the rotator interval, which is reinforced externally by the coracohumeral ligament
(CHL) and reinforced internally by the superior glenohumeral ligament (SGHL) and capsular fibers, which blend
together and insert medially and laterally to the bicipital groove. (LHB = long head of the biceps.)
4. Points to remember: While scanning the rotator interval region, it is important to remember
that anisotropy may affect the imaging; therefore, a tilting movement of the probe is required
for better visualization of the structures. It is important to not mistake anisotropy that presents as a hypoechoic signal in tissue for an abnormal signal. Color Doppler ultrasound should
be used in scanning the rotator interval region for signs of neoangiogenesis or vascularity.
Shoulder 111
ROTATOR CABLE
1. Patient position: Same position as in a supraspinatus scan
2. Probe/transducer position: The probe is placed in the SX view of the supraspinatus tendon to
visualize the cable in the LX at the level of humeral head, where the cable is visualized over
the articular cartilage (Figures 4-35 and 4-36).
AB
Figure 4-35. LX view of the rotator
cable. (A) Probe placement. (B) LX view
of the rotator cable (white arrows)
under the supraspinatus tendon.
A
Figure 4-36. SX view of the rotator
cable. (A) Probe placement. (B) In the SX
view, the rotator cable (white arrows)
appears as thickening of the capsule
under the supraspinatus tendon.
B
112 Chapter 4
3. Relevant anatomy: The rotator cable is a capsuloligamentous complex, which is essential for
normal biomechanics and kinematics of the shoulder.22 The rotator cable is a band of transversely oriented fibers of the coracohumeral ligament. These fibers course posteriorly on the
undersurface of the supraspinatus and infraspinatus tendons and terminate at the superior
margin of the teres minor muscle.
23
The cable marks out the region of the overlying tendon
that is relatively hypovascular, known as the rotator crescent. Tendon tears most frequently
occur in the region overlying the rotator crescent. This cable-crescent region acts like a suspension bridge, where biomechanical load is transmitted to the cable region so that the stress
is distributed over the humeral head region between the anterior and posterior anchors of the
rotator cable, thereby assisting the rotator cuff tendons.23 In the absence of rotator cuff tendons, an intact cable attenuates the adverse consequence on the glenohumeral biomechanics
(Figures 4-37 and 4-38).
23
Figure 4-37. Superior view of the shoulder without the overlying tendons. The rotator cable is a capsuloligamentous
complex formed by a band of transversely oriented fibers of the coracohumeral ligament. (GT = greater tuberosity;
HH = humeral head; LHB = long head of the biceps; LT = lesser tuberosity; Subscap = subscapularis.)
Shoulder 113
Figure 4-38. Posterior view of the rotator cuff showing the rotator cable, which courses posteriorly on the
undersurface of the supraspinatus (Supra) and infraspinatus (Infra) tendons and terminates at the superior margin of
the teres (T) minor muscle. (GT = greater tuberosity; LHB = long head of the biceps; LT = lesser tuberosity.)
4. Points to remember: The rotator crescent provides capsular attachment to the greater tuberosi-
ty, and the rotator cable distributes the force to prevent capsular disruption from the humerus.
The rotator cable exerts the compressive force to stabilize the humeral head.
22
114 Chapter 4
REFERENCES
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2. Varacallo M, Mair SD. Biceps tendon dislocation and instability. In: StatPearls. Treasure Island, FL: StatPearls
Publishing; 2019. Updated March 13, 2020.
3. Ide J, Tokiyoshi A, Hirose J, Mizuta H. An anatomic study of the subscapularis insertion to the humerus: the
subscapularis footprint. Arthroscopy. 2008;24(7):749-753.
4. Arai R, Sugaya H, Mochizuki T, Nimura A, Moriishi J, Akita K. Subscapularis tendon tear: an anatomic and
clinical investigation. Arthroscopy. 2008;24(9):997-1004.
5. Jacobson JA. Shoulder US: anatomy, technique, and scanning pitfalls. Radiology. 2011;260(1):6-16.
6. Lee MH, Sheehan SE, Orwin JF, Lee KS. Comprehensive shoulder US examination: a standardized approach
with multimodality correlation for common shoulder disease. Radiographics. 2016;36(6):160 6-1627.
7. Lumsdaine W, Smith A, Walker RG, Benz D, Mohammed KD, Stewart F. Morphology of the humeral insertion
of the supraspinatus and infraspinatus tendons: application to rotator cuff repair. Clin Anat. 2015;28(6):767-773.
8. Williams MD, Edwards TB, Walch G. Understanding the importance of the teres minor for shoulder function:
functional anatomy and pathology. J Am Acad Orthop Surg. 2018;26(5):150-161.
9. Curtis AS, Burbank KM, Tierney JJ, Scheller AD, Curran AR. The insertional footprint of the rotator cuff: an
anatomic study. Arthroscopy. 2006;22(6):609.e1.
10. Faruch Bilfeld M, Lapègue F, Sans N, Chiavassa Gandois H, Laumonerie P, Larbi A. Ultrasonography study of
the suprascapular nerve. Diagn Interv Imaging. 2017;98(12):873-879.
11. Saccomanno MF, De Ieso C, Milano G. Acromioclavicular joint instability: anatomy, biomechanics and evaluation. Joints. 2014;2(2):87-92.
12. Nakazawa M, Nimura A, Mochizuki T, Koizumi M, Sato T, Akita K. The orientation and variation of the acromioclavicular ligament: an anatomic study. Am J Sports Med. 2016;44(10):2690-2695.
13. Dhawan R, Singh RA, Tins B, Hay SM. Sternoclavicular joint. Shoulder Elbow. 2018;10(4):296-305.
14. van Tongel A, MacDonald P, Leiter J, Pouliart N, Peeler J. A cadaveric study of the structural anatomy of the
sternoclavicular joint. Clin Anat. 2012;25(7):903-910.
15. Lee JT, Campbell KJ, Michalski MP, et al. Surgical anatomy of the sternoclavicular joint: a qualitative and quantitative anatomical study. J Bone Joint Surg Am. 2014;96(19):e166.
16. Arai R, Nimura A, Yamaguchi K, et al. The anatomy of the coracohumeral ligament and its relation to the subscapularis muscle. J Shoulder Elbow Surg. 2014;23(10):1575-1581.
17. Yang HF, Tang KL, Chen W, et al. An anatomic and histologic study of the coracohumeral ligament. J Shoulder
Elbow Surg. 2009;18(2):305-310.
18. Chahla J, Marchetti DC, Moatshe G, et al. Quantitative assessment of the coracoacromial and the coracoclavicular ligaments with 3-dimensional mapping of the coracoid process anatomy: a cadaveric study of surgically
relevant structures. Arthroscopy. 2018;34(5):1403-1411.
19. Tamborrini G, Möller I, Bong D, et al. The rotator interval—a link between anatomy and ultrasound. Ultrasound
Int Open. 2017;3(3):E107-E116.
20. Hunt SA, Kwon YW, Zuckerman JD. The rotator interval: anatomy, pathology, and strategies for treatment. J Am
Acad Orthop Surg. 2007;15(4):218-227.
21. Petchprapa CN, Beltran LS, Jazrawi LM, Kwon YW, Babb JS, Recht MP. The rotator interval: a review of anatomy, function, and normal and abnormal MRI appearance. AJR Am J Roentgenol. 2010;195(3):567-576.
22. Adams CR, DeMartino AM, Rego G, Denard PJ, Burkhart SS. The rotator cuff and the superior capsule: why we
need both. Arthroscopy. 2016;32(12):2628-2637.
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Ankle and Foot
Mohini Rawat, DPT, MS, ECS, OCS, RMSK
Contents
• Anterior Ankle
Joint Anatomy
º
Te nd on s
º
Anterior Inferior Tibiofibular Ligament
º
Anterior Talofibular Ligament
º
Deep Peroneal Nerve
º
• Lateral Ankle
Peroneal Tendons
º
Calcaneofibular Ligament
º
• Medial Ankle
Tarsal Tunnel and Its Contents
º
Deltoid Ligament Complex
º
• Posterior Ankle
Achilles Tendon
º
Posterior Inferior Tibiofibular Ligament
º
Posterior Talofibular Ligament
º
5
- 115 -
Atlas of Musculoskeletal Ultrasound of the E xtremities (pp 115-158).
Rawat M.
© 2021 SLACK Incorporated.
116 Chapter 5
• Hindfoot
Subtalar Joint
º
▪ Anterior Subtalar Joint (Medial Approach)
▪ Posterior Subtalar Joint (Medial Approach)
▪ Posterior Subtalar Joint (Lateral Approach)
▪ Posterior Subtalar Joint (Posterior Approach)
Plantar Fascia
º
• Midfoot
Lateral Ligaments
º
Medial Ligaments
º
• Forefoot
Metatarsophalangeal Joint and Plantar Plate
º
Intermetatarsal Space
º
Ankle and Foot 117
ANTERIOR ANKLE
Joint Anatomy
1. Patient position: Supine with the ankle in slight plantar flexion
2. Probe/transducer position: The long axis (LX) view/longitudinal view is obtained by placing
the probe longitudinally along the anterior ankle (Figure 5-1).
A
Figure 5-1. Ankle joint. (A) Probe placement. (B) Ultrasound image of the tibiotalar joint. From proximal to distal, bony
landmarks are visualized in the following order: the distal tibia, talar dome, and talar head. Anechoic cartilage (white
arrow) lines the talar dome surface. Overlying the cartilage, a hyperechoic fat pad (white star) is visualized.
3. Relevant anatomy: From proximal to distal, bony landmarks are visualized in the following order: distal tibia, talar dome, and talar head. The talar dome presents with an anechoic
cartilage-lined surface. Overlying the cartilage, a hyperechoic fat pad is visualized.
4. Points to remember: Anterior joint effusions are visualized as hypoechoic/anechoic signals in
the tibiotalar joint area.
B
118 Chapter 5
Tend on s
Relevant anatomy is shown in Figure 5-2.
Figure 5-2. Relevant anatomy of the anterior tendons of the ankle.
Ankle and Foot 119
1. Patient position: Supine with the ankle in slight plantar flexion
2. Probe/transducer position:
a. Short axis (SX) view/transverse view: The probe is placed transversely on the anterior ankle at
the level of the talus to visualize the tendons on the anterior aspect of the ankle (Figure 5-3).
AB
Figure 5-3. SX view of the anterior tendons of the ankle. (A) Probe placement. (B) SX view of the tendons. From
medial to lateral, they are the tibialis anterior (white arrow), EHL (yellow arrow), and EDL (red arrow). The EHL shows
the hyperechoic tendon and hypoechoic muscle part. The deep peroneal nerve (white triangle) is present deep to the
tendons in the middle, right under the EHL tendon. (A = dorsalis pedis artery.)
b. The LX view/longitudinal view can be obtained along each tendon to look for any focal
tendon pathology (Figures 5-4 through 5-6).
AB
Figure 5-4. LX view of the tibialis anterior tendon. (A) Probe placement. (B) LX view of the tibialis anterior tendon
(white arrow).
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