Point of Care Ultrasound on the Field of Play K AT I E N ANOS, MD

Point of Care Ultrasound on the Field of Play K AT I E N ANOS, MD H I GH P ERFORMANCE S PORTS MEDICINE P HYSI ATRIST, P R ACTICING S PORTS MEDI CINE

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Objectives Over the course of this session, we will: review some US fundamentals, including advantages and disadvantages of US use discuss the normal and abnormal appearances of different tissues (tendons, ligaments, and bones) and some relevant acute injuries that can be assessed on a sideline demonstrate/allow for hands-on practice of identifying these structures and pathologies

2009

Anisotropy

Choose a transducer Left: high frequency (15-7 MHz), small footprint, linear array transducer; hockey stick Center: high frequency (17-5 MHz) linear array transducer Right: low to medium frequency (5-2 MHz) curvilinear transducer linear transducers (higher frequency) are used for superficial imaging (e.g. knee, CMC) curvilinear transducers (lower frequency) are used for deeper structures (e.g. hip)

Sonographic evaluation of a normal tendon high frequency linear transducer is often best LAX: tightly packed linear, fibrillar pattern DIST SAX: stippled cluster of dots, broom end homogenous scan from myotendinous junction to bony insertion

Tendinosis thickened hypoechoic heterogenous +/- enthesopathy +/- calcification +/- neovascularity PROX RT PAT TND LAX RT ACH LAX DIST

Partial tendon tear Focal defect well defined not anisotropy seen in two planes dynamic imaging bursal vs articular sided vs intrasubstance Background tendinosis tendon usually thick may be atrophic if chronic or high grade PROX LT HS LAX RT PAT TND LAX PROX

Full thickness tendon tear From articular bursal surface Focal incomplete, entire width complete Gap vs absence control for anisotropy Acute fluid Chronic scar Identify tendon ends edge shadowing dynamic imaging LAX MEDIAL SAX

Tendon injuries

Achilles tendon tear: Dynamic evaluation ACH LAX ACH SAX

Acute posterior ankle pain 21 y/o NCAA division I track and field athlete Acute left posterior ankle pain developed during 100 M sprint Physical exam: minimal ecchymosis mild swelling along the medial Achilles border negative Thompson test achilles tendon palpably intact pain with active plantar flexion

acute plantaris tear/tendinosis RT ACH SAX MED

Distal biceps tendon Medial: pronator window elbow 90 degrees flexion, forearm full supination transducer placed parallel to humeral shaft, distal end at medial epicondyle translate anteriorly until distal tendon attachment is in view dynamically evaluate with pronation/supination

Distal biceps tendon Cobra view U BT R

Small avulsion seen with cobra view Partial tear with peritendinous edema but intact with dynamic imaging through pronator window

Pectoralis major tendon

Pectoralis major tendon most common tears are partial thickness and at the myotendinous junction

Anterior chest deformity 32 year old RHD hockey player

Anterior chest deformity 32 year old RHD hockey player acute onset pain and chest/arm weakness during eccentric phase of bench press during dryland training

Anterior chest deformity 32 year old RHD hockey player acute onset pain and chest/arm weakness during eccentric phase of bench press during dryland training Exam: ecchymosis over ipsilateral anterolateral chest wall and axilla loss of anterior axillary fold relative weakness with arm adduction and internal rotation

Identify LHBT in bicipital groove in short axis Scanning technique

Identify LHBT in bicipital groove in short axis Translate distally until you see the pec tendon come in medially in long axis

Rotate 90 degrees for short axis view Anterior layer all of clavicular head, part of the sternal head Posterior layer sternal head

Pectoralis major retracted tear (curved arrow), adjacent hemorrhage (open arrow), and no visible tendon in its expected location (arrowheads) superficial to the biceps tendon (B) - left side = medial

Ligament injuries

Ankle inversion ATFL evaluation appearance of ligaments similar to tendon retracted edges uncommon loss of ligament wavy appearance FIB TAL

Ankle inversion ATFL evaluation appearance of ligaments similar to tendon retracted edges uncommon loss of ligament wavy appearance NORMAL ATFL, LAX FIB FIB TAL TAL

Ankle inversion ATFL evaluation appearance of ligaments similar to tendon retracted edges uncommon loss of ligament wavy appearance NORMAL ATFL, LAX FIB TAL

Ankle inversion ATFL evaluation appearance of ligaments similar to tendon retracted edges uncommon loss of ligament wavy appearance NORMAL ATFL, LAX COMPLETE ATFL TEAR, LAX FIB FIB TAL TAL FIB TAL

Elbow: ulnar collateral ligament (UCL)

Elbow: ulnar collateral ligament (UCL) Anterior fibers Overuse: microtrauma from repetitive valgus stress overhead athletes Acute trauma: elbow dislocation valgus instability

Elbow: ulnar collateral ligament (UCL) Hyperechoic compact fibers Medial epicondyle to sublime tubercle Dynamic valgus stress testing at 30 degrees; partial tear more common >1mm difference between resting and stress test suggests full thickness involvement side to side comparison is most helpful Complete tear: separation of fibers LAX

UCL sprain

Medial collateral ligament (MCL) Normal: fibrillar structure medial femoral condyle tibia superficial and deep layers deep layer attached to medial meniscus

MCL sprain typically proximal LAX most helpful deep vs superficial thick and hypoechoic defect uncommon valgus stress test can be done (dynamic evaluation) chronic +/- calcium

Fractures

Sonographic evaluation of fractures Helpful: when x-ray unavailable radiographically occult fracture unsuspected fractures during routine exams early stress fractures We see: interruption of smooth cortical surface periosteal thickening hyperemia soft tissue edema pain on sonopalpation early callus formation RT 5 TH MET LG DIST

Acute distal fibular fracture

4 th metacarpal fx Fourth metacarpal fracture. (A) (A) Normal radiographs in a patient with post-traumatic pain at the fourth metacarpal phalangeal joint. (B) (B) Long-axis sonogram with (C) Doppler imaging of the dorsal aspect of the distal fourth metacarpal showing a minimally displaced fracture (arrow). Note the periosteal thickening (black arrowheads) and vascularity within the periosteum (white arrowheads).

Ischial avulsion fracture

Heel pain 25 year old avid runner with 2 weeks of right lateral calcaneal pain amidst training for a marathon wants to keep running PE consistent with possible stress fracture of calcaneus x-rays are negative

Occult calcaneal stress fracture Right side (symptomatic) Left side (asymptomatic)

Rib fracture US more sensitive than x-ray Direct signs: discontinuity of cortex acoustic edge shadowing localized pain Indirect signs: local hematoma reverberation artifact pneumothorax

Rib fracture US more sensitive than x-ray Direct signs: discontinuity of cortex acoustic edge shadowing localized pain Indirect signs: local hematoma reverberation artifact pneumothorax Scanning technique palpate the region of max tenderness identify rib in SAX evaluate the length of the rib in LAX don t forget the include the osteochondral junction

SAX LAX

DEMO

Thank you Email: katherine.nanos@hpsm.ca