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Hello, and welcome to Noon Conference hosted by Modality.

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Noon Conference connects the global radiology community through free live

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educational webinars that are accessible for all and is an opportunity to learn

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alongside top radiologists from around the world.

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Today, we are honored to welcome Dr.

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Richard Barger for a lecture entitled "MSK Ultrasound: Common

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Entities and Key Imaging Findings." Dr.

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Barger completed his radiology residency and musculoskeletal

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radiology fellowship at William Beaumont Hospital.

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He is an MSK radiologist at University Hospitals Cleveland Medical

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Center, where he is the medical director of MRI and lead

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musculoskeletal ultrasound. He has special interest in medical

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education, MSK ultrasound, informatics, and advanced

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MSK MRI imaging.

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At the end of the lecture, please join Dr.

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Barger in a Q&A session where he will address questions you may have on today's

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topic. Please remember to use the Q&A feature to submit your questions so we can

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get to as many as we can before our time's up.

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With that said, we are ready to begin today's lecture. Dr.

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Barger, please take it from here.

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Thank you for the invitation.

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Today, we're going to do a very fundamental overview of musculoskeletal

1:15

ultrasound. Hopefully, there's everything here for the beginner

1:19

to see,

1:20

as well as some pearls for those that may already do musculoskeletal

1:24

ultrasound.

1:26

I have no conflicts of interest, and we're going to go ahead and get right

1:29

into the fundamental principles.

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So first, we need to do an overview of

1:40

what things look like on musculoskeletal ultrasound.

1:44

So this is a table that highlights everything.

1:49

I will go into a little more detail as we course

1:52

through the different structures you may see on musculoskeletal

1:56

ultrasound.

1:59

So first and foremost, tendons and ligaments, as seen on musculoskeletal

2:02

ultrasound, are hyperechoic and demonstrate a fibrillar

2:06

architecture. Here we see the biceps tendon on this image

2:10

demonstrating the well-organized fibrillar

2:13

architecture and the hyperechogenicity.

2:17

I

2:20

find muscles to be a little harder and demonstrate more

2:23

variability.

2:25

And this graphic here demonstrates what we typically see

2:30

of skeletal muscle on musculoskeletal ultrasound.

2:33

So in the transverse projection,

2:36

we have what is known as the starry night pattern.

2:40

So there is a hyperechoic background studded with bright

2:44

hyperechoic specks, which make up the connective tissue septa of

2:47

the perimysium and endomysium.

2:50

And then there are hyperechoic epimysial fascial

2:54

layers in between. In the

2:58

longitudinal direction, we demonstrate the pennate

3:01

fiber pattern. So we have the oblique fascicle

3:05

lines with thin, evenly spaced fascicles,

3:09

and we're able to make some pennate angle

3:13

measurements,

3:15

and that's particularly helpful for dynamic musculoskeletal

3:18

imaging of the muscles, which I really won't cover during this.

3:23

And here is a composite layered view demonstrating all of the

3:26

layers of which we see with the starry night

3:30

pattern, the overlying skin, and the superficial fat and

3:34

fascia, and the underlying bone.

3:37

As far as structure is concerned, there are different muscle

3:41

architectures. So we have our parallel, our strap

3:44

muscles, our unipennate muscles, our bipennate muscles, and

3:48

our multipennate muscles.

3:53

There is a grading system to look for the echogenicity

3:57

of muscles. It's known as the Heckmatt grading scale.

4:00

And typically, what we expect to see is low

4:03

muscle echogenicity with the clearly

4:07

reflective bone in the far field,

4:12

with just the normal perimysial speckling only.

4:15

As we get more atrophy seen in the

4:19

muscle, there is increasing echogenicity, and we

4:23

lose the visualization of the bone.

4:28

So this is an example of a normal muscle, excluding this near field

4:32

finding, which I'll discuss a little later.

4:35

We see our fascicular architecture with

4:39

the muscles demonstrating the epimysial

4:42

hyperechogenicity with the intervening areas

4:46

of the normal muscle demonstrating hypoechogenicity.

4:51

So some fundamental pathologic muscle findings and

4:54

pitfalls. So we do grade our muscles by Grade 1, Grade 2,

4:58

and Grade 3 tears. So we look for a hypoechoic hematoma or

5:02

focal defect distorting the fascicular pattern.

5:07

You can see muscular dystrophy where we have muscle replacement

5:11

with fat.

5:12

Inflammatory myopathy is typically seen as diffuse areas

5:16

of increased echogenicities with patchy areas of

5:20

hypoechogenicity and perifascial and intramuscular

5:23

edema.

5:25

Denervation or neurogenic atrophy, we see

5:28

reduced muscle bulk with increased echogenicity in the

5:32

muscle due to the fatty replacement.

5:35

Again, intramuscular hematoma acutely will be

5:39

a hyperechoic collection, and as the

5:43

hematoma evolves,

5:45

it will become

5:47

more hypoechoic or mixed echogenicity and eventually resolve over

5:51

time. I will tell you, one of my principles with hematomas is that

5:55

I do follow them to resolution. And then calcific

5:58

myositis and

6:04

And myositis ossificans, obviously, we're going to get areas

6:08

of calcification within the musculature that are

6:11

hyperechoic with shadowing. So when we're looking at muscles, we want to

6:15

watch our gain settings because that can affect the echogenicity.

6:20

If it's too high, it can make the muscle appear falsely abnormal.

6:25

Subcutaneous fat will attenuate the beam, making the muscles

6:29

appear more hypoechoic when normal.

6:32

You can get post-exercise artifacts.

6:34

So if somebody's been exercising, you can actually get transient increased

6:37

echogenicity in the muscle. And the one artifact I will talk about is

6:41

anisotropy.

6:45

Moving on to some different structures.

6:47

So hyaline articular cartilage is hypoechoic to anechoic in nature,

6:51

as we see it here on this Taylor dome image, the

6:54

hypoechoic hyaline articular cartilage.

6:58

Fibrocartilage is hyperechoic, and this is an image

7:02

on ultrasound through the medial meniscus.

7:07

Peripheral nerves is another commonly assessed thing on musculoskeletal

7:10

ultrasound, and this figure here demonstrates what we typically

7:14

see. So in cross-sectional area, we have the

7:18

hypoechoic fascicles ensheathed by the

7:21

perineurium. And then we have the hyperechoic

7:25

epineurium that goes around the entire nerve and gives us what we call our

7:29

honeycomb pattern. In the longitudinal

7:33

axis, we see the parallel tract appearance,

7:37

and what we get is the alternating bright and dark parallel lines,

7:42

representing the fascia and the nerves.

7:46

And again, the outer hyperechoic area is the epineurial border.

7:50

There is anisotropy with nerves, but it is not to the same degree

7:54

as tendons and ligaments. So we can

7:58

use

8:00

ultrasound to differentiate between those, particularly

8:03

in the transverse dimension. So the honeycomb pattern for nerves,

8:08

whereas tendons have the fibrillar architecture, and vessels will have the

8:11

anechoic lumen.

8:14

So this is an example of a peripheral nerve. This one is pathologic.

8:18

But just to show you, we've got the outer area of

8:22

the

8:26

nerve with the hypoechoic fascicles and the intervening

8:30

perineurium, and here is the parallel tract appearance in

8:33

the transverse dimension.

8:37

So I've got a little bit of an analogy when looking at

8:40

nerves. So if anybody remembers back to their childhood, there was a

8:44

cereal called Cookie Crisp, and there's also Honeycomb cereal.

8:47

I think they still make Honeycomb cereal.

8:49

So abnormal nerves tend to have nerves where the

8:53

fascicles are irregular in morphology through the cross-section of the

8:57

nerve. Whereas a normal nerve has a more uniform

9:01

honeycomb appearance to it.

9:06

Bone is hyperechoic on ultrasound and demonstrates

9:09

posterior shadowing.

9:13

As I said, the one artifact that I like to talk about in musculoskeletal

9:17

ultrasound is anisotropy.

9:20

It is one of the more common artifacts that is encountered that can cause

9:24

serious problems. And here we have an image of a

9:27

supraspinatus tendon, and you can see away from

9:31

90 degrees from the transducer, we're getting hypoechogenicity and

9:35

loss of the fibrillar architecture of the supraspinatus tendon,

9:39

indicative of the anisotropy in this rotator cuff in a

9:43

normal person. I know this is a normal rotator cuff because it's

9:47

my asymptomatic shoulder.

9:50

So anisotropy is caused by highly organized structures due

9:54

to reflection, so tendons, ligaments, and nerves.

9:57

And depending on the angle of insonation, there is various degrees of reflection,

10:01

and not all echoes return to the transducer.

10:05

The maximum echoes return where the beam is perpendicular to the

10:09

structure. This reflection results in loss of signal and

10:13

can be interpreted as the structure being more hypoechoic than it

10:16

really is. To correct for this, we use the heel-toe

10:20

maneuver to get the angle of insonation as close to

10:23

perpendicular as possible.

10:26

So I have a nice

10:27

short movie here demonstrating a movement of a

10:31

transducer across a

10:34

structure with anisotropy. And we can see as we move away from 90

10:38

degrees, the structure becomes more hypoechoic.

10:41

And this one is more of an example of a tendon.

10:44

And here in cross-section, we have a nerve demonstrating the loss of

10:48

the echogenicity pattern in the

10:52

transverse dimension.

10:55

And just for

10:57

sake, I'll rerun that movie again one more time, showing us moving

11:01

the transducer away from the 90 degrees, demonstrating the

11:05

change in echo texture due to the

11:09

anisotropy.

11:14

So some clinical pearls about anisotropy.

11:17

We can use the heel-toe maneuver, or I call it rocking, where you move

11:21

the transducer back and forth to get it as close to perpendicular as possible.

11:26

Recognize that anisotropy can be a pitfall

11:30

in tendon tears. So you want to make sure you get it

11:34

as

11:35

close to the 90 degrees as possible and the maximum echogenicity.

11:41

You can use this if you're doing nerve blocks because of the fascicular

11:46

architecture

11:48

versus the fibrillar architecture of tendons

11:52

and ligaments so that due to that less abruptness, you

11:56

can better identify the nerves for nerve blocks.

11:59

I will say that you can use spatial

12:02

compounding to partially mitigate anisotropy

12:06

because that introduces sound beams from multiple different

12:10

angles. However, tissue harmonics does not Correct for

12:14

anisotropy. You can actually intentionally use anisotropy to

12:17

differentiate between tendons and ligaments from nerves and muscles

12:21

or blood vessels,

12:23

and recognize that higher frequency transducers have more pronounced

12:27

anisotropy due to greater specular

12:30

reflection.

12:33

Talking a little bit about transducer selection before you do a

12:36

musculoskeletal ultrasound, what I typically say is the higher the

12:40

frequency, the better. However, all transducer

12:44

arrays,

12:46

curvilinear or linear, do have their utility.

12:50

So a very high frequency transducer produces a nice wide parallel

12:54

beam for superficial structures and can resolve things down

12:58

to about 0.1 to 0.2 millimeters.

13:01

However, as we increase the depth, that limits our ultrasound

13:05

penetration, so as we get to deeper structures, we do have trouble.

13:09

A good balance is a standard linear transducer, so 5 to 12

13:13

megahertz. Again, flat surface with some beam divergence.

13:17

It is a balance between resolution and penetration.

13:22

And often, these transducers, we can adjust the frequency range.

13:26

So this is good for some intermediate depth structures.

13:30

And remember, a lot of this also depends on patient body habitus, so thinner

13:33

people, you might be able to do the same thing that you do with a standard

13:37

linear.

13:38

And then the curvilinear, with its curved footprint,

13:42

fan shape, diverging beam, is great for the deeper field of view

13:46

structures, can penetrate up to about 18

13:50

centimeters, but it does have poor near-field

13:53

resolution. I often use this in deeper

13:56

applications, such as when I'm looking at the hip joint,

14:00

particularly deep injections.

14:04

So some transducer tips. So start with your high frequency and step it

14:08

down as needed. Adjust your focal zone to get to

14:11

your target depth. You can use harmonic imaging for deeper

14:16

or difficult patients to see

14:18

the deeper structures. We can use a standoff pad for

14:22

shallow structures.

14:24

You can also modify your gain versus your time gain

14:27

compensation. So your time gain compensation applies differential

14:31

application at different depths to account for that

14:34

attenuation to balance things out.

14:37

And don't be afraid to mix things up.

14:40

I will often switch two or three times during an

14:43

examination to use different transducers to get

14:47

the optimal pictures based on what I may be assessing at the given

14:51

moment.

14:53

So standoff pad,

14:55

you can use a preformed gel block. You can use a fluid-filled bag or a

14:59

water bath. I use the quick and easy

15:03

most often. I'll put a giant gel bolus on the skin surface, and

15:07

I'll elevate that transducer away.

15:09

So what that does is it moves the superficial structures away from the transducer

15:13

face into the focal zone, reduces the ring-down artifact from

15:17

the transducer face, improves the resolution of superficial structures,

15:21

allows for lighter pressure, and enables also

15:25

better Doppler assessment near the skin and of

15:29

imaging of irregular surface contours.

15:34

I won't go into depth regarding optimization of machine settings.

15:38

That will depend on the manufacturer.

15:40

There's often different levels, so general, superficial, deep.

15:44

You can use harmonics. There's things like dynamic range.

15:48

What I basically say is, whatever your

15:51

ultrasound manufacturer is, get to know them, invite a rep out,

15:55

have them work with you on getting your ultrasound

15:59

machine set up to optimize what you may be doing.

16:02

And you can even have labels. So we recently put labels into our

16:06

machine so that our ultrasound techs have a checklist so that they make

16:10

sure that they cover all the bases for a given exam, and they've taken the

16:14

necessary representative images.

16:18

The last thing I will say is I do a fair amount of

16:21

in-person ultrasound,

16:24

and I am able to talk to patients. Oh, no, a radiologist doing a physical

16:28

exam and a focus history.

16:31

But it can be very helpful, and I do incorporate that information into

16:35

my report if I do some sort of physical exam

16:39

or I have additional history that may not be available to me.

16:42

And in this example that we see here, we've got lymphadenopathy in

16:46

the right arm in the epitrochlear lymph node chain.

16:50

I was a resident on call with this case, and

16:54

I went in and

16:57

I looked at her arm, and it looked like she had gotten into a fight with a tiger.

17:01

So she owned five cats, and immediately I was thinking, "Well, I kind

17:05

of know what this is already." So, we found the lymphadenopathy.

17:09

We were able to give a pretty good differential

17:12

diagnosis, and this did turn out to be a cat scratch

17:16

disease, a bartonella species, at excisional

17:20

biopsy.

17:23

So now I'm going to transition, now that we've covered some basics of

17:27

appearance and artifacts and some techniques on imaging,

17:31

into the different cases, and I will go through those for the rest

17:35

of our talk.

17:37

What we have here is an example of a supraspinatus tendon

17:41

in transverse and longitudinal dimension.

17:44

We see that we've lost the fibrillar architecture that is

17:48

typical of the tendon, and there is increased

17:52

hypoechogenicity within the tendon.

17:55

So we call this mild to moderate tendinosis.

18:00

This is another example of a patient that has a partial tear.

18:04

So we see again, there's loss of the fibrillar architecture with

18:07

hypoechogenicity. But in addition to that, we have

18:11

an anechoic fluid cleft along the insertional tendon,

18:15

some partial retraction, some fluid within the gap.

18:19

And this was a partial full-thickness

18:22

supraspinatus tendon tear.

18:27

All tendons are very similar, so supraspinatus,

18:31

infraspinatus, and I'll state that the rotator cuff

18:34

ultrasound, in addition to my Snowville screening ultrasound, is

18:38

the only examination that is relatively comprehensive.

18:42

The rest of the musculoskeletal realm in ultrasound is a

18:46

very focused exam. So here we have an

18:50

example. The deltoid muscle is draping over the greater tubercle

18:53

of the humerus. We don't see any tendon where the

18:57

infraspinatus tendon should be living, and this was a

19:01

complete infraspinatus tendon tear.

19:03

I will say that this patient also had a complete supraspinatus tendon

19:07

tear on this ultrasound.

19:11

This is an example of a complete subscapularis tendon

19:15

tear along a common theme. We see our biceps tendon

19:19

here at the bicipital groove. We see the lesser

19:22

tubercle. There is an anechoic fluid gap.

19:25

We see the deltoid muscle draping over the

19:29

lesser tubercle indicative of this subscapularis tendon

19:34

tear.

19:36

A very important tool to use in musculoskeletal

19:39

ultrasound is dynamic imaging, and

19:43

that is one of the areas that I always do with

19:47

rotator cuff. I usually use it for assessing the subscapularis, the

19:51

AC joint, and the gliding of the rotator cuff tendons under the

19:55

acromion. So here we have an example, and we can show it on the

19:59

movie, the dynamic imaging, that the biceps tendon is

20:03

subluxed out of the bicipital groove into

20:07

this high-grade subscapularis tendon tear

20:11

off of the lesser tubercle. So, I'll have a few more

20:14

examples of dynamic imaging that I show in the

20:16

cases. And again,

20:21

you can use it with pretty much any patient that you're doing

20:25

MSK ultrasound on.

20:30

Here's a photograph of an arm demonstrating a lot of

20:33

bruising in the arm and in the forearm.

20:36

I will tell you, one of my areas of interest

20:40

is incorporating photography into musculoskeletal imaging, not

20:44

only ultrasound, but also into MRI and radiography,

20:48

and CT imaging. I do a fair amount of remote imaging,

20:52

and sometimes the technologists may not be able to convey all the information

20:57

of what they're seeing or where something is exactly located.

21:01

I will have them take photographs.

21:02

There's a

21:05

tablet-type device that actually comes with our ultrasound machine and

21:09

is incorporated right into the pack.

21:10

So they took this photograph of this person's arm, and what we

21:14

see here is one of the common ordering indications for a musculoskeletal

21:18

ultrasound, a very easy, quick examination to

21:22

perform, much cheaper than an MRI.

21:24

And here we've got the biceps brachii tendon.

21:28

We see the redundant tendon here in the arm with the tendon stump.

21:32

This is just a little more distal, showing the retracted tendon stump and the

21:36

fluid gap going into the forearm, indicative of

21:40

this complete retracted tear of the biceps brachii tendon.

21:46

Something I actually include in a lot of my shoulder ultrasounds routinely when I'm

21:50

scanning the biceps brachii, we will take a look at the

21:53

pectoralis major. And I'll also say this is where that focus

21:57

history can be helpful. I've had a fair number of people come in with

22:01

orders for rotator cuff ultrasounds.

22:04

I go in the room, and I ask them what's going on, and they're like, "Well, my

22:07

shoulder doesn't hurt, but I got this big bruise on my chest.

22:11

And when I was bench pressing," so the classic story for

22:15

a pectoralis major injury is a bench press injury.

22:19

Recognize there are three heads, the sternal, the abdominal, and the clavicular

22:22

head.

22:23

The sternal and the abdominal head kind of blend together.

22:26

And recognize that the heads do cross one another with the sternal head

22:30

inserting more superiorly, the clavicular head more inferiorly.

22:34

And what we have here is we see in this trapezoidal image,

22:38

we've got the distal tendon, the biceps tendon's deep to it here,

22:42

and more proximally, we've got this large full-thickness

22:46

defect in the distal myotendinous

22:49

sternal head of the pectoralis major.

22:51

He had a bruise on his chest wall, and we were able to easily diagnose this

22:55

pectoralis major tear.

23:01

I wanted to show another example of pathology as

23:05

seen of the chest wall. So this was a young individual that came in

23:09

with an abnormality on the chest wall.

23:12

And I know we often diagnose this on radiography with

23:16

increased lucency on one side. They wanted to confirm it.

23:19

Ultrasound's a very cheap, easy way to confirm.

23:23

And indeed, in this patient, we've got a pectoralis major on the

23:27

left side, we have none on the right side, and we're able to confirm

23:31

on ultrasound that this young individual had Poland syndrome.

23:35

I like to also use this as an example for those of you that want to get

23:39

into doing musculoskeletal ultrasound.

23:42

Everything you see is pathology you've seen before.

23:46

You're just seeing it in a new or different modality.

23:49

So the differential diagnoses remain the same, and you've just got to

23:53

apply it to using musculoskeletal ultrasound.

23:58

Moving a little further into the upper extremity,

24:02

we've got lateral epicondylitis here.

24:05

So we've got hypoecogenicity with loss of the fibrillary architecture

24:09

in the common extensor tendon. We've got a mild undersurface fluid cleft.

24:14

We have a little bit of enthysophyte formation here at the

24:18

lateral epicondyle. In this patient, they really didn't have a lot of increased

24:21

color signal intensity, but you would want to add that on.

24:24

They had pain right in this region, so indeed, some common extensor

24:28

tendinosis,

24:30

as seen with lateral epicondylitis.

24:34

This is an example of an individual that came

24:38

in with a palpable lump in their forearm.

24:43

They're a bartender. They were in a fight in a bar,

24:47

and they decided to break up that fight, and they got lacerated

24:51

by a beer bottle, and they were concerned.

24:54

Even though the patient didn't have symptomatology, obviously, the primary

24:57

concern would be to assess the median nerve

25:01

in the forearm. But when we put the ultrasound

25:05

transducer down, at the level of the scar, we saw

25:09

the distal lump, we had a gap, we had a proximal lump, and we

25:13

were able to diagnose in this patient that they actually had a transection

25:17

of the palmaris longus tendon. So I want to talk a

25:21

little bit about this tendon. So it's a variable

25:24

superficial forearm muscle and tendon.

25:27

It's absent in about 10% to 20% of the population.

25:31

It originates from the common flexor tendon, adjacent intermuscular

25:34

septum, and the antebrachial fascia, passes superficially down the

25:38

mid-arm between the flexor carpi radialis and ulnaris

25:42

over the retinaculum, and inserts on the distal retinaculum and the palmar

25:45

aponeurosis. May have a short slip to the thumb.

25:48

It's a weak flexor and abductor of the thumb.

25:51

It's an often harvested tendon for grafts.

25:55

And probably one of the important things, a reverse belly of the

25:59

palmaris longus tendon. So instead of the tendon,

26:03

the muscle belly being proximal, the muscle belly is distal and in the

26:07

carpal tunnel, and it can be

26:10

a cause of refractory carpal tunnel syndrome

26:13

after a retinacular release if it's not identified.

26:17

Probably the most common

26:20

story that I've heard with the examples I've seen is actually

26:24

children who've presented with carpal tunnel-like symptomatology.

26:28

So whenever I hear of a nine or ten-year-old, maybe they've been playing too many

26:31

video games. But I'm always thinking

26:35

about whether or not, and I found a few examples of

26:39

a reverse belly palmaris longus in young individuals.

26:44

So there is such thing as proximal and distal intersection syndrome.

26:47

Yet another photograph. This was done remotely.

26:52

This individual had focal pain over the distal

26:56

dorsal forearm. We put the transducer down, and that was

27:00

right in the location of proximal intersection syndrome.

27:04

So

27:06

that's where we get crossing of the first and

27:10

second extensor compartments about four centimeters proximal to

27:14

Lister tubercle. There was a little bit of fluid in the tendon sheath

27:17

here. I will tell you, I've had some examples where there was no

27:21

finding at all on the ultrasound, but it's right where the patient had the

27:25

symptomatology. And it is possible that there are no sonographic

27:29

findings despite the presence of this syndrome.

27:32

So this is a

27:34

companion case as seen on MRI, and we've

27:38

got quite a bit of tenosynovitis here between the first and second extensor

27:41

compartments. It is more proximal than the distal intersection syndrome

27:45

where we get crossing of the second and third compartments.

27:49

I actually saw a case of distal intersection syndrome yesterday on ultrasound.

27:54

So the proximal is about four centimeters proximal to Lister's tubercle due to

27:58

repetitive flexion extension. You see fluid in the tendon sheath, plus or

28:02

minus tenosynovitis. And as I said, there may not be any imaging

28:06

findings at all.

28:08

So this individual here came in with a

28:12

palpable pulsatile lump on the ulnar side of their

28:16

palm. And before I even started scanning, I had an idea of

28:20

what we were going to be seeing. We had a tortuous blood

28:24

vessel with significant blood flow with aliasing artifact.

28:27

We even had a mass-like area with pulsatile

28:31

to-and-fro flow within it. So here we have tortuosity of the

28:35

ulnar artery with aneurysm, pseudoaneurysm formation.

28:40

This individual had Hypother Hammer Syndrome.

28:43

So it's felt to be due to chronic repetitive blunt trauma to the ulnar artery at

28:46

the wrist,

28:48

typically seen at the hook of the hamate at Guyon's canal,

28:52

where it passes over the hook. So vibratory motion or impact injuries such

28:56

as the use of pneumatic hammers, baker's meat cutters,

28:59

metalworking.

29:01

And that vibratory damage causes intimal damage,

29:04

vasospasm, or leading to artery tortuosity, aneurysm

29:08

formation, thrombosis, and digital ischemia.

29:13

I've actually got a case of Thanner Hammer Syndrome where I found a

29:16

radial artery that was tortuous with a pseudoaneurysm in a baker

29:20

that tended to use the more radial side of the palms of her hands to knead

29:24

dough. Be mindful that digital ischemia can happen about

29:28

45% of cases and can lead to gangrene.

29:34

Moving a little further down the upper extremity is a

29:38

great case of ulnar collateral ligament tear.

29:42

So in this case, this was an individual that was walking their

29:45

dog, got pulled by the leash and had significant pain and

29:49

swelling. And what we see here is we

29:53

see the

29:56

ulnar collateral ligament is torn and retracted back beyond the

29:59

adductor aponeurosis.

30:03

There was significant swelling. I guess the hand surgeon wasn't confident

30:06

in my ultrasound alone, so they did an MRI

30:10

redemonstrating the

30:13

tear of the ulnar collateral ligament retraction via proximal to the adductor

30:17

aponeurosis. The surgeon is a good friend of mine.

30:19

I asked him

30:21

to take some intraoperative images, and here we see that

30:25

torn ulnar collateral ligament, torn and protracted

30:28

proximal to the adductor aponeurosis.

30:31

And this is a little further in the surgery where they had opened

30:35

up the adductor aponeurosis, and they're getting ready to put the ulnar

30:39

collateral ligament down onto the bone surface and then over sew the

30:43

adductor aponeurosis. So this is a great modality to

30:47

use.

30:49

You can use dynamic imaging. You can flex the interphalangeal joint

30:53

to show the movement of the adductor aponeurosis.

30:56

And then with very gentle

30:58

motion, you can do some

31:02

stress on this to show That the ulnar collateral ligament is

31:06

torn.

31:07

I usually don't let my technologists do any of the dynamic imaging

31:11

in these cases out of the presumed fear of changing a non-stener

31:15

into a stener lesion.

31:17

This friend of mine, hand surgeon, did say, "Rich, this is a bread and

31:21

butter surgery for me. You're helping me out.

31:24

If you accidentally convert something to a stener,

31:26

I'm going to operate, I'll manage

31:30

it." And, I do have trust from my hand surgeons

31:34

when I'm assessing these patients for them.

31:39

Yet another example, this was done remotely.

31:42

The technologist took a picture of this patient for me, and we see

31:45

PIP flexion, DIP hyperextension of a boutonniere

31:49

deformity. And, we're immediately thinking, and again, we have

31:53

here a central slip extensor tendon expansion

31:57

tear from the middle phalanx, beautifully shown on

32:00

ultrasound and corroborating the

32:05

physical exam and photographic findings.

32:09

I'm going to move into our lower extremity for

32:14

the next part of the talk and

32:18

ultrasound's great at looking for hamstrings tendinosis and tears.

32:22

This individual here had pain, no trauma.

32:26

They were concerned about hamstrings tendinosis.

32:28

And what we've got here is we've got thickening of the hamstrings

32:32

tendon origin. We've got some loss of the fibular

32:35

architecture. I commented that I didn't see any fluid,

32:39

in this case, in the overlying

32:43

ischiogluteal bursa.

32:46

The patient did have persistent symptoms, and they went

32:49

on the MRI, just corroborating the ultrasound findings of

32:53

some mild increased signal here at the origin of the hamstrings tendons,

32:57

indicative of some hamstrings tendinosis.

33:02

Can we assess hardware or hardware complications? Absolutely.

33:07

This patient had had a hip fracture, and they had a hip

33:11

screw placed. They were complaining of focal pain over the

33:14

lateral proximal thigh hip, and what we see

33:18

here is the hip screw is protruding out of the bone, causing

33:22

some mild mass effect on the overlying iliotibial tract.

33:26

There's a little bit of fluid deep to that.

33:28

So we suggested the possibility that there could be

33:32

some friction and impingement on the IT band or tract

33:36

by the underlying screw. They actually went in and modified

33:40

this, and the symptoms went away. As an aside, another thing that I've not

33:44

uncommonly seen,

33:46

particularly in the lateral thigh, is a myofascial

33:49

hernia, where the stab incision causes a defect in the

33:53

lateral fascia, and you get muscle herniating through the defect, which is

33:57

causing a focal burning pain. So I had that in the back of my mind when

34:01

I was thinking in this patient.

34:09

We saw this patient a little earlier.

34:12

I used as the normal muscle example, and the reason I used her

34:16

as a normal muscle example is, a very fit

34:20

individual, aerial silk dancer.

34:22

She was doing her routine and felt a focal tearing

34:26

pain in her approximate mid

34:30

right thigh. We put the ultrasound transducer down, and here

34:34

we see this mild to moderate anechoic cleft within her

34:38

gracilis muscle, and we were able to diagnose a Grade 2

34:42

gracilis muscle strain.

34:45

Very easy, quick examination, much cheaper than an

34:48

MRI.

34:53

As we talked about earlier, I wanted to show a good example of what fat

34:57

atrophy will look like in the muscle.

34:59

This is an individual that had a remote history

35:03

of a

35:05

quadriceps injury, and they were actually feeling a focal

35:09

soft lump. We put the ultrasound transducer down,

35:12

and in the region where they had had their prior injury, we see this

35:16

hyperechoic area, posterior shadowing.

35:19

You can imagine with the Heckmatt grading scale that this can make the

35:23

bone harder to see if we were deep to it.

35:25

And what this patient was feeling was just some focal fatty atrophy within their

35:29

rectus femoris muscle.

35:34

The quadriceps tendon is an easily assessed structure

35:38

on ultrasound, and you put the transducer down and take a look at it.

35:41

So here we have the normal fibular architecture of the quadriceps tendon.

35:45

And in this example in the right, we see that there's some tendons still

35:49

intact, but there was a defect with retraction, so this patient had

35:53

a high-grade partial quadriceps tendon tear from the patellar

35:57

insertion.

35:59

I don't routinely look at menisci, but that doesn't mean we can't

36:03

necessarily see findings.

36:05

What I typically say is, I've got a few providers, they just want to get an

36:09

idea, and in this case, this patient actually had a medial knee

36:13

lump, and when we put the transducer down, we saw extrusion of the

36:17

body of the medial meniscus with an overlying parameniscal

36:21

cyst, indicative of a medial meniscus tear.

36:24

This patient could not have an MRI.

36:25

The surgeon actually took this patient to surgery and confirmed

36:29

exactly what we saw, a medial meniscus tear with a parameniscal

36:33

cyst and extruded medial meniscus.

36:37

Yet another example of something with tendinosis and tearing.

36:41

So this is the patellar tendon at its insertion.

36:44

We've got loss of the fibular architecture, hypoechogenicity within the

36:47

tendon. There's really no hyperemia in this case, so we

36:51

diagnose this as mild to moderate patellar tendinosis.

36:57

Yet another example of something where dynamic imaging may be

37:00

helpful,

37:02

areas in the body where we can use it, we can use it for patellar clunk syndrome,

37:06

we can use it to look at the biceps tendon.

37:09

We can use it to look at the superior peroneal retinaculum, amongst

37:13

other things. This patient came in complaining of an issue

37:17

that when they flexed and extended their knee, they felt a popping sensation at

37:21

the medial knee. So here we see in this movie, it's moving a

37:24

little fast, but we get the pes anserinus tendons that are actually

37:28

popping over the periphery of the medial

37:32

condyle, and we were able to diagnose this patient with

37:36

snapping pes anserinus tendon syndrome.

37:39

So we can see in this movie, those tendons popping over top of the periphery of

37:42

that medial femoral condyle in that video.

37:48

So tennis leg. So this individual was a SWAT

37:51

officer that was in training. They repelled off of a wall and

37:55

felt a sudden pop in their calf with bruising, and what we

37:59

see here is we've got fluid between the medial gastrocnemius and soleus

38:03

muscles,

38:04

indicative of a moderate strain of the medial head of the

38:07

gastrocnemius, colloquially known as tennis leg.

38:11

I'll say that in the past

38:13

it was often thought that this was a plantaris tear, which could be seen

38:17

in these cases, but more likely than not, it's

38:20

not a plantaris tear, it's a medial head of the

38:24

gastrocnemius tear. Often, these patients are managed conservatively,

38:28

whether it's the medial gastrocnemius or the plantaris that is torn.

38:34

Achilles tendon.

38:36

This is a good place if you're training ultrasound technologists, for them to

38:40

start with the Achilles tendon, large superficial tendon,

38:44

easy pathology to assess. And what we see in this individual that

38:48

had posterior heel pain is we've got thickening,

38:51

hypoechogenicity in the Achilles tendon, loss of fibular architecture.

38:55

We've got some enthisified formation, and we've got a little bit of fluid here in

38:59

the retrocalcaneal bursa, which did demonstrate some increased color signal

39:03

intensity. So I diagnosed this patient with moderate distal to

39:07

insertional Achilles tendinosis with mild retrocalcaneal

39:11

bursitis, no Achilles tendon tear.

39:14

This is an example. This individual

39:18

was put on a fluoroquinolone, and about five,

39:22

six days later, they came in with a sudden

39:27

posterior heel pain, felt a pop, and what we have here is

39:31

a complete Achilles tendon tear. We've got a fluid

39:35

cleft here near the critical zone of the tendon,

39:39

redundancy to the tendon, loss of fibular architecture, and

39:43

this patient had a complete Achilles tendon tear secondary to

39:46

fluoroquinolones. One of the things that I will state is

39:50

that fluoroquinolones are not the only class of drugs that this can

39:54

be seen with. Multiple classes have been implicated,

39:57

particularly steroids, statins, and aromatase inhibitors.

40:04

At the ankle, so ankle tendons are

40:08

easily assessed on ultrasound, and what we see here is we've got

40:12

a split

40:13

tendon bundle, and we've got something in between.

40:16

So what we have, and we can demonstrate on this movie, right about here

40:20

is where that other image is at. We've got a chevron-shaped

40:24

appearance to the retromalleolar peroneus brevis tendon.

40:28

I didn't see any subluxation, but here we have a degree of split tearing of

40:32

the peroneus brevis tendon with subsidence of the peroneus longus tendon

40:36

into the brevis split tear.

40:41

I don't get a lot of ordering indications for ligaments.

40:44

I do know that other individuals at other institutions do a

40:48

fair amount of ankle ligament assessment.

40:51

I don't know. I think a lot of my providers, they diagnose it clinically.

40:55

They've never really ordered it. But that said, I've had a few cases where

40:59

they've sent them in, and here we've got some mild prominence with loss

41:03

of the fibular architecture, particular at the fibular

41:07

attachment of the anterior talofibular ligament, but otherwise, the ligament

41:11

is intact, so I diagnose them with a mild

41:15

ATFL sprain.

41:18

Plantar fasciitis. This is actually yet another entity very

41:21

easily diagnosed with ultrasound.

41:24

I think a fair number of podiatrists, sports medicine doctors, are actually

41:28

using point-of-care ultrasound to diagnose this.

41:31

So what we have here is we've lost the fibular architecture.

41:34

The plantar fascia is thickened. This individual actually had a very small

41:38

fluid cleft at the undersurface attachment.

41:41

So we were able to diagnose mild to moderate calcaneal attachment plantar

41:45

fasciitis with a mild tear.

41:48

This patient also had calcaneal enthisophyte

41:51

formation. You can use color signal intensity to

41:55

assess for hyperemia. This patient really didn't have any in this

41:58

case.

42:01

So moving on to some examples of nerve assessment.

42:05

I will say, here at University Hospitals, we do have a Neuromuscular

42:09

Ultrasound Institute. They tend to do much more

42:12

comprehensive nerve ultrasound.

42:15

I do a much more focused nerve ultrasound.

42:17

So wherever they suspect the pathology is where I'm going to

42:21

do the ultrasound

42:23

from some of my orthopedic providers.

42:25

So some examples are shown here. One of the more common

42:29

ones are going to be cubital tunnel syndrome and

42:34

carpal tunnel syndrome. So whenever I look at an

42:37

elbow and I see a muscle over top of the cubital

42:41

tunnel, you're going to think about that anconeus, supinatrochlearis, or

42:45

accessory muscle. This patient also had

42:49

some thickening and loss of the homogeneity to the

42:53

nerve fascicles. So this patient had some ulnar

42:56

neuropathy, likely secondary to the presence of that anconeus

43:00

supinatrochlearis muscle. So what is the anconeus supinatrochlearis?

43:04

It's a short variable muscle originating at the medial epicondyle,

43:08

passes over the cubital tunnel, inserts on the olecranon, present in about 14% to

43:11

15% of the population.

43:14

You get hypertrophy of the muscle compressing the nerve, and then you get

43:18

cubital tunnel syndrome. On ultrasound,

43:23

you see the muscle as a hypoechoic fascicular structure over the

43:27

cubital tunnel.

43:29

Cubital tunnel syndrome typically results in loss of sensation in the fourth

43:33

and fifth fingers, clawing this grip of the ulnar

43:37

forearm, and some muscle wasting in severe cases.

43:40

So there is some variability in nerve cross-sectional area measurements.

43:45

But typically, at the distal arm, it's about four to five millimeters squared, and

43:49

the cubital tunnel gets a little bigger, six to seven

43:53

at the inlet and within the tunnel, five to seven, and it becomes a little

43:57

smaller as we get into the proximal forearm.

44:00

So yet another thing is you could have absence of the fascia

44:03

over top of the cubital tunnel that's known as Osborne's fascia

44:07

or Osborne's ligament. We have thickening of the ulnar

44:11

nerve

44:13

here in the cubital tunnel up

44:17

to about 12 millimeters squared. In longitudinal plane, we see

44:21

that there's mass effect or a change in caliber to this

44:25

nerve at the level of the cubital tunnel.

44:27

And again, dynamic imaging is very helpful.

44:30

So we have the patient flex and extend their arm, and we see an elegant

44:34

example here of when they're moving

44:38

their elbow, we get dislocation of the ulnar nerve out of the cubital

44:42

tunnel with the dynamic imaging. So you can imagine if they're doing this all day,

44:46

every day, that that's going to cause a rubbing and ulnar neuropathy.

44:51

I do, from time to time, see patients that have had surgery after

44:56

cubital tunnel syndrome, and they can transpose the ulnar nerve to

45:00

over the medial epicondyle. And what we see in this case, this

45:04

patient actually had some dense scar tissue formation, and we see a

45:08

multilobulated mass effect on the nerve where it was

45:11

transposed and some mild thickening of the trans nerve more

45:15

proximally. They went in and did a neurolysis, and the symptomatology

45:18

improved.

45:21

Somewhat of an odd bird example of yet another nerve pathology,

45:25

so lateral antebrachial cutaneous nerve entrapment.

45:28

So that's typically seen in individuals that have had a biceps tear or a biceps

45:32

tear and repair, and you can get scar tissue formation from

45:36

the repair, or they can accidentally injure the nerve when they're doing the

45:40

biceps brachii repair. And the key thing is, is we look

45:43

for our cephalic vein. The nerve is right next to it here in

45:47

transverse. And what we have here is there's some change in

45:51

caliber of the nerve

45:53

here in the proximal forearm, the cross-sectional area, which

45:58

was about four millimeters squared, and then typically the nerve is very

46:01

imperceptible. So it is the continuation of the musculocutaneous

46:05

nerve, provides sensation of the lateral forearm, runs close to the cephalic vein.

46:09

As I said, it can be injured directly from the biceps rupture or the

46:12

repair. The history is very important here.

46:15

So loss of sensation in the lateral forearm, you want to think of this nerve

46:19

injury. In this case, the surgeon did query

46:23

lateral antebrachial cutaneous nerve pathology, and that's what we found

46:27

in this case.

46:30

Carpal tunnel syndrome, and I know I'm getting near the end of my talk here.

46:34

I could talk for hours and hours on musculoskeletal

46:36

ultrasound. I do want to give time for questions.

46:40

I will say that I'm not going to really cover any tumors here, but we'll continue

46:44

with things until we manage to finish the talk and give some time for

46:48

questions. So when it comes to carpal tunnel syndrome, there's really no

46:52

established diagnostic criteria.

46:54

You don't want to rely on anything alone.

46:56

Some say the cross-sectional area is best,

46:59

and expect to see a CSA proximal to flexor retinaculum,

47:04

and the nerve gets slightly bigger and then smaller within the carpal tunnel.

47:08

So is the normal nerve about nine to 11 millimeters

47:12

squared? Recognize if you've got a bifid nerve, you want to get a sum

47:16

of the bundle of the areas. I typically measure at the pronator

47:19

quadratus and the proximal and distal carpal tunnel

47:23

and distal to the flexor retinaculum.

47:26

Some research shows that

47:29

a difference in two millimeters has got a high sensitivity and

47:32

specificity

47:34

for the nerve at the level of the pronator quadratus versus the carpal

47:38

tunnel greater than four millimeters squared for a bifid

47:41

nerve. We also can look for retinacular bowing.

47:45

So if there's greater than two millimeters of retinacular bowing, as we see in this

47:49

case, outward bowing of the flexor retinaculum, that may

47:53

also help with that.

47:55

Distal flattening of the nerve, intraneural hypervascularity,

47:59

irregularity to the fascicles, and as seen on this transverse image

48:03

here, you can get a knot sign where you get

48:07

a relatively discrete change in caliber of the

48:10

nerve at the level of the retinaculum.

48:13

Again, I tend to put all of these measurements together

48:17

and

48:19

take all the information together to give to my surgeons and

48:23

where they're thinking of equivocal findings in carpal tunnel syndrome.

48:29

This individual here was actually complaining of

48:32

numbness and a lump in their thumb.

48:35

The lump itself

48:39

was painless, but they had the numbness more distally.

48:41

And I will tell you that this individual is a semi-professional bowler.

48:46

And what we have here is we've actually got the ulnar digital

48:50

nerve, and we've got perineural fibrosis.

48:52

This was proven pathologically at surgery.

48:56

So this patient had bowler's thumb. They were a bowler. They had bowler's thumb.

49:00

So perineural fibrosis of the ulnar digital nerve.

49:03

So the repetitive bowling grip causes the microtrauma, kind of like a Morton's

49:07

neuroma but in the hand. You get the scar tissue, lump, pain,

49:10

and numbness.

49:12

They went in, and they cleared this perineural tissue, and the patient's

49:15

symptoms did get better. And it's commonly seen in bowlers.

49:19

They keep the thumb in a ball for an extended period of time to create

49:22

excessive spin.

49:24

Some case examples of the lower extremity.

49:28

So this individual had numbness along the lateral

49:32

thigh. So immediately thinking meralgia paresthetica, lateral femoral

49:35

cutaneous nerve entrapment. So this is right at the pelvic

49:39

outlet where it passes underneath the inguinal ligament.

49:42

We've got some thickening and change in caliber of the lateral femoral

49:46

cutaneous nerve and able to make a diagnosis in

49:50

this case.

49:52

Peroneal neuropathy. So this individual had a below-the-knee

49:56

amputation. They had stump symptomatology as well as

49:59

symptomatology at their fibular head, and we see here on ultrasound,

50:03

they've actually got an osteophyte at the fibular head.

50:06

There was thickening of the owner nerve as it wrapped around the head of the

50:09

fibula. And this patient also

50:12

actually had a mass at

50:16

the stump of the peroneal nerve. So this is just the

50:20

movie showing that osteophyte and the thickening of the nerves that

50:24

wrapped around the fibular head. So cross-sectional dimensions at the knee,

50:28

10 to 25 millimeters with a two to four-millimeter diameter.

50:32

Cross-sectional area between 30 and 40 millimeter squares, moderately

50:36

abnormal, and then greater than 70 millimeters is

50:40

severely abnormal.

50:43

And another common example that I get from my podiatrist,

50:47

so a Morton neuroma. So it's not a true neuroma, but scar

50:51

tissue.

50:52

It's typically hypoechoic scar tissue forming around the

50:56

plantar interdigital nerve, which we see here.

51:00

You can use the Mulder maneuver, which

51:02

is where you squeeze the metatarsal heads together.

51:05

You may feel a lump.

51:08

You can hear an audible click, and often that will elicit pain in patients.

51:14

I think I'll finish up here with

51:17

just one last example of a nerve pathology,

51:21

somewhat of a protean thing. This patient had abdominal wall pain.

51:25

They were told that they were

51:28

imagining things. A bright surgeon was

51:31

thinking about the possibility of entrapment of the anterior cutaneous nerve.

51:36

And what we see here on this movie is we pass through the fascia here

51:40

into the rectus abdominis muscle.

51:43

There is some hypoechogenicity within and hyperechogenicity around

51:47

a branch of the anterior cutaneous nerve.

51:50

This patient actually went to plastic surgery.

51:52

They released this, and all of her symptoms went away.

51:55

So this is an example of a not often thought about entity,

51:59

anterior cutaneous nerve entrapment.

52:02

I think I'm going to stop right there.

52:05

I do diagnose fractures, I do procedures.

52:09

And we also do a screening

52:13

ultrasound and assess arthropathies with musculoskeletal

52:17

ultrasound. I'm more than happy to come back and give another talk

52:21

where we

52:22

discuss more non-tumor pathologies.

52:25

And then, like I said, I can probably give an entire two to three-hour talk on the

52:29

lumps and bumps and masses we see on ultrasound as well.

52:32

I thank everybody for their time, and at this point, I'm going

52:36

to look in the chat and answer any questions that anyone may have.

52:45

So let's see here. So in the Q&A.

52:49

So any cases of ultrasound during interventions like dialysis catheter

52:53

insertion,

52:56

and then

52:58

what does muscle atrophy indicate if we see it?

53:04

And then we've got

53:08

some discussions about calcific tendonitis.

53:10

So what I'll go ahead and

53:13

zoom forward to. So the first question, so procedures.

53:18

I believe that

53:21

if you can see it, you can stick a needle in it.

53:27

So I will stick a needle in pretty much

53:30

anything that is asked of me within

53:34

reason. So,

53:36

I've aspirated and injected bursas.

53:40

Here's an example of a spinal glenoid notch cyst where I stuck my needle

53:44

in, aspirated that, injected some steroids,

53:48

inject the tendon sheath of the long head of the biceps, hip injection,

53:51

iliopsoas tendon injections.

53:55

Again, I'll inject pretty much anything with the

53:58

assistance of an orthopedic surgeon behind me.

54:02

And one of the things I like to show is from time to time, I've had surgeons even

54:05

ask me to put drains in joints.

54:08

So this is an example where I put a patient who was not a

54:12

surgical candidate, had a Pseudomonas

54:15

aeruginosa septic shoulder arthritis and

54:19

bursitis. And I went ahead and to help them out, I

54:22

put a single-step 8 French

54:25

locking pigtail drain in. So again, one stick, put the drain into the

54:29

joint and help them out. Obviously, doing things like

54:33

vascular lines is more of an interventional radiology subject,

54:37

and really beyond the scope. But from the musculoskeletal perspective,

54:41

again, I'll do pretty much anything.

54:44

The next question was actually somebody was asking about calcific tendonitis,

54:49

and separating that from enthesopathy.

54:53

I think my big thing with calcific tendonitis

54:57

is

54:58

thinking about locations.

55:01

Radiography often helps.

55:04

And in this example here of calcific tendonitis, unfortunately,

55:08

the calcium deposit was missed, but

55:12

here we see a relatively smooth rotator cuff tendon with

55:16

this echogenic focus, posterior shadowing.

55:20

Went back, looked at the radiographs, diagnosed as calcific tendonitis.

55:24

Again, classic locations,

55:27

trying to separate from an enthesophyte.

55:30

Sometimes that can be difficult. The radiographs help.

55:33

Obviously, the enthesophyte, usually, you see it contiguous with the bone.

55:37

The calcium deposit is usually within the tendon or ligament.

55:41

And you can do ultrasound-guided barbotage with that

55:45

as well. So that's an example of

55:49

calcific tendonitis.

55:52

Somebody's asking about muscle atrophy.

55:55

What does it indicate if we see it?

55:59

With the case of rectus femoris that I showed,

56:04

that patient actually came in with a palpable abnormality.

56:07

They had a known history of injury.

56:10

Probably the most important area,

56:14

is if anybody's looking for a muscular dystrophy,

56:17

the more routine location where we see muscle atrophy is

56:21

when we're assessing the rotator cuff.

56:23

It's included in all rotator cuff ultrasounds.

56:26

Obviously,

56:27

in an individual with massive rotator cuff tear with muscle

56:30

atrophy, those individuals, they may be

56:33

considering doing a reverse shoulder arthroplasty rather

56:37

than an anatomic arthroplasty

56:41

due to the loss of integrity of the rotator cuff

56:44

tendons. But that's where we usually

56:48

talk about it.

56:52

Let's go down with some more of the questions.

56:58

So ulnar neuropathy at the cubital tunnel.

57:00

Somebody would like me to go back over that.

57:01

I'm more than happy to go back over that.

57:05

And just a question about the radiologist doing

57:08

examinations. I've got trained technologists.

57:12

They've got their RMSK certifications.

57:17

But at the same time, I do a fair amount of ultrasound

57:21

myself. One of the things about training my

57:25

residents and fellows is, in particular the

57:29

fellows, is I do like

57:32

my fellows to scan themselves so that they get comfortable in putting the

57:35

transducer in their hand,

57:38

and seeing the anatomy and pathology.

57:40

Obviously, if a technologist is having difficulty, the person they

57:43

come to is the radiologist, and you're going to need to be able to do that.

57:47

So,

57:49

again, I like to incorporate that training into

57:53

particularly the fellow education and into the interested

57:57

resident education so that they get comfortable in doing the scanning

58:00

themselves. So to go back over

58:04

some cubital tunnel pathology. So the common

58:08

entities, so first of all, they've got numbness in their

58:12

fourth and fifth fingers,

58:14

grip weakness,

58:16

maybe something

58:17

that we see. And then, when looking for pathology at the

58:21

cubital tunnel,

58:24

probably the most common entities would be scar tissue formation

58:27

around the ulnar nerve, the presence of an anconeus epitroclearis,

58:32

absence of Osborne's fascia with ulnar nerve subluxation or

58:36

dislocation.

58:38

And then there's something known as snapping triceps syndrome.

58:41

I will tell you, I don't have a good example of triceps syndrome from the

58:45

wild. I've seen some examples in the textbook, but all of those

58:48

entities can cause irritation of the ulnar nerve.

58:51

So just to reiterate here, in this case, we've got a muscle over the cubital tunnel

58:56

indicative of an anconeus epitroclearis.

59:00

The ulnar nerve at the cubital tunnel or the distal forearm.

59:04

So we measure the cross-sectional area in the distal arm should be between about

59:08

four and five millimeters squared.

59:10

At the cubital tunnel inlet, six to seven millimeters, five to

59:14

seven millimeters within the tunnel, and then it becomes smaller again

59:18

at the proximal forearm, measuring about

59:20

four to five millimeters in cross-sectional area.

59:24

In the cross-section, you may see asymmetry

59:28

to the nerve

59:30

fascicles, what I call that cookie crisp appearance earlier in

59:34

my talk. And something else that you can

59:37

integrate into your ultrasounds are going to be movies.

59:42

So you see here, with the person flexing and

59:46

extending their elbow, we see dislocation of

59:50

the ulnar nerve out of the ulnar groove.

59:52

This patient had enlargement of the nerve as well.

59:55

So the repetitive motion issue here was causing

59:59

cubital tunnel syndrome due to absence of Osborne's fascia and that

60:03

medial nerve dislocation.

60:07

Excellent. I appreciate everyone's time.

60:10

Hopefully, you saw some cool things here, and enjoy the

60:14

rest of your day.

60:17

Awesome. Well, thank you for that lecture today,

60:21

Dr. Barger, and thanks to everyone who participated in

60:25

today's noon conference and asked so many great questions.

60:29

You can access the recording of today's conference and all our previous noon

60:32

conferences by creating a free account.

60:35

We'll also email a link to the replay later today.

60:39

Be sure to join us next week on Thursday, June 25th,

60:43

where Dr. M. Alejandro Bedoya

60:46

will deliver a lecture entitled Normal and

60:49

Abnormal MRI Appearance of the Pediatric Bone Marrow.

60:53

You can register for that at modality.com and follow us on social media for

60:57

updates on future noon conferences. Thanks again and have a great day.