Dynamic high resolution sonography (d-hrus) of the foot: a detailed didactic approach.

Dynamic high resolution sonography (d-hrus) of the foot: a detailed didactic approach. Poster No.: C-1871 Congress: ECR 2013 Type: Educational Exhibit Authors: S. Perugin Bernardi, A. Arcidiacono, A. Corazza, F. Nosenzo, 1 1 2 2 2 3 4 2 1 D. Orlandi, R. Sartoris, E. Silvestri, G. Ferrero ; Genova/IT, 2 3 4 Genoa/IT, Genoa (GE)/IT, Genova (GE)/IT Keywords: Education and training, Technical aspects, Education, Ultrasound, Musculoskeletal soft tissue, Musculoskeletal joint DOI: 10.1594/ecr2013/C-1871 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 29

Learning objectives The purpose of our educational exhibit is to: 1. illustrate the normal anatomy and normal d-hrus appearance of foot structures; 2. describe a systematic technique for d-hrus evaluation of such structures; 3. produce anatomical schemes with didactic purpose and show correlations with sonographic imaging. Background The foot can be subdivided in two compartments : hindfoot and forefoot. Each of those contains a group of small structures that are extremely important for foot functionality. Currently, HRUS represents the first level imaging in the foot evaluation. For each of the following structures we will provide a dedicated HRUS image compared with a detailed anatomic scheme, and a practical guide on "how we do" a d-hrus scan : HINDFOOT : Plantar Aponeurosis FOREFOOT : * Plantar Side : Intermetatarsal spaces Flexor digitorum tendons * Dorsal Side : Intermetatarsal spaces Extensor digitorum tendons Page 2 of 29

Imaging findings OR Procedure details The exam can be started either from the dorsal or from the plantar side of the foot. HINDFOOT Check-list: Plantar aponeurosis The patient lies supine on prone with the foot hanging out of the bed. 1) Plantar aponeurosis The foot must be dorsally flexed with the first toe extended (Fig. 1). The probe must be placed longitudinally over the heel to evaluate the insertional region of plantar aponeurosis (Fig.2) on a longitudinal scan (Fig.3). Page 3 of 29

Fig. 1: Position of foot for evaluation of the plantar aponeurosis. References: - Genova/IT Page 4 of 29

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Fig. 2: Anatomical scheme of the plantar aponeurosis : C, Calcaneus; PAC central branch of the plantar aponeurosis; PAL lateral branch of plantar aponeurosis; PAM medial branch of plantar aponeurosis; DB, digital bands. References: - Genova/IT Fig. 3: Calcaneal insertion of the plantar aponeurosis on a longitudinal scan (arrowheads). H, heel. References: - Genova/IT FOREFOOT Check list : Plantar Side : Intermetatarsal spaces Plantar plate Flexor digitorum tendons Dorsal Side : Intermetatarsal spaces Extensor digitorum tendons Page 6 of 29

1)Plantar side The probe must be oriented on an axial plan over the metatarsal heads (Figs. 4-7). At this level, the intermetatarsal spaces and flexor digitorum tendons can be seen. Soft tissues within the intermetatarsal spaces must be evaluated displacing them from their natural position. This can be done either by pressing the skin on the dorsal side of the foot or by lateral compression of the whole forefoot (Mulder's maneuver). These maneuvers allow for an improved detection of intermetatarsal bursitis or Morton's neuroma. Page 7 of 29

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Fig. 4: US probe position to evaluate the intermetatarsal spaces and flexor digitorum tendons. References: - Genova/IT Fig. 5: Anatomical scheme of intermetatarsal space: M, metatarsal bone; arrowheads, flexor and extensor tendons; *, intermetatarsal bursa; void arrow, neurovascular bundle. References: - Genova/IT Page 9 of 29

Fig. 6: US axial scan of the plantar aspect of the foot. Arrowheads, flexor digitorum tendons; II, III, second and third metatarsal bone; *, intermetatarsal space. References: - Genova/IT Fig. 7: US axial scan at the level of the sesamoid bones. MS, medial sesamoid bone; LS, lateral sesamoid bone; *, flexor halluces longus tendon; M, first metatarsal head. References: - Genova/IT Page 10 of 29

Flexor tendons and metatarsophalangeal joints can be assessed using longitudinal scans and passive mobilization of toes (Figs. 8-11). Dynamic scans allow also for detecting the integrity of plantar plates. Page 11 of 29

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Fig. 8: US probe position to evaluate flexor tendons on the longitudinal axis. References: - Genova/IT Fig. 9: Anatomical scheme of a flexor digitorum tendon. P1, P2, P3, proximal, middle and distal phalanx; M, metatarsal bone; FDS, flexor digitorum superficialis tendon; FDP, flexor digitorum profundus tendon; PP, plantar plate. References: - Genova/IT Fig. 10: US longitudinal scan on the second metatarsal-phalangeal joint. M, metatarsal head; P1,proximal phalanx; arrowheads, flexor tendon course; *, plantar plate. References: - Genova/IT Page 13 of 29

Fig. 11: US longitudinal scan on the second flexor digitorum tendon (arrowheads) at its insertion on the distal phalanx. P2, P3, middle and distal phalanxes; *, plantar plate. References: - Genova/IT 1)Dorsal side The patient lies supine on the bed with the knee flexed and the plantar side flat on the bed. The probe must be oriented on an axial plan over the metatarsal heads (Figs. 12-13). The presence of intermetatarsal bursitis and Morton's neuroma can also be detected from this position, performing the same maneuvers described for plantar scans. Short and long axis scans must be performed to evaluate extensor tendons and laminae. Page 14 of 29

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Fig. 12: US probe position to evaluate the intermetatarsal spaces from the dorsal side. References: - Genova/IT Fig. 13: US axial scan over the intermetatarsal spaces with a dorsal approach. *, intermetatarsal space; II, III, second and third metatarsal bones; arrowheads, extensor tendons. References: - Genova/IT Images for this section: Page 16 of 29

Fig. 1: Position of foot for evaluation of the plantar aponeurosis. Page 17 of 29

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Fig. 2: Anatomical scheme of the plantar aponeurosis : C, Calcaneus; PAC central branch of the plantar aponeurosis; PAL lateral branch of plantar aponeurosis; PAM medial branch of plantar aponeurosis; DB, digital bands. Fig. 3: Calcaneal insertion of the plantar aponeurosis on a longitudinal scan (arrowheads). H, heel. Page 19 of 29

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Fig. 4: US probe position to evaluate the intermetatarsal spaces and flexor digitorum tendons. Fig. 5: Anatomical scheme of intermetatarsal space: M, metatarsal bone; arrowheads, flexor and extensor tendons; *, intermetatarsal bursa; void arrow, neurovascular bundle. Page 21 of 29

Fig. 6: US axial scan of the plantar aspect of the foot. Arrowheads, flexor digitorum tendons; II, III, second and third metatarsal bone; *, intermetatarsal space. Fig. 7: US axial scan at the level of the sesamoid bones. MS, medial sesamoid bone; LS, lateral sesamoid bone; *, flexor halluces longus tendon; M, first metatarsal head. Page 22 of 29

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Fig. 8: US probe position to evaluate flexor tendons on the longitudinal axis. Fig. 9: Anatomical scheme of a flexor digitorum tendon. P1, P2, P3, proximal, middle and distal phalanx; M, metatarsal bone; FDS, flexor digitorum superficialis tendon; FDP, flexor digitorum profundus tendon; PP, plantar plate. Fig. 10: US longitudinal scan on the second metatarsal-phalangeal joint. M, metatarsal head; P1,proximal phalanx; arrowheads, flexor tendon course; *, plantar plate. Page 24 of 29

Fig. 11: US longitudinal scan on the second flexor digitorum tendon (arrowheads) at its insertion on the distal phalanx. P2, P3, middle and distal phalanxes; *, plantar plate. Page 25 of 29

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Fig. 12: US probe position to evaluate the intermetatarsal spaces from the dorsal side. Fig. 13: US axial scan over the intermetatarsal spaces with a dorsal approach. *, intermetatarsal space; II, III, second and third metatarsal bones; arrowheads, extensor tendons. Page 27 of 29

Conclusion D-HRUS allows a quick, real-time evaluation of such structures and, in particular, a detailed visualization of their anatomy. In addition, dynamic evaluation adds several important informations about the biomechanics of foot structures. References [1] Beggs I, Bianchi S, Bueno A, Cohen M, Court-Payen M, Grainger A, Kainberger F, Klauser A, Martinoli C, McNally E, O'Connor PJ, Peetrons P, Reijnierse M, Remplik P, Silvestri E. Musculoskeletal Ultrasound Technical Guidelines. European Society of Musculoskeletal Radiology. [2] Martino F, Silvestri E, Grassi W. Musculoskeletal sonography: technique, anatomy, semeiotics and pathological findings in rheumatic diseases. Springer, 2007. [3] Bianchi S, Martinoli C. Ultrasound of the musculoskeletal system. Springer 2007. [4] Jacobson J. Fundamentals of Musculoskeletal Ultrasound. Saunders, 2008. [5] Van Holsbeeck M, Introcaso J. Musculoskeletal Ultrasound 2nd ed. Mosby, 2000. [6] McNally E. Practical Musculoskeletal Ultrasound. Elsevier, 2004. [7] Chhem R, Cardinal E. Guidelines and Gamuts in Musculoskeletal Ultrasound. WileyIEEE, 1999. [8] Bradley M, O'Donnell P. Atlas of Musculoskeletal ltrasound Anatomy. Cambridge University Press, 2002. [9] Marcelis S, Daenen B, Ferrara MA. Peripheral Musculoskeletal Ultrasound Atlas. Thieme, 1996. [10] Balboni G, et al., Anatomia Umana III ed, 2004. Page 28 of 29

[11] Standring S. Anatomia del Gray. Le basi anatomiche per la pratica clinica. Elsevier, 2009. [12] Silvestri E., Muda A., Sconfienza L.M. Normal Ultrasound Anatomy of the Musculoskeletal System, 2011. Personal Information S.Perugin Bernardi, Department of Radiology, University of Genoa, via L.B. Alberti 4, 16100, Genoa. A. Arcidiacono, Department of Radiology, University of Genoa, via L.B. Alberti 4, 16100, Genoa. A. Corazza, Department of Radiology, University of Genoa, via L.B. Alberti 4, 16100, Genoa. F. Nosenzo, Department of Radiology, University of Genoa, via L.B. Alberti 4, 16100, Genoa. D. Orlandi, Department of Radiology, University of Genoa, via L.B. Alberti 4, 16100, Genoa. R. Sartoris, Department of Radiology, University of Genoa, via L.B. Alberti 4, 16100, Genoa. E. Silvestri, Department of Radiology, Ospedale Evangelico Internazionale, Corso Solferino 2, 16100, Genoa. G. Ferrero, Department of Radiology, University of Genoa, via L.B. Alberti 4, 16100, Genoa. Page 29 of 29