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CHAPTER 15 Musculoskeletal Scanning Protocol for Rotator Cuff, Carpal Tunnel 419
9. DISTAL Achilles tendon.
ACHILLES
Labeled: TRV AT DIS
Review Questions
Answers on page 630.
1. Sonographically, muscles appear _______ compared to most
adjacent structures.
a) echogenic.
b) hypoechoic.
c) hyperechoic.
d) cystic.
2. How many muscles make up the rotator cuff complex?
a) 1
b) 2
c) 3
d) 4
3. What is a function of the bursa?
a) Stabilize the joint
b) House the nerves supplying the muscle
c) Aid in movement
d) Help to attach the bone to the muscle
4. Which is the largest muscle in the rotator cuff?
a) Supraspinatus
b) Subscapularis
c) Teres minor
d) Infraspinatus
5. Tendons attach muscles to
a) bones.
b) other muscles.
c) ligaments.
d) organs.
6. Which is the largest bursa in the rotator cuff?
a) Subhumeral bursa
b) Acromial bursa
c) Subacromial bursa
d) Subdeltoid bursa
420 PART V Small Parts Scanning Protocols
7. What is the Bouffard position?
a) Hand resting on thigh
b) Hand across body touching opposite shoulder
c) Hand in back pocket of affected side
d) Hand reaching for opposite back pocket
8. Which of the rotator cuff muscles may have a trapezoidal shape in
the long axis?
a) Subscapularis
b) Supraspinatus
c) Infraspinatus
d) Teres minor
9. To image the rotator cuff muscles in the long axis how must the
transducer be oriented?
a) Longitudinally
b) Transversely
10. Which rotator cuff muscle contains the critical zone for rotator cuff
tears?
a) Subscapularis
b) Supraspinatus
c) Infraspinatus
d) Teres minor
11. What is the name of the ligament that stretches across the carpal
tunnel and forms the most anterior border?
a) Flexor digitorum ligament
b) Median nerve ligament
c) Flexor pollicis ligament
c) Flexor retinaculum ligament
12. The ulnar nerve and artery make up what anatomical area in the
wrist?
a) Carpal tunnel
b) Guyon’s canal
c) Synovial sheath
d) Anterior compartment
13. What are the most posteriorly located tendons in the carpal tunnel?
a) Flexor superficialis tendons
b) Flexor profundus tendons
c) Flexor pollicis longus tendons
d) Flexor retinaculum tendons
14. What are the more anteriorly placed tendons in the carpal tunnel?
a) Flexor superficialis tendons
b) Flexor profundus tendons
c) Flexor pollicis longus tendons
d) Flexor retinaculum tendons
15. What bones form the medial and lateral borders in the proximal
carpal tunnel?
a) Ulnar and radius
b) Metacarpals
c) Hamate and trapezium
d) Pisiform and the scaphoid
CHAPTER 15 Musculoskeletal Scanning Protocol for Rotator Cuff, Carpal Tunnel 421
16. What bones form the medial and lateral borders in the distal carpal
tunnel?
a) Ulnar and radius
b) Metacarpals
c) Hamate and trapezium
d) Pisiform and scaphoid
17. What is the sonographic appearance of the median nerve?
a) Hypoechoic with echogenic border
b) Hyperechoic with echogenic border
c) Hypoechoic with thick striations
d) Hyperechoic with hypoechoic ring
18. What tendon connects to the first digit?
a) Flexor superficialis tendon
b) Flexor profundus tendon
c) Flexor pollicis longus tendon
d) Flexor retinaculum tendon
19. In the sagittal plane of the carpal tunnel the median nerve will
appear in what position?
a) Anteriorly
b) Posteriorly
c) Medially
d) Laterally
20. When scanning the carpal tunnel in what position should the hand
be placed?
a) Medial edge down
b) Lateral edge down
c) Palm facing up
d) Palm facing down
21. At the midsection of the Achilles tendon what is the normal
anteroposterior measurement?
a) 1 to 2 mm
b) 3 to 4 mm
c) 5 to 6 mm
d) 7 to 8 mm
22. What two calf muscles does the Achilles tendon attach to in the
lower posterior leg?
a) Calcaneus muscle
b) Gastrocnemius muscle
c) Soleus muscle
d) a and b
e) b and c
23. Where is the insertion point of the Achilles tendon?
a) At the gastrocnemius muscle
b) At the soleus muscle
c) At the lateral malleolus bone
d) At the posterior calcaneus bone
24. The Achilles tendon is necessary for walking.
a) True
b) False
422 PART V Small Parts Scanning Protocols
25. What is another name for the subcutaneous calcaneus bursa?
a) Retro–Achilles bursa
b) Retrocalcaneal bursa
c) Posterior heel bursa
d) Krager’s bursa
26. Which is true about the outer border of the Achilles tendon?
a) The border is hypoechoic.
b) The border has a fibrillar pattern.
c) The border is indistinguishable from the surrounding muscle
tissue.
d) The border is echogenic.
27. Which bursa near the insertion of the Achilles tendon can be identified by a small amount of hypoechoic fluid?
a) Subcutaneous calcaneus bursa
b) Retrocalcaneal bursa
c) Posterior heel bursa
d) Krager’s bursa
28. In what region of the Achilles tendon is it the thickest?
a) The proximal region
b) The midregion
c) The distal region
d) The normal Achilles tendon should be the same thickness
throughout
29. Which of the following correctly describes the shape of the Achilles
tendon in the transverse plane?
a) Irregular shape with fibrillar pattern
b) Circular shape and hypoechoic
c) Elliptical shape with fibrillar pattern
d) Elliptical shape with echogenic center
30. What is the best patient position for imaging the Achilles tendon?
a) Patient lying prone with feet hanging off the end of the
stretcher
b) Patient lying supine with feet hanging off the end of the
stretcher
c) Patient standing with even weight on both feet
d) Patient standing with all weight on affected leg
31. At what region of the Achilles tendon will the tendon begin to
blend in with the muscle?
a) The insertion
b) The proximal region
c) The midregion
d) The distal region.
32. What is the name of the fatty tissue located just posterior to the
Achilles tendon?
a) Subcutaneous fat pad
b) Achilles fat pad
c) Krager’s fat pad
d) Retrocalcaneal fat pad
CHAPTER 15 Musculoskeletal Scanning Protocol for Rotator Cuff, Carpal Tunnel 423
33. Which tendon is considered to be the strongest in the body?
a) Biceps tendon
b) Achilles tendon
c) Patellar tendon
d) Hamstring tendon
34. What technology can the sonographer use to show the entire
length of the Achilles tendon?
a) Panoramic imaging
b) Harmonic imaging
c) 3D technology
d) Widescreen imaging
35. Which of the following correctly describes how the Achilles tendon
will move with dorsiflexion of the foot?
a) The tendon will move in a sliding motion.
b) The tendon will move anterior to posterior.
c) The tendon will become smaller and larger with movement.
d) The tendon does not move with dorsiflexion movement.
Thyrohyoid membrane
Common carotid artery
Thyroid gland
Internal jugular vein
Hyoid bone
Thyroid cartilage
Cricoid cartilage
Parathyroid gland
Isthmus
Trachea
Aorta
Location and Anatomy of Thyroid and Parathyroid Glands
CHAPTER 16
Thyroid and Parathyroid Glands
Scanning Protocol
Wayne C. Leonhardt
Key Words
Adenomas
Anterior strap muscles
Calcitonin
Dilated follicles
Ectopic parathyroid glands
Ectopic thyroid
Endocrine gland
Esophagus
Isthmus
Minor neurovascular bundle
Parathormone (PTH)
Posterior longus colli muscle
Pyramidal lobe
Recurrent laryngeal nerve
Thyroxine (T4)
Trachea
Triiodothyronine (T3)
Vagus nerve
Variant parathyroid gland
shapes
Objectives
At the end of this chapter, you will be able to:
• Define the key words.
• Distinguish the sonographic appearance of the thyroid and
parathyroid glands and the terms used to describe them.
• List the transducer options for scanning the thyroid and parathyroid
glands.
• Name the suggested breathing techniques for patients when
scanning the thyroid and parathyroid glands.
• List the suggested patient position (and options) when scanning
the thyroid and parathyroid glands.
• Explain the patient prep for a thyroid and parathyroid glands
study.
• Distinguish the thyroid and parathyroid glands normal variants.
• Name the survey steps and explain how to evaluate the entire
length, width, and depth of the thyroid and parathyroid glands.
• Explain the order and exact locations to take representative
images of the thyroid and parathyroid glands.
• Answer the review questions at the end of the chapter.
Overview
Location
Thyroid Gland
• Located in the lower, anterior portion of the neck, anterior to the
trachea and inferior to the larynx.
425
426 PART V Small Parts Scanning Protocols
• Has bilateral lobes that lie on each side of the trachea. They are
bordered laterally by the common carotid artery and internal
jugular vein.
• The isthmus of the thyroid gland unites the lobes at the level of
the second, third, and fourth tracheal rings.
• Lies between the anterior strap muscles: (sternocleidomastoid,
sternothyroid, and sternohyoid muscles) and the posterior longus
colli muscle and minor neurovascular bundle (consisting of the
inferior thyroid artery and recurrent laryngeal nerve).
Parathyroid Glands
• The 4 glands lie between the posterior aspect of the thyroid gland
and the longus colli muscle.
• The 2 superior parathyroid glands are situated slightly more medial
than the 2 inferior parathyroid glands.
• Typically, the parathyroid glands are symmetric in position.
• Lie deep to the cricoid cartilage, midway between the Adam’s apple
(apex of thyroid cartilage) and the suprasternal notch.
Anatomy
Thyroid Gland
• A superficial, butterfly-shaped gland that is variable in size but
weighs approximately 25 to 35 g.
• The size and shape of the thyroid gland is greatly influenced by body
habitus and gender, therefore, normal thyroid gland measurements
have a wide range of variability:
• Tall, thin individuals have elongated lateral lobes that can mea-
sure up to 8 cm long.
• Short, obese people’s lateral lobes are 5 cm or less.
• The thyroid gland is normally larger in women and becomes
enlarged during pregnancy.
• The average, normal adult thyroid gland is approximately 4-6 cm
long, 1.3 to 1.8 cm anteroposteriorly, and 3 cm at its greatest width.
The anteroposterior measurement of the isthmus is approximately
2 to 6 cm.
• In newborns and children, the gland is approximately 2 to 3 cm long,
0.2 to 1.2 cm anteroposteriorly, and 1.5 cm at its greatest width.
• The thyroid is highly vascular; its blood supply consists of paired supe-
rior and inferior arteries and veins, and often, middle thyroid veins.
Parathyroid Glands
• The oval or bean shaped parathyroid glands are approximately
5 to 7 mm long, 1 to 2 mm thick, and 3 to 4 mm wide.
• Parathyroid glands are supplied blood by separate small branches
of the inferior and superior thyroid arteries. Venous drainage is via
the superior, inferior, and middle thyroid veins.
CHAPTER 16 Thyroid and Parathyroid Glands Scanning Protocol 427
Physiology
Thyroid Gland
• An endocrine gland (ductless gland that secretes hormones directly
into the bloodstream) that is responsible for secreting the hormones
thyroxine (T4) (regulates metabolism), triiodothyronine (T3)
(regulates metabolism), and calcitonin (decreases blood calcium
levels, preventing hypercalcemia) that assist in regulating the metabolic rate and the metabolism of lipids, proteins, and carbohydrates
and in the absorption of calcium from the blood for storage in the
bones.
Parathyroid Glands
• Endocrine glands that secrete the hormone parathormone (PTH)
which acts as the antagonist for calcitonin and controls the calcium
level in the bloodstream.
Sonographic Appearance
Thyroid Gland
• Appears homogeneous and moderately echogenic. It is similar
in appearance to normal liver and testes parenchyma and hyperechoic compared to adjacent musculature.
• For appearance’s sake, the long axis of the thyroid gland is situated
horizontally in the neck. Therefore, longitudinal and long axis
views of the entire gland would be visualized in transverse scanning planes. However, for diagnostic purposes the thyroid’s right
and left lobes and the isthmus that connects them are examined
separately.
• Each lobe is oriented vertically in the neck; therefore, the long
axes are visualized in sagittal scanning planes. The long sections of the lobes appear sandwiched between the hypoechoic
strap muscles anteriorly and longus colli muscles posteriorly
(Figure 16-1).
• Axial sections of the right and left lobes are seen extending later-
ally from each side of the isthmus to axial sections of the common carotid arteries and internal jugular veins, which appear as
anechoic round or oval structures with bright walls. In transverse
scanning plane images showing axial sections of the thyroid
lobes, adjacent neck structures such as the vagus nerve, recurrent
laryngeal nerve, the esophagus, and various muscles are routinely
identified (Figure 16-2).
◼ The vagus nerve (part of the major neurovascular bundle) is
visualized as a hypoechoic dot posterolateral to the thyroid
lobe, usually between the carotid artery and jugular vein.
◼ The recurrent laryngeal nerve (part of the minor neurovas-
cular bundle) is best identified as an echogenic rim located
between the trachea, esophagus, and left posterior thyroid lobe.
428 PART V Small Parts Scanning Protocols
THY
FIGURE 16-1 Sagittal scanning plane image of the left lobe of the thyroid gland and adjacent vascu-
lature. THY, Thyroid gland; LCM, longus colli muscle (arrows).
STRAP MUSCLE
LCM
SCM
LCM
VN
CCA
OH
JV
SH
TR
RLN
ST
THY
E
FIGURE 16-2 Transverse scanning plane section of the thyroid gland’s left lobe and relevant adjacent
anatomic structures. THY, Thyroid; CCA, common carotid artery; JV, jugular vein; E, esophagus; TR,
trachea; LC M, longus colli muscle; RLN, recurrent laryngeal nerve; VN, vagus nerve; SH, sternohyoid
muscle; ST, sternothyroid muscle; SCM, sternocleidomastoid muscle; OH, omohyoid muscle.
◼ The esophagus (part of the alimentary canal that connects
the throat to the stomach) is seen just to the left of the midline of the neck, posterior to the left thyroid lobe, between
the trachea (large membranous tube reinforced by rings of
cartilage, extending from the larynx to the bronchial tubes
and conveying air to and from the lungs) and longus colli
muscle. Its axial section appears round to oval; the outer wall
is hypoechoic relative to the bright appearance of the inner