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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5833_Библиотеки_им_академика_М_И_Перельмана.pdf
Lateral Hip
87
Fig. 6.15 The anatomical pattern shows, in an anteroposte-
rior sense, minimus (GMi), medius (GMe), and maximus
(GMa) gluteus. GT, greater trochanter of the femur
Fig. 6.16a Probe position to
evaluate the gluteus muscles’
insertion onto the greater
trochanter
Fig. 6.16b The axial scan
shows the tendinous insertion
of the gluteus minimus (*),
medius (arrow), and maximus
(star) into the femoral greater
trochanter (GT). Arrowheads,
tensor fasciae latae tendon
6 Hip
88
Fig. 6.17a Probe position for
the longitudinal evaluation of
the tensor fasciae latae tendon
Fig. 6.17b The longitudinal scan shows the tensor fasciae latae tendon (arrowheads) superficial to the
greater trochanter (GT)
6.4 Posterior Hip
There are two trochanteric bursae: the trochan-
teric bursa of the gluteus medius that separa-
tes the homonymous tendon from the anterior-
superior side of the greater trochanter, and the
trochanteric bursa of the gluteus maximus,
often multilocular, that separates the deep side
of the gluteus maximus from the postero-late-
ral bony surface of the greater trochanter.
6.4.1 Ischiocrural Tendons
(Hamstrings)
Patient lies prone with the lower limb in a neu-
tral position (Fig. 6.18). Anatomical scheme of
ischiocrural tendons is presented in Fig. 6.19.
With the patient prone and an axial orienta-
tion of the probe, find the ischiatic tuberosity
and visualize the conjoined tendon insertion of
the ischiocrural muscles on it (Figs. 6.20a, b,
6.21a, b).
From lateral to medial, the conjoined ten-
don of long head of the biceps femoris and the
semitendinosus can be seen. More medially, the
semimembranosus tendon is visible. It has a
very thin muscle and a very short proximal ten-
dinous component.
6.4.2 Sciatic Nerve
Lateral to the hamstring insertions, also exami-
ne the sciatic nerve axially and then longitudi-
nally (Figs. 6.22a-c).
Posterior Hip
89
Fig. 6.18 Lower limb position for posterior hip
evaluation
Fig. 6.19 Anatomical scheme: ischiocrural tendon inser-
tion into ischiatic tuberosity and course of sciatic nerve. BF,
biceps femoris; SM, semimembranosus; ST, semitendino-
sus; S, sciatic nerve; IT, ischiatic tuberosity; F, femur
6 Hip
90
Fig. 6.20a Probe position to evaluate the ham-
strings’ insertion into the ischiatic tuberosity on an
axial plane
Fig. 6.21a Probe position to evaluate the ham-
strings’ insertion into the ischiatic tuberosity on a
longitudinal plane
Fig. 6.20b The axial scan shows the tendinous insertion of the
long head of the biceps femoris (1), semitendinosus (2) and
semimembranosus (3) muscles. IT, ischiatic tuberosity
Fig. 6.21b The longitudinal scan shows the tendinous insertion
(*) of the semitendinosus (St) and semimembranosus (Sm) ten-
dons into the ischiatic tuberosity (IT)
Posterior hip
91
Fig. 6.22a Probe position to evaluate the sciatic
nerve on an axial plane
Fig. 6.22b The axial scan shows the sciatic nerve (arrowheads)
on a short axis
Fig. 6.22c Longitudinal scan of the sciatic nerve (arrowheads);
ST, semitendinosus muscle belly; BF, biceps femoris muscle belly
The knee can be divided into four compart-
ments: anterior, medial, lateral and posterior.
7.1 Anterior Compartment
The patient lies supine with the knee flexed at
about 30–45° to correctly stretch the patellar
and the quadriceps tendons (Fig. 7.1).
Anatomical scheme of the anterior compart-
ment of the knee is reported in Fig. 7.2.
7.1.1 Quadriceps Tendon
The quadriceps tendon must be scanned on
both a long and short axis. The longitudinal
view is obtained by orienting the probe on a
sagittal plane and placing the distal edge on the
patella (Figs. 7.3a, b). The typical multi-lay-
ered appearance of the tendon is due to the
overlap of the different tendinous aponeuroses
that concur to build the quadriceps tendon
(Figs. 7.4a, b). This appearance may be more or
less clear close to the insertional region, as the
amount of adipose tissue interspersed between
tendon layers may vary.
Moving the probe cranially, the myotendi-
nous junctions of the quadriceps femoris can be
seen. Note that the rectus femoris junction is
located more proximally than the others (Figs.
7.5a, b).
Knee
7
Content s
7.1 Anterior Compartment
• Quadriceps Tendon
• Suprapatellar and Paracondylar Recesses
• Femoral Trochlea
• Patellar Retinacula
• Patellar Tendon or Ligament
7.2 Medial Compartment
• Medial Collateral Ligament
• Goose’s Foot Tendons
7.3 Lateral Compartment
• Iliotibial Tract
• Lateral Collateral Ligament
7.4 Posterior Compartment
• Medial Tendons
• Semimembranosus Bursa
• Popliteal Neurovascular Bundle
• Posterolateral Corner and Biceps Femoris
• Peroneal Nerve
93
E. Silvestri, A. Muda, L. M. Sconfienza, Normal Ultrasound Anatomy of the Musculoskeletal System,
© Springer-Verlag Italia 2012
Fig. 7.1 Lower limb position to
evaluate the anterior compartment
of the knee
Fig. 7.2 Anatomical scheme of quadriceps (QT) and
patellar tendons (PT). F, femoris; T, tibia; Fi, fibula;
P, patella (under PT)
The quadriceps muscle is made up of four
separate heads: vastus lateralis, vastus
intermedius, vastus medialis (mono-articu-
lar muscles) and the rectus femoris muscle.
This latter is the only bi-articular muscle.
With its fibers, it forms a sort of sleeve
around the femoral shaft and it relates to
the hamstrings and the adductor muscles
distally.
The four heads join about 8–10 cm proximally
to the insertion on the patella, contributing to
form a three-layered tendon in which the super-
ficial layer is a prosecution of the rectus femoris,
the intermediate layer belongs to the vastus me-
dialis, and the vastus lateralis, and the deep lay-
er belongs to the vastus intermedius. Some ten-
don fibers insert on the patella, while the others
continue to form the patellar tendon, then in-
sert on the anterior tibial apophysis.
7 Knee
94
Fig. 7.3a Probe position to
e
valuate the quadriceps ten-
don on a longitudinal scan
Anterior Compartment
95
Fig. 7.3b US scan shows the characteristic layered appearance of
the quadriceps tendon (arrowheads). P, upper pole of patella
Fig. 7.4a Position of the probe
for evaluation of quadriceps ten-
don along the short axis
Fig. 7.4b Quadriceps tendon on its short axis (arrowheads). F, femur
Fig. 7.5a Probe position to
evaluate the quadriceps femoris
myotendinous junctions
Fig. 7.5b Quadriceps femoris myotendinous junctions. VL, vastus lateralis; RF,
rectus femoris; *, rectus femoris myotendinous junction; VM, vastus medialis;
VI, vastus intermedius ; F, femur
7.1.2 Suprapatellar and Paracondylar
Recesses
The lower limb must be kept in the same posi-
tion described above to evaluate the quadriceps
tendon.
The suprapatellar fat pad (Figs. 7.6a, b) is
located under the quadriceps tendon and proxi-
mally to the superior pole of the patella. The
suprapatellar synovial recess can be seen as a
large hypoechoic space between the suprapatel-
lar fat pad and the prefemoral fat pad that lies
deeply, over the distal third of the femur.
In physiological conditions, the amount of
synovial fluid contained within the suprapatel-
lar synovial recess is very low. To detect the
presence of intrarticular effusion, dynamic
scans can be performed, asking the patient to
flex the knee completely or to contract the
quadriceps muscle. Paracondylar recesses can
be assessed performing longitudinal and axial
scans of the lateral and medial sides of the
quadriceps tendon (Fig. 7.6c).
7.1.3 Femoral Trochlea
The knee must be positioned in full flexion. On
the axial scan, the femoral trochlea and the
overlying articular cartilage (Fig. 7.7a) can be
seen. When normal, the articular cartilage is
characterized by a hypo/anechoic and homoge-
neous echotexture, while the bony surface of
the trochlea is represented by an underlying
hyperechoic line (Fig. 7.7b).
7.1.4 Patellar Retinacula
Anatomical scheme of the patellar retinacula is
showed in Fig. 7.8. Medial and lateral retinacula
can be evaluated by axial scans on the medial and
lateral side of the patella, respectively. They
appear as bilayered structures that can hardly be
differentiated from the underlying joint capsule
(Figs. 7.9a, b).
7 Knee
96
Anterior Compartment
97
Fig. 7.6a Probe position to
evaluate the suprapatellar
recess
Fig. 7.6b The sonogram shows the
physiological fluid distension of the
suprapatellar recess (*) under the
quadriceps femoris tendon (arrowheads).
F, femur; P, proximal patellar pole;
ffp, prefemoral f
at pad; pfp, suprapatellar
fat pad
Fig. 7.6c Paracondylar recess (arrow-
heads) distended by a minimal
amount of fluid. C, femoral condyle