Ultrasound of the Knee Joint. Jun Sung Park,M.D. Bundang General Hospital Dept. of Rehabilitation Medicine

Transcription

1 Ultrasound of the Knee Joint Jun Sung Park,M.D. Bundang General Hospital Dept. of Rehabilitation Medicine

2 Clinical History and P/E Chronic or Acute Symptoms Chronic Sx. : possible of systemic articular disorders rheumatoid and psoriatic arthritis : repeatitive microtrauma (sports activities ) Acute Sx. diffuse knee pain : joint? more local knee pain : tendon or local lesion?

3 Inspection, Palpation, Range Both knee comparison Local areas of increased temp. Range of motion of knee joint : flexion and extension Meniscus Collateral ligaments Cruciate ligaments

4 Knee joint evaluation MRI study : best of choice MSUS study : limitation (meniscus, cruciate ligaments)

5 Probe frequency 10 ~ 15 MHz linear Probe : anterior, medial, lateral knee aspect 5 MHz Probe : Popliteal area, GCM,

6 Panoramic view 긴구조물을평가하는데큰도움이된다. Large cysts Enlarged bursa Medial collateral ligament Anterior knee aspects

7 Anterior Knee Supine position. Knee flexion of 20 ~ 30 by small pillow Avoid anisotrophy : Patellar tendon을 extension 시킨다. Examination starting from cranial to caudal.

8 Anterior Knee Supine position. Knee flexion of 20 ~ 30 by small pillow

9 Anterior Knee 검사할주요구조물들 Quadriceps tendon. Suprapatellar synovial recess Suprapatellar fat pad Prefemoral fat Femoral condyle

10 Anterior Knee : quadriceps tendon Probe position : longitudinal scanning. Proximal : quadriceps muscles Distal : edge on the patella Quadriceps tendon stretched. - US beam : perpendicular to long axis - Hyperechoic fibrillar apperance.

11 Anterior Knee : Quadriceps Multilayered appearance by high-frequency probes.(both long- and short-axis planes) 1) superficial layer : rectus femoris 2) intermediate : vastus lateralis & medialis 3) deep layer : vastus intermedius Superficial layer is always evident. 2) & 3) 은구분이가지않을경우가많다.

12 Suprapatellar tendon area Rectus femoris tendon 1. suprapatellar fat pad 2. prepatellar fat

13 Anterior Knee : Recess Suprapatellar synovial recess can be identified with US. Two fat pads (suprapatellar and prepatellar)

14 Anterior Knee : Recess Small effusion is suspected? in supine position : isometric contraction of quadriceps : ankle dorsiflexion with knee extension : check out parapatellar recesses.(med & lat) MRI 검사는 fluid 의위치가파악이되지만, MSUS 에서는직접구석구석찾아야한다.

15 Parapatellar recesses

16 Anterior Knee Suprapatellar Plica (Reminants of embyonic life) intrauterine 5 개월 : septum formation complete septum found in 12% of normal

17 Anterior Knee FEMORAL TROCHLEA ; full flexion of knee transverse plane trochlea cartilage appears as a hypoechoic line in normal condition, thicker in central portion. mean thickness ranges : 1.8 ~ 2.5 mm

18 Anterior Knee : infrapatella Supine position : 20 ~30 knee flexion Infrapatellar tendon : 4~5 mm AP thickness Infrapatellar portion V Shaped appearance Proximal 1/3 * Distal 1/3 * * thickened

19 Anterior Knee : infrapatella Increased thickness of the prox. & distal 1/3

20 Anterior Knee Deep to the patellar tendon : Hoffa Pad appears as a fatty tissue space - hyperechoic septations Deep infrapatellar bursa : small synovial cavity between distal portion of patellar tendon and ant. aspect of tibial epiphysis.

21 Bursa Diagnosis of bursa - large effusions or local pain generated by pressure with the probe Prepatellar bursa - located subcutaneous tissue. - thin wall, absence of internal fluid. - if detected minimal amout of fluid, sign of inflammation(prepatellar bursitis)

22 Medial Knee Best exam position : leg external rotated Anatomy : medial collateral ligament, medial femorotibial joint space, medial meniscus and pes anserinus complex. US assessment of the medial asepct begins with medial collateral ligament.

23 Medial Knee medial collateral ligment Elongated band 1~3 mm thick Formed by two hyperechoic layers Superficial part Deep meniscofemoral and meniscotibial component (separated by a slight hypoechoic line related to fatty tissue) On transverse planes, superficial comp. as a small, crescentic shaped hyperechoic structure.

24 Medial Knee Medial Meniscus Triangular hyperechoic structure. Difficult to obtain the image by US Attenuation of the US beam its small size Vagus stress by widening of medial joint space Increased visibility of the medial meniscus.

25 Medial Knee Pes Anserinus complex Sartorius, gracilis, semitendinosus Insert into the anteromedial aspect of the tibial metaphysis 5~6 cm below the joint line. More proximal level(hamstring) : 구분이가능하다. Tendon insertion level : 구분이전혀앆된다.

26 Lateral Knee Supine position to rotate the leg internally. evaluate from anterior to posterior Distal iliotibial band External femorotibial joint space Lateral meniscus Lateral collateral ligament Popliteus tendon Superior tibiofibular joint.

27 Lateral Knee Iliotibial band Best imaged on long-axis scans Insertion Land mark : Gerdy s tubercle, anterolateral aspect of the tibial epiphysis. Local compression : painful in tendinitis

28 Lateral Knee Lateral meniscus Intrisic limitation as medial meniscus Smaller than the medial meniscus Meniscal cyst : knee forceful flexion bulging of the cyst outside the joint space

29 Lateral Knee Lateral collateral ligament Cordlike fibrillar structure Located at posterolateral aspect of the joint. Inserts into the lateral femoral condyle and the fibular head. 3~4 mm thick Lies in a more anterior plane than the biceps tendon. Best evaluated on oblique longitudinal scans and knee fully extension.

30 Lateral Knee popliteus Just deep to the proximal part of the lateral collateral ligament Popliteus tendon can be imaged on longitudinal US scans. Oval structure located in its bony groove.

31 Posterior Knee Lie prone position with knee extended For Baker s cyst(pedicle opening) : take different degrees of knee flexion position. 3 zone : internal( 내측 ), central, external( 외측 ) Internal zone에서볼수있는구조물들 - Pes Anserinus complex. - semimembranosus tendon. - semimembranosus-gastrocnemius bursa

32 Posterior Knee Semimembranosus-grastrocnemius bursa Baker s Cyst medial femoral condyle Posterior central zone medial head of the GCM (triangular shape) the popliteal artery and vein tibial nerve.

33 Posterior Knee Posterior external zone muscles and tendons of the biceps femoris lateral head of the gastrocnemius common peroneal nerve.

34 MUSCULOSKELETAL KNEE ULTRASOUND EXAMINATION 2010 AUGUST

35 Anterior Knee Supine position. Knee flexion of 20 ~ 30 by small pillow Avoid anisotrophy : Patellar tendon을 extension 시킨다. Examination starting from cranial to caudal.

36 검사할주요구조물 Anterior Knee Quadriceps tendon. Suprapatellar synovial recess Suprapatellar fat pad Prefemoral fat Femoral condyle

37 Anterior

38 Anterior

39 Anterior

40 Medial Knee Best exam position : leg external rotated Anatomy : medial collateral ligament, medial femorotibial joint space, medial meniscus and pes anserinus complex. US assessment of the medial asepct begins with medial collateral ligament.

41 Medial

42 Medical Collateral Ligament

43 Medical Meniscus

44 Lateral Knee Supine position to rotate the leg internally. evaluate from anterior to posterior Distal iliotibial band External femorotibial joint space Lateral meniscus Lateral collateral ligament Popliteus tendon Superior tibiofibular joint.

45 Lateral Collateral Ligament LCL LCL LCL appears as homogeneous, hyperechoic bands

46 Lateral Lateral asepct of the knee 1) internal rotation with full extension 2) lateral decubitus position 3) lateroposterior structures, prone. - iliotibial tract on Gerdy s tubercle (proximal tibia) - popliteal tendon origin, - lateral collateral ligament on fibular head (hyperechoic and fibrillar echotexture) - distal biceps femoris tendon (less compact fibrillar echotexture & associated with hypoechoic muscle)

47 Lateral Knee Gerdy s tubercle Fibular head

48 Iliotibial band

49 Posterior Knee Lie prone position with knee extended For Baker s cyst(pedicle opening) : take different degrees of knee flexion position. 3 zone : internal( 내측 ), central, external( 외측 ) Internal zone에서볼수있는구조물들 - Pes Anserinus complex. - semimembranosus tendon. - semimembranosus-gastrocnemius bursa

50 Posterior Knee Semimembranosus-grastrocnemius bursa Posterior central zone medial head of the GCM (triangular shape) the popliteal artery and vein Posterior external zone muscles and tendons of the biceps femoris lateral head of the gastrocnemius common peroneal nerve.

51 Posterior Knee Rt. Medial GCM insertion

52 Posterior Knee semitendinosus and med. GCM head Medial femoral condyle : insertion of medial GCM head

53 Posterior Knee transverse scan Popliteal artery and vein

54 Disease of the KNEE

55 Suprapatellar Bursitis

56 Suprapatellar Bursitis

57 Villonodula Synovitis

58 Osgood-Schlatter Disease

59 Osgood-Schlatter Disease

60 Collateral Ligament

61 Collateral Ligament After Acute Injury local tenderness & reflective muscle spasms difficult to gait and weight bearing Knee Instability gradually subside spontaneousn pain & tenderness weakness, giving way, muscle atrophy more severed knee instability

62 Medical Collateral Ligament Rupture tear after forceful valgus stress. If not treated, a painful granuloma / calicification. usually located at the prox. insertion. Complete rupture concurrent with ACL rupture and medial meniscal tear

63 Medical Collateral Ligament Rupture identified by an interruption in the hyperechoic bands that represent the superficial and deep components. Fluid fills the gap : either hypoechoic or anechoic Chronic injury : hypertrophic, excessive formation of granulation tissue and mucoid degeneration.

64 Medical Collateral Ligament

65

66 Medical Collateral Ligament

67 Medical Collateral Ligament

68 Medical Collateral Ligament

69 Latellar Collateral Ligament

70 Latellar Collateral Ligament

71 Meniscus

72 Meniscus Tear

73 Meniscus Tear

74

75 MR Imaging Criteria of Meniscal Tear Grade III : increased signal extending to articular surface Grade IV : several areas of high signal as well as deformity & fragmentation

76 Meniscal Tear in MSUS Hypoechoic or anechoic cleft through meniscus that extend to articular surface Defect in the hyperechoic meniscus

77 Medical Meniscus MCL Femur Tibia Tear in posterior horn of left medial meniscus.

78 Medial Meniscus Tear Femur Tibia Right knee reveals longitudial and radial tear

79 Lateral Meniscus Tear Femur Tibia Rt. Knee shows tear and lateral inferior displacement (Flap tear).

80 Lateral Meniscus Tear with Meniscal Cyst Right lateral meniscus tear, with suspected meniscal cyst posterolateral to lateral femoral condyle, about 26 x 21 x 11 mm in size.

81 Infrapatella

82 Infrapatella Tendinitis

83 Infrapatellar Tendinitis Patellar tendon shows diffuse swelling with inhomogeneous echotexture and slightly increased vascularity proximally.

84 Chondrocalcinosis Medial meniscus shows intrameniscal amorphous echogenic area, especially posterior.

85 Baker s cyst (Popliteal Cyst) Origin : from the posteromedial aspect situated between the medial head of the GCM and the semimembranosus tendon. Divided three portions anatomically. the base, superficial extent and neck.

86 Baker s cyst (Popliteal Cyst) Some limitation of flexion Cysts occur most often when the knee is damaged due to arthritis, gout, injury, or inflammation in the lining of the knee joint

87 Baker s cyst (Popliteal Cyst) not communicate at birth but developed during growth synovial proliferation in inflammatory disease. - increased intraarticular fliud & arthritis - fracture, cartilage defects, meniscal lesion and loose bodies.

88 Baker s cyst (Popliteal Cyst)

89 Bursa

90

91 Prepatellar Bursitis Prepatella Bursa The most frequent type of bursitis, especially in patients who have to kneel repeatedly in their work Patient complains of pain and swelling in front of knee Diagnosis is made on simple inspection If swelling is gross, limitation of flexion Palpation shows effusion to lie between skin and patella

92 Prepatella Bursa Fluid collection with thickened wall infrapatellar portion of right knee without definite increased vascularity

93 Prepatella Bursa Presence of heat suggests hemorrhage into bursa Heat and redness indicate possibility of sepsis

94 Infrapatella Bursa

95 Medial Collateral Liagment Bursa Usually middle aged women Complains of localized pain at medial side of knee Flexion is limited by O Painful valgus strain and lateral rotation Differential diagnosis: meniscal cyst, chronic ligament sprain

96 Medial Collateral Liagment Bursa MCL

97 Medial Collateral Liagment Bursa MCL

98 THANKS FOR YOUR ATTENTION!