Ultrasonography of Muscles and Tendons

Ultrasonography of Muscles and Tendons

Bruno D. Fomage Ultrasonography of Muscles and Tendons Examination Technique and Atlas of Normal Anatomy of the Extremities With 612 Illustrations Springer-Verlag New York Berlin Heidelberg London Paris Tokyo

Bruno D. Fornage, M.D. Associate Professor of Radiology Division of Diagnostic Radiology Chief, Section of Ultrasound The University of Texas M.D. Anderson Cancer Center Houston, Texas, USA Associate Professor of Radiology Institut Jean-Godinot, Reims, France Translation of Echographie du systeme musculo-tendineux des membreslatlas d'anatomie ultrasonore normale, Vigot, Paris, 1987. Translation by the author. Library of Congress Cataloging-in-Publication Data Fornage, Bruno. Ultrasonography of muscles and tendons. Translation of: Echographie du systeme musculotendineux des membres. Includes bibliographies and index. 1. Muscles-Imaging. 2. Tendons-Imaging. 3. Ultrasonic imaging. 4. Muscles-Atlases. 5. Tendons-Atlases. I. Title. [DNLM: 1. Musclesanatomy & histology-atlases. 2. Tendons-anatomy & histology-atlases. 3. Ultrasonic Diagnosis-methodsatlases. WE 17 F727e] QM151.F6713 1988 611'.73 88-4657 Printed on acid-free paper 1989 by Springer-Verlag New York Inc. Softcover reprint of tbe hardcover 1 st edition 1989 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer-Verlag, 175 Fifth Avenue, New York, NY 10010, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use of general descriptive names, trade names, trademarks, etc. in this publication, even if the former are not especially identified, is not to be taken as a sign that such names, as understood by the Trade Marks and Merchandise Marks Act, may accordingly be used freely by anyone. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Typeset by Publishers Service, Bozeman, Montana. 9 8 7 6 543 2 1 ISBN-13: 978-1-4612-8119-1 DOl: 10.1007/978-1-4612-3482-1 e-isbn-13: 978-1-4612-3482-1

Introduction Muscles, tendons, and the other soft tissues of the extremities have historically been neglected by radiology, in the main because of the lack of an effective imaging technique. Yet it is surprising that until recently sonography has not received much attention in this application, since, even with conventional equipment, it readily evaluates superficial tissues. In this setting, there is no obstacle from gas or bone to the propagation of sound. Further, sonography permits both depiction in any orientation and real-time dynamic study. I was induced to undertake ultrasound examinations of muscles and tendons by physicians specializing in sports medicine. Before this specialty emerged, physicians had limited interest in the traumatic and inflammatory disorders of muscles and tendons, given the questionable severity of the lesions, the paucity of late sequelae impairing normal activity, and the absence of life-threatening complications. Now, however, athletics is a major social activity and sonography is used more and more frequently. In the domain of muscular sonography, a dual expertise is required. First, precise knowledge of the regional anatomy is a prerequisite to any ultrasound examination. Second, the sonologist must be familiar with the clinical evaluation of patients with muscle trauma, in whom physical examination is often equivocal. In this book, the technical fundamentals of the sonographic examination of muscles and tendons and the normal ultrasound anatomy of the extremities are presented.

Note to the Reader In this atlas, sonograms are oriented according to the international standards for imaging techniques. All scans have been performed on right extremities. With few exceptions, which are noted, transverse sonograms are "seen from below;' whereas longitudinally oriented scans, whether sagittal or coronal, are shown with the proximal part of the extremity on the left and the distal part on the right. Acknowledgments. The author is indebted to Veronique Dupuis who prepared the manuscript, and Suzanne Simpson of the Department of Scientific Publications, The University of Texas M.D. Anderson Cancer Center, for her valuable editorial assistance.

Contents Introduction......................................................... Note to the Reader................................................... v VI Part I. Technique of Sonographic Examination and General Considerations on Ultrasound Normal Anatomy Anatomic Considerations........................................... 3 Skeletal Muscles........... 3 Tendons......................................................... 3 Synovial Bursae................................................... 4 Joints... 5 Fatty Tissue...................................................... 5 References....................................................... 5 2 Technique for Sonography of Muscles and Tendons of the Extremities................................................. 6 Type of Sonographic Equipment...................................... 6 Probe Frequency.................................................. 6 Standoff Systems.................................................. 6 Orthogonal Views................................................. 10 Examination of the Contralateral Segment... 11 Real-Time Dynamic Study... 11 Palpation Under Sonoscopy... 11 References....................................................... 11 3 Normal Ultrasound Anatomy of Muscles... 13 Longitudinal Sonograms............................................ 13 Transverse Sonograms.............................................. 14 Dynamic Examination.............................................. 17 References....................................................... 19

4 Normal Ultrasound Anatomy of Tendons.............................. 20 Longitudinal Sonograms... 20 Transverse Sonograms.......................................... 22 Dynamic Study................................................... 25 References....................................................... 25 5 Artifacts and Pitfalls in Sonography of Muscles and Tendons.............. 26 Muscles......................................................... 26 Tendons......................................................... 30 Internal Fixation Devices........................................... 38 References....................................................... 39 6 Sonographic Patterns of the Other Anatomic Components of the Extremities. 40 Bones... 40 Joints........................................................... 40 Surrounding Soft Tissues........................................... 42 References....................................................... 44 7 Other Imaging Techniques for Muscles and Tendons..................... 45 Plain Radiography... 45 Low-Kilovoltage Radiography... 45 Xeroradiography.................................................. 46 Computed Tomography... 46 Magnetic Resonance Imaging... 46 Angiography..................................................... 46 Tenography...................................................... 47 Radionuclide Imaging.............................................. 47 Thermography... 49 Prospects in Ultrasonography... 49 References....................................................... 51 Part II. Atlas of Ultrasound Scans of the Extremities List of Abbreviations.............................................. 56 A Upper Extremity.................................................. 59 Shoulder........................................................ 61 Arm, Upper Third................................................ 67 Arm, Midthird................................................. 73 Arm, Lower Third................................................ 76 Elbow.......................................................... 81 Forearm, Upper Third............................................. 90 Forearm, Midthird................................................ 96 Forearm, Lower Third............................................. 101 Wrist........................................................... 104 Hand........................................................... 118 VlIl Contents

B Lower Extremity.................................................. 131 Thigh, Upper Third... 133 Thigh, Midthird... 143 Thigh, Lower Third............................................... 154 Knee, Patellar Tendon.............................................. 163 Knee, Popliteal Fossa.............................................. 171 Knee, Other Scans... 178 Leg, Upper Third................................................. 180 Leg, Midthird.................................................... 189 Leg, Lower Third................................................. 196 Leg, Achilles Tendon.............................................. 201 Foot............................................................ 211 Index.............................................................. 229 Contents IX