2. Musculoskeletal Ultrasound Topics What is ultrasound ? How does it work ? Equipment Artefacts Safety What does it offer to those interested in musculo-skeletal problems ?

3. What Is Ultrasound? Sound waves with frequency above 20,000hz. Frequency for musculoskeletal use 5 to 25 mega hz Use of ultrasound depends on detecting echoes.

4. Components of an Ultrasound System Source of ultrasound waves Echo detection system Computer processing Image Display Image storage

5. Ultrasound Production and Detection Systems Piezo-electric crystals Vibrate when exposed to electrical current Produce electrical output when excited by vibration. Parallel arrays Acoustic focussing 1% of time emitting ultrasound 99% of time listening

6. Piezo electric crystals Ultrasound waves Ultrasound Production and Detection Systems Focussing by acoustic lens

7. Piezo electric crystals Ultrasound waves Processing Ultrasound Production and Detection Systems

8. Piezo electric crystals Ultrasound waves Cyst

9. Ultrasound Processing and Display Huge progress with advances in computers. Display modes B Mode - brightness mode, grey scale

10. Ultrasound Equipment Radiology department based systems £120-150K Philips, Siemens, GE, Accuson, etc Late 1990’s new companies involved. Dedicated musculo-skeletal machines. Portable machines

11. Diasus Musculoskeletal Ultrasound Dedicated musculoskeletal machine £30-35 K Variety of probes The machine I trained on and still use regularly. No colour Doppler

12. Portable/Hand Held Ultrasound Machines Sonosite Portable can be run off battery. 5-10mHz probe for musculoskeletal work £15 – 25 K

13. Sonosite Portable Machines Handheld Version Makes Imaging Technology Battle-Ready Ultimate Ultrasound March 28 — A technology widely used for a glimpse at the soon-to-be-born has now been turned into a battlefield unit that may help keep soldiers from dying in Iraq.

14. What Do You Need To Perform Ultrasound Successfully ? Equipment Training Anatomy knowledge Time

15. What Does Ultrasound Offer Diagnosis Assessment of disease activity and treatment monitoring Guiding procedures –Aspiration 3x normal likely to obtain fluid –Injection accuracy increased from 59% to 96%

16. Diagnosis Extends clinical examination More sensitive for detecting effusions and synovitis than clinical exam Better than MRI for tendon and tendon sheath problems 7-10 x more sensitive than plain x-ray at detecting erosions. Equals MRI for detecting synovitis and erosions. Equals MRI for soft tissue shoulder problems.

17. Safety Issues BMUS Guidelines British Medical Ultrasound Society 15 points 1.Medical endorsement 2.Operator training 3.Awareness of machine factors 4.Initial power setting 5.Exposure time 6.Stationary probe 7.Probe self heating 8.Pre-existing temperature elevation 9.Sensitive tissues 10. Pulsed doppler 11. Thermal and mechanical indices 12. Doppler for fetal heart monitoring 13. Peripheral pulse monitoring 14. Transcranial ultrasound 15. Non-diagnostic uses of ultrasound equipment

18. Future Developments 2D, 3D, 4D High resolution power Doppler Microbubble contrast

19. Future Developments High resolution power Doppler Microbubble contrast

20. Future Developments Panorama Views

21. Advantages of Musculoskeletal Ultrasound Increasingly available No major safety issues Extends clinical examination More sensitive than plain radiology As sensitive as MRI for erosions and synovitis. Allows more accurate injection and more successful aspiration. Dynamic, allows movement.

22. Ultrasound of Normal Musculoskeletal Tissues

23. Tendon and ligament Muscle Nerve Bone Joints Cysts, bursi and effusions Blood vessels Fat

24. Tendons

25. Muscle Longitudinal Cross section

27. Nerves

28. Bone

29. MCP Joint MCP head Phalangeal head Cartilage Extensor tendon

30. Bursi, Cysts and Effusions Pre-Tibial Bursitis

31. Knee Effusion Cyst

32. Artery

34. Veins

35. Fat

36. Common Artefacts Anisotropy Reverberation Acoustic shadowing Increased transmission through cyst

37. Piezo electric crystals Ultrasound waves Anisotropy

38. Anisotropy Achilles Tendon

39. Reverberation

40. Piezo electric crystals Ultrasound waves Bone Acoustic shadowing

42. Increased Transmission Thru Cyst

43. Ultrasound Pathology Hand and Wrist

44. Tenosynovitis

45. Flexor Tenosynovitis

46. Joints

47. Erosions 1-2mm erosion 2-4mm erosion >4mm erosion Thanks to David Kane

48. Effusions and Synovitis Thanks to David Kane

49. Assessment of Synovitis using Power Doppler MCP joint Erosion

50. Normal US 1 st MTP

52. . Patella tendonitis or jumpers knee. Patella tendon insertion hypo-echoic and swollen. Patella Patella tendon Hypo-echoic area

53. Osgood Schlatters Patella tendon Tibial tuberosity

54. . Baker’s Cyst Cyst

55. . Medial head of gastrocnemius Bakers Cyst

56. Muscle Tears

57. Achilles Tendinopathy

59. Calcification in Achilles Tendon

60. Achilles Tendon Insertion Problems

61. Achilles Tendon Rupture

62. Tibialis Posterior Tenosynovitis

63. Stress Fractures