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MSK ULTRASOUND Ramon Ylanan, MD CAQSM
Team Physician University of Arkansas Razorbacks Director Primary Care Sports Medicine Fellowship UAMS NW Assistant Professor Family and Preventative Medicine UAMS NW
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Conflicts of Interest I have no conflicts of interest regarding this presentation, nor do I support one manufacturer over another
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Objectives Recognize basic scanning techniques, probe placement and probe orientation Differentiate between common structures such as muscle, tendon, ligament and bone Outline appropriate uses for diagnostic ultrasound and terminology Identify common findings associated with tendinopathy
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Outline Principles of Sound MSK US 101 Pathology under US
Equipment Knobology Terminology Pathology under US Advantages and limitations to MSK US
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Outline Principles of Sound MSK US 101 Pathology under US
Equipment Knobology Terminology Pathology under US Advantages and limitations to MSK US
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Principles of Sound It’s all about frequency
<20Hz (lower frequency) Whales, elephants 20Hz -20kHz (audible sound) Humans >20kHZ (higher frequency) Dogs, dolphins, bats
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Principles of Sound Why is sound important in MSK US
Higher frequency sound Greater resolution Shorter depth of sound penetration Lower frequency sound Less resolution Greater depth of sound penetration
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Principles of Sound How does it work in MSK US
Transducer crystals produce sound waves Piezoelectricity conversion of electricity to sound Sound bounces off structures and returns to transducer crystals Picture is dependent on stiffness and/or density of acoustic interface (structure) Each body part type has a different acoustic signature Transducer converts sound waves into electricity which machine converts into a picture Reverse-piezoelectricity conversion of sound into electricity
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Outline Principles of Sound MSK US 101 Pathology under US
Equipment Knobology Terminology Pathology under US Advantages and limitations to MSK US
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MSK 101: Equipment Console Transducers
GE, Sonosite, Terason, Arthrex, etc Each have pros and cons Cost ranges $20,000-$100,000 Personal preference Transducers Linear array transducer Compact linear array transducer Curved linear array transducer
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MSK 101: Equipment Transducers Linear array transducer
Workhouse of MSK US High frequency Superficial structures Able to scan most parts Shoulder Knee Elbow High resolution
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MSK 101: Equipment Transducers Compact linear array transducer
“Hockeystick” Subspecialty Very high frequency Small joints Very superficial structures High resolution
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MSK 101: Equipment Transducers Curved linear array transducer
Lower frequency Deep structures Hip Abdomen Lower resolution
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MSK 101: Knobology Each machine Modes Depth Gain
different layout, same principles Modes B-mode is common MSK scanning mode Depth Control depth of field of view Can be modified for each transducer, but has limits Gain Volume or picture brightness Just like listening to music, operator dependent
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MSK 101: Terminology Already got some
Transducer, piezoelectricity, etc Long axis – longtitudinal picture of target Short axis – cross sectional picture of target Anisotropy – poor picture due to poor scanning technique Sound wave/transducer was not perpendicular to target
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MSK 101: Terminology Anisotropy
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MSK 101: Terminology Hyperechoic – brighter gradient, relatively more dense Bone, tendon, ligament Hypoechoic – darker gradient, relatively less dense More solid cysts Isoechoic – grey gradient, relatively equal density Muscle Anechoic – very dark gradient, Vessels or fluid pockets
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MSK 101: Terminology
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MSK 101: Terminology Procedure In plane vs out of plane
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Outline Principles of Sound MSK US 101 Pathology under US
Equipment Knobology Terminology Pathology under US Advantages and limitations to MSK US
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MSK Pathology under US Muscle Tendon Ligament Vessles Nerves Bone
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Muscle Long axis feather-like, pennate
Short axis starry night appearance
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Muscle Not this starry night!
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Muscle
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Muscle Hamstring tear
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Tendon Achilles Tightly packed, fibers of a broom, fibrillar Normal
Tendinosis/Degeneration
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Tendon Patellar tendon Normal long axis Proximal patellar tendinosis
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Tendon Rotator Cuff
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Ligament MCL Similar characteristics to tendon (broom, fibrillar)
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Ligament Elbow UCL
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Vessels Femoral triangle N - nerve A - artery V - vein E - empty
L - lymphatics
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Nerve Carpal Tunnel Honeycomb in short axis Fascicular in long axis
(not as tighly packed as tendon)
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Bone Hip
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Outline Principles of Sound MSK US 101 Pathology under US
Equipment Knobology Terminology Pathology under US Advantages and limitations to MSK US
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MSK US: Advantages High resolution imaging of soft tissue
Real-time imaging with dynamic evaluation Patient experience and education Not affected by hardware Just can’t scan deep to the hardware
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MSK US: Advantages Guided injections Portable No radiation
Inexpensive for patients
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MSK US: Limitations Focal/limited field and depth of view
MRI better for wider field of view Limited with eval of bone or intra-articular pathology Operator dependent Picture quality depends on sonographer skill
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MSK US: Limitations Education is post-training
Building into fellowships now Cost to provider for equipment Purchase vs rent Quality of image depends on multiple factors Patient position Machine Sonographer skill
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Basic Principles of MSK US
Know the question What do you want to answer? Is US the modality to properly eval? Keep patient comfortable If patient is uncomfortable, results will be limited Select appropriate transducer Know you anatomy, know transducer limitations
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Basic Principles of MSK US
Keep control of transducer If it’s not stable, poor picture quality Hard to hit a moving target Take your time Using a 2D slice to reconstruct a 3D structure Must use multiple planes to properly scan
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Scanning Time
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References Smith, J. Finnoff, JT. Diagnostic and Interventional Musculoskeletal Ultrasound: Part 1. Fundamentals. PM&R 2009;1:64-75. Smith, J. Finnoff, JT. Diagnostic and Interventional Musculoskeletal Ultrasound: Part 2. 6th ed. Philadelphia, PA. WB SaundClinical Applications. PM&R 2009;Vol 1: Kremkau F. Diagnostic Ultrasound: Principles and Instruments.ers; 2002:428 Nazarian L, McShane J, Ciccotti M, et al. Dynamic US of the anterior band of the ulnar collateral ligament of the elbow in asymptomatic major league baseball pitchers. Radiology 2003;227: O’Conner P, Grainger A. Ultrasound imaging of joint disease. Imaging 2002;14:
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