2009/2/18. HRUS in Musculoskeletal system ( 超音波於骨骼肌肉及周邊神經糸統之應用 ) Tpe-VGH Radiology. Tpe-VGH Radiology. Tpe-VGH Radiology.

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1 HRUS in Musculoskeletal system ( 超音波於骨骼肌肉及周邊神經糸統之應用 ) 邱宏仁 醫師 台北榮民總醫院放射線部超音波科國立陽明大學醫學院 1/74 Examination Equipment HP SONOS 4500,, with 11-3L, 15-6L linear transducers Acuson Sequoia 512 with 13MHz linear transducer GE Logiq 700MR,, with 12MHz linear transducer ATL HDI 5000, with 12 MHz linear probe Standoff cushion (+/ -) 2/74 Neuro-Musculo-Skeletal System Muscle Tendon & ligament Peripheral nerve Synovial membrane Bone Normal US Anatomy of Muscle Endomysium (enveloped muscle fiber): Hypoechoic Perimysium (enveloped muscle fascicle): Echogenic fibroadipose septa Epimysium (enveloped total muscle): Echogenic 3/74 4 4/74 正常肌肉之超音波影像 Endomysium : Hypoechoic ( 低回音 ) Perimysium : Echogenic ( 高回音 ) Epimysium : Echogenic ( 高回音 ) Normal Muscle 5/74 6/74 1

2 Muscle Pathology Injury: compression, distraction (hamstrings, rectus femoris, triceps) Edema: Reverse echogenicity Infection Tumor 小腿肌肉部份斷裂 7/74 8/74 Calf muscle partial tear Calf muscle partial tear 9/74 10/74 股四頭肌部份斷裂 股四頭肌部份斷裂 12/99 02/00 05/00 09/00 11/74 12/74 2

3 FPL rupture RT Myositis Hyperechoic muscle fiber Hypoechoic septa Pyogenic myositis: abscess LT 13/74 14/74 Forearm myositis Calf abscess 15/74 16/74 Buttock abscess with gas US evaluation soft tissue tumor Composition of tumor (solid, cystic) Margin (smooth, infiltration) Extension Topographic anatomic relationship 17/74 18/74 3

4 Soft tissue tumor Benign Ganglion (Baker cyst), lipoma, hemangioma, neurogenic tumor, lymphangioma,fibroma, fibromatosis, muscle hypertrophy, hematoma,..etc. Malignant Metastasis, MFH, liposa, synovial SA, leiomyosa, lymphoma, Others: malignant schwannoma, rhabdomyosa, extraskeletal OGS, chondrosa,..etc. 19/74 Hand ganglion 20/74 Calf venous malformation Elbow lipoma 21/74 22/74 血管球瘤 (Glomus tumor) Myxoid liposa, Calf G Sag 23/74 24/74 4

5 Lymphoma 25/74 Tendon and Ligament Dense fibrous connective tissue with longitudinally oriented collagen fibrils Endotenon Peritenon Epitendineum (synovial sheath, paratenon) Fibrillary echogenic texture Hypo- or hyper- echogenecity depending on transducer angle (anisotropy artefact) 26/74 Anisotropy effect Achillodynia Inflammation Haglund s disease (dermis & hypodermis thickening) Retrocalcaneal bursitis Insertion tendonopathy, tendinitis Tendon rupture Tendon luxation 27/74 28/74 Achilles rupture Ankle Injury mechanism supination, inward rotation Lateral anterior fibula-talar ligament Medial flexor digitorum longus tendon Deltoid ligament 29/74 30/74 5

6 Anterior Talo-fibular Ligament 膝內側副靭帶部分斷裂 31/74 32/74 Quadriceps tendon rupture Lat. meniscus tear ĉ ganglion 33/74 34/74 Hip joint effusion Normal joint capsule: concave anterior Anterior joint capsule displaced 3mm Distension joint capsule 2mm more than normal side Hip Joint 35/74 36/74 6

7 US Criteria of Rotator Cuff Tear echogenicity of normal RC >= deltoid muscle. complete absent rotator cuff (+- subdeltoid fluid) focal thinning of RC (+- subdeltoid fluid) focal hypoechoic cleft of RC (+- subdeltoid fluid) focal depression of RC focal heterogeneous hypoechoic RC (+- subdeltoid bursa fluid) fluid in biceps tendon sheath and subdeltoid bursa Floating echogenic spots Normal rotator cuff (RC) 37/74 38/74 Non-visualization of RC Focal depression of RC 39/74 40/74 鈣化性肌腱發炎 Calcify tendonitis aspiration 41/74 42/74 7

8 Peripheral nerve Basic units: nerve fiber, embedded by endoneurium( 神經內衣 ) (hypoechoic) Neural fasciculus: embedded by perineurium( 神經束衣 )(echogenic lines) Peripheral nerve: embedded by epineurium( 神經外衣 ) (echogenic bold lines) (Murphey et al. Radiographics 1999;19:125 43/74 Normal peripheral nerve 44/74 Sural nerve traumatic neuroma Common pernoneal nerve: schwannoma 45/74 46/74 風濕免疫病症 經常侵犯 Synovial-linedlined 之關節滑液囊及肌腱腱鞘 其致病機轉為滑液膜發炎 增生, 之後 pannus 形成, 並導致軟骨及附近硬骨的破壞 Synovitis : 呈現相關之關節積液及滑液膜腫脹 Bursitis : 常呈現低回音或無回音之水囊 Tenosynovitis : 低回音且血流增加於腱鞘變厚區 47/74 US Application in Rheumatology Fluid collection Pannus US-guided aspiration or biopsy Evaluating response to treatment decreased fluid (48hrs post treated) decreased pannus formation 48/74 8

9 Biceps tenosynovitis Shoulder Arthritis 49/74 50/74 Joint involvement in RA (%) Hands 91 Wrist 78 Shoulder 65 Knees 64 Ankle 50 Feet 43 Elbow 38 Hips 17 TMJ 8 Spine 4 Sternoclavicular 2 51/74 RA: US presentation Synovitis: joint effusion, synovial swelling Bursitis: echo-free fluid accumulation Tenosynovitis: hypoechoic thickeing tendon sheath and hypervascularity Bony erosion: echoic cortical line discontinuity 52/74 Wrist RA RA: wrist with kenacort injection 7/31 7/31 LT RA 7/31 10/15 53/74 54/74 9

10 Articular recesses in RA Joint Shoulder Elbow Wrist Hip Knee Ankle Detection site Posterior recess Ant/post. Recesses Prestyloid recess Anterior recess Supra-patellar patellar recess Anterior recess 55/74 Elbow effusion 56/74 Baker cyst 57/74 Enthesitis Enthesis: a a union point between a tendon, ligament, or capsule to bone. Enthesitis: inflammation of enthesis Might associated adjacent bursitis. May occur in spondyloarthropathy, gout, mechanical stresses (trauma or joint instability) 58/74 Enthesitis: US findings edema, perientheseal effusion heterogeneous hypoechoic, insertional fusiform swelling, entheseal thinning and irregularity, bony erosion (later), multiple, irregular enthesophytes Psoriasis: Achilles tendon 59/74 60/74 10

11 M/13, RST pain, AS AS: PTT 61/74 62/74 Gout: Achilles tendon Bony cortex Trauma Ilizarov lengthening Tumor Osteomyelitis 63/74 64/74 Radial fracture Humeral head fracture 65/74 66/74 11

12 F/18, Fibula fracture Rib fracture 67/74 68/74 Rib fracture Paralysis, left arm About 40% rib fracture overlooked by CXR in minor blunt chest truma detected by US. (Kara et al. Eur J Cardiothorac Surg 2003;24: ) 613) 69/74 70/74 Humeral fracture Patella fracture with hemoarthrosis 71/74 72/74 12

13 尺骨骨折 Thanks for your attention 一個月後 73/74 邱宏仁 醫師 台北榮民總醫院放射線部超音波科 國立陽明大學醫學院 74/74 Intramuscular hemangioma Arm lipoma 75/74 76/74 MCL partial tear Hip joint effusion 77/74 78/74 13

14 Focal hypoechoic cleft Calcify tendinitis 79/74 80/74 Sonoanatomy of peripheral nerve Rounded hypoechoic areas surrounded by echogenic lines (reticular pattern) The nerve structure is very similar to the tendon. It also has apparently anisotropy effect and resulted in poorly defined in non- perpendicular section. 81/74 Sonoanatomy of peripheral nerve Rounded hypoechoic areas surrounded by echogenic lines (reticular pattern) The nerve structure is very similar to the tendon. It also has apparently anisotropy effect and resulted in poorly defined in non-perpendicular section. 82/74 Carpal tunnel syndrome Cubital tunnel syndrome 83/74 84/74 14

15 Neurofibroma Neurofibroma 85/74 86/74 Olecranon bursitis Prepatella bursitis 87/74 88/74 Biceps tenosynovitis RA: bursal abnormality Bursal synovial hypertrophy or fluid may be normal due to cushion effect. Shoulder subdeltoid bursitis might be due to impingement. D.D. with RA is bony erosion (usual in articular margin) Baker s cyst 89/74 90/74 15

16 RA: bone abnormality Joint cavity widening: synovial thickening +- effusion Bony erosion: major in 2nd MCP and 5th MTP, radial and ulnar aspect Size of erosion: small (<2mm): early RA, large (>4mm): late RA 91/74 RA: bony erosion Sensitivity of bony erosion: HRUS > plain film due to 3D capability and US can detect smaller erosions. Earlier therapeutic intervention of RA improves disease outcome. US might be an essential tool for clinicians managing patients with inflammatory arthritis, for diagnosis and monitor disease progression. (Wakefield RJ et al. Arthritis Rheum 42: , 2770, 2000) 92/74 RA elbow RA shoulder 93/74 94/74 Ankle RA Hand RA 95/74 96/74 16

17 Psoriasis: PTT DD of Proliferative synovitis 97/74 RA Septic arthritis: bacteria, TB Crystal induced arthropathies Amyloid arthropathy, PVNS Synovial osteochrondromatosis Hemophilic arthropathy Spondyloarthropathy 98/74 Hand abscess TB: Subdeltoid bursa MC 99/74 100/74 Gout Bursae Wine skin Separate joint capsule, tendon, ligament, fascia plane Subcutaneous (prepatellar bursa); Deep (retrocalcaneal bursa) Thin film of viscous fluid (1mm thick) 101/74 102/74 17

18 Olecranon bursitis Baker s cyst 103/74 104/74 Panniculitis of thigh Ganglion cyst 105/74 106/74 Lipoma Lymphadenitis 107/74 108/74 18

19 Biceps tenosynovitis Arthritis 109/74 110/74 Normal sciatic nerve Rheumatoid arthritis BF ST SM Involved synovial-lined lined joint capsule & tendon sheath. Mechanism: synovial inflammation, hyperplasia, pannus formation, cartilage and bony destruction 111/74 112/74 RA wrist LT RA RT RA 113/74 Crystal arthropathy US of gout: non-specific, subcutaneous edema, synovitis, enthesitis, urate crystal deposition, periarticular erosion. Chondrocalcinosis: less entheseal and erosive change. US: knee joint capsule and menisci calcification (calcium pyrophosphate) in all patients, 50% in capal disc calcified. 114/74 19

20 Gout: Big toe Calcify tendinitis 115/74 116/74 屈指肌腱斷裂 正常 117/74 Malignant soft tissue tumors MFH: well-defined, homogeneous soft tissue mass, calcify(?) LipoSA: ill-defined, heterogeneous, calcify(?) Synovial SA: variable peripheral margin, spotty calcification RhabdomyoSA: ill-defined, calcify(?) FibroSA: ill-defined LeiomyoSA, metastasis, etc. 118/74 Hip Joint RA: Hand 119/74 120/74 20

21 Myxoid liposarcoma 121/74 21