For those who are writing the SPI- Ultrasound physics exam. I have notes for sale it is about 2000 multiple choices sets for ARDMS -spi exam = 50 USA DOLLARS. I study those notes and passed my exam 670/700 . If you want to buy i can copy the notes and send them to you in e mail or by mail you can reach me at drsteveramsey@gmail.com . I will also include some of the ideas about the 12 simulation questions. The payment with PayPal to drsteveramsey@gmail.com , fetal gender , Saad Ismail .
With permission from ;Ultrasoundpedia.
Over the last decade, US has proven to be a useful tool in the assessment of tendons, ligaments, muscles, nerves, synovial recesses, articular cartilage, bone surfaces and joint capsule. The goals of US imaging are to detect and localize pathological processes, to differentiate between intra articular and extra articular pathology, to perform diagnostic and therapeutic intervention procedures and to monitor the efficacy of the therapy.Ultrasound is essentially used for .Ultrasound is a valuable diagnostic tool in assessing the following indications;
- Muscular, tendinos and some ligaments damage (chronic and acute)
- Bursitis
- Joint effusion
- Vascular pathology
- Haematomas
- Soft tissue masses such as ganglia, lipomas
- Classification of a mass eg solid, cystic, mixed
- Post surgical complications eg abscess, edema
- Guidance of injection, aspiration or biopsy
- Some bony pathology.
Limitations ; The size of the patient can limit the visualization of the normal anatomical landmarks.
Equipment Selection ; Use of a high resolution probe (7-15 MHZ) is essential
Careful scanning technique to avoid anisotropy (and possible misdiagnosis)
4 TO 6 MAJOR BURSAE are the most common reason for the us.
Beam steering or compounding can help to overcome anisotropy in linear structures such as tendons.Good color / power / Doppler capabilities when assessing vessels or vascularity of a structure.Be prepared to change frequency output of probe (or probes) to adequately assess both superficial and deeper structures.
INDICATIONS FOR TROCHANTERIC BURSITIS
- Pain over greater trochanter
- Pain in buttock
- Pain down lateral thigh
- Aggravation with lying on side , walking, abduction, internal rotation and external rotation
- More common in females
- More common over 50 yrs
Before scanning know the origins and insertion sites of the gluteus minimums, gluteus medius, gluteus maximus, piriformis tendons and the fascia latae position.
- Know the 3 common sites of bursitis
- Roll patient onto unaffected side initially then assess supine and compare
- Start with a curved linear array probe approx 6-8 Mhz to assess the muscles deep to the hip
- To evaluate the bursae use a 7-12 MHz linear probe
- Use a multi focus
- Narrow the dynamic range
- Ask the patient where the pain is and scan there first
- Run the probe up and down the lateral hip aligned to the long axis of the femoral shaft, and then move anterior and posterior.
- Look in coronal and transverse
- Compare sides.
- Remember that fluid is mobile and gravity dependent so do notover compress and do look in supine .Also vary the patients leg position from extension to flexion and even abduction if this creates the pain.Look at the patient erect.
start with the iliopsoas area, muscle, tendon and look for bursae.
must use color flow to check for hyperemia.
There are 2 ways of approaching the lateral hip to start imaging.
- Start posteriorly and work towards anterior greater trochanter
- Start anterior and work posteriorly
The anterior-posterior technique (just adapt it in reverse if you prefer to work posterior to anterior).
- Use a high frequency curved linear array probe to appreciate the entirety of the muscle bellies.
- Start anteriorly to look at the linear hyperechoic band superficial to the gluteus minims and gluteus medius muscles, this is the tensor fascia latae.
- Change to a high frequency linear array probe 5-12 MHz to scan in transverse and coronally.Check for tendinopathy at its origin or any fluid under it.
- Now move posteriorly to visualize the anterior portion of the gluteus minimus and gluteus medius.The gluteus minimus is seen on the anterior surface of the greater trochanter.The muscle comes from deep below the gluteus medius and is a hyperechoic tendon.
- The gluteus medius inserts further posteriorly but can be seen in a transverse view of the greater trochanter with the gluteus minimus insertion.
- Run up and down to check its insertion into the greater trochanter.
- As you move posteriorly the gluteus maximus comes into focus.
- Usually a curved linear array probe is the only way to see it because it runs deeply and attaches into the lateral femur.
- The piriformis,oblique muscles and quadratus femoris are not seen well enough to reliably diagnose pathology.
Ultrasound Appearance
- Beware of anisotropy at the insertion of the gluteus tendons onto the greater trochanter. It can mimic a partial of full thickness tear.
Trochanteric Bursitis
- Tendinopathy
- Tendinosis
- Enthesopathy
- Tears
- Snapping Hip
- Tensor Fascia Latae Tendinopathy
- Injections
you can check the groin areas for lymph nodes or other masses.
In addition, US has considerable advantages over CT and MRI: absence of radiation, good visualization of the joint cavity, quantification of soft tissue abnormalities, possibility for multiple joint scanning, non-invasiveness, speed of performance, rapid side-to-side anatomic comparison, better characterization of fluid, relative low cost, good compliance with the patient as well as a dynamic real-time study of multiple planes .
Anterior joint recess In longitudinal view, the transducer is placed in a sagittal oblique plane parallel to the long axis of the femoral neck .
The femoral neck lies lateral to the palpable pulsations of the femoral artery. The probe is moved from proximal to distal and then from lateral to medial regions to scan the entire hip recess .Four osseous structures are identified as highly reflective lines when moving from proximal to distal regions: the antero-inferior iliac spine, Acetabular rim, femoral head and femoral neck .
For children examination 10-14 MHz transducers are recommended due to the relatively superficial position of the hip joint. When inflammatory pathology is suspected. Sagital oblique image of normal anterior hip joint:
1-sartorius muscle; 2-iliopsoas muscle, 3-rectus femoris muscle; 4-femoral head; 5-iliofemoral ligament.US scans of the Hip:
always compare both sides if you find a bursa .
Anterior examination Anterior recess of the hip Bony profile Anterior regional muscles Medial examination Insertion of the Iliopsoas tendon Pelvic insertion of the adductor muscles Lateral examination Greater trochanter Gluteus minimus and medius tendons Fascia latae.
Posterior examination ; Ischial tuberosity,( Hamstrings and sciatic nerve if possible – this is a different exam and time spot).
The synovial recess lies between the profound fascia of the Iliopsoas and the femoral neck. Over the femoral head and neck the joint capsule can be seen as a concave thin linear hyperechoic structure extending from the Acetabular rim to its distal insertion to the femoral neck .However, the most important finding for effusion diagnosis is the symmetry between the two sides (right-left difference 1 mm) .
In transverse view, the probe is placed transversely to the long axis of the femoral neck and then moved from proximal to distal and from lateral to medial regions to scan the entire hip recess .
In normal conditions, the Iliopsoas bursa, located between Iliopsoas muscle and the hip joint, communicates with the joint cavity in 10-15 % of cases and cannot be visualized with US because its cavity contains only a thin film of synovial fluid.
The bursa can be seen, when distended, along the medial aspect of the hip joint as an anechoic/hypoechoic mass . The Iliopsoas tendon overlies the labrum medially. This tendon is a hyperechoic band running on the posterior aspect of the Iliopsoas muscle. The distal attachment of the Iliopsoas tendon can be difficult to identify with US in this position .
The adductor compartment includes three adductor muscles (from anterior longus, brevis and magnus) descending into the thigh capped by the more medially placed and perpendicularly lying gracilis muscle .The US scan of the myo-tendinous insertions of these muscles and their tendons up to the pubis – longitudinal and transversal approach – demonstrates a fibrillar internal structure .The abductor longus is the prominent and the most easily recognizable muscle. It has both muscular and tendinous components close to its origin. The most superficial muscles are the abductor longus and gracilis. Both of them arise from the body of symphysis itself and can be traced distally.
The adductor brevis and then the larger adductor magnus are found deep to this muscle pair .
Lateral examination The patient lies in lateral decubitus with hip joint in full extension . Greater trochanter and Gluteus minimus and medius tendons The transducer is placed longitudinally, parallel to the femoral diaphysis. The probe should be moved from anterior to posterior to scan the gluteus tendons insertions.
There is a number of Bursae that surrounds the greater trochanter and including the gluteus minimus, the gluteus medius anteriorly, and the gluteus Maximus bursa posteriorly. All of them are a potential space for fluid collection or thickening .
The bursae around the greater trochanter are not visible with US in normal conditions. Lateral hip tendons are best imaged by tilting the probe parallel to their long axis in order to avoid anisotropic effects .
Fascia lata The fascia lata arises from the iliac crest anteriorly and appears as a linear hyperechoic band joining the anterior edge of the gluteus maximus and the posterior portion of the tensor fasciae latae muscle .
The ischiogluteal bursa is located between the ischial tuberosity and the gluteus maximus. In normal conditions, the bursa is invisible under an US examination because of the small amount of fluid inside it.
US Pathology Joint Effusion Ultrasound is the imaging modality of choice for detection of fluid collections inside the hip joint. The most common causes of hip effusions in adults are osteoarthritis and osteonecrosis (avascular necrosis). The most common synovial disease involving the hip joint in adults is rheumatoid arthritis.inflammatory process inside the hip joint. Non homogeneous echogenicity of the synovial fluid and/or echogenic spots with or without acoustic shadowing can be generated by protein containing materials, cartilage fragments, crystal aggregates and calcified loose bodies .
adductor longus tendon appears totally separated from symphysis pubis. It may be difficult to differentiate with US between the three adductors lesions in case of trauma . By Doppler US, the activity of synovial proliferation /with or without local hyperemia can be distinguished . Ischiogluteal bursitis This disorder is also known as “weaver’s bottom”. Sometimes, it is encountered in neoplastic patients affected by cachexia and severe weight loss.
Fluid distension of the trochanteric bursa appears as a well-circumscribed round-shaped hypoechoic to anechoic collection located superficially to the posterior insertion of the gluteus medius and the lateral aspect of the greater trochanter and deep to the gluteus Maximus .
always check the femur labrum for tear and thickness, fluid or lose bodies.
Make sure to do internal foot rotation with cine loop so the radiologist can see the maneuver and you can see small tears more clearly
There are several approaches to ultrasound examination of the adult hip.
Anterior approach; supine with the hip in mild external rotation ;
- sagittal oblique plane parallel to the long axis of the femoral neck to assess femoral head and neck and for any joint effusion
- sagittal and axial planes to assess labrum, Iliopsoas tendon and bursa, femoral vessels, sartorius and rectus femoris muscle
- dynamic evaluation of snapping hip syndrome.
Lateral approach ;Patient positioning, lateral decubitus
- axial and coronal (longitudinal) to assess greater trochanter, greater trochanteric bursa, gluteal muscles and tensor fascia lata
- dynamic evaluation of ITB- ILIOTIBIAL BAND BY FLEXING AND EXTENDING THE LEG.
check for calcifications.
Medial approach; 45-degree knee flexion, external rotation (frog-leg position)
- sagittal oblique and axial planes to assess the adductor muscles, pubic bone and insertion of RECTUS ABDOMINIS MUSCLE this is only if you have trauma or if the radiologist ask you to do this along with posterior part the thigh and the hamstrings ( this is a different exam and time slot).
Thank you for reading.
Steve Ramsey, PhD- Public Health.
MSc – Medical Ultrasound.
Calgary, Alberta- Canada.
Some pictures taken With permission from ultrasoundpedia.com