Pediatric Musculoskeletal Ultrasound: Cases reviewed and lessons learned Jessica Leschied, MD Sections of Pediatric and Musculoskeletal Radiology C.S. Mott Children s Hospital University of Michigan Ann Arbor, MI
No disclosures Acknowledgements Dr. Micheal Dipietro Dr. Jon Jacobson My husband and 2 year old son for action shots
Objectives: Discuss the role of pediatric musculoskeletal ultrasound at our institution by showing a mix of cases Highlight the challenges of performing pediatric musculoskeletal ultrasound Demonstrate ultrasound imaging of a few specific pathologies affecting musculotendinous structures in children and adolescents
Indications Numerous Garden variety pediatric MSK US: DDH, hip or elbow joint effusions Congenital: clubfoot, vertical/oblique talus, bracket epiphyses and supernumerary digits, radial head dislocation, trigger thumbs Lumps, bumps and hernias Inflammatory or hemophilic arthropathy Adolescent sports medicine: snapping tendons, ankle ligament tear, knee injury, shoulder injury labral tear or RTC abnormality, elbow UCL injury, thumb UCL injury, finger injuries sagittal band, pulley injury, Other: trauma fractures, nerve studies brachial plexus injury
Tips and tricks Train techs in MSK US and help each other Follow a protocol Distraction techniques, modify positions for young children Image contralateral side! Recognize osseous and cartilagenous landmarks
Cases: Focus on upper extremity
Cases: Shoulder Structures assessed with US Biceps tendon Subscapularis tendon Supraspinatus tendon Infraspinatus tendon AC joint - dynamic Subacromial impingement dynamic Muscle bulk/atrophy of supraspinatus, infraspinatus, teres minor Posterior humeral head/posterior glenohumeral joint recess/posterior labrum
17 yo competitive male swimmer with several months of shoulder pain Biceps tendon transverse Supraspinatus longitudinal Subscapularis transverse Infraspinatus longitudinal
Humerus Scapula Posterior shoulder
Humerus * Scapula Normal posterior view with echogenic triangle of posterior labrum
Humerus Scapula
Rotator cuff muscle innervation If paralabral cyst, check for muscle atrophy boneandspine.com/suprascapular-nerve-anatomy-clinical-significance/ Accessed 2/2/2017
Infraspinatus Teres Minor Supraspinatus
Swimmer s shoulder Shoulder injuries most common injury in swimmers Labral tears and subacromial impingement most common Rotator cuff tendon problems rare (in general rare in the adolescent and young adult population) Labral injury due to increased glenohumeral laxity resulting in increased humeral head translation on the glenoid Wanivenhaus F, Fox AJS, Chaudhury S, Rodeo SA. Epidemiology of Injuries and Prevention Strategies in Competitive Swimmers. Sports Health Vol 4, Issue 3, pp. 246 251 First published date: April-06-2012 10.1177/1941738112442132
Case 16 yo male with left perinatal brachial plexopathy, Brachial plexus clinic decreasing ROM
Infraspinatus Teres Minor Supraspinatus
Glenoid dysplasia
Cases: Elbow Elbow structures assessed with ultrasound: Joint effusion, anterior and posterior joint recesses Biceps tendon Triceps tendon Common flexor and common extensor tendons Radial and ulnar collateral ligaments Annular ligament Ulnar nerve, median nerve, radial nerve Radial head, distal humerus, olecranon Olecranon bursa
Case -15 yo competitive cheer flyer with one year of elbow pain, instability following fall
Anterior elbow
Posterior elbow
Posterior elbow * H Normal posterior fat pad Abnormal posterior fat pad, elevated by large effusion in young child with septic elbow joint
CET RCL Lateral elbow H R
CFT UCL Medial elbow H www.studyblue.com Accessed 2/6/2017 U
Medial Elbow
Medial Elbow
US evaluation of UCL injury Incidence of UCL injuries in overhead throwing athletes increasing Anterior band of UCL is primary stabilizer of the medial elbow during valgus stress Dynamic US demonstrating ulnohumeral joint widening greater than the asymptomatic contralateral side may help differentiate full from partialthickness injury H Valgus stress widening of ulnohumeral joint U Dynamic sonography with valgus stress to assess elbow ulnar collateral ligament injury in baseball pitchers. Skeletal Radiol 2002 Nov;31(11):671-6
Cases: Digits Digital structures assessed with ultrasound: Flexor and extensor tendons Joint recesses Annular pulleys Thumb UCL, RCL
Case -17 yo competitive rock climber with injury to ring finger during difficult climb
Metacarpophalangeal joint Proximal phalanx Middle phalanx
Proximal interphalangeal joint A3 pulley; Site of pain
Pulley injuries in rock climbers climber s finger One million sport rock climbers in the U.S. 26% of elite level rock climbers have had a flexor pulley injury (usually A2 pulley) Dynamic US for A2 and A4 pulley injuries is 98% sensitive and 100% specific for detection of pulley injuries Measurements? >1 mm distance between phalanx and tendon at A2 and A4 = complete tear, more difficult at joints (A1, A3 and A5) Bowstringing Diagnosis of finger flexor pulley injury in rock climbers: A systematic review. Can J Plast Surg Vol 14(4) 2006
Case -22 yo male rugby player, injured thumb
Normal thumb UCL Metacarpal head Proximal phalanx 17 year old boy, normal
Case courtesy of Dr. Yoav Morag, University of Michigan Abnormal UCL
gamekeeper s thumb, skier s thumb Primary goal of US is to identify Stener lesion displaced and retracted full-thickness UCL tear yo-yo on a string sign Stener lesion displaced proximal to adductor pollicis aponeurosis Presence of Stener lesion indication for surgery UCL injury and Stener lesion US diagnosis of UCL tears of the thumb and Stener lesions: technique, pattern-based approach, and differential diagnosis. Radiographics. 26:1007-1020. 2006
Lessons learned Pediatric MSK US different but similar to adult MSK US Can borrow techniques/gain knowledge from adult MSK imagers and adapt to the pediatric musculoskeletal system Checklist Learn osseous and cartilagenous landmarks Start slow specific studies based on referring clinicians needs, practice will grow
Jessica Leschied, MD jleschi@med.umich.edu Thank You!