AJR 2000; 175:1071-1079
© American Roentgen Ray Society
An Illustrated Tutorial of Musculoskeletal Sonography
Part 2, Upper Extremity
John Lin1,
Jon A. Jacobson,
David P. Fessell,
William J. Weadock and
Curtis W. Hayes
1
All authors: Department of Radiology, The University of Michigan Medical
Center, 1500 E. Medical Center Dr., TC 2910, Ann Arbor, MI 48109-0326.
Received December 8, 1999;
accepted after revision February 10, 2000.
Address correspondence to J. Lin.
Introduction
Sonography is a useful technique for the assessment of many conditions that
can affect the upper extremity because of the superficial nature of most
structures in this anatomic region. As technical advances continue to improve
image quality, the role for, sonography in the diagnosis of musculoskeletal
disorders will grow. Examination of the rotator cuff tendons and evaluation
for ganglion cysts of the hand and wrist are common indications for
sonography; other applications also continue to gain popularity.
Shoulder
Assessment of the integrity of the rotator cuff tendons is the primary
indication for shoulder sonography. Most commonly, the supraspinatus tendon is
affected, in isolation or in combination with other tendons. A disruption of
the normal fibrillar pattern results in a focal hypoechoic or anechoic defect
[1].
A full-thickness tear is diagnosed when the disruption extends from the
articular to the bursal surface of the tendon (Fig.
1A,1B,1C).
Secondary signs of a full-thickness tear include volume loss with associated
flattening or concavity of the echogenic subdeltoid bursal fat (often
accentuated with compression), substantial subdeltoid bursal fluid, and
cortical irregularity of the humeral tuberosity adjacent to the tear
[2,3,4]
(Fig.
2A,2B).
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Fig. 1A. —Rotator cuff tear and normal anatomy. Longitudinal (A) and
transverse (B) sonograms of 64-year-old man reveal massive, complete
full-thickness tear of supraspinatus tendon with large defect extending from
articular to bursal surface (double arrow). Note marked retraction
(arrow) of torn proximal tendon end and debris (arrowheads)
present within defect. H = humeral head, D = deltoid muscle, m = medial, l =
lateral, a = anterior, p = posterior.
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Fig. 1B. —Rotator cuff tear and normal anatomy. Longitudinal (A) and
transverse (B) sonograms of 64-year-old man reveal massive, complete
full-thickness tear of supraspinatus tendon with large defect extending from
articular to bursal surface (double arrow). Note marked retraction
(arrow) of torn proximal tendon end and debris (arrowheads)
present within defect. H = humeral head, D = deltoid muscle, m = medial, l =
lateral, a = anterior, p = posterior.
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Fig. 1C. —Rotator cuff tear and normal anatomy. Longitudinal sonogram of
healthy 28-year-old woman shows normal supraspinatus tendon
(arrowheads). G = greater tuberosity, l = lateral, m = medial.
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Fig. 2A. —54-year-old woman with rotator cuff tear. Longitudinal (A)
and transverse (B) sonograms of supraspinatus tendon reveal
full-thickness tear, confirmed at surgery. Several secondary signs of
full-thickness rotator cuff tear are present including cortical irregularity
(solid arrow) of tuberosity adjacent to tendon tear, volume loss
(double arrow), subacromial—subdeltoid bursal contour deformity
and flattening (open arrows), and subdeltoid bursal distention
(arrowhead). l = lateral, m = medial, a = anterior, p =
posterior.
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Fig. 2B. —54-year-old woman with rotator cuff tear. Longitudinal (A)
and transverse (B) sonograms of supraspinatus tendon reveal
full-thickness tear, confirmed at surgery. Several secondary signs of
full-thickness rotator cuff tear are present including cortical irregularity
(solid arrow) of tuberosity adjacent to tendon tear, volume loss
(double arrow), subacromial—subdeltoid bursal contour deformity
and flattening (open arrows), and subdeltoid bursal distention
(arrowhead). l = lateral, m = medial, a = anterior, p =
posterior.
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A retracted tear results in a large hypoechoic to anechoic fluid-filled
space that may show echogenic debris (Fig.
1A,1B,1C).
The deltoid muscle may closely approximate the humeral head in the space
normally occupied by the rotator cuff tendons
(Fig. 3).
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Fig. 3. —80-year-old woman with rotator cuff tear. Longitudinal sonogram
shows chronic full-thickness tear of retracted supraspinatus tendon (solid
arrows). Note deltoid muscle (D) is adjacent to humeral head (H) within
space (between open arrows and arrowheads) normally occupied
by distal supraspinatus tendon. l = lateral, m = medial.
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Sonographic findings of a partial-thickness tear include a focal hypoechoic
defect reaching either the bursal or the articular surface, but not both,
similar to criteria for MR imaging examinations (Fig.
4A,4B).
Typically, no significant volume loss or subdeltoid contour abnormality is
seen [5].
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Fig. 4A. —67-year-old man with partial-thickness rotator cuff tear.
Longitudinal (A) and transverse (B) sonograms of supraspinatus
tendon show discrete bursal surface defect (black arrows)
representing partial-thickness tear with intact articular surface fibers
present (white arrows). l = lateral, m = medial, a = anterior, p =
posterior.
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Fig. 4B. —67-year-old man with partial-thickness rotator cuff tear.
Longitudinal (A) and transverse (B) sonograms of supraspinatus
tendon show discrete bursal surface defect (black arrows)
representing partial-thickness tear with intact articular surface fibers
present (white arrows). l = lateral, m = medial, a = anterior, p =
posterior.
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Tendinosis is considered mucoid degeneration without significant
inflammation and can be associated with a painful shoulder. Findings include
heterogeneity and thickening of the tendon without discrete defects
(Fig. 5).
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Fig. 5. —51-year-old man with supraspinatus tendinosis. Longitudinal sonogram
of supraspinatus tendon shows diffuse thickening and heterogeneity (white
arrows) without discrete defect, consistent with diffuse tendinosis. Note
small region of relatively spared normal fibrillar pattern of tendon
(black arrows). m = medial, l = lateral.
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Calcium hydroxyapatite deposition within the rotator cuff tendons and
adjacent bursa is a cause of pain that can simulate symptoms of a rotator cuff
tear [6]. Calcifications appear
as echogenic foci that typically shadow
(Fig. 6), although small
calcifications may not show shadowing.
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Fig. 6. —37-year-old woman with calcific tendinitis. Longitudinal sonogram of
supraspinatus tendon reveals large irregular hyperechoic foci (black
arrows) with associated distal shadowing (white arrows), along
with several smaller lesions, representing intrasubstance calcifications.
Tendon is also focally thickened. m = medial, l = lateral.
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Fluid surrounding the biceps tendon may indicate simple joint effusion or
biceps tenosynovitis, especially when power Doppler sonography shows increased
flow (Fig.
7A,7B).
Loose bodies in the shoulder joint may travel into the dependent bicipital
sheath when an effusion is present (Fig.
8). The long head of the biceps tendon can be displaced from the
bicipital groove, usually in a medical direction
(Fig. 9). The tendon may be
subluxed so that it is partially displaced over the lesser tuberosity or fully
dislocated, often with an associated tear of the subscapularis tendon
[7]. Rupture of the long head
of the biceps tendons can also occur, resulting in discontinuity of the tendon
and associated hematoma [8]
(Fig.
10A,10B,10C).
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Fig. 7A. —72-year-old woman with biceps tenosynovitis. Transverse sonogram of
anterior shoulder shows circumferential hypoechoic fluid (black
arrows) surrounding slightly thickened and heterogeneous long head of
biceps tendon (white arrows). L = lesser tuberosity, G = greater
tuberosity.
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Fig. 7B. —72-year-old woman with biceps tenosynovitis. Transverse sonogram
with power Doppler sonography reveals increased flow in peripheral ring
pattern representing inflammation of bicipital tendon sheath synovium.
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Fig. 8. —66-year-old man with left glenohumeral joint loose bodies.
Transverse sonogram of anterior shoulder reveals several small echogenic foci
(arrowheads) medial to intraarticular portion of biceps tendon
(arrows), floating within joint effusion. Echogenic foci were mobile
on real-time dynamic imaging, confirming presence of loose bodies.
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Fig. 9. —42-year-old man with pain and weakness of left shoulder. Transverse
sonogram of anterior left shoulder shows dislocation of long head of biceps
tendon (arrows) medially out of bicipital groove
(arrowheads). Subscapularis tendon was torn on sonographic
examination. Findings were confirmed at surgery. L = lesser tuberosity.
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Fig. 10A. —68-year-old man with ruptured biceps tendon and hematoma.
Longitudinal sonograms of long head of biceps tendon show completely ruptured
and retracted tendon (white arrows) with massive fluid collection
slightly more distally, representing chronic hematoma (black arrows).
Note frayed end of residual tendon (arrowheads). Image in B
was obtained just distal to A. p = proximal, d = distal.
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Fig. 10B. —68-year-old man with ruptured biceps tendon and hematoma.
Longitudinal sonograms of long head of biceps tendon show completely ruptured
and retracted tendon (white arrows) with massive fluid collection
slightly more distally, representing chronic hematoma (black arrows).
Note frayed end of residual tendon (arrowheads). Image in B
was obtained just distal to A. p = proximal, d = distal.
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Ganglion cysts commonly occur within the suprascapular or spinoglenoid
notch, or both, and may cause symptoms by exhibiting a mass effect on adjacent
structures. Compression of the suprascapular nerve may cause supraspinatus and
infraspinatus muscle atrophy. Ganglion cysts appear as well-defined, round or
lobulated, anechoic lesions, and may show posterior acoustic enhancement
[9]
(Fig. 11).
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Fig. 11. —27-year-old man with spinoglenoid notch ganglion cyst. Longitudinal
sonogram of posterior shoulder reveals cystic lesion (black arrows)
in spinoglenoid notch region consistent with ganglion cyst. Note posterior
scapular cortex (arrowheads) immediately beneath scapular spine and
humeral head cortex (white arrows).
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Patients are often referred for sonography to exclude a rotator cuff tear
after a traumatic episode and normal findings on radiologic examination. The
tomographic nature of sonography allows imaging in multiple planes to
optimally reveal a subtle cortical disruption representing a minimally
displaced fracture, most commonly involving the greater tuberosity
[10] (Fig.
12A,12B).
Direct correlation to patient symptomatology with transducer pressure is
helpful. A Hill-Sachs lesion can be evaluated with sonography in the setting
of anterior shoulder dislocation (Fig.
13).
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Fig. 12A. —36-year-old man with occult greater tuberosity fracture after
trauma. Longitudinal (A) and transverse (B) sonograms of right
shoulder reveal cortical disruption of greater tuberosity (arrows) at
supraspinatus insertion. Fracture was not identified on radiographs obtained a
week before sonographic examination. l = lateral, m = medial, a = anterior, p
= posterior.
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Fig. 12B. —36-year-old man with occult greater tuberosity fracture after
trauma. Longitudinal (A) and transverse (B) sonograms of right
shoulder reveal cortical disruption of greater tuberosity (arrows) at
supraspinatus insertion. Fracture was not identified on radiographs obtained a
week before sonographic examination. l = lateral, m = medial, a = anterior, p
= posterior.
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Fig. 13. —65-year-old man with history of left anterior shoulder dislocation.
Longitudinal sonogram of posterior shoulder shows notched defect present in
posterolateral aspect of humeral head (H) consistent with Hill-Sachs lesion
(arrowheads). Infraspinatus tendon was intact. m = medial, l =
lateral.
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Elbow
Sonography is sensitive for the detection of a joint effusion in the elbow.
The joint capsule will be distended by hypoechoic to anechoic fluid displacing
the fat pads, seen best in the posterior recess with the elbow flexed
(Fig. 14). When there is
clinical concern for septic arthritis, sonographically guided aspiration of
the joint fluid can be performed
[1].
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Fig. 14. —76-year-old man with elbow joint effusion. Transverse sonogram of
posterior elbow held in flexed position shows large amount of fluid present in
olecranon fossa, representing joint effusion (asterisk).
Sonographically guided aspiration of fluid revealed infection consistent with
septic arthritis. Note posterior humeral cortex of posterior fossa
(arrows). l = lateral, m = medial.
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Inflammation of the olecranon bursa is a common condition that can be
confused with other sources of elbow pain. Characteristic findings of
olecranon bursitis include hypoechoic distention of the olecranon bursa with
increased power Doppler sonography flow, typically in a rimlike fashion (Fig.
15A,15B).
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Fig. 15A. —47-year-old man with right elbow olecranon bursitis. Longitudinal
sonogram of elbow superficial to olecranon process (O) shows marked thickening
of soft tissues with irregular anechoic fluid collection (arrows)
representing distended olecranon bursa. Note dorsal cortex of olecranon
(arrowheads). p = proximal, d = distal.
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Fig. 15B. —47-year-old man with right elbow olecranon bursitis. Longitudinal
sonogram with power Doppler sonography shows increased flow in synovium around
periphery, consistent with olecranon (O). Arrows indicate bursal fluid
collection; arrowheads indicate dorsal cortex of olecranon.
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The distal triceps tendon insertion onto the posterior olecranonis is well
visualized with sonography; however, the distal biceps tendon insertion onto
the radial tuberosity is more difficult to consistently visualize
[11]. Directed inspection of
these structures can reveal injuries ranging from strains to complete rupture
(Fig.
16A,16B).
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Fig. 16A. —20-year-old woman with partial triceps muscle tear. Longitudinal
(A) and transverse (B) sonograms of distal triceps muscle near
musculotendinous junction show discrete defect involving long head of triceps
muscle, representing tear (arrows). p = proximal, d = distal, m =
medial, l = lateral.
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Fig. 16B. —20-year-old woman with partial triceps muscle tear. Longitudinal
(A) and transverse (B) sonograms of distal triceps muscle near
musclotendinous junction show discrete defect involving long head of triceps
muscle, representing tear (arrows). p = proximal, d = distal, m =
medial, l = lateral.
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With epicondylitis, there is thickening and hypoechogenicity of the tendon
at the attachment on the epicondyle
[1]. Calcification within the
tendon can indicate chronic injury and should be correlated with radiologic
findings. Tenderness with transducer pressure is a helpful secondary finding.
Integrity of collateral ligaments in the elbow, particularly the ulnar
collateral ligament, is also accessible to sonographic examination
[1]
(Fig. 17).
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Fig. 17. —24-year-old man with ulnar collateral ligament tear. Longitudinal
split-screen image compares abnormal, torn ulnar collateral ligament on left
with that of normal, intact ulnar collateral ligament (black arrows)
on right. Heterogeneous, relatively hypoechoic material (white
arrows) is in expected location of left ulnar collateral ligament and
represents debris and hemorrhage. Note medial epicondyle (arrowheads)
of humerus (H) and medial proximal ulna (U).
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Enlargement of the lymph nodes can be revealed sonographically. Cat-scratch
disease classically involves the medial epitrochlear lymph nodes of the elbow
after a superficial wound inflicted by a cat's claw
(Fig. 18). Reactive lymph
nodes maintain a kidney bean shape with a typical echogenic central region
related to multiple interfaces.
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Fig. 18. —73-year-old man with enlarged epitrochlear lymph nodes. Longitudinal
sonogram of medial elbow shows several ovoid masses representing enlarged
epitrochlear lymph nodes (arrows) from nonspecific cause.
Sonographically guided core biopsy was performed that did not reveal
malignancy or infection. p = proximal, d = distal.
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The ulnar nerve is normally positioned in the cubital tunnel along the
posteromedial aspect of the distal humerus, in a groove adjacent to the medial
epicondyle. Cubital tunnel syndrome is a result of inflammation of the ulnar
nerve manifested by an enlarged, hypoechoic appearance on sonography. Dynamic
imaging can reveal intermittent subluxation of the ulnar nerve, a cause of
ulnar neuritis [12].
Hand and Wrist
Ganglion cysts represent the most common soft-tissue mass in the hand and
wrist and are generally attached to tendon sheaths, muscles, or cartilage.
Unlike synovial cysts, ganglia do not have a synovial lining and infrequently
communicate with a joint. Sonography reveals a hypoechoic to anechoic
well-defined structure with posterior acoustic enhancement consistent with a
cystic lesion [13]
(Fig. 19).
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Fig. 19. —48-year-old woman with nontender palpable mass involving snuff box
region of her hand. Longitudinal sonogram of thumb revealed superficial simple
cystic lesion (arrows) adjacent to extensor pollucis longus tendon
(arrowheads) representing ganglion cyst. p = proximal, d =
distal.
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Tenosynovitis appears as tendon sheath distention from fluid and thickened
synovium. Increased flow on power Doppler sonography indicates synovial
inflammation (Fig.
20A,20B).
Coexisting tendinosis or tendon tear may be present.
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Fig. 20A. —28-year-old woman with systemic lupus erythematosis and swollen,
painful left index finger. Transverse sonogram of flexor compartment of index
finger adjacent to middle phalynx cortex (white arrows) shows
hypoechoic distention of tendon sheath (black arrows) and slight
heterogeneity of flexor tendon (arrowheads).
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Fig. 20B. —28-year-old woman with systemic lupus erythematosis and swollen,
painful left index finger. Transverse power Doppler sonogram reveals
peripheral pattern of increased flow consistent with tenosynovitis.
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Carpal tunnel syndrome is a peripheral neuropathy frequently related to
occupational causes. Compression of the median nerve may result in neuropathy
with pain and paresthesias in a typical distribution. Sonographically, carpal
tunnel syndrome appears as enlargement and hypo-echogenicity of the median
nerve [14]
(Fig. 21).
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Fig. 21. —32-year-old woman with carpal tunnel syndrome. Transverse sonogram
of left wrist reveals enlarged cross-sectional area of median nerve (black
arrows), consistent with diagnosis of carpal tunnel syndrome. Findings
were confirmed with electromyography. Note flexor tendons (white
arrows). r = radial, u = ulnar.
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Top
Introduction
Shoulder
