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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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170 Chapter 6
Figure 6-15. LX view of the anterior fascial layers over the quadriceps and patella showing the tendon layer (white
arrows), oblique fascia (blue arrow), and superficial fascia (pink arrow). (Q = quadriceps tendon.)
A
B
Figure 6-16. (A) LX view over the patellar tendon showing the location of the deep
infrapatellar bursa (white arrow). There is minimal fluid. (B) Same view with increased probe
pressure causing disappearance of the minimal fluid seen before.
4. Points to remember: Lots of gel and very light transducer pressure is required to scan these
subcutaneous bursae because increased pressure will force the fluid away from the probe, and
therefore, bursal f luid may not be visualized. In a normal state, these bursae are not visible.
An anatomic variant of the bipartite or tripartite patellae may be present, which can be
confused with a fracture or breach in the continuity of the bony surface of the patella. This
anatomic variant is caused by nonunion of an accessory ossification center of the patella.
Misinterpretation can be avoided with thorough history taking, clinical correlation, and, in
some cases, follow-up radiographs.
Hoffa’s fat pad should not be confused with deep infrapatellar bursal effusion because the
fat pad between the distal patellar tendon and the tibia can sometimes appear hypoechoic.
Any abnormal signal should be confirmed in the SX view. Deep infrapatellar bursal effusion,
when present, is accompanied with posterior enhancement artifact.
Knee 171
Medial and Lateral Patellar Retinaculum
1. Patient position: Supine with the knee extended and resting on the table
2. Probe/transducer position: The probe is placed along the medial retinaculum bridging the
patella and the medial femoral condyle (Figure 6-17). For the lateral retinaculum, the probe
is placed along the lateral retinaculum bridging the patella and the lateral femoral condyle
(Figure 6-18).
AB
Figure 6-17. Medial retinaculum. (A) Probe placement. (B) Medial retinaculum (white arrows) as a bilaminar structure.
A
Figure 6-18. Lateral retinaculum. (A) Probe placement. (B) Lateral retinaculum (white arrows) as a bilaminar structure.
B
172 Chapter 6
3. Relevant anatomy: The patellar retinaculum appears as a bilaminar structure that stabilizes the
patella in the transverse plane (Figure 6-19). With the knee extended, the medial patellar facet
can be seen by pushing the patellar medially from the lateral edge. The medial patellar retinaculum is longer and laxer than the lateral patellar retinaculum, which allows the visualization of
the medial patellar facet by pushing the patella medially from the lateral edge of the bone (Figure
6-20). The lateral patellar facet cannot be visualized by pushing the medial edge laterally.
Figure 6-19. Relevant anatomy of the patellar retinaculum. (ITB = iliotibial band; LCL = lateral collateral ligament;
MCL = medial collateral ligam ent.)
Knee 173
A
Figure 6-20. Medial patellar facet. (A)
Initial probe placement is similar to
medial retinaculum scanning. After
pushing the patella medially, the probe
is hooked under the patella so that the
beam is directed toward the medial
patellar facet. (B) Cartilage-lined medial patellar facet (red arrow) and overlying retinaculum (white arrow).
B
4. Points to remember: It is important to remember when placing the probe along the patellar
retinaculum that the orientation of the probe is along the fiber length and not in SX/transverse
orientation with respect to the knee.
MEDIAL KNEE
Medial Joint and Meniscus
1. Patient position: Supine with the leg externally rotated and the knee flexed approximately 30
degrees with a pillow or roll on the lateral aspect of the knee for slight valgus stress
2. Probe/transducer position: For the LX view of the medial joint space, the probe is placed lon-
gitudinally to bridge the femur and tibia (Figure 6-21).
A
B
Figure 6-21. Medial meniscus. (A) Probe placement. (B) Medial meniscus (white arrow) as a triangular hyperechoic
structure.
174 Chapter 6
3. Relevant anatomy: The medial meniscus in the medial joint space appears as a hyperechoic
triangular structure (Figure 6-22).
Figure 6-22. Relevant anatomy of the medial joint. (ACL = anterior cruciate ligament; dMCL = deep medial collateral
ligament; PCL = posterior cruciate ligament; sMCL = superficial medial collateral ligament.)
4. Points to remember: Ultrasound provides a limited view of the medial meniscus and therefore
cannot assess the extent of meniscal pathology. Other imaging modalities, such as magnetic
resonance imaging (MRI), are preferred when meniscal pathology is in question.
Knee 175
Medial Collateral Ligament, Posterior Oblique Ligament,
Adductor Magnus Tendon, and Medial Patellofemoral Ligament
1. Patient position: Supine with the leg externally rotated and the knee flexed approximately 30
degrees with a pillow or roll on the lateral aspect of the knee for slight valgus stress
2. Probe/transducer position: The probe is placed in the LX along the MCL (Figures 6-23 and
6-24).
A
B
Figure 6-23. MCL. (A) Probe placement. (B) LX view of the MCL (white arrows).
Figure 6-24. Panoramic view of the MCL (white arrows). The darker area over the distal part of the MCL is the pes
anserine tendons (red arrows) in the oblique SX view.
176 Chapter 6
3. Relevant anatomy: The MCL is a bilaminar structure composed of the dMCL and the sMCL
(see Figure 6-22). The dMCL can be divided into the meniscofemoral and meniscotibial ligaments. The dMCL blends with the medial meniscus. The f ootprint of the sMCL at the femoral insertional area is about 3 cm from the medial joint line, and the footprint at the tibial
insertional area is about 6.3 cm from the medial joint line. The footprint of the dMCL at the
femoral insertional area is about 2 cm from the joint line, and the footprint of the dMCL at
the tibial insertional area is about 0.7 cm from the joint line.
2,3
The posterior oblique ligament (POL) attachment is just posterior to the sMCL attachment at the femur (Figures 6-25
through 6-27).
Figure 6-25. Relevant anatomy and footprint of the MCL. The footprint of the sMCL at the femoral insertional area is
about 3 cm from the medial joint line, and the footprint at the tibial insertional area is about 6.3 cm from the medial
joint line. The footprint of the dMCL at the femoral insertional area is about 2 cm from the joint line, and the footprint
of the tibial insertional area is about 0.7 cm from the joint line.
attachment at the femur.
2,3
The POL attachment is just posterior to the sMCL
Figure 6-26. Meniscofemoral (yellow arrows) and meniscotibial (red arrows) portions of the dMCL.
Knee 177
Figure 6-27. Relevant anatomy of the medial knee ligaments and tendons. (MPFL = medial patellofemoral ligament.)
178 Chapter 6
4. Points to remember: The MCL is wider at the joint level, and the posterior portion of the sMCL
blends with the medial meniscus.2 The MCL is tight at 30 degrees of flexion, and the POL is
tight in extension. The POL, adductor magnus tendon, and medial patellofemoral ligament
can be scanned medially (Figures 6-28 through 6-31).
A
Figure 6 -28. POL. (A) Relevant anatomy
and probe placement. (B) Proximal MCL
(small red arrow). (C) POL (white arrow).
B
C
Knee 179
A B
Figure 6-29. SX view of the MCL and POL. (A) Relevant anatomy and probe placement. (B) Proximal MCL (red arrow)
and POL (white arrow).
A
Figure 6-30. Adductor magnus tendon. (A) Relevant anatomy and probe placement. (B) LX view of the adductor
magnus tendon (white arrows) attaching to the adductor tubercle, showing an oblique view of the MCL (red arrow).
B
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