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Disorders of the Ankle and Foot: Posterior

Introduction The most common symptoms leading to an ultrasound examination of the posterior ankle region are those associated with disorders of the Achilles tendon or the plantar aponeurosis (heel pain and/or swelling). In an acute setting, ultrasound is most often performed for suspicion of Achilles tendon tear. Other common acute and chronic indications are Achilles tendinopathy and/or paratenonitis, insertional Achilles tendon diseases, bursitis and plantar fasciitis.…

Ankle Joint and Forefoot: Anatomy and Techniques

Introduction Ultrasound examination of the ankle and foot is one of the most common examinations in musculoskeletal ultrasound. The superficial location of most structures means that ultrasound plays an important role in the management of many patients with painful conditions of the foot. As in many other joints, symptoms guide the ultrasound approach. Patients who present with pain that is located to a single area are…

Knee Pathology

Introduction Ultrasound has an important role to play in the investigation of pathology relating to the knee. However, it is important to recognize it has significant limitations, particularly with regard to the demonstration of intraarticular pathology involving structures such as the menisci, cruciate ligaments and articular cartilage. Consequently ultrasound is predominantly used for the assessment of extraarticular pathology about the knee and is particularly useful for…

Knee Joint and Calf: Anatomy and Techniques

Overview As with other larger joints, ultrasound is most useful when the patient's symptoms are localized to a relatively specific area. More diffuse symptoms suggest internal derangement due to meniscal, cruciate and cartilage injuries. These are diagnosed by MRI with relative ease and, although there have been efforts to use ultrasound to depict these structures, it is not sufficiently reliable for general diagnostic use. Until meniscal…

Disorders of the Groin and Hip: Paediatric Hip

Developmental Dysplasia of the Hip Developmental dysplasia of the hip (DDH) is a disorder where under development of the acetabulum leads to reduced femoral head coverage which, in turn, predisposes to acetabular labral abnormalities and early cartilage disease. If uncorrected, these abnormalities predispose to premature osteoarthritis, requiring hip replacement. If dysplasia is severe, the femoral head may sublux or frankly dislocate. The older name for this…

Disorders of the Groin and Hip: Lateral and Posterior

Introduction Lateral and posterior hip pain may be due to variety of intra- and extraarticular conditions. Ultrasound is a useful image modality for rapid assessment of extraarticular soft tissue abnormalities, many of which are tendon or muscle related. Certain specific soft tissue mass lesions occur around the lateral aspect of the hip, and may or may not be associated with pain. Common conditions include: greater trochanteric…

Disorders of the Groin and Hip: Anterior

Introduction The hip region is an area of complex anatomy with numerous vascular, nervous and muscular structures passing between the trunk and the lower extremity. Conditions remote to the hip joint may present as pain in the groin. Clinical examination may be nonspecific, and the choice of imaging modality may be difficult. Ultrasound is often used as a complementary technique to radiography, MRI and CT. Ultrasound-guided…

Disorders of the Groin and Hip: Groin Pain

Introduction Commoner causes of groin discomfort in the general population include inguinal hernias and muscle strains in the lower abdominal wall and upper thigh. Muscular strains in this group of patients often do not present to a primary care physician and certainly further management in the form of imaging is not necessary. The majority of symptomatic inguinal hernias can also be diagnosed clinically but there is…

Hip Joint and Thigh: Anatomy and Techniques

Introduction Although a comprehensive hip examination will be described, in the majority of cases the examination is focused on the particular presenting symptom. Potential causes of anterior hip pain extend from the pubic symphysis to the hip joint itself. Patients with lateral hip pain most frequently require an examination of the gluteal insertion and associated bursae. Posterior pain could be due to abnormalities extending from the…

Disorders of the Fingers and Hand

Introduction This section will be divided into abnormalities that occur on the flexor side and those that occur on the extensor side of the fingers. Each section will deal separately with disorders of tendons and ligaments and retinacula. The flexor and extensor tendons of the hand are divided into zones to help describe and plan the treatment of injuries. The extensor zones are numbered 1 to…

Finger Anatomy and Techniques

Introduction Like the wrist, most patients with finger pathology are examined seated opposite the examiner. Interventional procedures can be carried out with the patient prone and their hand extended above their head if there is anxiety or fainting risk. Position 1: Base of Thumb Imaging Goals 1. Identify the scaphotrapeziotrapezoid joint (STTJ) and the first carpometacarpal joint (CMCJ). 2. Locate the ulnar collateral ligament (UCL) and…

Disorders of the Wrist: Miscellaneous

Neural Entrapment Carpal Tunnel Syndrome The carpal tunnel is formed posteriorly by the carpal bones and extrinsic ligaments, and anteriorly by the flexor retinaculum or transverse carpal ligament, a thin fibrous band which inserts into the scaphoid and trapezium on the radial aspect and into the pisiform and hook of hamate on the ulnar side. The flexor retinaculum can normally be identified as a thin, 1–1.5 mm,…

Disorders of the Wrist: Ulnar Side

Tendon Disease Extensor Carpi Ulnaris Instability The extensor carpi ulnaris (ECU) tendon passes through the sixth extensor compartment, a fibroosseous tunnel over the distal 2 cm of the ulna. Key Point The ECU subsheath is a retinaculum, separate from the extensor retinaculum, which keeps the ECU tendon in the correct position during rotation, flexion and extension of the wrist. The subsheath may be normally visualized at ultrasound…

Disorders of the Wrist: Radial

Tendon Disease De Quervain's Disease De Quervain's disease is an overuse tenosynovitis of the abductor pollicis longus and extensor pollicis brevis tendons in the first extensor compartment (EC). Low-grade chronic microtrauma is thought to underlie the condition, leading to localized thickening of the extensor retinaculum at the level of the radial styloid. This results in narrowing of the first extensor compartment with impingement and subsequent inflammation…

Forearm and Wrist Joint: Anatomy and Techniques

Forearm Anatomy The anatomy of the forearm in one sense is as straightforward as the arm in that there are only two compartments, flexor and extensor, separated by an interosseous membrane. It is made a little trickier, however, as the flexor and extensor muscles begin medially and laterally respectively and then rotate as they are followed distally. In the midforearm, the flexor compartment occupies the anterior…

Disorders of the Elbow: Posterior

Introduction The differential diagnosis of pain in the posterior elbow includes olecranon bursitis, joint disease, triceps disease, as well as less common causes, including olecranon stress fractures and posterior impingement syndromes. You’re Reading a Preview Become a Clinical Tree membership for Full access and enjoy Unlimited articles Become membership If you are a member. Log in here

Disorders of the Elbow: Anterior

Introduction The principal structures of interest in the anterior elbow are the biceps and brachialis tendons. The biceps tendons form from its two muscle bellies and each inserts, close to one another, on the radial tuberosity. The two muscle heads can easily be distinguished from one another but the tendons are grouped close together, although the two components become more separate as the tendon approaches its…

Disorders of the Elbow: Medial

Common Flexor Origin Enthesopathy Tendinopathy of the common flexor origin (CFO) is less common than its extensor counterpart. The presenting features are similar, although the sporting and occupational associations are different. There is a particular sporting association with golf and the term golfer's elbow has come into common use. Other names, such as medial tennis elbow and flexor–pronator sprain, are also applied. Key Point Flexor–pronator sprain…

Disorders of the Elbow: Lateral

Lateral Elbow Common Extensor Origin Epicondylalgia The commonest cause of pain in the lateral aspect of the elbow is tendinopathy or enthesopathy of the common extensor origin (CEO). The term ‘tennis elbow’ originates from early descriptions of this condition and it has largely stuck, passing into common usage. Despite the name, the condition occurs much more commonly in nontennis players and a wide variety of occupations…

Arm and Elbow Joint: Anatomy and Techniques

Arm Anatomy The anatomy of the arm is generally best understood by considering two compartments: flexor and extensor. In each, there are proximal and distal configurations roughly delimited by the level of the deltoid insertion on the lateral aspect of the mid humerus. Position 1: Anterior Compartment Proximal The neurovascular bundle on the medial aspect of the arm provides a useful landmark to begin to view…