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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5831_Библиотеки_им_академика_М_И_Перельмана.pdf
44
D. Orlandi and S.P. Bernardi
How We Do It
STEP 1
The patient is positioned in a different way according to the bursa to treat, and a US scan is
made to identify the enlarged bursa and to assess its anatomical extension.
Iliopsoas bursitis or paralabral cyst : the patient lies in supine position with the lower limb
slightly extra-rotated. The bursa or the cyst is well demonstrated by means of a parasagittal
scan, and the needle can be inserted with an in- plane caudo-cranial approach to reach the bursal/
cyst space. The procedure is shown in Fig. 6.1 .
6 Bursitis and Cysts Around the Hip
a
b
IP
45
d
IP
>
>
>
F
e
F
c
IP
IP
F
Fig. 6.1 US-guided treatment of iliopsoas bursitis on
a long axis. ( a ) Probe and patient position to perform
US-guided treatment of iliopsoas bursitis. ( b )
Anatomical scheme and ( c ) US scan of iliopsoas bursi-
tis treatment. F femur, IP iliopsoas muscle, asterisk
bursa, arrow needle tip. ( d ) US image taken during
F
aspiration of the bursa. Arrowheads show the bowing
of the superfi cial surface of the bursa. ( e ) End of the
procedure; the bursa is completely drained and steroid
has been injected inside ( circles )
46
D. Orlandi and S.P. Bernardi
Peritrochanteric bursitis : the patient lies on the contralateral side. The bursa is demonstrated with
an axial scan over the greater trochanter avoiding applying excessive pressure. The needle can be
inserted with a posterior-to-anterior, medial-to-lateral, in-plane approach. In the case of distention
of the gluteus medius or minimus bursae, an anterior-to-posterior insertion of the needle is neces-
sary. The procedure is shown in Fig. 6.2 .
a
d
GMe
b
Gme
Gmi
Gma
e
GMe
GT
c
Fig. 6.2 US-guided treatment of peritrochanteric bursitis
on a long axis. ( a ) Probe and patient position to perform
US-guided treatment of peritrochanteric bursitis. ( b )
Anatomical scheme and ( c ) short axis US scan of peritro-
chanteric bursitis. Gma gluteus maximus muscle, Gme
gluteus medius muscle, Gmi gluteus minimus muscle, GT
greater trochanter, arrow bursa, arrowheads needle tip, S
subcutaneous tissue. ( d ) Bursal aspiration performed on a
long axis. ( e ) End of the procedure; the bursa is com-
pletely drained and steroid has been injected inside
( asterisks )
6 Bursitis and Cysts Around the Hip
Ischiogluteal bursitis : the patient is positioned prone and the bursal structure is demonstrated by means
of a parasagittal US scan. The needle can be inserted with an in-plane, caudal-to-cranial approach.
STEP 2
A needle connected to a syringe is inserted with an in-plane approach until the needle tip enters
the bursa or cyst. The content may be very dense and drainage could be extremely challenging.
In these cases, the operator may inject in the bursa or in the cyst a small amount of lidocaine
(5 ml) to dilute the content and aspirate it more easily. A larger shielded cannula and application
of a manual compression over the bursa may also be helpful. A biopsy handle may also be used
to obtain a more effective vacuum effect.
STEP 3
When the bursa or cyst is completely drained, a small amount of steroid (1 ml) is then injected.
This has the purpose of both reducing infl ammation and helping the walls to remain collapsed.
The needle is then removed, local compression is applied, and a plaster is placed over the
puncture site.
Post-procedure Care
The patient is kept in observation for about 10 min. Pain after treatment may occasionally occur
and it could be managed using oral NSAIDs.
47
Part II
The Knee
The Knee: Focused Ultrasound Anatomy and Examination Technique
Riccardo Sartoris and Angelo Corazza
7
The knee can be divided into four compartments,
anterior, medial, lateral, and posterior.
Anterior Compartment
A n a t o m y
The quadriceps tendon is formed by four independent slips that come from the four muscles
composing the quadriceps muscle, namely, the
rectus femoris, vastus lateralis, vastus intermedius, and vastus medialis. The four slips are interspersed with thin fat and connective layers and
conjoined in a single tendon that inserts over the
proximal pole of the patella. Under the quadriceps tendon, the suprapatellar joint recess can be
seen. This space is particularly useful to perform
ultrasound-guided intra-articular injections.
The patellar tendon (or ligament) arises
from the inferior pole of the patella, courses
longitudinally, and inserts distally over the
anterior tibial apophysis.
Scanning Technique
The patient lays on the bed with the lower limb
extended and the knee 30° to 45° fl exed. A pillow or a cylindrical support may be placed
under the popliteal fossa to support the knee
during the examination. The probe should be
placed on a longitudinal plane over the proximal
pole of the patella that can be easily palpated
and sled proximal to encounter the patellar tendon. Then, the probe should be sled distally and
the patellar tendon evaluated with longitudinal
scans up to the anterior tibial apophysis.
Attention should be paid to tendon insertions, as
the deepest portion may be affected by anisotropy (Figs.
7.1 and 7.2 ).
R. Sartoris (*) • A. Corazza
Postgraduate school in Radiodiagnostics , University
of Genoa, School of Medicine , Genoa , Italy
riccardo.sartoris@hotmail.it;
e-mail:
angelcoraz@libero.it
© Springer-Verlag Italia 2015
L.M. Sconfi enza et al. (eds.), Ultrasound-guided Musculoskeletal
Procedures: The Lower Limb, DOI 10.1007/978-88-470-5764-7_7
51
52
R. Sartoris and A. Corazza
a
b
c
Fig. 7.1 Evaluation of the anterior knee to assess the
quadriceps tendon and the suprapatellar joint recess. ( a )
The probe and patient are positioned to evaluate the
quadriceps tendon and the suprapatellar joint recess on a
long- axis scan. ( b ) Anatomical scheme of the quadriceps
tendon and the suprapatellar joint recess as seen frontally.
F femoris, P patella, arrowheads quadriceps tendon, circles
suprapatellar joint recess. ( c ) US long-axis scan of the
quadriceps tendon and the suprapatellar joint recess
7 The Knee: Focused Ultrasound Anatomy and Examination Technique
a
b
53
c
Fig. 7.2 Evaluation of the anterior knee to assess the
patellar tendon. ( a ) The probe and patient are positioned
to evaluate the patellar tendon on a long-axis scan. ( b )
Anatomical scheme of the patellar tendon as seen frontally. T tibia, P patella, arrowheads patellar tendon. ( c ) US
long-axis scan of the patellar tendon
54
R. Sartoris and A. Corazza
Medial Compartment
A n a t o m y
The medial collateral ligament is a band-like ligament that courses oblique from the medial aspect
of the femoral condyle to the medial aspect of the
tibia. Slightly anterior to the distal attachment of
the medial collateral ligament, the insertion of the
three tendons of the goose’s foot can be seen,
namely, sartorius, gracilis, and semitendinosus.
The tendons are surrounded by the goose’s foot
bursa, which cannot be seen when not distended.
Scanning Technique
The knee is positioned similarly to what was
reported for the examination of the anterior
compartment. The probe is placed on a coronal
oblique plane to detect the double-layered
appearance of the medial collateral ligament.
Then, the probe should be sled more distally
and anteriorly to perform a longitudinal scan of
the goose’s foot tendons. Of note, if the goose’s
foot bursa is not distended, the tendons can be
scarcely differentiated one from the other
(Fig. 7.3 ).
7 The Knee: Focused Ultrasound Anatomy and Examination Technique
a
b
55
c
Fig. 7.3 Evaluation of the medial knee. ( a ) The probe
and patient are positioned to evaluate the medial knee on
a long-axis scan. ( b ) Anatomical scheme of the medial
knee. T tibia, F femur, arrowheads medial collateral liga-
ment, asterisk medial meniscus. ( c ) US long-axis scan of
the medial knee