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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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180 Chapter 6
A
B
Figure 6-31. Medial patellofemoral ligament. (A) Relevant anatomy and probe placement. (B) LX view of the medial
patellofemoral ligament (white arrows).
Knee 181
Pes Anserine Tendons
1. Patient position: Same position as for MCL scanning
2. Probe/transducer position: The probe is placed in the LX view along the MCL, and the MCL
is followed distally just before its insertion at the tibia. Three diffused hypoechoic structures
can be visualized crossing over the MCL. By tilting the probe, the echotexture of the tendons
changes from hypoechoic to hyperechoic, which is due to anisotropy (Figure 6-32).
A
Figure 6-32. Pes anserine tendons.
(A) Relevant anatomy and probe
placement. (B) SX view of the pes
anserine tendons showing the sartorius
(white arrow), gracilis (small red arrow),
and semitendinosus (yellow arrow). (C)
LX view of the pes anserine tendon
(white arrows).
B
C
3. Relevant anatomy: From superior to inferior, the pes anserine tendons are arranged as sarto-
rius, gracilis, and semitendinosus. The pes anserine bursa lies between the MCL and the pes
anserine tendons (see Figure 6-27).
4. Points to remember: Close to their distal insertion, the pes anserine tendons are thin, flattened
structures, and therefore the distinction between the tendons on ultrasound is based on their
relative position.
182 Chapter 6
LATE RA L KNEE
Lateral Joint and Meniscus
1. Patient position: Knee flexed 30 degrees with a pillow between the knees for some varus stress
2. Probe/transducer position: The probe is placed along the lateral aspect of the knee joint in the
LX view (Figure 6-33).
A
Figure 6-33. Lateral meniscus. (A) Probe placement. (B) Lateral meniscus (white arrow) as a hyperechoic triangular
structure.
3. Relevant anatomy: The lateral meniscus appears as a hyperechoic triangular structure in the
lateral joint space.
4. Points to remember: You may need to increase gain, or brightness, to visualize the lateral
meniscus.
B
Knee 183
Popliteus Tendon
1. Patient position: Same position as for the lateral joint
2. Probe/transducer position: The probe is placed along the lateral aspect of the knee joint in the
LX view, and attention is focused on the femur to visualize the groove where the popliteus
tendon sits. The popliteus tendon is visualized in the oblique SX in this view. The probe can
be rotated to be exactly short on the tendon and then rotated long on the tendon to obtain the
LX view (Figure 6-34).
A
Figure 6-34. Popliteus tendon. (A)
Probe placement. (B) SX view of the
popliteus tendon (white arrow) in the
popliteus groove of the femur. (C) LX
view of the popliteus tendon (white
arrow).
B
C
184 Chapter 6
3. Relevant anatomy: The popliteus muscle originates from the posteromedial aspect of the
proximal tibia above the soleal line. It is a thin, flat, triangular muscle that forms part of the
floor of the popliteal space. It continues superiorly and laterally, forming a tendon that lies
intracapsular laterally. The tendon attaches to the depression on the lateral aspect of the lateral
femoral condyle. The tendon passes beneath the LCL and biceps femoris tendon. The insertion
of the tendon is anteroinferior to the proximal attachment of the LCL. The popliteus bursa,
which lies between the posterior knee and the popliteus, is an extra-articular extension of the
synovial membrane of the knee joint. It extends from the popliteus hiatus to the proximal part
of the tendon. Other ligament attachments of popliteus include the p opliteofibular ligament
and the ligament between the popliteus and the posterior horn of the lateral meniscus (Figure
4,5
6-35).
Figure 6-35. Relevant anatomy of the popliteus muscle. (Ant. = anterior; PFL = popliteofibular ligament;
Post. = poste rior.)
4. Points to remember: The popliteus tendon is intracapsular but extra-articular and extrasynovial. Repeated stress on the popliteus with activities like downhill walking or running can lead
to tendinosis or tenosynovitis.4
Knee 185
Lateral Collateral Ligament
1. Patient position: Knee flexed 30 degrees with a pillow between the knees for some varus stress
2. Probe/transducer position: The probe is placed along the lateral aspect of the knee joint in the
LX view, visualizing the 3 bony landmarks; distal to proximal, they are the fibula, tibia, and
femur. The LCL is visualized from the distal attachment at the proximal end of the fibula to
the proximal attachment at the lateral condyle of the femur (Figure 6-36).
A
B
Figure 6-36. LCL. (A) Probe placement along the lateral aspect of the knee
joint in the LX view visualizing the 3 bony landmarks; distal to proximal, they
are the fibula, tibia, and femur. (B) LCL (white arrows). (F = fibula; P = popliteus
tendon.)
186 Chapter 6
3. Relevant anatomy: The LCL attaches on the lateral femoral condyle, anterior to the lateral head
of the gastrocnemius attachment and posterosuperior to the popliteus tendon attachment.
There is a conjoint attachment of the LCL and biceps femoris tendon on the proximal fibula
(Figures 6-37 and 6-38).
6
Figure 6-37. Relevant anatomy of the lateral knee. (PFL = popliteofibular ligament.)
Knee 187
Figure 6-38. Footprints of the LCL, popliteofibular ligament (PFL), and biceps femoris (BF) insertion on the proximal
fibula. (Ant . = anterior.)
4. Points to remember: Due to its course, the LCL may exhibit anisotropy close to its distal and
proximal portions.
Iliotibial Band
1. Patient position: Supine or side-lying
2. Probe/transducer position: The probe is placed on the lateral aspect of the knee with Gerdy’s tuber-
cle as a bony landmark to orient the probe along the iliotibial band (Figures 6-39 through 6-41).
AB
Figure 6-39. Iliotibial band. (A) Probe placement. (B) LX view of the iliotibial band (white arrows) attaching to Gerdy’s
tubercle.
188 Chapter 6
AB
Figure 6-40. Iliotibial band attachment to the patella. (A) Probe placement. (B) LX view of
the iliotibial band (white arrows) attachment to the patella.
Figure 6-41. Panoramic view of the iliotibial band (white arrows) attaching to Gerdy’s tubercle.
3. Relevant anatomy: The iliotibial band attaches to Gerdy’s tubercle on the anterolateral tibia
distally. Proximally, it is divided into superficial and deep layers, anchors the tensor fascia lata
muscle to the iliac crest, and receives most of the tendon of the gluteus maximus. The iliotibial band is dense, fibrous connective tissue that runs laterally from the iliac crest to Gerdy’s
tubercle on the lateral aspect of the thigh that passes over the femoral epicondyle, where it is
anchored by fibrous strands associated with a layer of fat that is richly innervated and vascularized.7 The iliotibial band has 2 distinct attachments to Gerdy’s tubercle of the tibia and to
the patella. The iliotibial band is an important dynamic stabilizer.
4. Points to remember: Gerdy’s tubercle is an important landmark in sonographic visualization
of the iliotibial band. From anterior to posterior, 3 important bony landmarks are seen: the
tibial tuberosity, Gerdy’s tubercle, and the head of the fibula.
Knee 189
Biceps Femoris Tendon
1. Patient position: Prone or side-lying
2. Probe/transducer position: The probe is placed in the LX along the biceps femoris tendon distal
attachment at the fibular head, and the tendon is scanned proximally to scan the entire length
of the tendon. The SX view can be obtained by rotating the probe to place it transversely across
the tendon (Figure 6-42).
A
B
C
Figure 6-42. Biceps femoris tendon. (A) Probe placement. (B) LX view of the biceps femoris tendon (white arrow)
attaching to the fibula. (C) SX view of the biceps femoris tendon (white arrow) just proximal to the fibula.
3. Relevant anatomy: The biceps femoris muscle has 2 heads: (1) the long head that arises from
the medial aspect of the ischial tuberosity and (2) the short head that arises from the lateral
lip of the linea aspera, the proximal two-thirds of the supracondylar line of the femur, and
the lateral intermuscular septum. Distally, the tendon inserts on the head of fibula, the crural
fascia, and the proximal tibia.
4. Points to remember: The biceps femoris long head is supplied by the tibial component of the
sciatic nerve, and the short head is supplied by the common peroneal component of the sciatic nerve. There may be selective atrophy of the short head of the biceps femoris in peroneal
neuropathy.
5,8
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