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Musculoskeletal Sonography: A Dynamic Tool for Usual and Unusual Disorders

Viviane Khoury1, Étienne Cardinal2 and Nathalie J. Bureau2

1 Department of Radiology, Notre-Dame Hospital, University of Montreal, 1850 Sherbrooke St. E, Montreal, QC, Canada H2L 4M1.
2 Department of Radiology, St-Luc Hospital, University of Montreal, Montreal, QC, Canada.


Figure 1
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  		Fig. 1A —Shoulder impingement syndrome. Diagram of coronal section through glenohumeral joint shows anatomic relationship of supraspinatus tendon, subacromial-subdeltoid bursa, and acromion. Arrow points to movement of tendon and bursa with shoulder abduction. SS = supraspinatus tendon.

 

Figure 2
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  		Fig. 1B —Shoulder impingement syndrome. Sonogram (left) and photograph (right) of dynamic maneuver technique; see text for explanation of maneuver. There is complete passage of tendon and subacrominal-subdeltoid bursa under acromion. For video see supplemental Figures S1B and S1C. In both maneuvers, video of sonogram shows smooth gliding of tendon and subacrominal-subdeltoid bursa under acromion.

 

Figure 3
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  		Fig. 1C —Shoulder impingement syndrome. Sonogram (left) and photograph (right) of dynamic maneuver technique; see text for explanation of maneuver. There is complete passage of tendon and subacrominal-subdeltoid bursa under acromion. For video see supplemental Figures S1B and S1C. In both maneuvers, video of sonogram shows smooth gliding of tendon and subacrominal-subdeltoid bursa under acromion.

 

Figure 4
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  		Fig. 1D —Shoulder impingement syndrome. Coronal sonogram of moderate shoulder impingement syndrome shows bunching up of subacromial-subdeltoid bursa (asterisk) lateral to acromion (A) during shoulder abduction. T = greater tuberosity. For video, see supplemental Figure S1D.

 

Figure 5
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  		Fig. 2 —Long head of biceps tendon dislocation. Transverse sonogram shows medial dislocation of long head of biceps tendon (arrow) out of bicipital groove (BG) during external rotation of glenohumeral joint.

 

Figure 6
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  		Fig. 3 —Trigger finger. Longitudinal sonogram of trigger finger at level of metacarpophalangeal (MCP) joint shows focal tenosynovitis (TS) on palmar aspect of flexor tendon (T) and thickened A1 pulley. There is hesitation of flexor tendon movement during extension. For video, see supplemental Figures S3A (normal) and S3B (trigger finger).

 

Figure 7
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  		Fig. 4A —"Boxer knuckle." Extensor tendon anatomy: diagram of dorsal tendon apparatus of finger. ET = extensor tendon; SB = sagittal bands; IN = intrinsic muscle.

 

Figure 8
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  		Fig. 4B —"Boxer knuckle." Ulnar dislocation of third extensor tendon at metacarpophalangeal joint is evident with flexion. (Courtesy of Dhanju J, Toronto, ON, Canada)

 

Figure 9
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  		Fig. 4C —"Boxer knuckle." Transverse sonogram of dorsal aspect of third metacarpophalangeal (MCP) joint (different patient than B) shows initial anatomic position of extensor tendon of third finger when MCP joint is in extension. Note fluid in extensor tendon sheath in keeping with tenosynovitis and focal split of tendon. With flexion, there is ulnar subluxation of (split) extensor tendon (E) relative to metacarpal head (MC). For video, see supplemental Figure S4C. (Courtesy of Dhanju J, Toronto, ON, Canada)

 

Figure 10
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  		Fig. 5A —Snapping iliopsoas tendon. Diagram of transverse section of right hip shows relationship of iliopsoas tendon, hip joint, and surrounding structures. For video of snapping iliopsoas tendon, see supplemental Figures S5A-S5C.

 

Figure 11
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  		Fig. 5B —Snapping iliopsoas tendon. Streak artifact, manifested by linear, hyperechoic striated band oriented superoinferiorly (arrow), in this case of iliopsoas tendon snapping. This artifact is also evident in video (near end) in supplemental Figure S5B. A = femoral artery.

 

Figure 12
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  		Fig. 5C —Snapping iliopsoas tendon. Snapping iliopsoas tendon over cyst. In this case, iliopsoas tendon (solid arrows) was seen to snap over synovial cyst (dashed arrows).

 

Figure 13
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  		Fig. 6 —Snapping iliotibial band: Diagram of transverse section through iliotibial band rotated 90° clockwise to show orientation of sonograms in videos. Boxed region indicates area scanned in videos. For videos, see supplemental Figures S6B-S6D.

 

Figure 14
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  		Fig. 7A —Snapping knee syndrome. Snapping meniscus. Coronal sonogram of medial aspect of femorotibial joint shows heterogeneous torn meniscus. During flexion and extension, there is abnormal jerking movement of heterogeneous torn meniscus. Note streak artifact in video, which correlates with clinical snap. For video, see supplemental Figure S7A.

 

Figure 15
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  		Fig. 7B —Snapping knee syndrome. Snapping knee with prosthesis. Coronal sonogram of medial side of knee (oriented on its side) shows abnormal movement of polyethylene component (hyperechoic line with ring-down artifact) that is misaligned with adjacent tibia. Initially polyethylene component is aligned with adjacent tibia. However, with knee flexion and extension, there is abnormal movement of component (hyperechoic line with ring-down artifact). For video, see supplemental Figure S7B.

 

Figure 16
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  		Fig. 7C —Snapping knee syndrome. Anteroposterior radiograph of knee (on its side) zoomed in on medial aspect to show orientation of sonogram in B.

 

Figure 17
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  		Fig. 8A —Peroneal tendon dislocation. Illustration shows anatomy of peroneus brevis (upper arrow) and longus tendons (lower arrow) in transverse section through ankle. Curved arrow indicates direction of peroneal tendon subluxation or dislocation.

 

Figure 18
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  		Fig. 8B —Peroneal tendon dislocation. Dynamic maneuver in peroneal tendon evaluation. During dorsiflexion and eversion of the ankle, the peroneal tendons maintain their normal position posterior to the lateral malleolus. For video, see supplemental Figure S8B.

 

Figure 19
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  		Fig. 8C —Peroneal tendon dislocation. Transverse sonogram shows dislocation of peroneal tendons (P), with positioning lateral to fibula (f) during dorsiflexion and eversion of ankle. For video, see supplemental Figure S8C.

 

Figure 20
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  		Fig. 8D —Peroneal tendon dislocation. Transverse sonogram shows dislocation of one portion of split peroneus brevis tendon. L = peroneus longus tendon, f = fibula, arrowheads = split peroneus brevis tendon. For video, see supplemental Figure S8D.

 

Figure 21
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  		Fig. 9 —Pseudomass due to chronic muscle tear. Longitudinal sonogram of quadriceps muscle during isometric contraction shows proximal retraction and bulging of muscle secondary to chronic tear more distally, simulating mass (M) For video, see supplemental Figure S9.

 

Figure 22
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  		Fig. 10A —Soft-tissue masses. Lipoma. Sonograms of subcutaneous lipoma manifested by elliptic, well-defined mass (arrows) that is compressible. Mass is shown with (right image) and without (left image) transducer pressure.

 

Figure 23
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  		Fig. 10B —Soft-tissue masses. Hematoma. Longitudinal sonogram of calf muscles shows heterogeneous, oval-shaped hypoechoic complex intramuscular mass. Compression with transducer shows swirling of liquified contents of mass, in this case representing hematoma. For video, see supplemental Figure S10B.

 

Figure 24
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  		Fig. 10C —Soft-tissue masses. Venous malformation. Sonogram of calf muscle shows typical appearance, with hyperechoic fat, multiple dilated hypoechoic serpiginous vessels, and sluggish flow (hence little signal on color Doppler sonography). There is increased color signal with dynamic compression with sonography transducer. For video, see supplemental Figure S10C.

 

Figure 25
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  		Fig. 11A —Ulnar nerve dislocation. Diagram of transverse section through elbow shows position of normal ulnar nerve (pink) posterior to medial epicondyle. Note common flexor tendon origin (F, red). Arrow refers to direction of ulnar nerve dislocation.

 

Figure 26
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  		Fig. 11B —Ulnar nerve dislocation. Transverse sonogram during elbow flexion shows abrupt dislocation of hypoechoic oval-shaped nerve over medial epicondyle and superficial to common flexor tendon insertion, correlating with clinical snap. E = epicondyle, arrowhead = dislocated ulnar nerve. For video, see supplemental Figure S11B.

 

Figure 27
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  		Fig. 12A —Joint disorders. Sagittal sonogram of palmar and ulnar aspect of wrist shows multiple small round hyperechoic bodies in distended pisiform-triquetral joint recess. With motion and compression (for video, see supplemental Figure S12A), mobility of these bodies is well shown (sagittal, followed by transverse scan of same region). PISI = pisiform bone, FCU = flexor carpi ulnaris tendon, RAD = radius.

 

Figure 28
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  		Fig. 12B —Joint disorders. Coronal sonogram of right acromioclavicular joint shows increased mobility during shoulder motion. For video, see supplemental Figure S12B. ACRO = acromion, CLAV = clavicle.

 

Figure 29
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  		Fig. 13A —Miscellaneous conditions. Snapping scapula. Sagittal sonogram shows abnormal grating movement of scapula against ribs during motion. For video, see supplemental Figure S13A.

 

Figure 30
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  		Fig. 13B —Miscellaneous conditions. Tendon impingement by screw. Longitudinal, followed by transverse sonograms of medial side of ankle show impingement of tibialis posterior tendon (T) by tip of protruding screw (arrowheads) with ring-down artifact through cortex. For video, see supplemental Figure S13B.

 

Figure 31
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  		Fig. 13C —Miscellaneous conditions. Costal cartilage fracture. Longitudinal sonogram along axis of right anterior rib at sternal junction shows fracture (arrow) of hypoechoic costal cartilage (C) with small anechoic hematoma (asterisk). With probe compression, there is abnormal movement at fracture site with slight separation of fragments. For video, see supplemental Figure S13C.

 

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