This includes whether the object is solid or filled with fluid. The Musculoskeletal Imaging staff strives to utilize the least invasive technology for diagnosis, advancing to more complex options only as warranted. McNeil CR, McManus J, Mehta S. Nonetheless, some points should be made and the sonographer should concentrate on pattern recognition of … Your doctor will then share the results with you. Common percutaneous ultrasound-guided musculoskeletal procedures are demonstrated, including transducer and needle positioning. Viewed transversely, muscle striations or septa appear dotted and punctuate, or form short lines. This is discussed in the Pitfalls section. Tayal VS, Antoniazzi J, Pariyadath M, Norton HJ. 15. Fundamentals of Musculoskeletal Ultrasound. (Figure 2 and 3). Any portions that are not wiped off will dry quickly. • Failure to obverse structures throughout their dynamic range when possible Musculoskeletal Ultrasound. In some cases, the radiologist may discuss results with you after the exam. This view (corresponding to video clip 3) shows the posterior humeral head rotating in the glenoid, confirming shoulder reduction, and demonstrating the infraspinatus/teres minor complex in motion. • Scan all structures in two planes, i.e. Nearly 400 new ultrasound images show scanning technique, … LaRocco BG, Zlupko G, Sierzenski P. The first principle of technique is patient positioning. You may be asked to wear a gown during the procedure. 6 For optimal musculoskeletal imaging, these frequencies range … To help ensure current and accurate information, we do not permit copying but encourage linking to this site. Ultrasound guided hip arthrocentesis in the ED. The Musculoskeletal Ultrasound Society is the only radiological society dedicated to the application of ultrasound to the entire range of musculoskeletal imaging. When a sound wave strikes an object, it bounces back, or echoes. Ultrasound technology allows us to see rotator cuff tears, tendinosis, fluid in the joints, … [14]. Nerves are visible running along fascial planes, paired with blood vessels, and sometimes within muscles. More advanced uses include detecting occult pediatric fractures, small avulsion fractures, and guiding fracture reductions. Ultrasound can show pictures in real-time, like a movie, and therefore, can demonstrate abnormalities that are only seen with motion like impingent of the bursa in the shoulder, he explains. Targeted musculoarticular sonography in the detection of joint effusions. However, even a novice may compare the acute structure to the normal contralateral structure and reasonably deduce the presence and likely, the nature, of the lesion present. Clinically, indications for emergency department MSK ultrasound include pathology such as fractures, effusions, bursitis, dislocations, and tendon injuries. Muscle can be evaluated for injuries and inflammatory changes such as partial or full thickness tears, hematoma and edema. Fortunately, the sonographic appearance of these structures is largely intuitive. One of the advantages of clinician-performed ultrasound is the ability to perform a dynamic exam. Figure 6: A Colles fracture of the distal radius. Images related to Ultrasound - Musculoskeletal. Occasionally, an ultrasound exam may be temporarily uncomfortable, but it should not be painful. Anisotropy is an artefact encountered in ultrasound, notably in muscles and tendons during a musculoskeletal ultrasound.In musculoskeletal applications, the artefact may prompt an incorrect diagnosis of tendinosis or tendon tear. The program is designed for physicians and sonographers who currently perform ultrasound imaging and wish to extend their capabilities to incorporate musculoskeletal ultrasound imaging. As with all ultrasound, knowing the normal appearance of the sonographic anatomy is essential. (Figure 4)  This probe is useful for showing superficial structures at high resolution and is also best to visualize blood vessels and nerves located near the surface. Understanding the scope of the ED amateur sonographer in point of care musculoskeletal ultrasound creates much anxiety and hesitation to use the ultrasound out of fear of doing an inadequate exam. When evaluating musculoskeletal and soft tissue structures, it is generally best to use a high frequency linear array transducer (7-12 MHz). Only 5% was for ultrasound, which is cost-effective and avoids the inherent risk of radiation exposure. 2010 Oct 13. Please contact your physician with specific medical questions or for a referral to a radiologist or other physician. Bücklein W. When viewing a nerve, for instance, in transverse axis, angling the probe back and forth along the nerve’s axis will cause the bright honeycombed pattern to darken and become less discernable. The teddy bear denotes child-specific content. Musculoskeletal Imaging’s state-of-the-art 3-D magnetic reso… Because images are captured in real-time, they can show the structure and movement of the body's internal organs. 10. In such a case ultrasound may be especially useful to guide an arthocentesis. Simply identifying abnormal fluid in musculoskeletal structures is almost all that an EP need be able to do to derive the majority of use from point of care musculoskeletal US. Marshburn TH, Legome E, Sargsyan A, Li SM, Noble VA, Dulchavsky SA, Sims C, Robinson D. By measuring these echo waves, it is possible to determine how far away the object is as well as the object's size, shape and consistency. longitudinal and transverse Ultrasound images of the musculoskeletal system provide pictures of muscles, tendons, ligaments, joints, nerves and soft tissues throughout the body. By definition, musculoskeletal ultrasound involves the imaging of muscles and the skeleton, and most often involves the interaction of both, such as joints and tendons. Orientation marker is proximal. Some applications of bedside ultrasound may be superior to conventional radiographs such as fractures of the ribs and sternum. Musculoskeletal ultrasound imaging allows us a degree of diagnostic precision that is otherwise impossible. Emerg Med J. Figure 4: A high-resolution linear transducer (7-12 MHz or higher) is recommended for most musculoskeletal applications. Ligament Injury, Fracture and Joint Relocation As the transducer is angled away from being perpendicular to the nerve (Video clip 9) the nerve that is normally bright with a honeycomb-like appearance becomes dark and difficult to distinguish. 14. The staff maintains a commitment to rapid turnaround. Ultrasound imaging is faster than MRI and does not require the patient to remain completely still, allowing infants to be imaged without sedation. What are some common uses of the procedure? 11. A diagnostic radiologist or radiologist is a medical professional who is trained to interpret ultrasound images. Once the imaging is complete, the clear ultrasound gel will be wiped off your skin. It is often helpful to have patient pinpoint the area of maximal tenderness to guide your exam. The Sonographic Ottawa Foot and Ankle Rules Study (the SOFAR Study). AJR Am J Roentgenol, 1999; 173:1603-1609. [Accessed January 5th 2011]. 2006;25(10):1263-8. Infection, inflammation, effusion, cysts, abscesses, hematomas are all the hallmarks of emergency musculoskeletal pathology and easily identifiable by US. See also video clip 7. Publications. Rontgenpraxis. Fractures The ultrasound image is immediately visible on a video display screen that looks like a computer monitor. 2007;32(3):295-7. Video clip 5: Anispotropy: angling the transducer over the flexor tendons of the hand will cause anisotropic derangements of tendon and nerve appearance. J Ultrasound Med. fluid in a painful hip joint in children. Scanning Technique and Normal Findings. not echogenic or anechoic) collections around the joint or fracture as fluid reflects virtually no ultrasound waves (anechoic) back to the probe to produce an image. Video clip 1: Tendon range of motion – technique: place the hand in a water bath and, hover a high frequency linear transducer over the tendon in question – in this case a flexor tendon of the hand, have the patient flex the digit or other attached structure while observing the US screen. In these instances it can be helpful to first identify an anatomical point of reference, such as the hyperechoic cortical lines of expected bony structures, and then subsequently identify adjacent tendons, ligaments and muscles. Video clip 2: Tendon range of motion imaging: Observe the flexor tendon sliding along its path. Subcutaneous Fat is relatively hypoechoic with thin septations of connective tissue (Figure 1). [1-17] In its ideal role, bedside ultrasound is rapid, focused, accessible, portable, real-time, and interactive. As it is a good medium for transmitting ultrasound waves, there is little wave reflection, thus fluid appears black (anechoic) on ultrasound. Septic arthritis and bursitis: emergency ultrasound can facilitate diagnosis. of the median nerve appearance. Musculoskeletal ultrasound provides several distinct advantages in relation to basic radiography (X-rays), computed tomography (CT) and magnetic resonance imaging (MRI)—especially in focused musculoskeletal and neurological examinations. Musculoskeletal Ultrasound. ACEP clinical policy approved by the Board of Directors, October 2008. 12. Consider using a copious amount of gel or a standoff pad on a painful area to minimize the need for pressure with the transducer. • Use copious gel or stand-off pad over painful or topographically convoluted surfaces Musculoskeletal Ultrasound Ultrasound or sonography involves sending sound waves into the body. Video clip 3: Shoulder evaluation technique: This video shows the positioning and technique for observing shoulder internal and external rotation. It is often helpful to have patient pinpoint the area of complaint or maximal tenderness to guide the exam. Some exams may use different transducers (with different capabilities) during a single exam. Patient convenience is another priority. This procedure requires little to no special preparation. Patellar tendon originating from the inferior patella. Ultrasound has difficulty penetrating bone and, therefore, can only see the outer surface of bony structures and not what lies within (except in infants who have more cartilage in their skeletons than older children or adults). The EP need only locate and recognize this and use his or her clinical observations to progress them onto the next best step. The Musculoskeletal Ultrasound Pocket Guide is a portable and easy-to-use reference for students, residents and physicians. Ultrasound-assisted ankle arthrocentesis. In terms of ultrasound, the physical properties of nerves and tendons require that the transducer beam must be perpendicular to the axis of the tendon or nerve. Roy S, Dewitz A, Paul I. Ultrasound imaging is also called ultrasound scanning or sonography. Griffith JF, Rainer TH, Ching AS, Law KL, Cocks RA, Metreweli C. This is a sonographic artifact that is occurs when viewing tendons and nerves. Tendons have a characteristic pattern of fine parallel lines when viewed longitudinally (Figure 2,3). They can also show blood flowing through blood vessels. Role of sonography in the emergency room to diagnose sternal fractures. When the ultrasound … When assessing tendons, it is crucial to understand the artifact of anisotropy, which gives the appearance of dark areas within the tendon and can be mistaken for tears or defects. Ultrasound has been studied for use in identifying numerous anatomical fractures. Thus, sensitivity for fracture detection in these areas is less reliable. Video clip 5: Anispotropy: angling the transducer, Video clip 7: Anisotropy demonstrated on the median nerve in the forearm. 18. The characterization of abnormal fluid is, in fact, a complex subject that should be left to expert radiologists, however, the emergency physician is certainly capable of locating and recognizing abnormal fluid. The gel will help the transducer make secure contact with the body and eliminate air pockets between the transducer and the skin that can block the sound waves from passing into your body. • Failure to account for anisotropy in the study of tendons and nerves However, if scanning is performed over an area of tenderness, you may feel pressure or minor pain from the transducer. The probe collects the sounds that bounce back. Ultrasound guidance of hematoma blocks for anesthesia of the fracture is another simple and effective application. The dramatic difference in echogenicity of the bright outer cortex of the bone with the overlying hypoechoic soft tissue makes distinguishing even small cortical disruptions of 1mm relatively easy. Follow-up exams may be needed. Costantino TG, Roemer B, Leber EH. 4. Copyright © 2020 Radiological Society of North America, Inc. (RSNA). Ultrasound is most unambiguous when evaluating long bone fractures such as distal radius fractures, femur, clavicle, etc. Furthermore, examination of contralateral normal structures for comparison is helpful. soft tissue masses (lumps/bumps) in children. J Emerg Med. Jacobson, Jon A. As emergency physicians we do not aspire to perform comprehensive exams, but rather focused investigations to identify focal acute pathology. Outside links: For the convenience of our users, RadiologyInfo.org provides links to relevant websites. Ultrasound of fractures in or around joints is more difficult to evaluate due to the convoluted surfaces and anatomy involved. Some of the conditions that might cause a doctor to call for a musculoskeletal ultrasound … 1. Sometimes a follow-up exam is done because a potential abnormality needs further evaluation with additional views or a special imaging technique. What are the limitations of Ultrasound Imaging of the Musculoskeletal System? There are also limitations to the depth that sound waves can penetrate; therefore, deeper structures in larger patients may not be seen easily. Did you find the information you were looking for? 2007;25:80-86. The technologist applies a small amount of gel to the area under examination and places the transducer there. Bone appears bright on ultrasound because its hard densely calcified cortex reflects virtually all ultrasound waves (highly echogenic or hyperechoic) back to the transducer. 2007;26(9):1143-8. inflammation or fluid (effusions) within the. There is usually no discomfort from pressure as the transducer is pressed against the area being examined. sonographer. Print. This website does not provide cost information. The accuracy of portable ultrasonography to diagnose fractures in an austere environment. Rather, these adjustments should be considered simply routine technique. Video clip 8: Transducer tilting resulting in anisotropic alteration Sonographic anatomy, as with all radiology, is simply gross anatomy in black and white. These signature waves are instantly measured and displayed by a computer, which in turn creates a real-time picture on the monitor. foreign bodies in the soft tissues (such as splinters or glass). Ultrasound is safe, noninvasive, and does not use ionizing radiation. When assessing tendons and nerves it is crucial to understand the artifact of anisotropy (see below), which gives the appearance of dark areas within the tendon and can be mistaken for tears or defects. The appearance of musculoskeletal anatomy on ultrasound is fortunately usually intuitive. Acad Emerg Med. Web page review process: This Web page is reviewed regularly by a physician with expertise in the medical area presented and is further reviewed by committees from the Radiological Society of North America (RSNA) and the American College of Radiology (ACR), comprising physicians with expertise in several radiologic areas. Am J Emerg Med. Note: we are unable to answer specific questions or offer individual medical advice or opinions. Recommended Ultrasound … Figure 5: Longitudinal view of a clavicle. Most of the pathology the EP cares to find will be marked either by a visible fracture or abnormal fluid or both. When viewing these structures angling the probe back and forth long the axis of the structure will cause the structure to appear darker and less distinct when the transducer is no longer parallel. Hyaline Articular Cartilage appears as a thin hypoechoic rim over a hyperechoic bony cortex. line with no visible structures beneath. The hip joints of infants, unlike those of adults, are largely made of cartilage. A computer uses those sound waves to create an image. Observe tendons moving through their range of motion, for example, have the shoulder internally an externally rotate to observe the humeral head in the glenoid when evaluating for dislocation, and so on (Video clip 3,4). To locate a medical imaging or radiation oncology provider in your community, you can search the ACR-accredited facilities database. Figure 4: A high-resolution linear transducer (7-12 MHz or higher) is This modality empowers the clinician to advance care in the ED with less dependence on other departments to acquire studies and then await the results. 5. Freeman K, Dewitz A, Baker W. • Failure to set up the exam beforehand so as to be comfortable for both patient and … A follow-up exam may also be done to see if there has been any change in an abnormality over time. Bringing books, small toys, music or games can help to distract the child … Bone appears as a distinct bright echogenic. Valley VT, Stahmer SA. As a result, usually only the cortex or surface is visualized (Figures 1,2,4). Longitudinally, they appear as hyperechoic fibrillar cords. We are committed to teaching the anatomy, techniques and interventions applicable to the musculoskeletal system using Ultrasound… Comparison of ultrasound-guided and standard landmark techniques for knee arthrocentesis. 2010 Apr 30. Areas of interest and expertise of faculty members include sports medicine imaging, musculoskeletal ultrasound, tumor imaging, spine related procedures, and resident/medical student education. For certain ultrasound examinations of the musculoskeletal system, the patient may be seated on an examination table or a swivel chair. Ligaments connect bones and appear similar to tendons but tend to be more compact and irregular. One of the advantages of clinician-performed ultrasound is the dynamic nature of exam. When a … RadiologyInfo.org, RSNA and ACR are not responsible for the content contained on the web pages found at these links. 1999;52(3-4):103-9. Review. Who interprets the results and how do I get them? The transducer is a small hand-held device that resembles a microphone. 2010;38(3):135-7. Canagasabey MD, Callaghan MJ, Carley S. If the sonologist is in an ergonomically awkward or uncomfortable position, the exam will be an unpleasant experience for all, and likely of poor quality. In 2009 alone, CT and MRI accounted for 95% of Medicare allowed charges for all extremity imaging. Wiler JL, Costantino TG, Filippone L, Satz W. Joint Effusion The presence of irregular internal echoes or material may indicate pus, fibrinous material, or a complicated effusion. Orientation marker is proximal. The gel allows sound waves to travel back and forth between the transducer and the area under examination. Figure 7. In an ultrasound exam, a transducer both sends the sound waves and records the echoing waves. You may be asked to wear a gown. Fracture Hematoma Block. Prehosp Emerg Care. Clinical bedside ultrasonography offers the emergency physician (EP) numerous useful applications for diagnosing musculoskeletal pathology and guiding related procedures. For visualizing internal structure of bones or certain joints, other imaging modalities such as MRI are typically used. Comparison of bedside ultrasound and panorex radiography in the diagnosis of a dental abscess in the ED. Nerves and tendons, of course, rarely run a straight course for any significant distance. Definition Musculoskeletal ultrasound (MSK US) involves the use of high-frequency (up to 17 MHz) sound waves to image soft tissues and bony structures in the body for the purposes of diagnosing pathology … The radiologist will send a signed report to the doctor who requested the exam. One or more frames of the moving pictures are typically captured as still images. Philadelphia, PA: Saunders/Elsevier, 2007. Ultrasound imaging uses sound waves to produce pictures of muscles, tendons, ligaments, nerves and joints throughout the body. This is generally adequate because fractures of only a few millimeters displacement can be seen in the cortical margin. Soft Tissue, Muscle, Tendon and Ligament Injuries Ultrasound is safe and painless. As with all diagnostic ultrasound, knowing the normal appearance of the sonographic anatomy is essential to assure successful identification of pertinent structures. RadiologyInfo.org is not a medical facility. Musculoskeletal (MSK) Ultrasound MSK Ultrasound is a dynamic imaging solution that allows you to see, in real time, the state of a patient’s bones, ligaments, muscles, tendons, cartilage and nerves. Sonography compared with radiography in revealing acute rib fracture. Fracture Finally, examination of contralateral normal anatomy for comparison is crucial. Often recognition of abnormal fluid combined with physical exam and clinical observations will lead to a diagnosis. Video clip 6: Anisotropy artifacts: when the transducer is not perpendicular to the tendon or nerve – in this case the flexor tendons of the hand as demonstrated in video 5 – the structure darkens and loses the bright fibrillar/punctate pattern that makes them recognizable. To ensure a smooth experience, it often helps to explain the procedure to the child prior to the exam. 17. III. The ultrasound exam room may have a television. Ultrasound examinations are very sensitive to motion, and an active or crying child can prolong the examination process. It uses a small probe called a transducer and gel placed directly on the skin. Very superficial structures might be better visualized when scanned with a standoff pad or in a water bath; whatever is feasible in the clinical environment. Nevertheless, it is possible to use other transducers to evaluate deeper structures such as a femur within a large thigh. There are some simple applications of bedside musculoskeletal (MSK) ultrasound that require minimal training and are within the scope of emergency ultrasound. Ultrasound exams do not use radiation (as used in x-rays). and Christopher Raio M.D., RDMS. Transversely, tendons appear as round or flattened ovals with a punctate interior. The transducer sends out inaudible, high-frequency sound waves into the body and then listens for the returning echoes. The ultrasound gel does not usually stain or discolor clothing. German. Figure 1: Bone appears as a distinct bright echogenic Using a lower cost and a safer approach to imaging would make clinical sense for many conditions without compromising care. 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