1. No category

MS ultralydsscanning
Faggruppen for UL-scanning
Hofte - Lyske
Henrik Aagaard
ortopædkirurg, idrætsmediciner
Amager Hospital
Artroskopisk Center Amager
Gildhøj Privathospital
Kgl. Ballet
1
UL (US) bruger
- kliniker
• 15 års UL
• daglig amb. brug
– ort. kir.
– idrætmedicin/ballet
• kliniker
– bedsite UL
• klinikerens forlængede arm
– ≠ radiologisk specialist
2
Hofte - UL teknik, udstyr
• udfordring
– pos./neg.
• udstyr
– standard MS UL
– transducere
• lineær
– lavere frekvens, dybere
• curved
– dybde > 4-6 cm
MRI or/and US - hip/groin
• MRI has become the workhorse in the imaging
evaluation of the painful or clinically abnormal hip. It
provides an excellent anatomic overview and
demonstration of the bony structures, articular surfaces,
and surrounding soft tissues.
• Conversely, US can also demonstrate superficial
intraarticular structures and the periarticular soft tissues,
is quickly performed, allows dynamic evaluation of
tendons and muscles, and can guide percutaneous
procedures.
• These two modalities are complementary
Friedman, Miller. MRI, HSS. Clin N Am 2013
4
Indikation - formål med billeddiagnostik
(rtg, CT. MT UL m.fl.)
• diagnose
– assistent
– NB! klinisk us.
• forløb
– behandlingsstrategi
• (behandlingseffekt)
• dokumentation
• pt. forståelse/tilfredshed/kompliance
5
UL-scanning
• adskil
– beskrivelse
– fortolkning
• beskriv
– form, struktur
– afvigelser fra normal
– uregelmæssigheder
– normalt
• fortolk
– mulig patologi
– ‘tegn på’, ‘forenelig med’
• anatomisk atlas
• Uv.-mål
– scanning strukturer - genkende
– eksempler patologi - kendskab
6
MS ultralydsscanning
1a. Hofteled
• caput (collum)
• ledkapsel, recess = omslagsfold
• labrum
7
Hofte artrose - rtg.
• caput
– form
– osteofytter
• ledspalte
– afsmalning
– >50%, >2 mm -> a-skopi
• acetabulum
– form
– labrum, forkalkning
• ledkapsel (omslagsfold)
– ansamling
– bløddelshævelse
– mus
52 år, tidl. elite fodbold
Hofte artrose - UL scan
Normal
• caput
– form
– uregelmæssigheder
• ledflader/-spalte
– brusk
• acetabulum
– form
– labrum
• ledkapsel
– ansamling
– bløddelshævelse
– mus
Artrose
mus
osteofyt
9
Hofte artrose - UL scan
Tilspidsning - osteofyt
• caput
– form
– brusk
• bløddele
– fortykkelse
– hypoeccocitet
mus
Uregelmæssig overflade
– ansamling
10
FAI - CAM
• Femuro Acetabular
Impingement (FAI)
• form
• evt. artrose
– grad
– 50% ledspalte
FAI - CAM
MR
• standard
• systematisk udmåling
• MR/røntgen
• golden standard
MR
UL
Buck Eur Rad 2011
UL
FAI - CAM
Bump: ostofyt/exostose?
MR
• variation
– ‘bump’
– hyppig
• artrose grad?
– røntgen
UL
Omslagsfold, ansamling Buck, Eur Rad 2011
Case - hip FAI
• 29 y. female b. dancer
• hip/groin pain 2 y.
– intermittent
– progressing
• FAI: X-ray, MRI
– cortisone inj.
– rehab.
• surgery?
– return to ballet?
• caput, collum
– lat -> med
– form, udbygning, mus, brusk
– med -> lat -> post
– dynamisk (rot, flex/ext)
Hofteled - scan A
Beskriv – fortolk
15
Hofteled
Case A:
59 år, ♂ murer
- omslagsfold = recess
- ledkapsel
• ledkapsel
– fortykket
– fibrøse kapsel
– synovitis
– væske i recess
• diagnose?
– viderehenvis
– rtg., MR
– blodprøver
Case A:
59 år, ♂ murer
Hofteled
• led, knogle, sene/mm
– MR
– caput/collum
nekrose?
Hofteled
- ledansamling
- i recess
hø.
coll. fem.
• smerter, mobilitet
• UL: ansamling
– artritis
– synovitis
– årsag?
• diagnose?
ve.
coll. fem.
– rtg., MR
– blodprøver
• UL vejledt blokade
Case B:
66 år, ♀
Hofteled
- ledansamling
- i recess
• diagnose
– MR
– AVasculær Nekrose (AVN)
Case B:
66 år, ♀
Doppler - hofteled
Artritis - infektion
Artritis – TB infektion
Ansamling, synovitis – Ewing sarcom
20
UL vejledt injektion - hofteled
Curved transducer
US-guided hip injection. Needle (arrows) obliquely toward the femoral head neck
junction. (B) As the injection progresses, the capsule is distended by the hypoechoic
injectate (asterisk). A, acetabulum; H, femoral head; N, femoral neck.
• blokade: lokal anæsteticum (LA) + steroid
• diagnostisk/terapeutisk
• vs. MR
21
• ledkapsel, recess, omslagsfold
–
–
–
–
følg lat -> med, dist -> prox
dynamisk, adskil kapsel fra psoas
hypoeccoicitet (væske)
doppler v. basis
Hofteled - scan B
Beskriv – fortolk
22
FAI - pincer
(intro: labrum)
• Form
pincer?
normal
– form
– udbygning
– tag
• UL mindre egnet
osteofyt
Labrum læsion
Acetabular labral tear. (A) MR image shows a high-signal-intensity tear (arrow)
through the low-signal-intensity labrum. (B) Longitudinal US image in the same patient
shows the hypoechoic tear (arrow) through the echogenic labrum.
24
Perilabral cyste
 obs. labrum læsion
Perilabral cyst. (A) MR image shows a bilobed cyst (arrow). (B) Longitudinal US image of the
same patient shows the anechoic bilobed cyst (thin arrows). The labral tear (thick arrow) is
better appreciated on this image than the MR image. H, femoral head.
25
Perilabral cyste
Perilabrale cyster
26
Hip - labral tears: Diagnostic challenge
Reiman MP BJSM 2013, review
27
• (acetabulum)
– form, udbygning
– med -> lat -> post
Hofteled - scan C
Beskriv – fortolk
• labrum
– identificér
– form, læsioner, cyster
28
• caput, collum
– lat -> med
– form, udbygning, mus, brusk
– med -> lat -> post
– dynamisk (rot, flex/ext)
Hofteled - scan
Beskriv – fortolk
• ledkapsel, recess = omslagsfold
–
–
–
–
følg lat -> med, dist -> prox
dynamisk, adskil kapsel fra psoas
hypoeccoicitet (væske)
doppler v. basis
• (acetabulum)
• labrum
– form, læsioner, cyster
29
MS ultralydsscanning
1b. Hofte
•
•
•
•
iliopsoas
cyster
forkalkninger
trochanter region
30
Iliopsoas
iliopsoas tendon (arrows)
31
Cyste/bursa
longitudinel
• iliopectinea/iliopsoas
• diff. diagnose
• DVT
• aneurisme
transverse
m. doppler A=arterie V=vene
32
Iliopsoas cyste
THA
Iliopsoas bursitis. (A) MR image in a patient with a total hip arthroplasty shows a mildly
distended iliopsoas bursa (asterisk) adjacent to the iliopsoas tendon (arrow). The tendon is
difficult to see because of the susceptibility artifact from the arthroplasty components. (B)
Transverse US image of the same patient shows the bursa (asterisk) adjacent to the tendon
(arrow). There is no artifact from the arthroplasty.
33
Iliopsoas cyste
34
Iliopsoas
- impingement
THA
THA (total hip alloplastic). Iliopsoas impingement and tendinosis. (A) Longitudinal US image in a patient
with a total hip arthroplasty shows the acetabular component (A) contacting the overlying iliopsoas
tendon (arrow). Incidentally, notice the small effusion (asterisk) and the marked capsular thickening (C).
H (prosthetic femoral head), N (prosthetic femoral neck). (B) Transverse US image at the level of the
pelvic brim (P) in a different patient shows iliopsoas tendinosis (arrow) with thickening and a
heterogeneous appearance. The adjacent iliopsoas bursa is distended (asterisk). a, femoral artery.
35
Iliopsoas - impingement
42 år, tidl. labrum repair. Smerter.
Prominerende acetabularkant. (A) Acetabulum, (Pile) psoas
36
Springhofte - intern
A. før klik - sene roteret
B. efter - normal, horizontalt
lateral
medial
37
Iliopsoas
•
•
•
•
•
25 år ♂
ikke motionsaktiv
traume, nedspring, 1½-2 mdr.
læsion
intra-/peritendinøst flow
• doppler
38
• iliopsoas
–
–
–
–
prox -> dist, langs/tværs
struktur, fibre (sene mm.)
relation til acetabulum, caput, kar
dynamisk, adskil fra ledkapsel
Hofte - scan A
Beskriv – fortolk
39
Rectus fem. - ruptur, forkalkning
avulsion fra SIAI
• avusion
– posttraumatisk
– forkalkninger
– doppler
normal.
40
Rectus fem.
22 år, fodbold, rectus fem.
• læsion
– fiberstruktur
– omfang
– total/partiel ruptur
– dynamisk
– kontraktibilitet
41
Rectus fem.
• mm. læsion
– ældre
– forkalkning
– væske
– (doppler, næppe)
42
Rectus fem.
• myositis ossificans
– post traumatisk
– hæmatom (ansamling)
– fiberlæsion
Vastus intermedius,
fluid + calcifications
43
• (rectus femoris)
– identificer, adskil fra andre mm.
– følg sartorius dist (tværs)
– prox -> dist på femur langs/tværs
Hofte - scan B
Beskriv – fortolk
44
Bursitis GMe
Trochanter
• bursit
• trochanter major
cranial
– GT = Greater Trochanter
Bursitis trochanterica
45
Bursitis trochanterica
Bursa
• trochanter major (GT)
• UL vejledt blokade
• longitudinel
• langs
• fiberretning
• transversel
• tværs
Nål - blokade
46
47
Glut. med. (GMed)
• GMed
• ruptur
• bursa
48
Glut. min. (GMin)
GMi
GMin tendinosis. (A) MR image shows a thickened and heterogeneous GMin tendon (white arrow)
with a focal insertional tear (black arrow) and highsignalintensity shallow tearing along its deep
surface. (B) Longitudinal US image in the same patient shows the thickened tendon (arrows) with
loss of the normal echogenic fibrillar appearance. G, greater trochanter.
49
• trochanter
– bursae
– fascie latae
– GMin, GMed
Hofte - scan C
Beskriv – fortolk
50
• iliopsoas
–
–
–
–
dist -> prox, langs/tværs
struktur, fibre (sene mm.)
relation til acetabulum, caput, kar
dynamisk, adskil fra ledkapsel
Hofte - scan
Beskriv – fortolk
• (rectus femoris)
– identificer, adskil fra andre mm.
– følg sartorius dist (tværs)
– prox -> dist på femur langs/tværs
• trochanter
– bursae
– fascie latae
– GMin, GMed
51
MS ultralydsscanning
2. Lyske - hofteregion
• tendionopati,
calcificationer, rupturer
• adduktorer
• symfyse
• hasemm.
• tuber
• bursitter
• lyskebrok
52
53
Normal
Adduktor
• mm./sene - udspring
• conjoint tendons
Fortykkelse, fortætning
54
Adduktor
• mm. - udspring
– med lille partiel læsion
55
Adduktor
• mm. - udspring
– doppler
32 år, ♂
volleyball
elite
Adduktor - intramuskulær (add.)
Adductor hematoma. (A) MR image shows a large hematoma (asterisk)
in the left adductor muscles. (B) Transverse US image in the same
patient shows the hypoechoic hematoma (asterisk).
57
Adduktor - ældre læsion
Adductor ruptur, forkalkning
Adductor ruptur, forkalkning
Adductor ruptur, væske + forkalkning
58
Symfysitis
Athletic pubalgia. (A) MR image shows a thickened and hyperintense rectus abdominis
aponeurosis (thin arrow) and extensive cortical erosion (thick arrow) of the anterior aspect of the
right superior pubic ramus. (B) Transverse sonographic image in a different patient during a
cortisone injection shows a thickened rectus abdominis aponeurosis (black arrow) with a
horizontal tear (secondary cleft sign) (thin solid white arrows). Note the cortical erosion (thick solid
white arrow) of the anterior aspect of the right superior pubic ramus and the cortical irregularity of
the anterior aspect of the left superior pubic ramus. The reverberation artifact from the needle is
59
present (hollow white arrow).
Fremmedlegemer
Træsplint – indkapslet, subcutant
• muskel, underhud
– frit i væv
– indkapslede (granulom)
– vævsirritation
– evt. ansamling
– evt. bløddelslæsion
Glas - subcutant
Glas - flere, intramuskulært
60
• adduktorer
– udspring, conjoint tendons, symfyse
– prox -> dist, langs/tværs
– struktur, fibre (sene mm.)
Lyske - scan A
Beskriv – fortolk
61
Hasemm.
• hasemm.
• biceps F
• semiM
• semiT
62
Hasemm. - læsion
63
Tendino-/myopati
Hamstring calcification,
post traumatic (partiel lesion)
CT 3-D: Hamstring calcifications,
stress/overload induced
64
• hasemm.
– tuber iscii (GMax inf.)
– semiT, biceps F, semiM
– prox. -> dist, langs/tværs
Lyske - scan C
Beskriv – fortolk
65
Hernie
•
•
•
•
lyskebrok
femoralis
inguinalis
sportshernie?
66
Hernie
• symptomer
– pop ud
– smerter/ømhed
• intermitterende
– incarceration
• UL
– væske
– Lokalisation
– ligge/stå, bugpress
Hernie
• smerter
– intermitterende
– progression
• UL
– væske
– lokalisation
incarcereret hernie, væske, distenderet
Lymfeknuder – NB!
lokal
infektion
lokal
infektion
Hodkin
lymfom
metastase
blærecancer
metastase
blærecancer
metastase
rectumcancer
De Gregorio Onc Gyn 2013
foreslå egen læge: henvisning til radiolog
69
• (hernie)
– kar arterie/vene (doppler, bugpresse)
– inguinalkanal annulus int./ext.
– bugpresse, stående
Lyske - scan C
Beskriv – fortolk
70
• adduktorer
Beskriv – fortolk
Lyske - scan
– udspring, conjoint tendons, symfyse
– prox -> dist, langs/tværs
– struktur, fibre (sene mm.)
• hasemm.
– tuber iscii (GMax inf.)
– semiT, biceps F, semiM
– prox. -> dist, langs/tværs
• (hernie)
– kar arterie/vene (doppler, bugpresse)
– inguinalkanal annulus int./ext.
– bugpresse, stående
71
Litteratur
• ESSR
– www.essr.org
• Textbook on Musculoskeletal US
– Bolvig L, Fredberg U, Rasmussen OS
– 2011
– ISBN: 9788762808249
• Cases
– www.ultrsoundcases.info
• Practical Musculoskeletal US
–
–
–
–
McNally EG
2004
ISBN-10: 0443073503
ISBN-13: 978-0443073502
72