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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5782_Библиотеки_им_академика_М_И_Перельмана.pdf
PART V
SMALL PARTS SCANNING
PROTOCOLS
399
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CHAPTER 15
Musculoskeletal Scanning
Protocol for Rotator Cuff, Carpal
Tunnel, and Achilles Tendon
Amy T. Dela Cruz
Key Words
Achilles tendon
Aponeurosis
Biceps tendon
Bicipital groove
Bouffard position
Bursae
Carpal tunnel
Guyon’s canal
Infraspinatus muscle/tendon
Krager’s fat pad
Median nerve
Neutral position
Plantaris tendon
Retrocalcaneal bursa
Rotator cuff
Subacromial bursa
Subcutaneous calcaneus bursa
Subdeltoid bursa
Subscapularis muscle/tendon
Supraspinatus muscle/tendon
Synovial sheath
Teres minor muscle/tendon
Transverse ligament
Objectives
At the end of this chapter, you will be able to:
• Define the key words.
• Distinguish the sonographic appearance of the musculoskeletal
system and the terms used to describe it.
• Describe the transducer options for scanning the musculoskeletal
system.
• List the suggested patient position (and options) when scanning
structures in the musculoskeletal system.
• Name the survey steps and explain how to evaluate the
structures in the musculoskeletal system.
• Explain the order and exact locations to take representative
images of the structures in the musculoskeletal system.
• Answer the review questions at the end of the chapter.
Rotator Cuff Scanning Protocol Overview
Location
The rotator cuff is located at the humeral head sitting in the shallow
glenoid fossa at the proximal humerus. It surrounds the shoulder joint,
providing stability.
401
402 PART V Small Parts Scanning Protocols
Anatomy
• The rotator cuff consists of 4 muscles and the corresponding
tendons
1. Subscapularis muscle/tendon: largest muscle in the rotator
cuff complex. The subscapularis originates from the scapula
and drapes along the anterior surface of the scapula, inserting
by way of subscapularis tendon to the lesser tuberosity of the
humeral head.The transverse ligament is a lateral extension
of the subscapularis tendon that covers the anterior aspect
of the biceps tendon (a landmark for locating rotator cuff
anatomy).
2. Supraspinatus muscle/tendon: originates and courses along
the anterior and superior scapula, inserting by way of the supraspinatus tendon to the greater tuberosity.
3. Infraspinatous muscle/tendon: originates and courses along
the posterior scapular inferior to the supraspinatus, attaching
by way of the infraspinatous tendon to the greater tuberosity.
4. Teres minor muscle/tendon: courses inferior to infraspinatus
muscle along the posterior scapula, attaching by way of teres
minor tendon to the greater tuberosity.
• The shoulder complex contains 2 bursae, which are fluid-filled
sacs aiding in the movement of the shoulder joint and protection from the bone causing friction with the soft tissue:
1. Subdeltoid bursa (largest in the shoulder complex)
2. Subacromial bursa
Physiology
• The rotator cuff surrounds the shoulder joint, providing stabil-
ity to the head of the humerus sitting in the shallow glenoid
fossa. The tendons provide the attachment for the muscles to the
bones.
• The muscles and tendons creating the cuff aid in movement:
1. Subscapularis muscle and tendon aid in internal rotation of
the shoulder.
2. Supraspinatous muscle and tendon aid in abduction of the
shoulder.
3. Infraspinatous muscle and tendon aid in external rotation
of the shoulder.
4. Teres minor muscle and tendon aid in external rotation of
the shoulder.
CHAPTER 15 Musculoskeletal Scanning Protocol for Rotator Cuff, Carpal Tunnel 403
Sonographic Appearance
• Most muscles appear very low-gray and hypoechoic relative to adja-
cent structures, often having a compartment type feature caused
by the connective tissue that surrounds the bundles of muscle
fibers. Axially, the muscles can appear speckled as a result of the
perimysium separating the muscle fibers into small bundles. Longitudinally, the muscle will appear more fibrillar. The technique
of rotating the transducer to confirm the change from speckled to
striated appearance is helpful in distinguishing muscle from other
structures. The aponeurosis is the tissue that binds the muscle
fibers together and aids in the connection to the bone. Sonographically it will appear as a bright reflecting linear structure.
• Tendons such as the biceps tendon appear midgray (and often have
bright reflectors throughout) with medium to high level echoes
that are hyperechoic to adjacent muscles. Some tendons, like the
biceps tendon, are surrounded by a synovial sheath, a membrane
or bursa that contains a small amount of fluid or mucinoid material, aiding in movement. The fluid will appear hypoechoic around
the tendon. Excess fluid may accumulate during some pathological
processes.
• Ligaments are thin structures coursing in many different directions,
making their sonographic identification challenging. When visualized, ligaments will typically appear highly echogenic.
Preparation
Patient Prep
• No prep needed.
Transducer
• Linear 7 MHz to 18 MHz.
Patient Position
• Sitting.
• Arm in neutral, external rotation, or Bouffard position (hand in
back pocket; elbow extending posteriorly).
Breathing Technique
• None.
Rotator Cuff Survey and Required Images
Biceps Tendon
1. Patient position should be sitting with the arm in a neutral
position resting on the thigh with the hand facing upward.
404 PART V Small Parts Scanning Protocols
se
As illustrated below, begin with the transducer in transverse orientation just inferior to the humeral head. The image demonstrates
how the biceps tendon sits within the bicipital groove (arrows)
of the humerus between the greater and lesser humeral tuberosities (GT, LT). The tendon appears as a midgray, ovoid structure
with medium- to high-level echoes that are hyperechoic compared
to the deltoid muscle. It is normal to see a very small amount of
anechoic fluid surrounding the tendon. Notice how the transverse
ligament appears as a bright band sandwiched between the deltoid
muscle (anteriorly) and biceps tendon (posteriorly).
Skin
Deltoid
muscle
Transver
ligament
Sheath
(Bursa)
TRV BICEP TENDON
GT
Biceps tendon
LT
2. As illustrated on the facing page, rotate the transducer 90 degrees
into the longitudinal plane to image the full length of the biceps
tendon. The image demonstrates the tendon anterior to the
*Images in this chapter courtesy of the University of Virginia Imaging Center,
Charlottesville, Virginia.
CHAPTER 15 Musculoskeletal Scanning Protocol for Rotator Cuff, Carpal Tunnel 405
muscle
humeral shaft and posterior to the deltoid muscle. Note the consistent architecture of the biceps tendon; any disruption is indicative of an abnormality.
Skin
Humeral shaft
LONG BICEP TENDON
Subscapularis
1. The patient should begin with the arm in a neutral position. As
illustrated on the following page, return the transducer to the
transverse orientation and image the axial biceps tendon, then
move the transducer slightly superior and medial (toward the
humeral head) to image the long axis of the subscapularis tendon.
The image demonstrates how the long axis of the subscapularis
tendon appears as a fibrillar band of medium level echoes posterior
to the deltoid muscle. Dynamic imaging during internal and external rotation will provide full evaluation of the tendon. (S, Subscapularis tendon; BT, biceps tendon; D, deltoid muscle; C, coracoid
process.)
Deltoid
Fluid
Biceps
tendon
Fluid
406 PART V Small Parts Scanning Protocols
D
BT
S
COR
2. With the patient still in the neutral position, rotate the transducer 90 degrees into the longitudinal plane, as illustrated below.
The image demonstrates how the subscapularis tendon (S) will be
seen in short axis just anterior to the humeral head (H). (D, Deltoid muscle.)
D
S
H
Supraspinatus
1. The patient should be placed into the Bouffard position with
hand in back pocket and elbow extended posteriorly. In a slightly
oblique transverse scanning orientation move the transducer laterally, superiorly and slightly posteriorly. The medial edge of the
transducer will be pointing in the direction of the patient’s ear.
The following image shows that in this plane the long axis of the
supraspinatus tendon (SS) can be evaluated just anterior to the
echogenic line of the humeral head (H). (D, Deltoid muscle.)
CHAPTER 15 Musculoskeletal Scanning Protocol for Rotator Cuff, Carpal Tunnel 407
D
SS
H
TRV SUPRASPINATOUS
2. Maintaining the Bouffard position, the supraspinatus tendon
should be evaluated in a longitudinal plane by rotating the transducer 90 degrees from the previous oblique transverse position.
The critical zone of the rotator cuff is located here, about 1 cm
lateral and posterior to the biceps tendon. (D, Deltoid muscle;
H, humeral head; SS, supraspinatus tendon.)
D
SS
H
LONG SUPRASPINATOUS
Infraspinatus
1. Return patient to neutral position. Turn the transducer to an
oblique transverse orientation to align with the infraspinatus tendon. Move the transducer posteriorly and laterally just inferior to
the spine of the scapula. The following image shows the deltoid
muscle (solid arrow) anterior to the echogenic appearing infraspinatus tendon (dashed arrow). The echogenic line of the humeral
head (dotted arrow) and scapula are posterior. Internal and external
rotation or movement from neutral to hand reaching to opposite
shoulder can be used for identification and evaluation.
408 PART V Small Parts Scanning Protocols
2. Turn the transducer to an oblique longitudinal orientation. The
following image shows the infraspinatus tendon (IT) between the
medially placed glenoid (G) and the laterally placed humeral head
(HH). (D, Deltoid muscle.)
INFRASPINATOUS
D
IT
G
TRV INFRASPINATOUS
LONG AXIS OF TENDON
HH
Teres Minor
1. The patient should be in the neutral position. Return transducer
to transverse position and move slightly inferior to image the trapezoidal shaped tendon in the long axis. The humeral head (HH)
will be lateral and the deltoid muscle (solid arrow) anterior to the
teres minor tendon (dashed arrow).
HH