This page intentionally left blank Atlas of Musculoskeletal Ultrasound Anatomy Second Edition Atlas of Musculoskeletal Ultrasound Anatomy Second Edition Dr Mike Bradley, FRCR ConsultantRadiologist, NorthBristolNHSTrust, HonorarySeniorLecturer, UniversityofBristol Dr Paul O’Donnell, FRCR ConsultantRadiologist, RoyalNationalOrthopaedicHospital, Stanmore,Middlesex, HonorarySeniorLecturer, UniversityCollege, London CAMBRIDGE UNIVERSITY PRESS Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo, Delhi, Dubai, Tokyo Cambridge University Press The Edinburgh Building, Cambridge CB2 8RU, UK Published in the United States of America by Cambridge University Press, New York www.cambridge.org Information on this title: www.cambridge.org/9780521728096 © First edition © Cambridge University Press 2002 This edition © M. Bradley, P. O’Donnell 2010 This publication is in copyright. Subject to statutory exception and to the provision of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press. First published in print format 2009 ISBN-13 978-0-511-69121-8 eBook (NetLibrary) ISBN-13 978-0-521-72809-6 Paperback Cambridge University Press has no responsibility for the persistence or accuracy of urls for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. Every effort has been made in preparing this publication to provide accurate and up-to-date information which is in accord with accepted standards and practice at the time of publication. Although case histories are drawn from actual cases, every effort has been made to disguise the identities of the individuals involved. Nevertheless, the authors, editors and publishers can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. The authors, editors and publishers therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this publication. Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use. Contents Foreword vii Principles andpitfalls of musculoskeletal ultrasound ix Echogenicity oftissues xi 1 Chest and neck 1 Supraclavicular fossa 1 TS infraclavicular fossa 11 Sternoclavicular joint 12 Chest wall 13 Axilla 22 2 Upper limb 26 Shoulder 26 Arm 42 Elbow 49 Forearm 65 Wrist 70 Hand 86 3 Abdomen andpelvis 98 Anterior wall 98 Posterior wall 109 Groin 112 Pelvisand hip 123 4 Lower limb 143 Thigh 143 Knee 152 Calf 178 Ankle 187 Foot 206 Index 220 v Foreword Thequalityofultrasonicimageshasseenradicalimprovementoverthelastcoupleofyears, and – as can be appreciated in the new edition of this Atlas of Musculoskeletal Ultrasound Anatomy – high frequency applications such as musculoskeletal ultrasound have profited from this development. Significant advances in ultrasonic probe design and refined manufacturing techniques have resulted in transducers with outstandingly high bandwidth and sensitivity to provide ultrasonic images with both excellent spatial resolution and penetration at the same time. State-of-the-art transducer technology also boosts Doppler performance and supports advancedimagingfunctionssuchastrapezoidscanforanextendedfieldofviewatnoloss ofspatialresolution.Highfrequencymatrixtransducersmakeuseofgenuine4-Dimaging technologytoachievefinerandmoreuniform ultrasonicbeamsinallthreedimensionsto deliver themost superb andartefact-freeimagesfromthe very near to the farfield. Also the dramatic increase of processing power in premium ultrasound systems such as the Aplio XG, with which most of the cases described in this book were acquired, has triggeredaquantumleapinimagequality.Advancedplatformscanprocesstheamountof dataworth oneDVDeachsecond,whichallowsustoimplementthemostcomplexsignal processing algorithms toimproveimage quality,suppress artefacts and extract the desired information from theultrasonic raw data in real time. Uncompromised image quality remains the fundamental merit and to support this in obtainingthefastestandbestinformeddiseasemanagementdecisions,avarietyofpowerful imaging functions such as Differential Tissue Harmonics, Advanced Dynamic Flow or Precision Imaging have been developed. ApliPureþ real-time compounding, for example, cansimultaneouslyperformspatialandfrequencycompoundingintransmitandreceiveto enhance both image clarity and detail definition while preserving clinically significant markers such as shadows behind echo-dense objects. These advanced imaging functions work hand in hand with each other to providethe highestresolution and the finest detail. Naturally, they can be combined with virtually any other imaging mode such as colour Doppler or3D/4D forevengreater uniformity within each application. In spite of all this technical development, we must not forget that the result of an ultrasound scan is highly dependent on the examiner’s skills. Only the combination of technologicalexcellencewiththededicationandexpertiseofultrasoundenthusiastssuchas theauthorsofthisatlasmakesultrasonicimagesofoutstandingdiagnosticvalueasshown in this book areality. Joerg Schlegel vii