膝关节内外侧超声评估

- Well thank you so much for joining us everybody. My name is Chris Pennell and I'll be moderating today's webinar. Welcome to the rerun of the behind the scan webinar titled Ultrasound Evaluation of the Knee Part two, the Medial and Lateral Knee. Now this is the second in a three part series on the knee and we'd love it if you come to the last rerun on May 7th for part three, the posterior knee, which is at the same time as today. You can sign up for that on sonosite.com/webinars. Before we begin, please be advised all attendees are muted. We'll be conducting a q and a session at the end of the presentation. However, we are currently broadcasting this webinar on multiple platforms and in order to ask questions you must be on the main zoom stream. If you're on the zoom stream, you can type your questions into the q and a box at the toolbar located at the bottom or the side of your screen. And feel free to enter those questions throughout the presentation and we'll get to those after the presentation is over. Now the webinar will be recorded and archive for future reference on our webinars page as well. So today we have Daniel Shelton. Daniel is the director of musculoskeletal market development for Fujifilm Sono site. Daniel has spent 19 years as a dedicated musculoskeletal sonographer and 14 of those years have been here at Sono site. He now leads musculoskeletal market development where he works to spread the word about the benefits of point-of-care ultrasound. I'll go ahead and get the presentation started now. - Thanks Chris and excited to be here. This is one, one of my favorite topics to really discuss because I think there's a lot of challenges when evaluating the medial and lateral knee as easy as the anterior knee was. This one is just a bit different. So we're gonna, we're gonna take a different approach to how we look at the anatomy today and very excited to show you the pearls and scanning tips for the medial and lateral knee, especially those collateral ligaments and the Pez complex, which I think is pretty mysterious for a lot of people when they're learning this. So hopefully you're, we're catching you early in your learning curve and you can get some of these tips and take them straight to your clinical practice. As Chris mentioned, we're gonna start with the lateral knee. We're gonna be discussing the IT band, the lateral collateral ligament and briefly in the live scan we'll discuss the biceps femoris. We're not gonna spend a lot of time on that anatomy as it's more of a kind of a posterior structure and we'll, we'll cover that in the posterior knee webinar as it traces up and follows some of the neurovascular structures that are helpful as landmarks. We'll begin with this IT band. So on the IT band, what I typically tell people to do is go to the tibial tuberosity and just palpate one inch lateral and one inch superior and that's gonna get you a new bony and landmark called gertie's tubercle. Alright, so once you palpate that gertie's tubercle, you're just gonna plant the distal edge of the probe and point the rest of it up the femur and you should be able to visualize the the IT band and pan across that until you see a bony cord landmark. So up here, label number one is dirty tubercle and I want you to find these fibers. If you don't see them drape across the femur, it's time to windshield wiper and move your transducer across until you align those structures. We do have a lateral recess or lateral gutter, the super patella recess here and the lateral, the beginnings of the lateral epicondyle of the femur and we'll be covering that for the LCL evaluation, not visualized here very well because it's not the focus is the lateral meniscus. And we'll discuss that just a little bit at the end of the webinar, but it's not the primary focus of today's discussion. So this is a C one, do one and we're just gonna move straight over to the live demonstration now. Alright, lemme grab some ultrasound gel. Alright, so I've got the socy PX here using a 15 to four megahertz linear array transducer. It's a 50 millimeter footprint and I start when I'm imaging the LCL at the, or sorry, the girds tubercle here, palpating that tibial tuberosity. And like I said, we're gonna go one inch lateral and one inch superior and I can already feel girds tubercle just resting right here under my finger. So another scanning pearl is as I'm scanning I tend to hang a finger underneath the transducer. Okay, so don't hold the transducer out like this. You really need to have several fingers on the anatomy, that's very important. But most importantly when we're scanning anything that's inserting to a tubical tuberosity any of these other bumps on the cortical surface of the bone is to feel that while you're scanning it. So what you'll see me doing or what you might not see my fingers doing is hanging a finger just posterior to the probe or distal to the probe. And then as I plant that down, I'm just gonna first scan through the ultrasound gel, that first cortical landmark that we're seeing there. That is the girdle. I'm gonna adjust my depth, put an arrow up here. So here's Girds, here's the ultrasound gel L Okay, here's the lateral femur. So we're on the tibia here. Lateral meniscus is very deep cartilage coming up here and and as I mentioned, I'm just gonna windshield wiper, move the the proximal edge of the probe until I elongate this IT band structure. So here's the IT band and as I pan across gertie's tubercle, I wanna find the point that the IT band is the most bulky, right? So I see these fibers really nice and now I'm just gonna windshield wiper the proximal edge of the probe from posterior all the way to anterior. But based on her presentation here, our model's knee is bent just close to 45 degrees and I know the IT band is coming from the lateral thigh so it originates out on the lateral ileum and I know I need to point my probe that way to get it in its long axis. Okay, so here we can see the IT band jumping over the pop groove lateral epicondyle of the femur and we'll get to that on our LCL. And then I could just keep following this dark band proximally and it will remain a dark band. This muscle underneath it, for example, is not a part of the IT band that's vastus lateralis and we won't see any muscle come off of that very broad band until we go up to the hip and it changes names at the trocanter level and a bit more proximal and and turns into the tensor fascia lata. So not expecting to see a muscle belly here at all. Just wanna pan proximally and distally looking for any abnormalities here. Okay. And then we're gonna follow it to its distal termination here. And then if we don't see any thickening or anything like that, it is helpful to do a dynamic study here for kind of an IT friction syndrome on the lateral aspect of the knee, I'm just gonna rotate the transducer. I'm gonna take the orientation marker to screen left and just rotate it right there on the epicondyle. And I'm gonna use antrop to my favor here. So superficially you can see how wide from here to here that IT band is. It's very broad. Underneath it is the LCL. But right now at this scan angle, 'cause I'm 90 degrees to both of them, it really looks similar and it's hard to tell which is which. And that's why we want to both em employ some dynamic maneuvers. And then you should tilt the transducer handle and isolate the IT band. So you can see the IT band superficially turning dark first, okay 'cause we're using the angle artifact or advantage. So that's the margins of the IT band. And then I could just passively or even with weight bearing it may be a little bit more challenging to stand the patient up and scan this, but sometimes that's the only time you're gonna catch the IT band friction pathology that you can feel sometimes clinically. But you can get that abrasive structure, you can see it right there just rubbing over the lateral epicondyle of the femur and I'm just doing passive flexion extension of the knee. So I'm just gonna rest the knee right back on top of the other. And we'll go ahead and move forward now with the rest of the slides. Okay, so we segue from the IT band down to the lateral collateral ligament and it shares a few common landmarks and one that I just scanned over was that lateral epicon do of the femur and that's where we're gonna end up pointing our transducer. So let's talk about that a little bit in this 3D ct, which I did in the carpal tunnel because the anatomy's a little bit tricky. I also did this in the lateral knee so that you can appreciate the the, the posterior nature of the LCL. So here's that lateral epicon of the femur right here. That's easy to palpate. The fibular head might be less easy to palpate, but if you're scanning a very obese knee, both of those are gonna be very hard to palate and you may be a little bit lost in which direction to orient the probe. So most people just start in a mid coronal plane and they end up looking for what, what appears to be a bright fibrous structure jumping over the joint and they would call that the LCL and just keep going. But we have to rely on our bony landmarks. So here we have the lateral epicondyle of the femur underneath that not visualized here is the pops groove and and diving posteriorly really. And then we should see a joint line followed by the tibia, the lateral aspect of the tibia. And then we should very superficially see the fibula and then sharing an insertion we're gonna talk about that also is the biceps femoris. They do overlap and interdigitate a bit here on the fibular head and we're gonna be scanning that live even though we're not gonna be discussing it completely agnostically here. So landmark wise, looking for that joint re that joint line. Okay, now what we're gonna do is rotate this 3D CT and let's cut the anatomy, how it should look on the ultrasound. So let's remove a few layers here and let's cut into the, to the femur just 'cause we can have a little bit of fun with our, our radiology depictions here. All right, so we're gonna zoom in and we should see this surface. So knowing that we can't see through the bone, I should at the very least be able to see the lateral epicondyle of the femur popliteus groove joint with lateral meniscus lateral tibia. And then I should be able to see the fibular head. So let's see if that's what it looks like on ultrasound. All right, so underneath here is our ultrasound. There are some nice correlations here. The the easiest one to see is the joint. So if we go proximal to the joint, we can see this pop groove back it up as we travel up the inflection point of that ous groove, it will turn into the lateral epicondyle of the femur and we'll appreciate that on the live scan a little bit better. We also now have the lateral tibia, tibial fibular joint and then we have the fibular head here. Now there's a little shadow up here, this little oblique looking shadow that sits on top of the, of the LCL. Don't confuse that for pathology, it's not a degeneration of the ligament fibers, for example, that is what degeneration of ligament fibers does look like if it's isolated in a ligament. But today's one of those days where it really helps to learn some of the overlapping anatomy at some of these insertions. For example, the rotator cuff where the supraspinatus and in infraspinatus share a common insertion at that greater tuberosity of the the midline between the superior and middle facets. Here we have overlapping fibers of the biceps femoris and the underlying LCL. And if you're not careful, you're gonna call that some sort of ligament degeneration or inflammation depending on how prominent that overlap looks from patient to patient. But I would say pitfall wise, this is one of the biggest pitfalls when scanning the distal LCL. And then proximally, we're really gonna, we're really gonna harp on visualizing this proximal ligament here. So I think I have some pathology here, what to look for, calcium deposits, degenerative signs, inflammatory tendinopathy or ligament pathology, I should say not tendinopathy, but we shouldn't see any internal vascularity within the LCL. So here's our papa groove, here's our joint, here's that lateral epicondyle. We see an old injury in the form of a smooth margin calcium deposit. Okay, so if, if this looked jagged and I saw some bone irregularity underneath it, I might call it an emulsion, but this is quite old, especially compared to the rest of the patient clinical presentation. This was a very severe osteoarthritic knee. So these are degenerative changes and, and possibly some healing still happening within the, the collateral ligaments of this particular patient. But you can see this internal vascularity within the architecture of the ligament that should not be there. And that's why we traditionally set our ultrasound machines to detect low level flow in the form of vascularity in areas that shouldn't be there. And then just panning through that in gray scale, just looking and appreciating at just huge rock formation that's in the ligament shouldn't be there at this point where you see it shadowing that would show up on a radiograph for example. But some of these, these other parts right here that are not shadowing, say this was a patient that presented only with that bright hyper coic structure in the tendon that did not shadow. You wanna watch out for those because they're not quite gonna show up on a radiograph if they're not shadowing. So they're not dense enough to cast a shadow on ultrasound. You're catching calcium at a early enough phase that it could possibly be lavage and aspirated. So looking into your, your clinical toolbox using all the tools you can, ultrasound is a great one to decide hey, you know, could you chase down a calcium deposit early and get it out of, get it out of there far right inside of the screen scanning live, you can see that biceps fems creeping its way over the LCL just as a pitfall it's normal and we'll check that out in the live demo. As promised, we'll be moving back and forth between live demo and presentation. So I'll go ahead and get moving on that. The common landmark is the lateral epicon of the femur. I like to scan that and show where the IT band is in relation. But when I'm teaching beginners how to do LCL ultrasound, I always start with the fibular head and I go ahead and tell them and, and there's some, some of my mentors out there will probably slap me, but I tell them to palpate while they scan. So here I can feel the fibular head. Okay, as I, as I plant my fingers on each side of the fibular head right there, I'm gonna set the transducer right between my fingers and as I set my transducer between the fingers, my next motion is gonna be to windshield wiper, maneuver the transducer until I see the lateral epicondyle come into view. And when I see that lateral epicondyle come into view, I'll work on my angle to get the rest of the LCL to look good. So I'm gonna plant both fingers on each side of the fibular head. I'm gonna rest my transducer between my fingers and I'm just gonna slowly lower the transducer into the gel there. And I can see this superficial hyper echoic structure, which is the fibular head. I'll move my arrow just momentarily here, but here I'm just gonna windshield wiper over and I can already see that elongated LCL very nicely. So for the sake of me using the arrow, I'm just gonna plant my, like I said earlier, I'm gonna plant one finger behind the fibula, that way the transducer drops right on the fibular head. And then I'm just gonna windshield wiper across and then I'll use my arrow and start pointing out some anatomy here. So distally, we have the fibular head, we have the tibia here, we have the joint between the fibular head and the tibia, which some bursal effusions, joint effusions and ganglions can come out of here. And also a neuroma can also live here. So be aware of any soft tissue masses that arise out of this joint. Then we have superficial to the, to the LCL fibers. Look up here, everybody see this, this oval right there. And we're gonna, we're gonna focus on that just real quick because it is a scanning pitfall. If you don't know it's there, you're gonna call that some sort of pathology. So what I'm gonna do is just pan the transducer from posterior to anterior, posterior to anterior. Do that in small one centimeter segments until you kind of rule that what we're looking at is a cross section of something coming in and out of view. And to prove that what we're gonna do now is just plant the probe on the fibula and I can palpate her, her biceps femoris just fine. It's probably not that way for everybody that needs an ultrasound, right? So I'm just gonna swing the posterior part of the probe, or sorry, the proximal side of the probe posteriorly. And we're gonna elongate that biceps fems. So here we can see the biceps fems confirming that that shadow here. So here's our, our distal tibia or our proximal tibia, and then here's our superficial fibula. And then there we're elongating the fibers of the biceps femoris. So just a pitfall to watch out for. I'm gonna go back to long axis fibula, or sorry, long axis LCL. And I'm just, like I said earlier, I'm pivoting, I, I have a finger hanging behind the the fibular head. I'm gonna move the legs back just a bit. There we go. I'm just gonna plant my finger behind the fibular head, place my transducer in front of the finger and then rest it right down on the fibula, just like that. And then I'm windshield wiping distally. Now distally, my landmark is the lateral epicondyle of the femur. So I wanna see this, this high bony peak right there. And then it's gonna jump over a more posteriorly, or sorry, at least anterior in this case you can see the pops groove with the knee inflection. We're not always gonna catch the LCL with the popple in the shot, as clear as we did in the slides. If we were to straighten her knee, I believe we get a really nice pop leu groove and LCL in the shots. We're just gonna straighten the leg. There's the difference in patient positioning. It's key. So if you were to be doing this weight bearing, you'd probably see that pal groove in the LCL L really nicely, all in one shot. Let's go ahead and bend the knee. There we go. So bending the knee is a much, much better way to kind of tighten that LCL and make it look really, really nice and uniform, avoiding an isotropy. But if you were just panning the transducer across that footprint of the proximal origin of the LCL looking for cortical irregularities, anything else that might clinically be relevant in this site here incidentally, we see some other fluid collections in the site here. Lateral inferior geni or sorry, yeah, lateral inferior OID artery. Throw some color on. One more thing to avoid if you're doing procedures in the area. Always do some sort of colored op doppler before a procedure by the way. And if you are using the Socy PX or the newly launched lx, this is a good time to show that you can be doing those procedures simultaneously with a top bottom feature and driving your needle without that color artifact flashing. And get your needle right up near the neurovascular structures that you might be doing a procedure around. So that's top bottom. I'm just gonna switch it to left right 'cause it kind of fills more of the screen for the webinar, but it is nice to see that I can, I can still move the transducer around. And on the right side of the screen, I don't have all that color flash that's associated with just trying to find my landmarks to get out that I'm gonna hit 2D takes us outta everything that takes care of the LCL scanning. Let's move to the next topic. Medial knee. So just a couple of structures on the medial knee. We're gonna look at the medial collateral ligament first and then we're going to see how that segues into the prine complex. So let's talk about the MCL and the anatomy around the MCL. I like to start out right here at the medial epicon do of the femur, just like the lateral aspect, there's a, there's a big bony perturbance sticking out of the medial side of the knee. And if you're all at home palpating the inside of your, your knee might feel the joint line go proximal about an inch and then feel for a bony rooftop feel it's very prominent, it's easier to palpate than the lateral epicondyle, I feel on the prominence of that epicondyle that you're feeling. The MCL more, more or less lies on the more posterior side of that prominence. And we're gonna show that in the live scan. We can also visualize that the medial meniscus, but we're not gonna focus on that today just a bit as a, as a landmark reference, we're gonna scan past this medial tibial plateau. And then the medial neck of the tibia is gonna be a huge reference here and it's gonna tell us how far we have to go until we see the insertional MCL. And then the, the distal and thesis of the MCL will also provide a nice landmark for the pian ring complex. So this MCL has two components. We're not gonna focus on those terribly too much today. There is a superficial component and the deep component. The deep component does attach partially to the medial meniscus and this medial aspect of the tibia right at the plateau level. There's also the superficial component, which is most commonly seen easily on ultrasound as this huge long thin layer that drapes like a bow string over the medial tibial neck. Very easily appreciated in an ultrasound. The deep component of the MCL less appreciated unless there's some pathology there. Little disclaimer. All right, so medial left condyle high B high, easy to see bony landmark cortical shadowing. Here we see the medial joint line. And then here's the medial tibia. So we're in a coronal scan plane. And then this MCL, if, if you had a chance to look at the elbow webinar that we did, this looks a lot like the UCL in the elbow. It's got this huge kind of bugle sail shape looking ligament fibers going across this medial epicondyle, which coincidentally it's the same, it's the medial epicondyle of the elbow. Same shape, same geometry. Imagine that same ligament jumping over the, the humeral ulnar joint. In this case we have the, the medial aspect of the knee joint where the femur and the tibia meet same shape, same appearance, and it's gonna drape distally here. Coincidentally, we do see a little bit of the enthesis of the deep component right here. This is a sono side PX image, very high image quality. And then superficially after, after the deep component insert, the superficial component still keeps going. Here's that medial neck of the tibia, we're gonna keep going, keep going, keep going way out of the frame here. It goes into a very loose leafy, very broad insertion across the tibial, almost to the tibial tuberosity distally. And it's a very, very long structure that a lot of anatomy models and diagrams really don't give it justice for how, how long the MCL actually goes. So you don't wanna stop scanning at this neck shape or proximal to the neck shape. You can't stop at the joint line. You really have to keep following until you see the neck of the tibia here and go distal, even another intra tube. So let's look at some pathology in that spot. In that spot. Here we have a raging degenerative ligament change and kind of an oblique short to long axis here, but this is, this is a really inflamed MCL. We do have cortical irregularities, we do have shadowing calcium deposits. So other things to add to your, to your clinical picture and aid in your diagnosis, otherwise might not have been palpated or showed up on a on plain radiographs. And then let's look over here in the gray scale. So the gray scale easily showing very similar pathology to what we saw on the lateral side. This is the same patient, this is the medial side of the exact same patient that we saw the same calcium deposits is severe osteoarthritis, very painful degenerative knees. And you can see that these ligament fibers are just giving way and causing all kinds of calcium deposits in here. And there's even some free, free fluid in between a lot of these fibers right here. So just something to be on the lookout for when you're scanning these diagnostically. It's a lot of fun when you do find something. All right, so I'm gonna combine these together and it's because the scanning technique goes hand in hand. So we scan the MCL and then we scan the Pez complex and we put 'em together because just like the biceps femoris had an overlap with the LCL, the Pez complex has even more of an overlap with the MCL. So we're gonna talk about those. The most common and easy to see structure here is number three, sartorious not labeled here on purpose as the semi tendinosis and the gracilis underneath the sartorious proximally inserting underneath this kind of shade of the sartorius is gonna be gracilis and then sartorious. Those are a lot less defined unless there's pathology. Okay, and forgive me for not having that anatomical reference here it is on the learning institute. It's the Stefano Bianchi and Parlo Marli book, introduction to musculoskeletal ultrasound textbook where this anatomy diagram came and it is just absolutely spot on. So you can see the sartorious and how large that isus and semi tendinosis stacked approximately and distally respectively. But you can see the MCLs relationship to these and that's why we're gonna scan the MCL first and then we're gonna rotate our transducer to an oblique nature kind of posteriorly. So long axis MCL gets you an oblique set of shadows on top of the MCL. So these oblique shadows, these are pez complex shadows and I've seen them called bursitis. I have seen people call these pez bursa and throw a needle in them and inject. And that's, that's wrong. These are not pez bursa and it's very rare to, it's sono graphically rare to see a real pez answering bursitis and it really only catch 'em a couple of times a year. And that's even if you're scanning a lot of needs, you might only see one troop has answering bursa over a period of five years. They're just sonographic, extremely rare. So don't get disappointed. But what you're gonna find a lot of is tendinopathy. So number one here we have the of the MCL now. So we went from a long axis to the MCL to a relatively short axis of the MCL because we're going long axis to the Pez complex. So this label number three is basically talking about the entire complex. It depends on how proximal or distal we are on which fibers we're actually seeing. But the pest complex comes from the posterior side of the knee up the thigh to the hamstrings all the way up into the hip and pelvis. But we're gonna focus at the joint, but we can see that these fibers jump up and over up and over the MCL. So this short axis structure, which we'll scan in just a second, is the MCL. And you can see the Pez complex jumping up and over. So as you probably saw my next slide on accident, here's the sonographic rare pez, the isolated Pez bursitis. This was in a diabetic that was asymptomatic, happened to be at a ultrasound workshop for example. He is a soccer player and there's just a, a slight palpable bump on the inside of that medial tibial neck did not communicate with the knee joint. This was not some sort of ganglion cyst that arise and it rose out of the joint. We, we traced it all over. This was just isolated strictly to the Pez complex. And you can see all these little septations that might be hard if you were to try to aspirate this, your needle would get trapped into one of these septations. So you might wanna go ahead and attack all of these with a needle and drain them individually. If they did not, if they weren't communicating, you could see that with ultrasound really nicely and be able to drain the entire soft tissue fluid collection if it was free fluid. Another hint that it's free fluid is all of this posterior acoustic enhancement on the femur, sorry, on the tibia. And that's because we know this up here is a simple fluid collection. If it were more solid and dense, we wouldn't see any amplification of the echoes underneath the fluid mass. It would just stay just as dark as some of these other blended tissues here. So one other hint that it could be aspirated is you can see the amplification or the brightening of the echoes underneath the fluid collection right over the underlying tendon. Briefly we'll talk about the meniscus ultrasound's, not where you want to hang your hat for a meniscus evaluation, but if you do see a meniscal cyst, it is a meniscal cyst. If you do see a meniscal tear, it is a meniscal tear. It's just ultrasound is not gonna tell you if that is the extent of the issue and you don't wanna stop there. But it may be a good confirmation that an MRI would do the patient Good. All right, so don't go in chasing a meniscal tear and if you don't find a menal tear, don't, don't rule it out. You may still have a meniscal chair. So that's just a little pitfall. Word of wisdom. Don't skip the meniscus. Look around as much as you can. It is very hard to scan the meniscus reli reliably. But it can be done with enough patients and study. But again, you're still probably not gonna rule out pathology based on ultrasound. You will rule in pathology when you find it. You're probably right when you find it. There is also some nice dynamic maneuvers we can do at the meniscus with the valgus and various stress maneuvers. And I'll do an example of that in just a second. So moving on to the inside of the knee with the live demo. Now a little bit more gel, I'm gonna move the machine a little closer to me because I don't like reaching across as much as I did. Hopefully that still looks okay. All right, so because this is just a demonstration, I have the liberty of just scanning the other knee, which happens to be facing up. So instead of flipping our model over to do the same thing, I'm just gonna have her move her leg outta the way. And we're gonna scan right here on the mid coronal section of her medial knee. So I can, I can palpate this medial epicondyle. You could go for the joint line if it's not so obvious first, so I can feel medial femur, I can feel medial tibia chase those medially and then go proximal and feel for that bony ridge right there. Then you wanna palpate that medial neck of the tibia that I was talking about and get a real feel for it. And just anatomically speaking, when I visualize what the Pez complex is doing here, I treat it a lot like the medial mallis of the ankle. I think of the, the Pez tendons wrapping around and taking a turn, kinda like a posterior tibials tendon of the, of the medial ankle where the, the medial mallis is just acting as this pivot point for a redirection and an added leverage to what we're trying to accomplish with the, with the anatomy. So just imagine this shape. I'm not gonna see any pez complex up here at the joint. I'm not gonna see it any further distal, it's just right around, right in that, that trough where I can feel the medial tibia. So palpating ahead of time studying this anatomy is very important. Try to confirm it with ultrasound. I'm gonna keep the left side of the screen anterior. I'm gonna start cross-sectionally so I can show you what the medial epicondyle of the femur looks like. So again, I'm hanging a finger underneath the ultrasound transducer. As I do that, I just slowly rest the probe onto the structure. So I'm, I'm doing that back here with my fingers. There's a little scanning pearl because we're dealing with superficial structures. I don't want to collapse any, any degenerative conditions that may show up nicely on ultrasound. I don't want to collapse any bursitis or any joint effusions that may help me. So you don't wanna start off just by cramming the tissue because we're trying to palpate while we scan. But what I will do is feel ahead of time right there. I feel the medial epicondyle, especially the backside of the medial epicondyle as it heads to the back of the knee. And I'm just gonna rest the transducer right on top of the skin. And I should see this bony peak representing our medial epicondyle of the femur. So on top of that medial epicondyle of the femur, we have this, this gray structure here. That's the cross-sectional MCL. If you don't see it right away, just use the angle artifact to your advantage. It appears that til tilting the handle towards the feet is causing more an isotropic artifact. Okay? And then if I go from posterior to anterior, I don't notice any more, any more ligament structures. I'm not gonna scan the MCL and short axis to identify it. I just wanna find the margins and see how broad that footprint is. So it's really telling me how I don't want to just take a slice here and call that good as I go long axis here, I need to scan from anterior to posterior. So what I'm gonna do is just take the same bony cortical landmark and I'm gonna rotate the transducer long axis now. So here's the long axis where I can see a medial joint line in the tibia here. Here's the origin of the MCL. Remember, i I settle. It looks a lot like an elbow. So this looks a lot like the UCL of the elbow and it's behaving a lot the same when I scan across the footprint. So the footprint is very long and broad anterior to posterior ear. So now what I want to do diagnostically is I wanna sweep the probe anteriorly until I see that shadow disappear. And then posteriorly again, I can see those shadows and all those little ligament striations, I can see those pop back up and I'm gonna go posteriorly too until I see them all whittled down and disappear. So there I scanned across the whole footprint. It all looks really good. If you see some of these little bony irregularities on any, and you suspect they to be clinically significant, check the other side, check the, the contralateral side. 'cause more often than not, these are nutrient foramen, small vessel feeder vessels into the cortex of the femur. And they're not pathological at all. You can throw your color on in a lot of cases and, and follow some vasculature that just dives right down into the cortex. So don't immediately find one of these and, and be suspicious of an avulsion, especially if you don't see, if you don't see a bony fragment correlating to the area that would've been tugged out and pulled distally. So don't, don't go chasing the bony fragments like, or sorry, the cortical irregularities like this without comparing to the other side. Big benefit of ultrasound is that we get to compare to the other side. So now that we've, we've looked at the framework here of the proximal aspect of the MCL, I'm still palpating my fingers is palpating. As I scan distally, I can feel the medial joint line and then I'm gonna be able to feel the medial tibia and then I'll be able to feel that medial aspect of the tibial neck right there. So what's happening behind the transducer is I'm digging my finger in a little bit just to stay on track and feel the anatomy as I scan. So I just wanna point that out, kind of why we join a live webinar, get some scanning tips instead of PowerPoint slides, right? So I'm just scanning posterior. My, my finger is posterior to the joint now, but it's keeping me on the ligament. And as I scan distally distally distally, I can see how thin the MCL is right here. And if I keep a mid coronal plane, if I keep just a mid coronal plane, especially if your knee was more straight, your, your image might look like this and we lose that tibial neck. If you lose the tibial neck as you're scanning, rotate the distal part of the transducer, rotate that anteriorly, and you'll see that MCL come right back into play. So here's the MCL right here. Let's follow it distally, distally distally until we see it terminate on that anterior tibial spine right about there. As I mentioned before, the segues into the Pez complex. So let's not call the shadows right here on top of the MCL and to cause those shadows. What I'm doing is just tilting the transducer slightly, aiming the beam posterior to the knee. And I'm, and I'm kind of calling out the shadows of the pez complex right there. So right, right where my arrow is is one of the shadows and they move. The transducer is another shadow and it's a complex and they really don't show themselves in their isolated pockets of sartorious, socius and semi tendinosis. They don't show themselves until there's pathology really and really high resolution machines like this. We can, we can certainly see the delineation between a proximal and distal component, but, but really what we're looking at is just the overall shadowing structures. Okay? So there we've, we've shown the Pez complex and how it's jumping up and over the MCL and this is where I'm gonna elongate the Pez complex. So now I'm gonna take the proximal side of this probe and I'm gonna point it down the back of the hamstrings. And I'm gonna imagine this is the same as me scanning a, a medial ankle around the malleolus. So I'm just gonna rotate the transducer and when we rotate the transducer, but very nicely, I'm just gonna leave my arrow there. It kind of landed in the right spot. We can see this, this peak shadow jumping up and over the tibia and inserting kind of like a, a very long tapered bird's beak like we learn a lot of tendons do throughout, throughout the body. They all have this, this long tapering insertion. And that's what we're seeing here. So you saw how broad the complex was in the MCLs long axis. So if I go long axis, it means I need to scan. Once I find that that rising peak of the pez complex, I need to scan from about here all the way to here. All right, so pez and serine, anine means goose foot and we're going to be scanning a structure that's inserting a lot like a goose foot. So we have to do that in long axis now. So now I'm just gonna take this, rotate the transducer. I can see that shadow diving. Let's follow that shadow with the arrow. So here's the shadow up, up, up and it's shadow because it's the, an isotropic artifact. If I were to chase that posteriorly, it would be a really nice tendon with great reflective echoes. So here I'll follow it anteriorly until it tapers very, very thin, mostly sartorious because of its superficial kind of umbrella like nature. But here it is still, still anterior tibia almost there I can see the last little segments of its insertion right there. So I do need to constantly remember just how broad of a structure that is. I'm just scanning from proximal to distal distal up and down. And then just like we saw in the PowerPoint slide, here's the cross-sectional MCL right here. And I could show that with a bit of an isotropic artifact, I'm sure closer up to the, to the joint line. Here we are up over the joint again and then jumping over the medial meniscus, then chasing that MCL, it's very thin, chasing it distally there. I just used atropy through that whole scan to really chase the MCL. Now, earlier I mentioned neurovascular structures on the lateral side of the knee, the, the inferior geniculate area here, just because we're in the neighborhood, we might as well point it out. Here's the inferior medial artery right there. So I know there's some, some pretty neat neurovascular procedures that are being done under ultrasound guidance. And it's very useful to be able to point out these vessels because they're roadmaps to the nerves, but also to point out what not to hit when you're doing procedures. So if you're doing a ultrasound guided pez answering bursitis injection, it, it may be beneficial to put on the color doppler and make sure you're not hitting this little medial inferior ular artery. Lemme hit 2D to get outta that. All right, so just to review, medial epicon of the femur looks a lot like the UCL in the elbow. Here's the medial meniscus. We haven't talked a lot about meniscus at all. It's this triangular homogeneous structure because of how we're cutting it. If you want to continue to scan meniscus, imagine you're scanning the rings of an onion and we need to stay 90 degrees to the rings. So these rings are circumferentially around the, the inside of the knee joint. And you need to scan staying 90 degrees to the rings a onion. It, it's very difficult to reliably scan these medial and lateral meniscus structures, but if you do suspect that you found some pathology, you're probably right to further verify any pathology. You could also place a pillow or a rolled up towel underneath the joint. And then what you do is you use your, your elbow, okay? And you push down on the tibia and you cause this valgus and various stress maneuver and you get the joint to open up. And we're looking for any extrusion of the meniscus. So scanning tips for the meniscus if you wanna try to challenge yourself there is, as you scan posteriorly, you need to aim back to the, to the middle of the meniscus. I'm gonna change my depth. Also helpful to hit gin and drop your frequency a bit. And in the posterior knee, we'll look at the posterior medial and lateral meniscal margins too to identify some, some other anatomy in that area. But it, it's a fun challenge to chase down the meniscus, but not a requirement in knee ultrasound. It is neat to, to image, but not a part of a checklist of a protocol to rule anything out diagnostically. Again, if you see a meniscal cyst, if you see extrusion, you're right, you're on the right track for pathology. Further imaging might be necessary. But if, if you're using ultrasound to rule out something like a meniscus tear, then it's, it's not, it's not reliable. So that is the end of the live scan portion, Chris, and I'm gonna open it up actually, we'll use this brief moment to call that the, the clean recording. And then from here on we will moderate any questions in the, in the live chat if you guys have any, go ahead and send them my way. - All right, that's the presentation. We'll go ahead and open it up for Q and a now. So thanks so much Daniel for being here for the live q and a. Let's see, we're broadcasting on multiple platforms, but we can only take questions if you're on the main zoom broadcast, the q and a box should be available at the bottom or the side of your screen. Right? Go ahead and get Daniel on here. Here we go. - Thanks Chris. How's my - Audio? Sounds good. - All right. So as you'll see here in just a sec, we've had a little bit of time go by and things have changed a little bit since we first hosted. So similar setup, but we're gonna demonstrate any of the live q and a with the onsight st. So that would be kind of a difference that you're seeing since we were live on that first recording. So happy to take your questions. If you could test our chat portal and make sure we're, we're getting you by, just let us know where you're watching from city, state, or country. It's been really interesting to see our specs online, to see where all people have tuned in and, and joined us after the fact. It's, it's neat to see who's actually joining us live. So as we, as we review some of the anatomy and I just kind of scan to fill a little little time while questions come in, just go ahead and shoot us your, your location and just let us know where you're coming in from. You probably noticed it's a, it was a high level basics overview and not so much geared towards procedures. So we, we do hope to have more procedural webinars in the future and more advanced diagnostics that might include crazy nerves can be done if, if you were to upvote that maybe in the chat or, or email me directly with any content you'd like to see performed. So my email's danielShelton@fujifilm.com and we'll take those suggestions and review them and get something up in the future. So earlier we had the pops groove, we'll just kind of play around with the ST for just a second. So I'm gonna throw an arrow up here. Here's that groove, which is a good LCL landmark. Here's the pops, which is almost looking like a biceps groove and it diagonally will traverse posteriorly in the knee and hang to the backside of the tibia in this oblique orientation. So if you were to follow it in short axis, you'd see a dive and hug the hug the meniscus down low or I think it's easier to follow in long axis. So it will do is take it back up to its groove here. And I'm just gonna pivot the transducer screen middle and elongate slowly. There we go. It starts to look like a lateral epicondyle of the elbow. If you catch it just right, you can see that high inflection point. And also if you're on the YouTube stream, I have the chat up, but I did put that you need to join the Zoom webinar to interact with the live session. The YouTube's about 10 seconds delayed and I don't want it to look like we're ignoring you. So if you do have a question, but anyways, there's that and long axis it, it has been known to snap and pop and click and postoperative cases. So that's one thing to take a look at. Get the knee in this position somewhat flexed, grab that palla tendon, center it in the screen and stress the knee in a way that they're feeling a click or a grind. And it might have to be done weight bearing too, so that might be a little bit different. So that wasn't in the PowerPoint, but that's why you stick around for a few extra pearls at the end of any presentation or conference. Right? So this is your time to just do a little bit of q and a on your own or clarify anything. If you have any questions we can sure answer those. But - Yeah, we've got a, - Just to scan and yeah, we've - Got a few people coming in here. A couple of comments. One person says, think for the presentation watching from NYC. Another person says, would love to see more nerve videos. That's from Sue from Saskatoon. First question is, this may not be specific to medial lateral scanning, but is there a mechanism to assess for synovial swelling or thickening at the knee joint? - Yeah, typically the super patella recess is your first giveaway. And given that her knee is already in this kind of position, you can see a nice lateral shot this way. So we would check the super patella recess for simple effusion versus synovitis here I'm gonna drag the depth button down or we can even use the buttons here at the bottom. This is an all touch screen display. So the, if you're used to the PX or the lx, we've taken your user interface and put it into a touch platform with the buttons in the middle for save image free. So you're gonna see me press a different spot of the screen, but this is the quadriceps fat pad. Get my arrow back up there. So we have quadriceps fat pad, which when the knee is inflection, it's real easy to see because it's not linear or striated, it's very homogeneous and it looks the same no matter how you slice it. But it's a nice little triangle. And when the knee is flexed, you'll see it taper off and end. And then here is the, the end of the cartilage here, the lene cartilage that is. And then here's the pre femoral fat pad wrapping around the femur here and we have the quadriceps tendon. So I'm just gonna have her slowly extend her knee. There we go. And you can see that interface right here, that's the synovial interface of the knee joint and it looks nice and thin. What I don't wanna see is that interface looking like a big folded sponge. I don't wanna see the walls be very thick and hypertrophic. That would be synovial hypertrophy versus a an effusion. If she did have a big joint effusion, I wouldn't call that synovitis, I would just call that a joint effusion. And you'd wanna do a more thorough cartilage evaluation. Maybe she has some, some cartilage damage, osteoarthritis oa, I think we covered a little bit of that in the anterior knee webinar. But having a synovitis question is very good because we're gonna be covering a little bit of arthritis ultrasound, hopefully mid-summer on the hand. And maybe we'll throw in just synovitis in general and what that means under ultrasound. But you'll see here we're in the the lateral gutter. So screen left, we have the patella here and I'm gonna go really shallow. So we catch the interface really nice and in focus. And I might even just zoom in a little bit. So I'm gonna go to my 2D menu and hit zoom, open the box up a bit and hit zoom again. There we go. So what this is gonna allow us to see is the lateral gutter and we're gonna get my arrow back up here we have patella femur K and the lateral patella, retin ulu patella femoral reticulum, which blends into the IT band and this slice. But you can see this dark layer here, that's the synovial gutter on the lateral aspect of the S patellar recess. And it's nice and thin. So when there's synovitis, it will look like a folded sponge. You'll see a thick homogeneous folded wall instead of a of a very thin hypoechoic wall. And if it's a simple joint effusion on top of this cartilage, you'll just see black anti coic fluid that is freely compressible. That's the other thing about synovitis is it's not so compressible. It may squish a little, but it's kinda like you would imagine squishing a sponge. So synovitis, spongy effusions, not so spongy. And if it's synovitis dealing with a more systemic rheumatoid condition, you're gonna look around for erosions, you're gonna be looking at cartilage for calcium deposition, you're gonna be looking at all kinds of other autoimmune potential that that may just contribute to your diagnosis. Hope that helped. Excellent question. - Yeah, we've got another one here. Can you demo finding the peronial nerve from Dan Malone in Madison, Wisconsin? - Oh, cool. Hey Dan, great to have you here. Incidentally, we'll have Dan as one of our guest speakers midsummer, which will be nice. But the easiest way to find it, earlier we had on the presentation I had you palpate with a finger behind the transducer, the lateral fibula right here. And I'm just gonna plant my transducer right on top of the fibula. And if you already have the biceps femoris and long axis, that's, that's good bonus. But if you don't go ahead and elongate the biceps femoris. So we have that tendon up here all the way across. So biceps femoris, if you get it in long axis, the shortcut really is just a fall off posteriorly while maintaining a little bit of your angle of incidents into the fibula. So this is all common peronial nerve or common fibular nerve, depending on when you learned what its name was. There it is in long axis. And so you could just simply go short axis on that and keeping it in the center of the screen. You have this nice oval and you wanna rotate it until it's as small as possible. You can artificially elongate this by cutting it obliquely like like this here. So I wouldn't call this an artificial or not artificially. I wouldn't call that a pathologically flattened nerve because I hadn't rotated enough. But yeah, nerve, we've got the common peroneal nerve. It would be great to do a nerve webinar I think. So if you could anybody on the on the call, just email me those topics that you wanna see because beyond that, these neuro machines are so nice. We have the common perennial nerve, but we also have thesal nerve, one of its branches here, lateral branch right here. So that's one of the branches of Thesal nerve. And they're typically followed by an adjacent artery. So you can throw an artery, or, sorry, not an artery. Here's another branch right here. And the way to scan nerves, just while we've got you on the line, is in short sweeps. So one centimeter sweeps, proximal distal, proximal, distal. If you've ever sat in a reading room with radiology and they're going through MRIs, you'll see 'em scrolling up and down the mouse wheel, up, down, up, down, up, down. And, and they just focus on one area at a time. They're not looking at this whole picture kind of skimming for everything in the image. They're focused on this one item here and they're gonna go proximal distal, proximal distal, proximal, distal. And then they're gonna scoot over. I'm gonna go to this little branch of the SSL and I'm gonna go proximal distal, proximal, distal. And if y'all don't believe me on that being a little branch of the surl, then we can zoom in 'cause zoom. As far as webinars go, I'm not sure how much detail we're getting but there, I just did a little, little bit of a zoom and let's throw the arrow back up there. Here it is right there. And you just wanna scan proximal distal, proximal distal. And there was another branch of the lateral circle right back here, a little bit more prominent, maybe has a few more fascial in it. I'm gonna unzoom just for perspective and where we were. There it is right there. Proximal distal. Proximal distal. So just some little bonuses there. Look superficial to that lateral gas rock, you'll catch a few branches of that SSL look superficial to the lateral gas rock here we've got our common perennial laying over the beginning of what I think is cous. And then up here we see it's crossover. The fibular head, neck, or just traversing distally, distally distally, that's where it gets a little tricky. So it's fun. You wanna keep it as an oval. So it's oval here. And you saw me rotate my transducer, so I, I went from a very axial orientation here. I'm gonna go distal, distal and right there where it tries to kind of spaghetti over the fibula. I'm gonna rotate my probe anteriorly facing there. Now it's in short axis because it's trying to stay towards that anterior side of the fibula. Right there, right there, right there. And here we see a divide. Excellent question. Really fun to ultrasound since you're in the neighborhood, find your fibula, find your LCL. So here's your LCL and your biceps femoris. So I'm just doing all this by palpating. If it looks like I'm doing it really fast, well and I am doing it a little fast too, just poke your finger under there and palpate, use that fibula to windshield wiper off of. And if you know, if you, if you also take your other finger and palpate the lateral epicon valve. So I know that that's LCL draping all the way across the screen. This little oval that we talked about, it's biceps femoris and I know that because I can windshield wiper posteriorly there just to check your work. Here's the muscle belly of the biceps femoris incidentally. So long axis to the muscle belly of the biceps femoris, I'm gonna drag the probe posteriorly and we should catch a really, really nice common perennial nerve. I'm gonna go short axis and we'll cover this in detail in the next webinar, which is the posterior knee and what not to hit with the needle. We'll do diagnostics like baker cyst stuff too, but we are gonna do everybody a favor and call out what is and is not needle worthy. But yeah, here it is. Branching off of the, the sciatic. So we'll see sciatic turn into tibial here and there's the split, here's the common perineal right there. So keep in mind as you go, proximal the nerve is diving so I have to maintain perpendicularity. So you see the, the very acute nature of the angle of my transducer, right? So if I were to just follow the skin and stay 90 degrees to the skin, it's very disappointing. Everything's blended in, it looks very homogeneous 'cause nerves are a bit anti isotropic or angle dependent. If you're new to ultrasound, MSK ultrasound is all about anti isotropic or angle dependent tissue. Right there actually tibial that was tibial. Here's perennial or fibular. And as it as it dives upward, remember I have to, I have to angle acutely north. So look at how far up I'm burying my transducer handle to catch that. So I'm gonna bring my depth up to focus. Our machines are gonna follow your depth for focus. So what you don't want to do is have a bunch of dead image in the bottom of your screen we're we are trying to focus for you as an overall image. What you're not gonna be able to do is move a focal zone. So you're gonna move your depth up and that's gonna clean up your image really nice, maximize your field of view and it helps you see things more clearly. Awesome question Dr. Malone. - All right, well it looks like we're at the top of the hour here and we don't have any more questions. Okay? So I wanna remind everybody that we are going to be doing the final part, part three here, the posterior knee on May 7th at the same time as today. And we'll also be announcing some more webinars soon. So keep an eye on sono site.com/behind the scan webinar for more details on those as well. Daniel, thank you so much for taking the time to put together the original presentation as well as being around for the q and a. I know you're feeling a little bit under the weather, but we really appreciate you being here and taking the time to share your expertise. Thank you so much everybody else for joining us and we'll see you at the next webinar. , plain_text