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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5833_Библиотеки_им_академика_М_И_Перельмана.pdf
Fig. 2.8 Position of the upper limb to
evaluate the subscapularis tendon
2.2 Subscapularis Tendon
The subscapularis muscle arises from the
subscapular fossa; most fibers are directed
upwards and laterally, running under the
coracoid, anterior to the glenohumeral
joint, and insert on the humeral lesser
tuberosity. The coracohumeral ligament
appears like a fibrous lamina, arising from
the coracoid. It is divided into two bundles.
The thicker one inserts on the humeral
greater tuberosity and merges with the joint
capsule, while the thinner is directed later-
ally and merges with the humeral insertion
of the subscapularis tendon (Fig. 2.7).
Keeping the probe on the bicipital groove,
the forearm should be extrarotated to expose
the subscapularis tendon. Note that the elbow
must be as close as possible to the thoracic
wall (Figs. 2.8 and 2.9a).
On the long axis, the subscapularis tendon
should be evaluated sliding the US transducer cau-
dally (Figs. 2.9a, b). Including the coracoid in the
scan also allows evaluation of coracohumeral lig-
ament. The subscapularis must then be evaluated
on the short axis (Fig. 2.10a), turning the probe 90°
2 Shoulder
14
Fig. 2.7 Anatomical scheme of subscapularis tendon
(SS). H, humerus; C, coracoid; A, acromion;
*, long head of biceps tendon
clockwise (Fig. 2.10b). This scan shows the com-
plex anatomy of the subscapularis tendon, formed
by an alternation of tendinous and muscular fibers.
This scan is particularly helpful in the case of par-
tial tears to assess the longitudinal extension of the
split.
Subscapularis Tendon
15
Fig. 2.9a Probe position to evaluate
the subscapularis tendon
Fig. 2.9b Longitudinal
scan of the subscapularis
tendon (*). H, humerus;
Co, coracoid;
Arrowheads,
coraco-humeral ligament
2 Shoulder
16
Fig. 2.10a Probe position to evaluate
the subscapularis tendon along its
short axis
Fig. 2.10b The short axis
scan shows the typical
appearance of the subscapu-
laris tendon, formed by an
alternation of tendinous
(arrowheads) and muscular
fibers. H, humerus
2.3 Supraspinatus Tendon and
Subacromial-Subdeltoid Bursa
(SASD)
The supraspinatus muscle is located in the
fossa supraspinata of the scapula. It arises
from the medial third of the supraspinata
fossa and from the homonymous fascia
(Fig. 2.11). Its bundles are directed lateral-
ly, run behind the clavicle lateral edge,
behind the acromion and the coracoacromi-
al ligament, inserting on the superior bor-
der of the humeral greater tuberosity.
The subacromial-subdeltoid bursa (SASD)
is a wide mucous bursa that lies over the
supraspinatus tendon. It is formed by a sub-
acromial part (located between the superior
face of the joint capsule and the inferior face
of the acromion) and a deltoid part (located
deep to the deltoid muscle).
Move patient upper limb from the position
used to evaluate the subscapularis tendon so his
hand is on the posterior region of the iliac wing (on
his “back pocket”). Note that the flexed elbow
should be as medial as possible (Fig. 2.12).
Supraspinatus Tendon and Subacromial-Subdeltoid Bursa (SASD)
17
Fig. 2.11 Anterior view of the shoulder. The supraspina-
tus tendon (*) runs within the subacromial space up to its
insertion on the humeral greater tuberosity
. Arrowheads,
subacromial-subdeltoid bursa; D, deltoid muscle; H,
humerus; G, glenoid; A, acromion; C, clavicle
Fig. 2.12 Position of the upper limb to evaluate
the supraspinatus tendon
2 Shoulder
18
Fig. 2.13a Probe position to evaluate the supraspinatus
tendon along its longitudinal axis
Fig. 2.13b The scan shows
the supraspinatus tendon
(longitudinal axis); *,
insertional area; arrowheads,
cartilage; arrow, anatomical
humeral neck; empty arrow-
heads, subacromial-subdel-
toid b
ursa; H, humerus
Once the tendon is identified, the probe
should be oriented along the long axis of the
tendon (Fig. 2.13a). A correct scan is obtained
when the humeral head cartilage, the anatomi-
cal neck of the humerus and the greater humer-
al tuberosity are seen together (Fig. 2.13b). The
tendon is limited anteriorly by the LHBBT.
Anisotropy artifacts could particularly affect
the insertional area of the tendon on the humer-
al neck. To avoid these artifacts, slightly tilt the
probe laterally to have the US beam as perpen-
dicular as possible to tendon fibers.
Supraspinatus Tendon and Subacromial-Subdeltoid Bursa (SASD)
19
Fig. 2.14b *, supraspinatus tendon;
H, humerus; L, LHBBT
Fig. 2.14a Probe position to evaluate the supraspinatus
tendon along its short axis
US can only show the portion of the sub-
acromial-subdeltoid bursa located superficial-
ly to the supraspinatus tendon and deep to the
deltoid muscle (Fig. 2.13b), while the portion
located deeply to the acromion cannot be
evaluated. For a complete evaluation of the
bursa, anterior, posterior, and lateral scans
should be performed.
After evaluating the supraspinatus tendon
along its longitudinal axis, the probe should
be rotated 90° clockwise (Fig. 2.14a) to
assess the short axis (Fig. 2.14b).
The patient sits opposite the examiner, with
the arm along the body.
Position the probe with the medial edge on
the coracoid and turn the lateral edge medially
and cranially to the acromion (Fig. 2.16a) to see
the coracoacromial ligament (Fig. 2.16b).
2.4 Coracoacromial Ligament
The coracoacromial ligament is a thin trian-
gular fibrous band, which links the acromion
with the lateral edge of the coracoid, being
part of the bony-fibrous roof above the
glenohumeral joint. Its medial end inserts on
the lateral edge of the coracoid, while its lat-
eral end inserts on the lateral edge of the
acromion (Fig. 2.15). The superficial side of
the ligament is covered by the deltoid mus-
cle, while the lower is adjacent to the sub-
acromial-subdeltoid bursa and the supraspina-
tus tendon and muscle.
2 Shoulder
20
Fig. 2.16b Longitudinal
scan of the coracoacromial
ligament (arrowheads).
Co, coracoid;
Ac, acromion
Fig. 2.16a Probe position to assess the coracoacromial
ligament on the longitudinal axis. The medial edge of the probe
is located on the coracoid (C) and the lateral edge is rotated up
to the acromion (A)
Fig. 2.15 Anatomical scheme of the coraco-acromial lig-
ament (*). A, acromion; C, coracoid; H, humerus
2.5 Infraspinatus and Teres Minor
Tendons
The infraspinatus is a flat, triangular shaped
muscle, arising from the medial part of the
fossa infraspinata and from the infraspinatus
fascia. Its fascicles run laterally and the mus-
cle becomes a tendon that courses under the
acromion, inserting on the posterior facet of
the humeral greater tuberosity (Fig. 2.17).
The teres minor is a long, flat muscle. It aris-
es from the fossa infraspinata and runs up and
laterally, inserting on the posteroinferior face
of the humeral greater tuberosity. Some fibers
also merge with the glenohumeral joint cap-
sule (Fig. 2.18).
The patient sits opposite the examiner,
with their elbow flexed and palm on the oppo-
site shoulder (Fig. 2.19).
The probe should be oriented vertically to
localize the scapular spine, which separates
the fossa supraspinata from the fossa infra-
spinata (Fig. 2.20a). Within the fossa infra-
spinata, infraspinatus and teres minor mus-
Infraspinatus and Teres Minor Tendons
21
Fig. 2.17 Posterior view of the infraspinatus muscle and
tendon (IS). A, acromion; S, spine of the scapula; H,
humerus
cles can be seen. The probe should then be
slid laterally to assess both tendons on a short
axis view (Fig. 2.20b).
Turn the probe by 90° and asses each ten-
don along its longitudinal axis (Figs. 2.21a-c,
2.22a-c).
For a better view of insertional region of
the tendon it is useful to have the patient’s
arm slightly externally rotated.
US can also be used to assess the gleno-
humeral joint posterior recess. Slide the probe
medially on the posterior side of the joint and
extrarotate patient’s arm (in the same position
used to evaluate the subscapularis tendon)
(Fig. 2.23).
2.6 Acromion-Clavicular Joint
The acromion-clavicular joint (Fig. 2.24a)
can be assessed by placing the probe on a
coronal-oblique plane on the top of the shoul-
der (Fig. 2.24b). From this position, abduct
the patient’s upper limb flexed to 90 degrees
to evaluate the presence of subacromial
impingement of the supraspinatus tendon.
Fig. 2.18 Posterior view of the teres minor muscle and
tendon (TM). A, acromion; S, spine of the scapula; H,
humerus
2 Shoulder
22
Fig. 2.19 Position of the upper limb to evaluate the
infraspinatus and the teres minor tendons
Fig. 2.20a Probe position to evaluate the infraspinatus
and the teres minor muscles and tendons on a short
axis vie
w
Fig. 2.20b Extensor
tendons myotendi-
nous junctions. IS,
infraspinatus; TM,
teres minor
Infraspinatus and Teres Minor Tendons
23
Fig. 2.21a Probe position to evaluate the
infraspinatus tendon on the long axis
Fig. 2.21b *, infraspinatus
tendon insertional area;
H, humerus
Fig. 2.21c Infraspinatus tendon
course (arrowheads).
*, myotendinous junction;
H, humerus