MSK Review questions

List three ligaments of the lateral and medial sides of the elbow.

Lateral elbow - Radial collateral ligament, lateral ulna collateral ligament and annular ligament Medial ulna collateral ligament with its three components, posterior, anterior & transverse bundles/band.

Is it normal to identify any fluid sonographically in the bursa surrounding the greater trochanter?

No, sonographically any fluid is abnormal.

A teenager presents for a knee ultrasound 'Query Osgood Slaters Disease where would you look and describe the sonographic appearance.

Osgood-Schlatter disease is a commonly encountered condition affecting growing adolescents and typically presents during the rapid growth of musculoskeletal structures at the anterior aspect of the proximal tibia where the patella tendon inserts onto the tibial tuberosity. Typically sonographic appearance is cortical irregularity associated with the tibial tuberosity along with excessive bony overgrowth at the same level. The overlying patella tendon often appears thickened and hypoechoic with an increase of vascularity in the region along with fluid in the deep infra-patella bursa. Even though the patient may not be symptomatic on the contralateral side it is worth examining it as frequently the sonographic changes are bilateral. Frequently the sonographic appearance looks as if there is two tibial tuberosity's, see below image's.

List two strengths of a 'hockey stick probe'

Personal preference and patient characteristics will determine what probe we use but as a general statement I would use the small foot print or 'hockey' stick probe in the following situations. Biopsy's, situations where it is difficult to maintain probe contact e.g. bony, curved structures, when following up a lesion that has been previously seen on this probe.

What is the mnemonic that can be used to remember the order of some of the structures of the medial ankle?

Tom, Dick and a very nervous Harry. So in order from anterior to posterior in the medial ankle we have; Tom - Tibialis Posterior Dick - Flexor Digitorium Longus And A - Artery Very - Veins Nervous - Nerve Harry - Flexor Hallicus Longus

When assessing tendons for increased vascularity what is important with respect to scan technique to do?

When assessing superficial structures for increased vascularity it is important to use light probe pressure (a useful technique I find is to 'float' the probe on a layer of gel with my 5th finger as a stabiliser to keep the probe head at a fixed distance from the patient). A low flow velocity should be selected eg around 2 cm/s with colour gain set appropriately. I do not have a preference for colour or power Doppler as I find both equally sensitive.

When examining a patient for a hernia list the seven key criteria we need to determine.

1/ Location 2/ Neck Size. 3/ Sac size 4/ Omentum. 5/ Fat and omentum 5/ Reducible 6/ Non-Reducible 7/ Are there any other hernias (often bi-lateral)

In the following images describe and indicate what abnormality is being depicted. a/

Bursitis with GTB indicating fluid in trochanteric bursa.

Is the calcaneo-fibular ligament superficial or deep to the peroneal tendons?

CFL is deep to the peroneal tendons. I often use the peroneal tendons to help me find the CFL as I know they are superficial to CFL so it helps me identify the correct level to be assessing. The CFL is difficult to find with there being quite marked variation in its size as shown by MRI. Foot placement is also important with slight dorsi flexion and inversion of the foot helping visualisation.

What is the name of the following condition within a tendon? Please note the patient has no pain. Longitudinal Achilles tendon image

Calcific tendinosis

Describe the appearance of this subcutaneous fat

Deep and adjacent to the dermal layer of the skin is a hypoechoic well defined structure extending across the length of the field of view. Fine, echogenic septations are noted within this layer separating the structure into lobules with each of the adjacent lobules being isoechoic. The overall appearance is consistent with subcutaneous tissue/fat with an adjacent deeper hyperechoic structure representing a ligament or tendon.

List and describe five different tears of the supraspinatus and why a surgeon may not detect a tear on shoulder arthroscopy.

a/ Partial articular surface tears b/ Rim rent tear c/ Partial bursal surface tears d/ Intrasubstance /delaminating tear e/ Full thickness tear But there are more: f/ Serpiginous tear g/ Complete tear h/ Massive rotator cuff tear

On the following images indicate the abnormality/s and provide a differential diagnosis: d)

. The image labelled Right is of a normal anterior sagittal view of the femoral neck, head and acetabular margin. Contrast this with the image labelled Left with shows capsular distension, low level internal echoes within the fluid and destruction of the bony cortex.

Label the diagram of the ankle

1 - Anterior Inferior Tibio-Fibular Ligament/Syndesmosis 2 - ATFL 3 - CFL (note CFL has fibers which pass deep to fibular and this is not shown on diagram)

Label the diagram

1. Extensor carpi radialis brevis 2. Listers Tubercle 3. Extensor pollicis longus 4. Extensor digitorum 5. Extensor indicis 6. Radius 7. Ulna.

Describe sign of tendon tears.

1.Muscle/tendon retraction - dynamic movements 2.Loss of volume 3.Altered echogenicity- Focal/diffuse 4.Increased vascularity 5.Tender 6.Collection 7.Bony fragment avulsion

a) List nine different types of hernias. b) Can ultrasound be used to accurately assess a patient for a hiatus hernia?

1/ Direct (superficial) 2/ Indirect (Deep) 3/ Umbilical 4/ Femoral 5/ Sportsman (some people do not consider this a true hernia) 6/ Epigastric 7/ Incisional 8/ Spigelian 9/ Obturator. b) No ultrasound cannot be used to reliably scan for epigastric hernias as the hernia contents extend up into the chest and sonography cannot 'see' through the air of the lungs.

List the required views in a standard elbow examination?

1/ Long and Trans of the C.E.O/T (images with and without colour should be recorded), Longitudinal Radial Collateral Ligament, 2&3/ Long of anterior and lateral joint lines, 4/ Long of Coronoid and Annular Recess, 5/ Transverse of Distal Humeral Cartilage Anterior Aspect, 6/ Long of Biceps Brachii Insertion, 7/Long of Common Flexor Origin/Tendon (C.F.O/T), 8/ Long of Anterior Bundle Medial Ulna Collateral Ligament, 9/ Trans of Ulna nerve (Split screen documenting arm in flexion and extension), 10/ Long of Triceps insertion, 11/ Long of Olecranon

List six indications for a hip ultrasound.

?joint effusion, ?ilio-psoas bursitis, ?rectus femoris injury, ?lump (most commonly reactive lymph node), ?underlying joint injury and while it is not strictly the hip joint ?trochanteric bursitis.

If there is a complete, full thickness tear of the supraspinatus what further documentation needs to be included in your imaging?

A complete full thickness tear of the supraspinatus requires us to exam and document the appearance of the supraspinatus muscle. Fatty replacement of this muscle is important for patient management. Please note a duel screen image should be obtained of the normal and abnormal sides (assuming one side is normal).

If a patient has a torn tibialis posterior what other structure should be assessed which if torn can result in the patient having a 'flat foot'?

A torn tibialis posterior results in us having to assess the spring ligament or at least the largest medial component which is the only one of the three components we can see with ultrasound. The tibialis posterior and spring ligament complex work together to maintain the proper shape or arch of the foot. If it is not recognised that the spring ligament is torn the patient will develop a flat foot and suffer from chronic pain and destruction of the tarsal bones. In your prescribed text there are more images and pictures of the spring ligament.

While scanning the popliteal fossa you notice the popliteal artery is dilated. What should you do and what images would you take to document this?

A dilated popliteal artery is an extremely important finding on ultrasound. As in all aneurysmal arteries the risk of rupture increases with increasing size. The normal diameter of the popliteal artery is about 1.5 cm with slight variations associated with patient sex and age. If the artery exceeds approx. 4cm (no definite guidelines) there is a significant risk of rupture. If it does rupture approximately 70% of patients will lose their lower leg. Images to take include long and transverse views just as we would with an aortic aneurysm. You should also ensure the artery is patent and there is no evidence of a leak. As a side note I would look at contralateral popliteal artery and aorta due to the increased risk of an aneurysm being present if one is seen in the popliteal artery. Also if I saw any evidence of leakage or if the aneurysm is greater than say 3 cm in size I would be discussing the findings with the radiologist before the patient leaves the department to ensure appropriate medical management is initiated.

A patient presents for a hip ultrasound and upon talking to them they tell you they have a snapping, painful sensation when they straighten their leg. List the areas you would pay particular attention to and describe the abnormal sonographic appearances you may see in this condition.

A snapping painful hip upon flexion and extension of the leg is termed 'snapping hip' note snapping without pain is considered normal. Snapping hip can be intra or extra articular in nature. Intra articular causes include; loose intra- articular bodies, labral tear in hip joint and labral cysts. Extra articular causes include; Ilio-tibial band (I.T.B) syndrome, tensor fascia lata/e rubbing on greater trochanter, ilio psoas catching on pectineal eminence of pelvis, ilio femoral ligament and gluteus maximus tendon. There is also some evidence to indicate that sudden flipping of the iliopsoas tendon around the iliac muscle may be responsible for the symptoms in some cases. See reading in this week's material 'The Snapping Iliopsoas Tendon by Deslandes et al.' The intra articular conditions often result in capsular distension with increased synovial production. With a labral tear you may also see a labral cyst which would look just like the labral cysts we see in the posterior shoulder or in the meniscus of the knee. Extra articular: Ilio psoas tendon becomes more round than oval with a decrease in echogenicity and may see a flicking of the tendon as it passes over the ilio pectineal eminence with leg flexion and extension. Three of the other extra articular conditions may show as a thickening and a decrease in echogenicity of the structures overlying the greater trochanter often more obvious in transverse/short axis and don't forget to compare sides. On flexion/extension of the leg may see a flicking of these structures over the greater trochanter. The final extra articular being the ilio femoral ligament (which by the way is the strongest ligament in the body) we see nothing on ultrasound i.e. not an ultrasound diagnosis.

In what anatomical plane should the probe be positioned to exam the annular and coronoid fossa/recesses of the elbow?

Annular and coronoid recess are positioned on the anterior aspect of the elbow. With the coronoid recess being in the coronoid fossa (number 1 on the image below) and annular recess distal to the annular ligament which wraps around the radial head (RH). The probe should be placed in the sagittal (longitudinal) plane with the elbow extended and wrist supinated in order to aid visualisation (provided the patient is able to do this).

List the sites or origin for the rectus femoris muscle.

Answered in question 1, origin of rectus femoris is Anterior inferior illiac spine (A.I.I.S) and anterior joint capsule. Insertion is patella as part of quadriceps tendon.

Describe the clinical significance of a simple knee joint effusion vs a complex joint effusion.

As simple knee joint effusion i.e. hypoechoic/anechoic indicates that the patient has injured the knee sufficiently to irritate the fibrocartilage (meniscus). When the meniscus is irritated/bruised the meniscus will respond by increasing synovial production resulting in a simple effusion with pain and swelling for the patient. If the underlying bony cortex and articular cartilage are normal the increased fluid within the joint will often resorb and the patient's symptoms dissipate. If the effusion is complex i.e. echogenic, thick walled, synovial fronding and layering of material within the joint the cause is more sinister. This may be a torn cruciate, torn meniscus, knee fracture or arthritic changes.

If a patient has joint arthropathy what sonographic changes would we be looking for in the osseous structures?

Changes to look for include; cortical erosions (see above images Qu 5), increased vascularity which indicates active arthropathy and may result in treatment changes for the patient e.g. Corticosteroid injection to settle inflammation and help to preserve remaining bone.

Is it possible for females to suffer from direct hernias?

Females can develop direct hernias however this is uncommon. In fact they are ten times more common in males.

Describe how you assess for impingement of the SA/SD bursa/supraspinatus tendon, while you are scanning the patient.

Dynamic assessment of the SA/SD bursa and supraspinatus tendon is done at the same time with the same movement by the patient. The elbow of the affected arm is flexed to 90 degrees and displaced posteriorly approximately 20 degrees past midline. The arm is then slowly abducted whilst ensuring the shoulders remain level so that arm abduction is not through scapular rotation rather than true abduction. The probe is placed along the long axis of the supraspinatus tendon with the acromion in view and the tendon bursa complex is observed until it either bunches (impinges) or 'disappears' under the arcomian. This arm abduction should be repeated at least five times across the entire width of the tendon. It should also observed while the patient actively abducts for them self and during passive abduction i.e while you abduct their arm. This information is relevant for the treating Physiotherapist.

When would you use dynamic scanning when assessing the wrist?

Dynamic scanning should be used in all areas of M.S.K sonography it is one of the great advantages we have over all other imaging modalities. In the wrist I use dynamic scanning to assess the flexor/extensor tendons, median nerve and wrist joint.

Is the below image of the Achilles tendon depicting a grade 1, 2 or 3 tear? Longitudinal Achilles tendon image

Full thickness tear of the Achilles with associated loss of normal tendon architecture. Please note that as we have only been shown the tendon in one plane we are unable to comment on whether it is not just a full thickness tear but a complete tear as well as a complete tear encompasses the entire width and depth of the tendon.

Tear grading

Grade 1 - No fibre disruption ( mainly related to muscles but larger tendons like achilles would see evidence of grade 1) • Often hypoechoic due to fascicles swelling with water • Within first 48 hrs may appear as diffuse hyper echogenicity due to blood • Let the patients symptoms guide you • Use colour/power Doppler Grade 2 - Partial tear, moderate disruption • Often at myotendinous Junction but direct trauma may result in muscle body tear • Depending upon extent/age may be hyper/hypo or complex echogenicity • Can be difficult to define edges so use movement • Can be massive Grade 3 - Complete disruption in depth and width • Echogenicity can vary from hyer/hypo to complex depending upon extent/age • Define size • Distance from attachment • Use movement While we have 3 grades of tear remember there are 4 stages a tendon can be in i.e. don't forget normal which is grade 0

Why is it important to identify what the hernia is composed of and whether or not it is reducible?

Hernias may be composed of omentum or both omentum and bowel. Remember, the omentum is the membranous double layer of fatty tissue that covers and supports the intestines and organs in the abdominal area. Hernia's which contain bowel are clinically more significant than those which contain omentum only. The reason for this is that a hernia which contains bowel has a higher risk of becoming strangulated. A strangulated hernia is a potentially life threatening condition and requires you to obtain directions regarding the patient's medical management while the patient is within the imaging department. If strangulation of the hernia persists for more than a few hours the structures within the herniated sac may become gangrenous resulting in multiple potential complications. If it happens to the omentum the risk to the patient's life is small. However, if there is bowel involved the bacteria in the bowel can escape resulting in c. Stranulated hernia -

What frequency and type of probe would you use to examine the ankle?

High frequency linear probe with the exact frequency being dependent upon equipment available. On the machines in the lab the L12-5 and 15 MHz small foot print (Hockey Stick) would be used.

Where does the iliopsoas tendon insert and should the patients leg be internally or externally rotated in order to view the insertion?

Iliopsoas inserts onto lesser trochanter. As a side note the iliopsoas bursa is the largest in the body and frequently communicates with the hip joint especially post hip surgery. To visualize the insertion externally rotate the leg and try to minimize anisotrophy by heel toeing the probe. May even need to use curved probe to assess.

What is iliotibial band syndrome and where, related to the knee region, would patients typically present with symptoms?

Iliotibial band syndrome of the knee refers to the painful condition whereby repetitive friction, as may be seen in athletes, results in the inflammation of the distal iliotibial band and adjacent fatty tissue at the level of the lateral femoral condyle. Patients suffering from this condition tend to spend a significant amount of time exercising and typically describe riding in excessive of 200 km per week. As in the case of Hoffa's fat pad the fat deep to the distal iliotibial band serves a stress dissipation function and as such it is often the vascular fat rather than the relatively avascular adjacent tendon with becomes inflamed and painful. If left untreated the adjacent tendon may become diseased however it is not, as originally thought, the tendon that is the initial source of pain.

In the lateral ligamentous complex what is the name of the structure most frequently injured?

In the lateral ankle the most frequently injured structure is the anterior talo-fibular ligament (ATFL). The next most commonly torn structure is the calcaneofibular ligament (CFL). Keep in mind the CFL is 2.5 times stronger than the ATFL.

In the paediatric/adolescent population why is it easy to say there is an ankle joint effusion when in fact there is not?

In the paediatric/adolescent population assess of any joint can result in us over calling a joint effusion due to the marked amount of anechoic articular cartilage. This is especially marked in the knee and ankle in children. Remember if it is a true joint effusion you will see the echogenic line at the anterior margin of the articular cartilage (see image below)

What structures are the red arrows pointing to in the below images?

In the top image the red arrow is indicating the synovial sheath of the peroneal tendons while in the bottom image the red arrow is indicating the paratenon of the Achilles tendon. Note how both structures essentially look the same sonographically, we only know the difference because we know that the peroneal tendons are a type 2 tendon while the Achilles tendon is a type 1 tendon.

What is the name of the artery that is used as a landmark to differentiate between direct and indirect hernias?

Inferior epigastric artery. Note how the inferior epigastric artery separates the superficial inguinal ring from the deep inguinal ring . With the yellow triangle indicating the boundaries of Hesselbach's triangle.

When assessing for bursitis of the lateral hip it is important to use light probe pressure and have the patients legs resting on each other in the decubitus position, why is this?

Light probe pressure is essential as is having the legs resting on each other. The reason for this is that the bursa is easily compressed and any fluid in the bursa is abnormal. So if we push too hard and/or let the leg fall forward the bursa can be compressed and we don't see the fluid.

In the following images describe and indicate what abnormality is being depicted. c/

Marked thickening or tendinopathic changes of Gluteus Medias with associated bursitis (long thin arrows).

In the following images describe and indicate what abnormality is being depicted. d/

Massive trochanteric bursitis containing 'rice' bodies. Please note it is not really rice just given this name due to appearance.

Plantar fasciitis refers to what clinical condition and describe the typical sonographic appearance that would be seen in acute plantar fasciitis.

Plantar fasciitis is the degenerative, inflammatory change of the plantar fascia on the sole of the foot. The typical sonographic appearance would be of a Hypoechoic, enlarged structure at the level of the calcaneum. Frequently a plantar spur is noted deep to the fascia and focal anechoic areas within the fascia consistent with intrasubstance tears or marked tendinopathic change can be seen. Note that while many patients believe that heel spurs are painful the current school of thought is that spurs just reflect the body's response to excessive load and are not inherently painful.

Label this long supraspinatus tendon

Proceeding from skin down we have in order 1. Skin 2. Fat/Subcutaneous tissue 3. Muscle (Deltoid in this case) 4. Bursa (Subacromial/Subdeltoid or SA/SD in this case) 5. Tendon (Longitudinal view of Supraspinatus in this case) 6. Articular Cartilage and 7. Bone (greater tuberosity of humeral head in this case).

Pain in the posterior aspect of the shoulder especially associated with muscle wasting of the posterior cuff would make you look carefully in what two locations of the shoulder?

Spinoglenoid and suprascapular notches due to the possibility of neural compression at these locations.

On the following images indicate the abnormality/s and provide a differential diagnosis: c)

Starting from the bone up and you can clearly identify the distended hip joint capsule. Within the distended capsule you can see low level echoes of an even echogenicity. You do not see this with reverberation artifact. You may see it if the collection was deep and you were having to increase your gain to image it. That is not the case here as the scale on the side indicates it is only about 4 cm deep and a linear probe is being used. So to generate this appearance you would need either synovial proliferation (in which case the capsule wall should be thicker), blood due to a fracture or an infective process. So I would say the patient has a newly evolving osteomyelitis (due to the thin capsule and normal bony cortex) and would need urgent clinical follow up with a diagnostic aspiration of the hip and i.v. antibiotics if the fluid came back positive for an infective process.

What syndesmotic structure of the anterior ankle if torn can have a devastating impact on the ankle joint?

The anterior inferior tibio-fibular ligament (AITFL) is the syndesmotic structure that if torn can result in rapid joint degeneration. This is because the AITFL helps hold the tibia and fibular together when we weight bear. If this structure is torn then the weight of our body as we walk can result in the talus being driven up between the tibia and fibular with devastating long term consequences.

a) Describe the sonographic appearance of a strangulated hernia. b) If you believe the patient is suffering from a strangulated hernia what should you do in order to fulfill the ethical requirements to your patient?

The appearance will vary depending upon duration of symptoms, bowel and omentum or just omentum. However some key things you should be looking for are; A sac protruding through a defect in the abdominal wall which is non-reducible, tender, presence of peristaltic activity in dilated small bowel proximal to the protruding loop, free fluid noted in peritoneal cavity, no peristalsis noted in herniated sac, if ruptured the hernia wall becomes ill-defined and inflammatory change in the surrounding tissues e.g. fat becomes white and a loos of tissue plane definition. Please note that the presence/absence of colour Doppler is non-specific for hernia strangulation.

What anatomical structure does the distal long head of the biceps brachii muscle insert onto, and describe a technique for visualising it?

The distal insertion of the long head of the biceps brachii tendon inserts onto the proximal radius at the radial tuberosity. Have the elbow extended and the wrist in supination. b/ Survey in the transverse/short axis of the tendon at the level of the cubital fossa until you find the biceps tendon. c/ Then whilst still in the transverse plane scan distally until you see the tendon start to dive deep into the forearm. d/ While continuing to maintain visualisation of the tendon turn the probe through 90 degrees and translocate the probe medially. This allows us to use the pronator teres as an acoustic window. e/ Gently heel toe the transducer to try and place the tendon as close as possible to 90 degrees to the scan head. This is to reduce the effects of anisotropy. When you have optimised your visualisation of the tendon follow it to the site of insertion onto the radial tuberosity. f/ It is best to visualise the insertion of the biceps brachii in the long axis only as visualisation in the transverse or short axis can give the impression of a tear when one is not present due to the strong effects on anisotropy with this structure. g/ Please be aware most tears occur at the insertion of the biceps onto the radial tuberosity however the anatomically extension of the short head of biceps is onto the fascia of the medial/proximal anterior forearm. This structure is not visualised as a discrete entity at present, however if a patient presents with symptoms at this site comparison with the contralateral side may demonstrate fascial thickening (remember duel screen). h/ Lastly don't forget there are various techniques to visualise this structure. Some of which utilise forearm rotation to demonstrate movement of the tendon. Best to try for yourself with willing volunteers.

Describe, using sonographic terminology, the below image and provide a possible clinical diagnosis including the name of the muscle most frequently affected? Longitudinal image of the common extensor tendon of the elbow.

The longitudinal image depicts the insertion of the common extensor tendon of the elbow. There is diffuse swelling of the tendon with a focal region of decreased echogenicity predominantly of the deep fibers of the CET. Underlying cortical surface of the lateral epicondyle appears normal as does the visualised radial collateral ligament. No joint effusion is noted however subcutaneous tissues are of increased echogenicity with a loss of normal subcutaneous tissue architecture and there is a marked increase in vascularity of the CET and adjacent tissues. Residual superficial fibers of the CET are noted with overall appearances being consistent with a grade two tear of the CET of the elbow with the most frequently involved muscle being the extensor carpi radialis brevis.

Describe, using sonographic terminology, the below image and provide a possible clinical diagnosis.

The longitudinal image depicts the tendons of compartment one of the wrist. . The sheath of compartment one is distended with a predominantly hypoechoic echotexture however anechoic regions are noted. The associated extensor tendons of compartment 1 appear of normal echogenicity with no focal regions of reduced echogenicity indicating Tendinopathic change associated with tearing or tendinopathy. There is a marked increase in vascularity of compartment one tendon sheath with overall sonographic features consistent with synovitis. Diagnosis De Quervain's synovitis. Note the image indicates compartment one if it had not then you would have just called it synovitis, not tenosynovitis as tendons look normal.

Describe the below image using sonographic terminology and provide a diagnosis. Longitudinal image of the volar tendons of the wrist.

The longitudinal image of the flexor tendons of the wrist depict marked thickening of the tendons and associated tendon sheath. There are hypoechoic and anechoic regions of the tendon sheath along with Septations of the tendon sheath. Further more there appears to be a longitudinal split tear within the tendons consistent with an intrasubstance grade 2 tear. The cortical surface of the depicted underlying carpal bones show some irregularity with a focal linear echogenic structure consistent with an intraarticular loose body. Overall appearances are consistent with marked tenosynovitis of the wrist flexor tendons with a grade two tendon tear and underlying cortical irregularity.

Describe the sonographic appearance of the below images and what medical term is used to describe this condition when the patient is in pain. Longitudinal Achilles tendon image

The longitudinal images of the Achilles tendon depicts diffuse fusiform swelling of the Achilles tendon with a marked increase in vascularity throughout the visualised tendon fibers. The superficial fibers of the Achilles appear hypoechoic however no focal disruption to the tendon architecture indicating a tear is noted. Superficial and deep soft tissue appear of increased echogenicity indicating associated inflammatory change. Overall appearances are consistent with Achilles tendon tendinopathy. Note if the patient was not in pain we would use the term tendinosis rather than tendinopathy.

Is the mesh used in hernia repair operations to strengthen the abdominal wall, visible on sonographic scanning?

The mesh used in hernia repairs to reinforce the abdominal wall is visible on sonography however it is very difficult to see. The reason for this is that it is a mesh i.e has holes in it and that the anterior abdominal wall is often not flat so the mesh is often not at right angles to the probe. . I find that rather than looking for the mesh directly I look for the shadowing behind the mesh. Sometimes this shadowing is quite pounced (Image B) other times it is quite subtle (Image A)

Where is the olecranon bursa?

The olecranon bursa lies in the subcutaneous layer superficial to posterior aspect of the olecranon. Please note while this structure is often very obvious when diseased, a light touch scan technique should be employed when assess this area as just like the pre-patella bursa it may be easily compressed due to scan pressure. Thereby resulting in a false negative study.

a) A hernia of the deep inguinal ring is also known as a __________ hernia? b) A hernia of the superficial inguinal ring is also known as a _________ hernia?

The other name for a hernia of the deep inguinal ring is an indirect hernia and the other name for a hernia of the superficial inguinal ring is a direct hernia.

Where is Hoffa's fat pat and how does the sonographic appearance in this area change when the patient is suffering from Jumper's knee?

The term Hoffa's Fat Pad referees to the region deep to the proximal patella tendon immediately inferior to the apex of the patella. The term Jumpers Knee refers to a painful condition whereby the fatty region of Hoffa's Fat Pad and adjacent patella tendon becomes inflamed. While the sonographic appearance will vary depending upon the severity of the condition possible sonographic changes include; a. Increased vascularity in both Hoffa's Fat Pad and the adjacent patella tendon. b. Fusiform swelling and reduced echogenicity of the adjacent patella tendon. c. Loss of definition with either an increase or decrease in echogenicity of Hoffa's Fat Pad. d. Cortical irregularity of the adjacent patella apex.

In one sentence describe how you would communicate your findings of sub acromial impingement to the radiologist/supervising sonographer.

The was bursal and tendon impingement on active and passive abduction of the anterior aspect of the supraspinatus. Impingement occurred at approximately 60 degrees abduction and elicited patients typical pain symptoms.

On the following images indicate the abnormality/s and provide a differential diagnosis: b/

There is marked capsular swelling with the loss of the normal convex capsular line. Along with this the capsular line is thickened and there is a loss of the normal echogenic femoral head. Rather there is an ill-defined apparent soft tissue mass where the femoral head should be. Osteomyelitis and cancer can cause this kind of destruction. So both would have to be ruled out.

In the following images describe and indicate what abnormality is being depicted. b/

Thickened I.T.B with a loss of normal tissue planes due to inflammation.

Do corticosteroids 'cure' the underlying cause for the patients pain?

This is a difficult question to answer and depends upon what the injections are attempting to treat. If we start with the most commonly performed ultrasound guided steroid injection into the SA/SD bursa of the shoulder then steroid injections may cure it depending upon the cause of the inflammation. If the inflammation is acute in nature due to a specific incident then dampening the inflammatory response by injecting steroids can cure it. In general though where inflammation is due to degenerative change, poor biomechanics or an acute tear in a structure then no, steroid injections do not 'cure' the condition but rather settle the inflammation and alleviate the pain.

On the following images indicate the abnormality/s and provide a differential diagnosis: a/

This is an image of the anterior hip joint at the level of the femoral neck. This is the location where we measure the A.P depth of the hip joint capsule. In the normal hip the measurement should be less than 7mm and there should be no more than 1mm difference between the two sides. In this image the joint space measures 9mm and the anterior capsular line is convex rather than concave. The material within the hip is quite anechoic, the capsule is thin walled (if we allow for the reverberation artifact making the wall appear thicker) and the underlying bony cortex is smooth. All these factors indicate a simple joint effusion such as would be seen if the hip was twisted/stressed or early arthritis.

List three strengths and three weaknesses of sonography.

Three strengths of sonography; Cost, excellent spatial resolution and dynamic assessment. While three weaknesses; Operator dependant, poor contrast resolution, cannot penetrate bony or air.

a. To assess for ulna nerve subluxation/dislocation what dynamic motion of the elbow should be performed and how should we document the findings? b. When assessing for ulna nerve subluxation/dislocation how does making note of the CFT/ulna nerve relationship useful to ensure correct scan technique?

To assess for ulna nerve subluxation we need to scan in the transverse plane on the medial aspect of the elbow at the level of the cubital tunnel. A light probe pressure should be employed so as not to hold the nerve in position while elbow flexion and extension are performed. The display should be split with one side annotated 'Ulna nerve elbow flexion' and the other 'Ulna nerve elbow extension'. Please note it is a normal variant for the ulna nerve to sublux and secondary signs of neuritis should be look for to support your diagnosis. Also compare with the patients other (contralateral) elbow. If you are unsure of what sonographic signs of neuritis might be revisit week two of the Moodle site. b. Due to the dynamic nature of ulna nerve mobility assessment it can be easy to 'slip' of the cubital tunnel during assessment for nerve subluxation/dislocation. One way to assess if this has occurred is to note the CFT ulna nerve relationship. If the ulna nerve is truly moving out of the cubital tunnel it will be noted to lie superficial to the CFT.

When should we use color/power Doppler in wrist sonography?

We should use colour/power Doppler in EVERY wrist examination to examine bone, tendon, tendon sheath, retinaculum and any abnormal structure. Remember lymphoma and melanoma can appear cystic and could easily be confused with a benign ganglion if not assessed with colour/power.

When examining the medial and lateral meniscus list the sonographic signs you may observe that indicate an abnormal meniscus.

Whether it be the medial or lateral meniscus the sonographic signs are the same: 1/ Meniscus protruding lateral to cortical margins 2/ Cystic change of meniscus indicates a tear 3/ Linear defect in meniscus indicating a tear. 4/ Marked loss of joint space indicating extensive joint degeneration. The X-Ray depicts a normal knee on the left with a maintained joint space with a markedly degenerate knee with a severe loss of joint space, bony destruction, and angulation deformity in the right image. The sonographic image depicts a loss of joint space with corresponding bulging of the meniscus.

What structures are the arrows pointing to?

White arrow is indicating the collagenous, echogenic endotendinium septa of the patella tendon. Red arrow is the articular cartilage of the distal anterior femur in a child/young adolescent. Note how hypoechoic it is and how easy this would be to confuse with a simple joint effusion. To differiante you can move the body part as fluid and cartilage will move differently with fluid often deforming/bulging as we move the structure whereas cartilage will not deform. Cartilage follows the contour of the underlying bone and mirrors the shape of the underlying bone. Also you should know your anatomy and realise that at a joint we have articular cartilage. So from this we can infer that if we only see one hypoechoic area it must be cartilage.

List some possible complications of corticosteroid injections.

With all injections there is the possibility of infection. This risk is the same regardless of the steroid type and according to one study is in the order of 1 in 4000. While all patients should be warned of the risk of infection special care should be taken for joint injections as a septic joint is extremely serious and if not managed appropriately is a disaster for the patient.

Describe the differing appearances of wrist joint effusions and provide a differential diagnosis for each condition.

Wrist joint effusion can differ in appearance from simple to complex. They may be quite hypoechoic or they may be echogenic with internal septations and increased vascularity.

If a patient presents with the typical pain distribution of SA/SD bursitis should you look along the lateral aspect of their humerus or is it not worth the time in a busy practice? Provide a short justification of your answer.

You should always look where the patient has pain. It is possible (and has been documented) that a patient can have a sarcoma resulting in their symptoms.

a) What is the difference between a type 1 and a type two 2 tendons? b) Provide an example of a type 1 and type 2 tendon.

a) A type one tendon does not have a bursal/synovial lining rather it has a paratenon lining it. A type 2 tendon does have a synovial lining such as a bursa or synovial sheath. b) Type one tendon could include the Achilles, patella or quadriceps tendon. Type two tendons include flexor tendons of the hand, peroneal tendons in the ankle and the supraspinatus tendon of the shoulder.

Describe what the following clinical test's assess a/ Empty can test b/ Hawkins Kennedy test c/ Gerber's test d/ Speed's test e/ Yergason's test.

a) Empty can test - Pain with this test implies supraspinatus abnormality. b)Hawkins Kennedy test - To test for impingement. c) Gerber's -Pain implies subscapularis tear. c) Speed's test - Resistance while flexing the forearm implies biceps injury. d) Yergason's test - Hand pronated on thigh with resisted flexion of forearm implies biceps injury

Name the origin and insertion of the following muscles; a. Long head of biceps b. Subscapularis c. Deltoid d. Infraspinatis e. Teres Minor.

a) Origin- Supraglenoid Tubercle Insertion - Anterior, proximal forearm onto radial tuberosity. b) Subscapularis Origin - Subscapular fossa. Insertion - Lesser tuberosity of humerus. c) Deltoid Origin - Lateral clavicle, acromion and the spine of the scapula. Insertion - Middle and lateral surface of the humerus d) Infraspinatus Origin - Posterior aspect of the shoulder from the infraspinatus fossa. Insertion - Greater tuberosity just posterior and inferior to supraspinatus e) Teres minor Origin - dorsal aspect, inferior and lateral border of scapula. Insertion - inserts into the medial lip of the intertubercular groove of the humeral shaft.

a) What is a tendon, what is a ligament? b) Describe the differing sonographic appearance between a tendon and a ligament and how anisotropy relates to these structures.

a) Tendon - A structure consisting of multiple layers of connective tissue connecting muscle to bone. Ligament - A structure consisting of multiple layers of connective tissue (more densely packed than tendons) which connect bone to bone or cartilage to cartilage. b) Sonographically tendons and ligaments appear very similar however the increased cross linking of the collagen within ligaments results in a less laminar 'black and white' appearance as seen in tendons. Also ligaments are seen to extend from bone to bone sonographically whereas tendons are seen to extend from muscle and insert into bone. Due to the strongly echogenic nature and specular/smooth surface of tendons and ligaments both structures are strongly affected by anisotropy. Resulting in these structures appearing artefactually hypoechoic sonographically if the incident ultrasound pulse is at an angle of greater than approximately 2-5 degrees to the tendon/ligament.

a) Name three different muscle types and provide an example of each muscle type. b) Why is it important as a sonographer to appreciate the difference between different muscle types?

a) Three different muscle types could include; Unipennate, Triangular and Multipennate but there are others e.g. circular. An example of a unipennate muscle is the extensor digitorum muscle of the forearm, triangular muscle the pectoralis major and multipennate the deltoid muscle. b) As a sonographer it is important to appreciate the variations in muscle architecture so to not confuse the normal tendinous slips which penetrate the muscle body with pathology also small muscle tears are more common at the tendon/muscle interface.

a. What is the name given to the main ligamentous stabiliser of the lateral and medial elbow? b. When assessing the lateral elbow what dynamic movements of the hand should be performed and why?

a. Medial elbow radial collateral ligament, especially important to look at in the case of tennis elbow as if this is torn conservative treatment for tennis elbow may be ineffective and patient requires surgery. Lateral elbow it is the anterior bundle of the ulna collateral ligament. b. Pronation and supination of the hand whilst scanning the common extensor origin (CEO) and radial collateral ligament is important as you may visualise fluid tracking from the joint through these structures which would confirm a radial collateral ligament tear.

a. The terms anterior and posterior fat pads referrer to which fossa's of the elbow? b. Elevation of the anterior and/or posterior elbow fat pads can indicate what with respect to elbow joint pathology?

a. The anterior fat pad is located within the coronoid fossa/recess of the elbow while the posterior fat pad sits within the olecranon fossa/recess of the elbow. b. Fat pad elevation indicates that something is within the elbow joint displacing the fat pad/s from their normal location, in the presence of trauma this is often seen indicating a haemarthrosis i.e. blood within a joint.

a/ Name the four tendons which are commonly involved in the condition termed intersection syndrome? b/ Why is it very important to use very light probe pressure when assessing for this?

a/ Extensor carpi radialis longus and brevis (ECRL/B) where the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) pass over. b/ It is very important to use VERY light probe pressure here as there is no bursa so the slight increase in vascularity that may be the only sonographic tell‐tale sign of inflammation which you can compress with pressure. Personally I use a 'blob' of gel when assessing this area.

a. What sonographic signs indicate the patient has a ruptured Bakers Cyst? b. Describe the clinical picture a patient may present with if they have a Bakers Cyst?

a/ Normally a Bakers Cyst will have a smooth, rounded inferior edge whereas a ruptured Bakers cyst typically has a 'pointed' inferior margin with some associated inflammatory change and possible blood and serous fluid adjacent to this. b/ The clinical signs a patient may present with are; Pain, swelling and a sensation that they were hit in the back of the leg and/or felt something 'pop' in the back of the knee. Often times these patients present for a query D.V.T examination which is why many departments routinely ask the sonographers to assess if the patient has a Bakers Cyst as part of a D.V.T examination.

Write definitions for the terms; Perimysium, fascicle and epimysium.

a/ Perimysium - Thin, echogenic linear structures seen separating hypoechoic muscle fascicles. b/ Fascicle - Term used to describe a hypoechoic unit of muscle fibres surrounded by perimysium. c/ Epimysium - Is the echogenic outermost layer of dense connective tissue surrounding the muscle and forms a part in the formation of the tendons. The Epimysium is situated immediately deep and adjacent to the surrounding fascia. Note, on ultrasound the perimysium and fascicles can be seen as discrete structures however the epimysium and surrounding fascia are indistinguishable as discrete structures.

a/ If you were asked to assess the ankle joint for an effusion in what probe axis and position of the ankle would you begin the examination? b/ What movements of the foot are required when we are asked to assess for an ankle joint effusion?

a/ Place the probe in the long axis positioned in midline at the level of the ankle crease. b/ Dorsi and planter flexion of the foot is required to asses for an ankle joint effusion. Note sometimes the effusion is so larger you need not do this however in a majority of cases you will need to so as to displace the fluid into the anterior recess for visualisation.

a. Name the muscles that form the quadriceps tendon. b. Where is the Pes Anserine Bursa and what tendinosis insertions are associated with it?

a/ Rectus Femoris, Vastus Lateralis, vastus intermedius and vastus medialis form the quadriceps tendon. b/ The Pes Anserine bursa is situated on the medial, proximal tibia and the tendons associated with it are the: Sartorius, Gracilis and Semi Tendinosis in order from anterior to posterior. Remember "Say (Sartorius), Grace (Gracilis) before Tea (Semitendinosus)"

a/ Describe what the condition De Quervain's would look like in its acute stage on ultrasound. b/ What tendons are involved with the above condition? c/ What does crepitus refer to in the above condition?

a/ The reason for the question being worded specifying acute stage is that the sonographic appearance of diseased tendons varies depending upon time and whether or not the tendon/sheath is symptomatic at the time of examination. In the acute stage there is typically a Hypoechoic halo of fluid and tendon sheath surrounding one or both tendons. The tendons are typically markedly enlarged with an increase in vascularity noted on colour/power Doppler. b/ Abductor pollicis longus and extensor pollicis brevis (APL/EPB) located in compartment one of the wrist. c/ Crepitus refers to the abnormal grating/crunching sensation and accompanying pain when a tendon sheath is inflamed and thickened.

a/ List the typical appearance of the abnormal median nerve when it is affected by carpal tunnel syndrome. b/ When assessing a patient for carpal tunnel how far up the arm should we scan?

a/ While a patient can clinically have the condition carpal tunnel and the ultrasound be normal the changes we are looking for include any and all of the following; Nerve becomes enlarged and round, conversely it may become quite flat and broad (not very sensitive sign), nerve becomes quite Hypoechoic, loss of normal fascicular appearance, increased vascularity (remember persistent median nerve artery), post compression dilatation of the nerve. There is one other sonographic sign which I assess for and this is nerve movement. When the fingers are moved the flexor tendons and median nerve will move however the nerve moves less than the adjacent tendons. This is a subjective assessment so it takes practice for you to appreciate the abnormal movement of the nerve. b/ You should follow the nerve up the arm as far as you can typically proximal humerus level. The reason for this is that while patient's symptoms may indicate they are suffering from carpal tunnel the real reason for their symptoms is because they have a benign/malignant nerve tumour.

The referring clinician sends a patient for an ultrasound with the referral stating "Knee ultrasound - Exclude cruciate injury" a. Are we able to do this examination? b. Are we able to answer this question?

b. In an acute knee injury where there is instability clinically then we may suggest there is a cruciate injury if a hemarthrosis (blood tinged joint effusion) is noted rather than a simple joint effusion. So we are able to suggest there may be a cruciate injury which needs further evaluation such as with an M.R.I or arthroscopy. We can never exclude a cruciate injury because we cannot fully assess these structures in sufficient detail.

Describe how you would test if the patient is 'Tinel's' positive for carpal tunnel?

c/ Tinel's Test - Light tapping over the flexor retinaculum at the level of the carpal tunnel elicits a tingling sensation along the distribution of the nerve

List the structures you are required to assess in a routine shoulder examination.

• Biceps trans prox and mid • Biceps long prox and MTJ • CHL • Subscapularis long & trans • Supraspinatus trans with arm in "Karate" position • Biceps tendon should be in view in this image • Supraspinatus trans with arm behind back • Supraspinatus trans at insertion • Supraspinatus long anterior • Supraspinatus long mid • Supraspinatus long posterior • Acromio-clavicular joint • Infraspinatus long at insertion • Glenoid labrum • Spinoglenoid notch • Suprascapular notch • Dual image left and right of the supraspinatus muscle if there is a full thickness tear of supraspinatus • Supraspinatus and bursa under the coraco-acromial ligament with the arm abducted 90 degrees