Musculoskeletal Ultrasound of the Knee, Foot and ankle
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1 Musculoskeletal Ultrasound of the Knee, Foot and ankle ADVANCED TEAM PHYSICIAN COURSE SAN DIEGO, CALIFORNIA DECEMBER 11TH 2016 Jonathan S. Halperin MD Learning objec-ves: Understand the basics of knee, foot and ankle MSK ultrasound scanning protocols Demonstrate the normal ultrasound echotexture of the tendons and ligaments in the knee, foot and ankle Recognize the important neurovascular structures in the knee, foot and ankle regions Be able to posixon the ultrasound transducer to demonstrate the bone acousxc landmarks in knee, Foot and ankle region ULTRASOUND OF THE LOWER LIMB Focused or target exam Transducers: Use Mhz for the foot and ankle, and an 8-13 Mhz transducer for the knee joint Assume a comfortable scanning posixon and then move the joint to assess ligament and joint laxity Follow tendons from myotendinous juncxon to bone inserxon Know your bone/osseous acousxc landmarks FOCUSED EXAM OF THE ANKLE ANTERIOR: Anterior Xbiotalar joint recess, TA, EHL, and EDL tendons, Dorsalis pedis artery, Superficial peroneal nerve LATERAL: Peroneus longus and brevis tendons, Superfical ReXnaculum, AITF, ATF, CF and PTF ligaments MEDIAL: Posterior Xbialis, Flexor digitorum longus, and Flexor Hallicus longus tendons, Tibial artery, Tibial vein Posterior Xbial nerve, and Deltoid ligament FOCUSED EXAM OF THE KNEE Anterior: Quadriceps tendon, Patella, Patellar tendon, Patellar rexnaculum, Suprapatellar recess, Pre- patellar bursa Medial: Medial collateral ligament, Medial meniscus, Pes Anserine tendons and bursa Lateral: IlioXbial tract, Lateral collateral ligament, Biceps Femoris tendon, Common peroneal nerve, Popliteus, Lateral Meniscus Posterior: Baker cyst, Neurovascular structures ANTERIOR KNEE EXAM PaXent supine, knee flexed to thirty degrees, pillow under knee In this posixon, the following structures can be assessed a. Quadriceps tendon b. Suprapatellar recess c. Pre- patellar bursa d. Patellar rexnaculum e. Patella f. Patellar tendon POSTERIOR: Achilles tendon, Retrocalcaneal and superficial Achilles bursa, and Plantaris tendon 1
2 EXTENSOR MECHANISM OF THE KNEE proximal ANATOMIC RELATIONSHIPS: ANTERIOR KNEE distal PROC EFOV PATELLAR TENDON Quadriceps tendon and suprapatellar recess Patellar tendon region Scan in short and long axis Bone acoutsic landmarks: distal patella and proximal Xbia Use doppler to ID inflammatory tendinopathy Scan in short and long axis Gentle squeeze of mid thigh can bring out fluid in suprapatellar recess IdenXfy bone landmarks of proximal patella and distal femur MEDIAL KNEE: Medial knee: anatomic relaxonships Bring hip into external rotaxon with knee flexed To thirty degrees Scan the following structures: a. Medial collateral ligament b. Body of medial meniscus c. Pes anserine tendons and bursa Note the relaxonship of distal MCL inserxon to pes anserine tendons Note the superfical and deep layers of MCL 2
3 Medial collateral ligament and medial meniscus LATERAL KNEE PaXent lying on side and knee flexed to thirty degrees Following structures assessed: a. Lateral ( Xbial) collateral ligament b. IlioXbial tract c. Biceps femoris inserxon on fibula d. Popliteus tendon e. Lateral meniscus f. Peroneal nerve Note: trilaminar appearance of MCL. Anatomic relaxonships: Lateral knee LATERAL KNEE: Lateral collateral ligament and Lateral meniscus Note relaxonships of Lateral collateral ligament and biceps femoris tendon as they insert on fibular head Use bone acousxc window of popliteal groove and fibular head to ID relevant structures LATERAL KNEE: LCL, ITB and popliteus tendon Use bone acousxc landmarks ( fibula, Gerdy s tubercle, Xbia and femur) to help IdenXfy structures POSTERIOR KNEE: PaXent is in prone posixon with pillow under patella Following assessment is done a. Asses for semimembrinosis/ medial gastrocnemius bursa ( Baker cyst) b. Neurovascular structures c. Posterior horn medial and lateral meniscus d. PCL inserxon Look for groove in distal femur to ID politeus tendon Depending on orientaxon of transducer the IlioXbial tract or LCL seen superficial to popliteus tendon 3
4 Anatomic relaxonships: Posterior knee Note relaxonship of MHG to SM and the other pes anserine tendons Note posixon of neurovascular bundle Note that popliteus muscle at anterior aspect of posterior fossa POSTERIOR KNEE: EvaluaXon for Baker cyst Key bone landmarks: Xbia plateau and MFC Key muscle tendon structures: Medial gastrocnemius muscle and semimembranosis tendon Posterior lateral knee: Biceps femoris tendon and peroneal nerve FOOT AND ANKLE EXAM ESSR MSK Ultrasound Technical Guidelines ANTERIOR ANKLE: PaXent signg or supine with knee flexed a. Anterior joint space b. Tibialis anterior, Extensor Hallicus Longus and Extensor digitorum tendons c. Neurovascular structures SAX Anterior ankle MD a Nelson Hager MD with permission b LAX 4
5 LATERAL ANKLE LATERAL ANKLE: PERONEAL TENDONS PaXent side lying with knee flexed to ninety degrees and ankle joint in neutral a. Peroneus longus and brevis tendons b. Anterior talo- fibular ligament c. Calcaneo- fibular ligament d. Anterior inferior talo- Xbial ligament Scan in short and long axis Scan along course of distal fibula Asses PB inserxon into 5th MT LATERAL LIGAMENTS ANKLE LATERAL ANKLE LIGAMENTS : AITF Anterior Talo- fibular ligament (ATF) Anterior Inferior Tibio- Fibular ligament AITFL Nelson Hager MD with permission Pictures obtained from ESSR Musculoskeletal Technical Guidelines VI Ankle LATERAL ANKLE LIGAMENTS: CALCANEO- FIBULAR MEDIAL ANKLE PaXent supine with knee flexed and leg in external RotaXon ( Frog leg posixon) a. Posterior Xbialis tendon b. Flexor digitorum tendon c. Tibial artery and vein d. Tibial nerve e. Flexor hallicus longus tendon f. Medial ankle ligaments ESSR MSK Ultrasound Technical Guidelines 5
6 POSTERIOR ANKLE: Achilles tendon POSTERIOR ANKLE: PaXent prone with leg over the edge of the table a. Achilles tendon b. Gastrocnemius/ soleus muscle complex c. Flexor hallicus longus tendon d. Plantaris tendon/muscle e. Bursal structures and fat pad Scan achilles tendon carefully in short and long axis Measure thickness 5cm from inserxon on calcaneus Pay aienxon to bone inserxon on calcaneus Use doppler to look for tendon inflammaxon POSTERIOR ANKLE: Flexor Hallicus longus TAKE HOME POINTS The MSK Ultrasound exam of knee, foot and ankle is a regional exam. The areas scanned are determined by history and physical findings PaXent Prone Look for FHL in LAX medial to Achilles Asterick is posterior fat pad Key components of knee exam: a. Extensor mechanism ( Quadriceps and patellar tendon) b. Ability to ID fluid in suprapatellar recess and posterior knee joint c. Use bone landmarks to asses tendinopathy and ligament injury Key components of ankle exam: a. Carefully scan achilles tendon to look for acute or chronic tendinopathy b. Use bone landmarks to idenxfy and scan tendon and ligament structures c. Areas lateral and median tendon pathology are best seen In short axis ( peroneal tendons, Xbialis posterior tendon) Key components of foot exam: a. Plantar fascia is best seen in long axis. Pay aienxon to medial band b. First MTP is a common source of pathology c. CorXcal defects seen in long axis view metatarsals may indicate early stress fracture ESSR MSK Ultrasound Technical Guidelines Thanks for your attention!!! 6
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