Post-graduate Certifcate Musculoskeletal Ultrasound - The Shoulder
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Lecture from The Post-graduate Certificate Musculoskeletal Ultrasound: Dr. Peter Resteghini Course Director Post-graduate Certificate Musculoskeletal Ultrasound - http://www.uel.ac.uk/study/courses/Musculoskeletal.htm
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Post-graduate Certifcate Musculoskeletal Ultrasound - The Shoulder
- 1. Diagnostic Ultrasound of the Shoulder Dr. Peter Resteghini Consultant Physiotherapist Musculoskeletal Medicine Musculoskeletal Sonographer peter.resteghini@homerton.nhs.uk Course Director Postgraduate Certificate Musculoskeletal Ultrasound http://www.uel.ac.uk/study/courses/Musculoskeletal.htm
- 2. Why Ultrasound? A lack of ionising radiation (Grassi 2004). High spatial resolution, has multiplanar imaging capability and is considered patient friendly due to its ease of tolerance and non- invasiveness (Wakefield 1999, Backhaus 2001, Tan 2003, Grassi 2004). Scanning time is short (5-15 minutes for an experienced sonographer compared to approximately 40 minutes for an MRI – Swen 2001) It provides not only anatomical information, but also informs on the physiological state of the joint, being particularly sensitive to inflammatory changes (Grassi 2003). Ultrasound is also unique in that scanning occurs in real-time making it possible to discuss reproduction of symptoms with the patient, and to view dynamic images of the structures under examination. ((Tan 2003, Grassi 2000, Ellis 2002, Shirtley 1999).
- 3. Guided Injection Ultrasound guided shoulder girdle injections are more accurate and more effective than landmark guided injections: a systematic review and meta-analysis (Aly, Rajasekaran, Ashworth 2014 ) Lack of aspirate from smaller joints such as the CMCJ of the thumb makes accurate needle placement in these joints also extremely difficult For this reason injections performed under imaging are becoming more popular (Balint 1997, Ghozlan and Vacher 2000, Koski 2000, Weidner et al 2004). Eustace (1997) demonstrated that even in the hands of musculoskeletal specialists only a minority of injections for shoulder pain are performed accurately (29% of subacromial and 42% of intra-articular injections), not surprisingly outcome significantly correlated with accuracy of injection. Similar results were found in patients with De Quervains tenosynovitis (Zhingis 1998). Leopold (2001) assessed the accuracy of needle placement with intra-articular injection using only anatomic landmarks as a guide. Using this ‘blind’ approach the needle pierced or contacted the femoral nerve in 27% of anterior injections and was within 5mm of the femoral nerve in 60% of all anterior attempts. Using a lateral approach the needle was never within 25mm of any neurovascular structure in any injection however only 80% of injections managed to reach the joint cavity.
- 4. Ultrasound of the Shoulder Long head of biceps Rotator cuff Bursa ACJ GHJ Impingement
- 5. Long Head Biceps - Transverse
- 8. LHB - Distal
- 10. Subluxed LHB
- 11. LHB - Injection
- 18. Sh thickened subcoracoid bursa with fluid and impingement.wmv
- 19. Supraspinatus – Transverse at Rotator interval
- 21. Ultrasound – SST tears Full thickness tears: sensitivity 96-100% specificity 85% Partial thickness tears: sensitivity 93% specificity 94%
- 22. Ultrasound and MRI are comparable in both sensitivity and specificity (Joseph 2009) 98.6% sensitivity & 99.3% specificity full thickness tears 97.9% sensitivity & 94.4% specificity partial thickness tears (Al Shawi, Bunker 2005)
- 23. Supraspinatus – complete rupture
- 24. Ruptures IST with associated posterior GHJ Effusion.wmv
- 25. SST Midsubstance full thickness tear
- 27. Impingement - Calcific SST & Subacromial bursa
- 29. Impingement SAB
- 30. Ultrasound guided shoulder girdle injections are more accurate and more effective than landmark guided injections: a systematic review and meta-analysis (Aly, Rajasekaran, Ashworth 2014 BJSM)
- 31. SAB - Injection
- 34. Infraspinatus
- 36. Infraspinatus – complete rupture
- 37. SCJ - Injection
- 39. GH Joint - Injection
- 40. SN - Injection
- 41. Homerton University Hospital Department of Physiotherapy & Sports Medicine Dr. Peter Resteghini Consultant Physiotherapist Musculoskeletal Medicine Musculoskeletal Sonographer peter.resteghini@homerton.nhs.uk Course Director Postgraduate Certificate Musculoskeletal Ultrasound http://www.uel.ac.uk/study/courses/Musculoskeletal.htm
Hinweis der Redaktion
- Rotator cuff: LHB, subscapularis, supraspinatus, infraspinatus Ligaments: Transverse ligament, coracoacromial Bursa: Subacromial, subcoracoid ACJ Posterior GHJ (useful for injection)
- Course of the LHB – Important as this can be used as a marker to find the anterior edge of supraspinatus Think about how you need to angle the probe to follow LHB from its distal edge proximally
- Transverse at the bicipital groove ensure you scan distally to reach the pectoralis major insertion
- Following LHB over the humeral head (note anatomy slide)
- Down to Myotendinous junction at the insertion of pectoralis major: The short head is tot he bottom left and the LHB in the triangle formed between pectoralis tendon and humerus
- Top - Transverse LHB just superior to Pec Major insertion demonstrating increased fluid around tendon Bottom – Associated synovitis
- Left nil LHB in groove Right ruptured transverse ligament with subluxation LHB overlying Subscapularis
- Keep probe still and externally rotate the arm to check back to the myotendinous junction In full external rotation you should be able to see the myotendinous junction
- The coracobrachialis originates from the coracoid as does the SHB which overlays this More superiorly onto the coracoid – look for subcoracoid bursa which may extend from under the coracoid The arrow indicates where a distended subcoracoid bursa may sit
- Note multi-fasicular arrangement of tendon in transverse
- Complete rupture subscapularis
- Complete rupture SUB
- Deeper arrow subscapularis Superficial arrow thickened bursa
- Thickening of the subcoracoid bursa with fluid and impingment
- The view on the right is shown by the more horizontal line on the diagram to the left
- You can use LHB to mark the most anterior edge of the supraspinatus and then move probe in a posterior direction to scan through the tendon Subacromial bursa appears as a thin hypoechoic line between supraspinatus and deltoid (extends over greater tuberosity). Up to 2mm normal. Cannot be seen clearly on this image (the line seen is a fascial line within deltoid)
- Trans over humeral head
- ‘The supraspinatus demonstrated a full-thickness tear at the anterior margin of the tendon with retraction of the tendon some 1.6 cm back from the the long head of biceps. Longitudinally a distal stump appeared to be attached to the greater tuberosity.’ Note the dip in the bursal side of the SST, loss of normal echogenicity and the associated articular cartilage sign. In this patient the LHB was also very thickened and demonstrated signs of tendinopathy
- The supraspinatus demonstrated an intact anterior edge at the rotator interval. However there was a region of hypoechogenicity located on the bursal surface of the mid region of the tendon - Arrow This was associated with a positive cartilage sign and some cortical irregularity – Curved arrow
- Left L SS calcific tendonitis Transverse – note acoustic shadow Right Small Subacromial bursa impinging with active abduction and below larger with some synovial thickening (RA patient)
- Calcific SST
- A thickened SAB with signs of impingement against the lateral edge of the acromium
- Clinically impingement although little to see on US other than some thickening and mild impingement with abduction.
- Note the close association with posterior edge of supraspinatus and infraspinatus and then again the inferior edge of infraspinatus and teres minor
- Complete rupture IST with effusion from the post GHJ Next slide demonstrates dynamic use of US
- Commonly demonstrates degenerative change with distension of the joint capsule Clavicle is higher than the acromium - Note line for injection dashed line
- Note line for injection (spinal)