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Original Research |
1 All authors: Department of Radiology, University of Michigan Hospitals, 1500 E Medical Center Dr., TC2910, Ann Arbor, MI 48109.
Received April 16, 2007;
accepted after revision July 22, 2007.
Address correspondence to D. A. Jamadar.
Abstract
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MATERIALS AND METHODS. Six hundred two patients evaluated over 6 months were scanned using a routine protocol. At the completion of the routine examination, each patient was asked to indicate a focal point of discomfort and, if present, was rescanned over the area of discomfort. Patients were classified in one of five categories depending on whether there was a focal point of discomfort and the presence or absence of an underlying sonographic abnormality.
RESULTS. Eighty-three percent of the 602 patients had a sonographically detectable abnormality, 2.2% of whom had an abnormality not detectable by routine protocol-based scanning. The more peripheral the body part, the more likely that abnormalities detected by sonography correlated with focal symptoms: 81% in the wrist and hand and 73% in the ankle and foot, compared with the more central body parts of 15% in the shoulder and 31% in the hip. Chi-square analysis showed a significant association between the body part scanned and a detectable abnormality (p < 0.0001).
CONCLUSION. Although a focused examination of the distal extremities correlated with an abnormality in most cases, a protocol-based approach ensured identifying 97.4% of the symptomatic abnormalities. The addition of a focused examination to an examination by protocol further increased the identification of abnormalities.
Keywords: emergency radiology • focused sonography • musculoskeletal sonography • sonography technique • sports medicine • trauma
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Compared with a routine systematic examination, a focused sonographic examination would have benefits because it would shorten the examination duration and allow a specific clinical question to be directly answered. However, potential confounding factors associated with performing only a focused examination include referred pain, the presence of abnormalities that are removed from the presenting complaint, and diffuse symptoms [3].
To optimize efficiency and throughput, we sought to evaluate the benefits of a limited but focused sonographic examination based on patients' presenting symptoms and to compare this examination with a general all-encompassing examination. Our hypothesis was that a focused sonographic examination of a superficial structure or joint guided by patient symptoms would show the existing abnormality, whereas a focused examination would be less effective for central and deep structures and joints. To address this issue, we retrospectively reviewed musculoskeletal sonography records to determine when abnormalities were identified during the focused portion of the sonography examination versus during the systematic evaluation.
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18 years)
seen in our sonography clinic who was initially scanned by one of our four
sonographers, each of whom had 1-4 years of musculoskeletal sonography
experience at the time of the study. Any patient initially scanned by a
musculoskeletal fellow or faculty member was excluded. Scanning was performed
using a linear array transducer (7-15 MHz) coupled to either of two sonography
machines (MHDI 5000, Philips-Advanced Technology Laboratories; or Logic 9, GE
Healthcare). The sonographers first followed a systematic musculoskeletal sonography protocol that consisted of a checklist of structures for each body part or joint. At the end of the routine sonographic examination, the patient was asked to indicate a focal point of discomfort. If a focal point of discomfort was present, that area was evaluated again.
A routine shoulder sonographic examination included dynamic imaging of the biceps tendon and subacromial-subdeltoid bursa and evaluation of the supraspinatus, infraspinatus, subscapularis, teres minor, and distal pectoralis major muscles; the long head of the biceps brachii muscle; the acromioclavicular joint; the subacromial-subdeltoid bursa; and the posterior labrum. An elbow examination included evaluation of the biceps brachii muscle, brachialis muscle, joint recesses, common flexor tendon, anterior bundle of the ulnar collateral ligament, ulnar nerve, common extensor tendon, radial head, radial collateral ligament, triceps brachii muscle, and olecranon bursa. A wrist examination included evaluation of the flexor and extensor tendons, joint recesses, scaphoid, ulnar nerve, median nerve, and dorsal component of the scapholunate ligament and evaluation for ganglion cysts. A digit examination evaluated the flexor and extensor tendons, joint recesses, and pulley system.
Sonography of the hip evaluated the hip joint recess; iliopsoas, rectus femoris, and gluteus minimus and medius muscles; and the greater trochanter region. Sonography of the thigh evaluated the quadriceps femoris muscle, hamstring muscles, adductor muscles, and sciatic nerve. Sonography of the knee evaluated the joint recess, distal quadriceps femoris muscle, patellar tendon, medial collateral ligament, medial and lateral meniscus, iliotibial tract, lateral collateral ligament, biceps femoris muscle, medial and lateral gastrocnemius muscle, anterior and posterior cruciate ligaments, and Baker cyst. Sonography of the calf evaluated the soleus, medial and lateral heads of the gastrocnemius, and plantaris muscles. Sonography of the ankle evaluated the tibiotalar joint recess, all tendons around the ankle, the anterior talofibular ligament, calcaneofibular ligament, deltoid ligament, and anterior inferior tibiofibular ligament, and dynamic imaging was used to evaluate for tendon subluxation. Sonography of the foot evaluated the flexor and extensor tendons and joint recesses and, if indicated, the digital nerves for a Morton's neuroma. Examination of the contralateral side was not routinely performed.
A focused examination was performed when the patient indicated a focal point of discomfort by pointing with one or two fingers in a reproducible confident manner. Patients using more than two fingers to indicate a point of discomfort or making circular or other types of movement over the area of discomfort were considered to not have focal discomfort. A focused examination included a more thorough interrogation of the area under the indicated point of discomfort, including the use of Doppler imaging, if not already performed, and of dynamic imaging if applicable.
All findings were confirmed by one of five supervising musculoskeletal radiologists with 1-10 years of experience (mean, 5 years). Sonographic findings were dictated by the sonographer and approved by the staff radiologist as part of each patient's medical record. Sonographic findings were also recorded in the departmental musculoskeletal sonography logbook, which included classifying each case into one of five categories (Table 1). At subsequent retrospective review, the five categories were further subdivided by location into different body parts: shoulder, elbow, wrist, hand, hip, thigh, knee, calf, ankle, foot, and other.
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One musculoskeletal radiologist retrospectively reviewed the sonography reports and logbook data. In cases in which multiple sonographic findings were present, a single abnormality was selected as the primary abnormality on the basis of clinical history and the severity of the finding. For example, if a patient was found to have a tear of the supraspinatus tendon, tendinosis, and thickening of the subacromial-subdeltoid bursa, the supraspinatus tendon tear was chosen as the primary abnormality. Medical records for each case were reviewed for surgery findings, biopsy results, and findings on other correlative imaging examinations, such as MRI, radiography, and CT, and those findings were related to the sonographic findings.
Descriptive statistical analyses included measures of dispersion by calculating percentiles. In addition, chi-square analyses using Fisher's exact test were performed to determine any relationships between the body part or joint examined and the sonographic findings.
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Of the 602 patients in the study group, an abnormality was detected by sonography in 499 (83%) patients (categories 2, 4, and 5). An abnormality was detected at focused sonography guided by patient symptoms that was not identified with routine scanning (category 5) in 13 (2.6%) of these 499 patients, or 2.2% of all 602 patients.
Categories 4 and 5, patients who had a focal point of discomfort under which there was a sonographic abnormality, were combined and were compared with category 2, patients who did not have a focal point of discomfort but who had a sonographic abnormality (Table 3). Chi-square analysis showed that there was a significant association between the site of sonographic evaluation and the detected abnormality (p < 0.0001).
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The most common joint where a focal symptomatic area corresponded to a sonographic abnormality in those examinations with a detectable abnormality was the wrist and hand in 34 of 42 (81%) and other in 60 of 74 (81%), followed by the thigh in 13 of 17 (76%), ankle and foot in 47 of 64 (73%), elbow in 11 of 17 (65%), calf in 10 of 16 (62%), knee in 27 of 49 (55%), hip in four of 13 (31%), and then shoulder in 31 of 207 (15%). In contrast, the most common joints in which there was no focal symptom but a sonographic abnormality was present were the shoulder in 176 of 207 (85%) patients and hip in nine of 13 (69%) patients.
Patients presenting with focal discomfort and no underlying sonographic abnormality (category 3) had examination of "other" category in 12 patients; shoulder in 10; wrist and hand in seven; ankle and foot in five; knee, hip, and elbow in three each; and one patient each in the calf and thigh (Table 2).
Examination of the shoulder was the most frequent musculoskeletal sonographic examination performed and comprised 238 (39.5%) of the 602 examinations. Further analysis of the 238 shoulder examinations showed 21 (8.8%) were in category 1, 176 (73.9%) were in category 2, 10 (4.2%) were in category 3, 26 (10.9%) were in category 4, and five (2.1%) were in category 5 (Table 2). Of the shoulders in which abnormalities were detected (i.e., 207 patients in categories 2, 4, and 5), there were 123 right shoulders and 84 left shoulders examined in 98 men and 97 women (12 bilateral examinations in six men and six women). In this same subgroup with an abnormality detectable by sonography, 155 patients had a primary abnormality of the supraspinatus tendon, whereas 52 patients had an abnormality elsewhere in the shoulder (Table 4).
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Abnormalities identified by sonography without corroborative imaging or surgery included masses, hernias, ganglion cysts, rotator cuff tears, screw impingement, foreign bodies, Achilles tendon tears, quadriceps tendon tears, fluid collections, peroneal tendon dislocation, and Baker cysts.
Retrospective review of the patients' records showed that 70 of 602 (11.6%) patients had surgical proof after sonographic detection of an abnormality. An additional 80 of 602 (13.3%) patients had corroboration by another cross-sectional imaging technique, and 128 of 602 (21.3%) had both surgical and imaging corroboration.
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In our study, 83% of all patients had a detectable sonographic abnormality. Most of the cases involving the wrist and hand (81%) and ankle and foot (73%) had abnormalities detected by sonography that corresponded to focal symptoms. This finding was different for the proximal structures, where focal symptoms were less frequently found, such as in the shoulder (15%) and hip (31%). For intermediate-sized body parts (Fig. 1), the percentage of detectable abnormalities under a focal point of discomfort was more variable and was between the values for peripheral and more proximal structures (Table 3). Because the proximal periarticular abnormality is often in the deeper tissues, exact localization by the patient and the pathophysiology of referred pain may make assessment more difficult and may partly explain these findings.
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The thigh is a part of the anatomy that is relatively more proximal, but most abnormalities here were detected at a site of focal symptoms, with a relatively large percentage of cases (76%) in category 4. This finding may be explained in part by the nature of the cases sent to us for evaluation. Assessment of the cases referred for sonography of the thigh revealed a high proportion of specific anatomic abnormalities, such as evaluation for masses, fluid collections, and hamstring and other muscle injuries. A similar conclusion was arrived at with the "other" category, for which many cases were also referred with very specific questions, such as "lumps and bumps" and focal pain, that often revealed abnormalities including masses, fluid collections, and foreign bodies.
The most frequently examined body part in our practice is the shoulder joint, usually for rotator cuff disease. As expected, most of the primary abnormalities identified were rotator cuff abnormalities, most often of the supraspinatus tendon. Of interest was the finding that in those examinations during which a supraspinatus tendon abnormality was detected, the patient did not indicate a focal point of discomfort in 145 of 155 (93.5%) examinations (Table 4 and Fig. 2A, 2B). In those patients with an abnormality other than a supraspinatus tendon abnormality, 28 of 52 (54%) did not indicate a focal point of discomfort in the presence of an abnormality detected at the same examination. Overall, 173 of 207 (83.6%) examinations of patients with a shoulder abnormality detectable at sonography did not indicate a focal point of discomfort. These findings suggest that focal shoulder discomfort is not reliable enough to direct a focused sonographic examination and that a protocol-based comprehensive study is more appropriate. Regardless, five abnormalities were identified only after a focused examination (category 5), so evaluation directed toward patient symptoms should always be considered after a comprehensive sonographic examination.
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In conclusion, although focused sonography examination of the distal extremities at the site of symptoms corresponded to an abnormality in most cases, a protocol-based approach identified 98% of symptomatic abnormalities. We advocate a protocol-based approach to musculoskeletal sonography supplemented with a focused evaluation at the site of patient symptoms to ensure a thorough and complete evaluation.
Acknowledgments
We acknowledge the work and support of Stephanie Creel, Brian Robertson,
and Wenzhen Liang.
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