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Transcript

- Welcome to the Sono webinar on diagnostic shoulder exams,

the anterior shoulder.

Before we begin, please be advised all attendees are muted.

You may type your questions into the q

and a box at the bar located in the bottom

of your screen at any time, and we will conduct a q

and a session at the end of the

presentation and demonstration.

The webinar will be recorded

and archived for future reference on our

behind the scan webinar page on sono site.com.

With us today we have Daniel Shelton.

Daniel Shelton is the director

of musculoskeletal market development

for Fuji Film Sono Site.

Daniel has spent 16 years

as a dedicated musculoskeletal sonographer

and 10 of those years have been here at Socy.

He now leads musculoskeletal market development

where he spent works to spread the word about the benefits

of point-of-care ultrasound.

And Daniel, I will turn it over to you.

- Thank you Laura, for that introduction.

Again, my name's Daniel Shelton.

I'm the director here at Food D Film Socy

of MSK market development.

Today's topic is the anterior shoulder

and specifically we're gonna be discussing the biceps tendon

and the subscapularis tendon.

Before we get started, we should talk about some

of the artifacts associated, especially around the shoulder,

which is angle artifact.

This is a loss, this an atrophy is a loss

of our reflectivity to the transducer due

to off perpendicular incident sound beam angle.

Normal tendon appearance depends upon incident angle

of the ultrasound beam being perpendicular to the tendon.

This can be a potential pitfall.

This can mimic focal areas of tendon injury

and it can reduce or prevent visualization or intra

or peritonitis pathology.

So here's an animation

of the an isotropic artifact in motion.

And you can see the tilting transducer is sliding up

and down the biceps in a pivoting motion.

So basically we're angling

and we'll do this in the live demonstration

to really drive this point home.

But look at the biceps groove as a bony landmark

and the biceps tendon isolated here is turning dark

versus the the surrounding contents

that are less angle dependent, such as a little bit

of fat little perivascular architecture here

underneath this transverse humeral ligament, not so affected

as the one that is popping in

and out of perpendicularity here.

So if we're slicing these tendons at 90 degrees,

we get really nice views of the tendon.

If we're off perpendicular,

we see the tendon disappear In a healthy normal tendon,

I will say scar tissue will remain reflective

because it's just a back filling

of collagen fibers in an unorganized manner.

So an isotropy is also primarily dependent on

the fibers being longitudinally arranged

linear striated in architecture,

not just any collagen fibers.

If it's more of a mesh like fascia

where the fibers are going in all directions,

then basically we still see the fibers

because we're, we're cutting any direction

of those fibers perpendicular.

But in this case, when we're isolating a tendon,

we're we're noticing that just

that tendon falls off in perpendicularity in the surrounding

structures remain.

We're gonna begin at the anterior shoulder.

We're gonna cut the shoulder in an axial body plane

and we're gonna locate this hyper echoic

cortical surface of the humerus.

If you're not seeing a sharp cortex,

that means the rest of the structures on top

of the shoulder are not gonna be very sharp.

So start with your bony landmark as a reference. First.

If you're not seeing sharp cortex work on your

angle to prevent that.

An isotropic artifact, we should say on the lateral side

of the groove, just as a just an FYI,

there is a normal vascular landmark is this ascending branch

of the circum humeral artery

that climbs up the biceps groove just parallel to the biceps

starting at about the surgical neck

and then it, it follows the biceps

and inserts into the lateral groove.

This is a normal arterial artifact

and we see it all the time.

You'll see these little divots in the,

in the lateral biceps groove.

And you should not confuse these little divots as pathology.

These are not, these are not ligament avulsions for example.

These are nutrient for Raymond and they are normal.

And we will see if you turn on your color powered doppler

or even just your regular directional Doppler feature,

you will see that these are normal vascular insertions into

the cortex.

So moving forward,

let's talk about scanning.

The bicep biceps tended just a little bit more distal,

and here you can see we've isolated the pectoralis

or the pec major here.

And you can see the anatomy diagram from the clavicle

all the way across the sternum.

We, we see this huge broad muscle tapering down to one

smaller tendon origin, and that is,

or insertion, I should say, it's very broad.

If we cut that transversely,

we'll see this big broad tendon.

But as a landmark for this exam, this kind of tells us

where we can stop scanning for the biceps.

So as we leave the biceps groove,

we traverse down to the pectoralis.

And unless pathology

or clinical clinically indicated, there's really no need

to go further distal.

But what we're seeing here in an internal

and external rotation is that long head

of the biceps is right under my mouse.

The short head of the biceps is here under my mouse.

Then we have the corco brachialis right here

deep to both of those.

So cross-sectionally, we're seeing

that musculo tendonous portion of the biceps here tucked

underneath this wedge of the humerus and the pectoralis.

And it's at that point that we can stop exploring the biceps

for pathology unless clinically indicated to go further

distal, like a distal biceps tendon rupture

or a Popeye sign, for example,

turning the transducer 90 degrees

to longitudinal orientation.

We see these longitudinally oriented tendon fibers and,

and here we can beautifully see why these

tendons really respond to angle artifact

or an isotropic artifact.

They are longitudinally arranged linear, fairly parallel,

and that is all the makings of angle artifact

and what we look for in a healthy tendon.

But we can see the anterior humerus here.

If you're not seeing the biceps tendon,

we'll go over this in the live scan next,

but you'll wanna pan the transducer medially toward the oid

or laterally towards the greater tuberosity.

If you're going further medial,

you'll see this humerus disappear.

And if you're going further laterally,

you'll see the humerus elongate to more of

that surgical neck of the humerus.

But here's the long axis of the biceps,

the musculotendinous portion is here

and the pectoralis major is also about this level,

but we're gonna keep moving forward to the subscapularis.

So in the subscap exam, basically

what we're looking at is a,

another large muscular structure tapering down

to a smaller tendon at its insertion on the lesser

tuberosity of the humerus here.

So here on the gray scale,

we have a lesser tuberosity looking like a bird's beak.

This was taught to me that birds have long pointed beaks

and we get around to the superspinatus tendon on

the lateral shoulder.

Later in the month it has a parrot speak

or more of a hooked bill,

more prominent, greater tuberosity.

So this lesser tuberosity is relatively flat

and that's how you can kind of tell the difference

of which tuberosity you're on.

Here. Here we have an anterior and a middle deltoid

or lateral deltoid.

And then sometimes there's a deltoid septation here

that can cast a shadow into the tendon.

And you're gonna wanna, you're gonna wanna be mindful of

that artifact as well.

But this is a great exam to do dynamically

and we will in the live demonstration,

your patients will love it

because it really puts the shoulder into motion and it,

and it makes this all really fun

to do when you're seeing the tendon glide

with the muscles turning short axis.

Now 90 degrees, we're gonna rotate the transducer,

it looks like a long axis biceps,

but we still have the arm externally rotated here.

So that's really important.

A failed to mention that on the last slide.

But what really brings this tendon out to you is

that you get to keep the transducer

stationary from the biceps exam

and just externally rotate the shoulder

and you end up with a beautiful subscapularis tendon.

So here we're in short axis cutting these tendon fibers.

This this very wide breadth

of the subscapularis tendon has all these little inner

digitating tendon slips.

Don't confuse these for pathology.

These dark hypoechoic areas are normal.

They should be there. They are just the spaces

between the tendons, the ligamentous kind of bands

between the three, sometimes four broad tendon

bodies that, that all make up the subscapularis.

So as we pan laterally, this will taper to something thinner

as we go more medial towards the, we'll have

to aim laterally and we'll do

that also in the live demonstration.

But that should conclude the last slide.

And now we'll just transition over

to the live demonstration.

One moment.

Okay, so now we'll start scanning the anterior shoulder.

And first I'm just gonna adjust the machine.

I've already kind of got it where I like it for height,

there's a little foot pedal here at the bottom,

but it does go down lower if you wanna be seated.

A lot of people will be seated and an adjacent stool

and scanning this way.

But I find it to be a really cool exam to show the patient.

So I like to scan standing next to the patient back here

and I'll go ahead and just, this is kinda like adjusting

your mirrors in the car, find the right angle.

We get, we get that chance with this tiltable

hybrid form factor here with the socy px.

So instead of it being in a,

in a clamshell configuration like this, I kind

of like those touch keys

to all face me so that I'm comfortable.

But in this configuration also the patient gets

to see the monitor too.

So I like to scan this way because I'm lefthanded.

If you're right-handed, you would just put the machine on on

the other side and and turn,

or you would, you would also to face the the opposite way.

But for today I'm gonna scanning right here.

I like to rest my hand on the top of the shoulder

for support

and start start scanning.

Alright, so I've got the thumb orientation marker going

to face the patient's, right?

Okay, so what I'm gonna do is just turn

and have that facing knee in this case or or lateral.

And I've got the patient position with a palm up in the left

and a really cool scanning tip

or pearl here is that as, as long as that palm is faced up,

it's pointing the elbow anterior, right?

Those epicon doles are also facing anterior.

So the, the medial lateral epicon doles are kind

of representative of where the bicep groove is.

So the biceps groove will be right in line

with the anterior elbow.

Obviously we don't hold the transducer like this,

but this is just to give you an idea of where we are.

I imagine the humeral head is this ball

and I have to stay 90 degrees to the surface of the ball.

So if I scan inferiorly, I have to point up,

if I scan superiorly, I have to point down step two is just

to make sure I have a really nice sharp cortex.

So I'm kind of ignoring all the soft tissues for now.

But I'm really focusing on the cortex of the,

of the lesser tuberosity medially

and the greater tuberosity laterally.

If your cortex is fuzzy like this, not sharp

and defined, then all your other soft tissues on top will

also be fuzzy and not sharp or defined.

So we're not hitting those at 90 degrees,

but all these connective tissues

and tendons are wrapping around the surface of that ball

and we wanna stay 90 degrees

to the surface of the ball as well.

So with that said,

we're gonna demonstrate this an isotropic artifact

that we discussed in the slides.

So here we have the biceps groove at its deepest point,

lesser tuberosity, greater tuberosity.

Here's the biceps and a lot of your patients,

there's gonna be a lot of scar tissue in here

and this biceps can really blend with a lot

of surrounding connective tissue.

So sometimes you can use the anti atrophic

artifact to your advantage.

So I'm just gonna tilt the handle up and down

and demonstrate that only the biceps tendon is gonna turn

dark there.

So this one sliver here, that's biceps,

not necessarily this outer edge.

So this is very likely to be a part

of the biceps tendon sheet right there.

So there I am at 90 degrees here I am using the tropic

artifact to define where the biceps tendon begins.

And in so transversely, I'm gonna scan distally.

Now as we discussed in the slides down to the major,

I'm just gonna keep following

that tendon if I get the tendon lost

because I didn't, I didn't stay 90 degrees to the tendon.

That happens a lot. As soon as you fall off,

if you don't drop the handle of the transducer

and you just remain 90 degrees to the surface of the skin,

watch the biceps tendon disappear into the deltoid

almost there.

So if you're just learning this, all of a sudden our,

our really nice oval of the biceps just looks like another

fsac of the deltoid.

So it's here, but it's, it's really blended in

with the rest of these fibers.

That's why it's important to, to imagine

that we're scanning the surface of a ball

and that as we scan distally, we have

to aim the beam proximal.

There we go. So let's follow this biceps tendon distally,

distally distally to the pec major.

So here we have the pectoralis, we have the

biceps long head here, little septum here,

biceps short head.

And then we have deeper corco brachi

my arrow down here.

So short head, long head, corco, brachialis.

We're gonna follow this biceps tendon right

back up to its groove.

Here we go. And now

what we're gonna do is just take the transducer

and go long axis.

I'm gonna bring the proximal, the left side

of the screen proximal and I'm gonna rotate.

It's, there's nothing wrong with

grabbing the transducer with two pan.

I do that all the time. So I'm gonna keep this hand right

where it is and I'm just gonna use this other hand

to pivot this way.

Now, right away I see nothing but greater tuberosity, right?

Like all of this is just humerus down to the humeral neck.

And I know I'm on the greater tuberosity

side for a few reasons.

I see a little bit of the bird's beak that would represent

where the supraspinatus begins and or I should say ends.

But if you're too medial, we're gonna cross over the biceps

here and then we're gonna go medial.

If you're too far medial,

all we see is lesser tuberosity, this bony peak.

So in short and long axis it's a bony peak.

So I'm gonna see lesser tuberosity

and then the, the humerus takes a sharp dive off the screen.

So we really lose a lot of humerus when we're scanning

medial or if we're two medial.

For the sake of zoom here, I'm gonna

adjust a little bit of the gain, noticing

that we could afford a little bit of brightness

there for the broadcast.

Here we go. So now I'm gonna go back to the center

of the groove there.

Biceps tendon is in its long axis.

Again, if I stay 90 degrees to the surface of the skin,

you notice that the tendon dives away from the

probe and it's dark.

Here's the tendon. Now there's nothing wrong

with the tendon, it's not tendinosis or anything.

I just need to make sure I'm staying 90 degrees

to the tendon and not the skin.

I'm gonna drop this handle down just

like we did in short axis.

I'm gonna level the transducer out with the biceps tendon.

I might even come up in my depth a little bit

so we get a bigger, more clear image.

And lemme outline the biceps.

So this is the long head of the biceps.

We didn't cover it in the PowerPoint.

The short head is attaching to the oid.

So if I come over here and palpate the OID

and just bring my transducer over to the oid, here's our cor

and short head of the biceps attaching on the,

so we talk about long and a short head.

Here's your oid, here's your short head,

your corcal brachialis here, short head

of the biceps on top.

Let's go back over to the humerus. There we go.

I'm gonna follow this tendon distally.

So it's myo tendonous junction here

and you can see the fibers of the biceps

that it's muscle belly starting to fan out.

And even superficially we see the pick major starting

to jump over very, very thin right there from here to here,

even further down the peck major tendon.

So here's the end of the peck major tendon here.

Here's the beginning of the peck major tendon.

And then here's all the biceps brachii fanning out.

Let's go back up approximately we see some

what looked like fluid collections here.

And let's see if those are actually fluid collections

or if they are the vessels

that we talked about in the PowerPoint.

So I believe these are the ascending branches

of that lateral circumflex humeral artery.

Someone hit the color button

and just put the box right odor.

And we see pul arterial flow.

Don't even have to switch over to color powered ler.

And I bet if we follow the lateral side of the tendon,

we'll see this really cool elongated artery

coming all the way up into the proximal groove.

And we'll see that artery diving right into the humeral

head, just like we talked about in the PowerPoint.

And that is a nutrient for

where these vessels are coming out

and feeding these soft tissues into the, into the cortex.

So if I go short axis, just like we saw on the PowerPoint,

you're gonna see the lateral groove gonna show

that ascending branch of the lateral circum.

All again, if you don't see it on your machine,

consider just tilting down the groove.

So you're gonna make a real ugly tendon.

When you make an ugly tendon, you get a really nice vessel.

So here we have a nice artery

and a really ugly biceps tendon

and that's kind of the trick to scanning

the groove and its contents.

But everybody has these little nutrient foramen here.

Do not call those avulsions

of the corco humeral ligament.

These are nutrient for, and I've seen them call

UL quite often.

So these are pretty normal on everybody

and I would challenge you to go ahead

and test that out at home if you have a machine with you

and see if maybe you can pick up those small

vessels on your machine.

Alright, so with this position here,

we're just gonna transition to the subscapularis.

This transition's really nice

because all we have to do is just find our, our biceps

here in the middle of the groove.

And then this time what I'm gonna do is just have our

patient externally rotate her arm.

There we go. And there we see the subscapularis

delivers out to us.

We don't even have to move the transducer at all.

So we wanna scan superiorly and interiorly.

Remember we're scanning a ball.

So as I scan superiorly, I have to, I have to aim down

and as I scan inferiorly, I have to aim up

to get the tendon at 90 degree.

So I'm starting at the top of the ball here.

We can see biceps, right, right there where the arrow is.

And we can see subscapularis.

Here I go rotate the transducer mark elongated

to the subcap,

the subscap.

So I'm entering the rotator cuff interval just about.

Now what I'm gonna do is scan down, I'm gonna go down

and as I go down I'm gonna lose the subscap

because I did not aim back up.

So now I'm gonna aim up.

Here we go and I can see it really, really nice.

Now as you go superior superiorly, don't forget

to bring the medial side of the probe over here

to the OID process and check for that subor impingement.

So here we can do that dynamic maneuver.

Sometimes it helps to passively rotate so

that the patient doesn't contract any, any muscles

that may distract what we're trying to look at.

So it's better sometimes for you to grab the patient's arm

and just go ahead and warn them that hey, you know,

we're gonna put your arm into some stress.

I may ask you to push

and pull just to get these soft tissues moving in a way

that we can see everything that's going on there.

But what I'm looking for is this space right here

underneath the corticoid.

So we have OID shadow here, subscapularis, you see the

subacromial bursal layer up here.

As we get down here to the subor area,

we enter the subor bursa there

and what we're gonna do is look for impingement.

And as she internally rotates, I wanna see

and make sure that that biceps tendon

and its lesser tuberosity have plenty of room

to clear lesser tuberosity due to chloroquine.

And that I don't see any grinding or popping or clicking

or adhesions showing themselves there.

So we see a good smooth action there.

And just scanning, what I am noticing I'm having

to do is point the medial side

of the probe pretty far north, pretty farce in the the,

the lateral part of the probe pretty far inferiorly to get

that long axis sub to show itself during this maneuver.

After we've done that evaluation across the footprint,

I like to keep the footprint in the middle of the screen

and I'm gonna do the same two handed switch.

So I'm gonna rotate with the top part of the probe here

and there we have the lesser tuberosity

and the short axis here.

If I go further lateral,

I'm just gonna rotate the chair for the camera.

If I go further lateral,

you're gonna see the biceps tendon in its groove.

Just to give you an idea of where we are,

here's the biceps tendon long axis,

I'm gonna climb up the lesser tuberosities peak and up

and over staying 90 degrees to the surface of the cortex.

And there we can see those interdigitated fibers

of the subscapularis and these little dark

components in between.

These are not pathology,

these are the little tenderness slips that make up the,

the space, the connective tissue space,

almost like a ligament between each

major head of the subscap.

So we have 1, 2, 3, sometimes there's four

where we get into the rotator cuff anatomy like the cor

ligament, superior ligament,

we'll about later.

So Subscap, really cool scanning trip

is taught by my friend Bill, is to go from the

humeral head surface

and bring the transer all the way over here to the cor.

So lo locate the cor just like we are here.

Hopefully you can see that on the, on the camera.

Okay, give yourself a little bit of depth

and I'm just going to keep my probe at the OID level

and I'm gonna tilt the tail of the probe towards the chest

and that's gonna fire the beam laterally.

And it gives you this beautiful shot right there

of a transverse subscapularis tendon right there on the

humeral head every time.

So this is really nice.

It gives you the right angle you need

to evaluate this cartilage.

On the humeral head we can see that

articular lene cartilage cap just beautifully resting on

the, on the cortex of the humeral head.

So we will just keep tracing distally, distally distally

until we see these cortical margins come up

to the tendon at a tapering edge.

And then we start to see the biceps here

and we've evaluated the entire subscapularis tendon at this

point, if we do more of an external rotation,

we'll get more muscle in view.

So there's muscle where the arrow is

and then here's tendon.

So muscle tendon.

Alright, so that will conclude

what we covered on the PowerPoint, at least

for the live demonstration.

Now's the time to go ahead and log those questions in the q

and A portal and we'll get started on

answering those questions live as as they come in.

Otherwise I'm just gonna keep scanning some of these areas

and I'll keep narrating other things that are kind

of tips and tricks.

If we don't have any questions, I'll do that

for a few more minutes while we let the questions come in.

But if not, hey it's been a great

demonstration of the anterior shoulder.

Next we have the lateral shoulder in the series

and then the posterior shoulder

and then we'll cover the superior shoulder.

And there's lots of content for each of these windows

and that's why we're gonna take our time covering the

shoulder in all of those necessary position

because we can't just skip over these areas.

We have to do a total shoulder exam every time we're doing

rotator cuff ultrasound.

So we'll wait for those questions

to come into the q&a portal.

And Laura, I'm not sure if there are,

- Daniel, we did have a comment actually, can you speak

to the European method of shoulder scanning?

- Yeah, I've, I've heard that also.

And I don't know if the question was just referring to

how I'm standing like this

or if it was which way I had the screen left.

Is it the patient's right or or not?

So I've heard that both ways in rheumatology scanning,

I see people scan specifically left side

of the screen is always medial or proximal.

I see that as a European carryover to the US

and it's a image consistency for interpretation style.

So basically every image is identical instead of having

to train your brain to recognize right, left flipping,

you have the convenience of doing that.

But as far as it being a European way of scanning, I don't,

I don't know the exact reference to that.

Maybe it was just funny, but standing like this Yeah, and

and scanning while upright might've been the comment source.

- Yeah, he clarified

and said it's the pos it's the fact

that your position is behind the patient.

So that's what it was referencing, so,

- Okay, great.

- Makes sense. - I think I, I like this

because the patient gets to kind of be involved, you know,

now they get to see their arm moving

and you know, it really, it just adds

to everybody's confidence in the room

why they're getting an ultrasound.

So I highly recommend every time you can position yourself

in a way that the patient gets to see the screen.

- Right. That makes sense.

Of course another comment just says thank you.

Great, great job, thanks for doing this in segments.

I think the feedback has been really good about that,

that we split this up into four segments.

So that's really good.

If there are any other questions, feel free

to type them in the q and a.

We are, oh, we got another comment here

about the European method.

Yes. And if you transition to posterior injection,

everything is already in place.

Yeah,

- Good point.

- Yeah, that makes sense. Boom, boom.

If there are any other questions,

we have a few more minutes here.

Well, Daniel, I'm not seeing any other

questions for a moment.

When you were talking about the upcoming webinars,

I did show, share my screen and show the website.

So we do have a

behind the scan webinar page on sono site.com under the

education tab, so you can see other webinars coming up.

And we did just get another question about any plans

to make this available publicly.

And the answer is yes.

We will be posting the recording of this webinar on

that webinar page

and I can address you privately to show you that link.

But it is on the webinar tab

on the education side of our website.

So that's where you can find it.

But we will be making it public probably in

the next 24 hours.

Okay, great. Lots of good comments here, Daniel,

but no more questions.

So I think we are at time if you have anything else to add.

- No, thank you again for your time.

- Wait, we had two more questions pop

up right as we're doing that.

So what if a patient cannot sit for the exam,

- Laying them down on their back is very, very comfortable

to do the anterior shoulder.

It's just fine. You can also,

and we can talk about patient position considerations once

we get to the lateral and posterior shoulder,

especially if you're doing shoulder injections,

I actually recommend that you lay them down.

Nobody, nobody likes to see the, the,

the 300 pound guy vasovagal

with the tiny needle in their shoulder and hit the floor.

So it is, it is a much more comfortable exam on, you know,

posterior injections to go ahead and just lay them down and,

or, or in the decubitus position, definitely the way

to go for procedures from a diagnostic standpoint,

if they can't sit upright like this,

the anterior shoulder's fine, you know, whatever.

If they're in a wheelchair, that's fine.

If they're laying down, it's very comfortable even to get

to the anterior lateral shoulder.

It goes from this position

to just hanging their arm off the bed

and it puts them in that modified crass

that we'll talk about next webinar.

But, but laying them down on their back is very comfortable.

And not to mention it, it, it eliminates one person needing

to stay more steady than the other in this position.

If you have somebody that's not comfortable,

say they have back problems

or whatever, you have to worry about them being steady

and you have to worry about you being

steady at the same time.

And then another thing to be aware of

and be mindful to your patient is

how hard are you pressing down?

Because the patient is most likely not gonna speak up

and say, you're, you're making my back hurt

because you're pushing me so hard.

You're getting really into the exam

and at the same time you're really pushing

and putting a lot of weight on their back.

So keep that as as a consideration.

If you're new to this, most

of the time you are pressing too hard

and that'll cause two problems.

It'll hurt your patient's back, they're gonna be too polite

to tell you anything.

And second, it's gonna collapse any useful data

that you're looking for, like a synovitis around the,

the biceps or any effusion that's surrounding the biceps.

You're gonna obliterate those little

vessels that I was talking about.

If you're pressing too hard, the ability

to see these little arteries around the biceps in a,

in normal flow states is going to be reduced.

So don't press too hard

because you're gonna hurt your patient

and don't press too hard 'cause you're gonna obliterate

these, this useful soft tissue data.

- All right, on that note,

you were just showing some really good detail there.

Someone asked what machine you're using.

- So this is the sono site px, this was released last June

and I am scanning with the new L 15

to four megahertz transducer, which has now been,

the broadband has actually been extended

to four megahertz on the low end

of the frequency versus the previous models

that went to six megahertz.

So our penetration is greater with this transducer.

And then we also released the L 19.

This is a smaller footprint, linear,

I mean it's just a demonstration clinically there's not a

lot of need to go to 19 megahertz on a shoulder

for anterior structures,

but I've done it on our, on our model here

and wow, do you see a lot of really cool stuff?

So remember that artery

and that transverse humeral ligament that's jumping over.

Look at the level of detail. We out of 19 megahertz.

So I always say use the highest frequency you can

on the patients that are sitting in front of you.

So it's not that the larger footprint,

linear is the only probe that is suitable for a shoulder.

So if you can get away with a higher frequency

and the transducer that you have is able to penetrate

to the depth to give you more diagnostic detail,

then look at that transverse humeral

ligament I'm getting on the screen.

I I say, why not?

If you're suspecting some sort of pathology

of the transverse humeral ligament,

why not get the most clean

and detailed image of

that ligament structure you can

with the probe that you have available.

So don't if you're,

especially if you're an upper extremity specialist on the

webinar, don't discount these, these higher frequencies.

15 is great,

but the, the world has really come a long way

with these higher frequencies

and their ability to, to even penetrate

things like a shoulder.

I would say five, 10 years ago,

19 megahertz was only suitable for a hand or a toe

or, or very, very super superficial structures in the wrist.

But technology and broadband technology that,

that we're dealing with now,

I mean we really do have the ability

to go down a little bit deeper to more practical depths.

This transducer bottoms out at at five megahertz,

which is going to allow me to penetrate

deeper depths than most

of these ultra high frequencies will get. So

- Great.

That's fantastic. I I do have a two part question

that just came up about pace patient positioning.

What is the best position to view the following,

a slap defect and a glenoid defect.

- So we're not gonna see a lot of slap detail that's going

to be more relied for your RI.

So okay, ultrasound does have its limitations

and I'm gonna say don't hang your hat on ultrasound

for s slaps to get down to the glenoid,

especially in the anterior shoulder.

You're probably gonna wanna switch to a curve linear probe.

So why not, why not pull out the third transducer over here

and we'll go to the curve and we will scan inferiorly

and aim superiorly to see the anterior glenoid.

It is not a common thing to scan

for routine shoulder diagnostics.

Okay, so I just wanna preface with that,

but I switched over to a curve linear probe

of five to one megaherz.

We call it the C five, C five one.

Let's see, switch a few things up so we get a broader field

of view, but we get a lot more penetration

and you're gonna see that I have to really angle

up under the corticoid to get any, any reasonable detail,

but use the OID as your, as your guide.

And what I'm gonna do is just either go on top

of the corticoid and bring the gain up,

bring my depth up more shallow, see how that looks on zoom.

- That looks good. - Not bad.

So I'm gonna have our internally and externally rotate

and we're gonna look at any,

any anterior paralabral cysts

or anything like that might show up here.

But again, the, the deeper especially anterior glenoid

pathology is not, it's,

it's not super famous for ultrasound.

I will say that it's a weakness for sure posteriorly,

you're gonna see a lot more detail in the glenohumeral joint

and we'll get, we'll get to that in the,

in the posterior shoulder webinar in great detail.

Actually we'll go over the shoulder joint capsule and,

and what you can see around paralegal cyst structures

and how to avoid false positives on those

with the little vessels around that superscapular artery

that, that tends to dump posteriorly.

But you can tell, you can see, you know, it,

it's not worthless on the anterior shoulder.

So if, if you didn't have access to an MRI, for example,

for a really long time

and you just wanted to see dynamically what's causing a

clicking or a popping, you can, you can get to certain parts

of the anterior glenoid

and even on a, on a patient, the size

that we have here today, I can go back to the traditional

L 15 and I can get a more than stellar shot.

It's just not, it's just not a part of our normal protocol.

So I'm gonna go corticoid first, give it some depth

and then I'm just gonna fall off the top

of the corticoid aiming right back into the humerus

and see what kind of glenoid shot we can get.

Now the curve was way better.

Now I'm gonna go in inferior and aim up

and see what we can get.

And again, the curved is just so much better

and a lot of that's because the beam is diverging away from

the source causing a fan.

So we're getting some data at different angles,

but you can see that limitation.

So if you are gonna be looking at a lot of that pathology,

consider the curved linear as an option.

Nobody really thinks of the curve linear as a,

a shoulder transducer, but it, it does have its uses.

- Well, and you mentioned the posterior shoulder webinar

and I just wanted to let everyone know that

that will be taking place on May 18th at the same time.

So if you kind check it out then too.

Okay, it looks like that's all of our questions.

That was really good. We had a, a little interaction there.

I like that. Anything else you wanna add, Daniel?

- There's a lot to, to chew on on the anterior

and the lateral and the posterior and the superior

and that's why we're gonna do it in bite-sized chunks.

The shoulder is the only joint,

at least in the United States,

that you must do a full protocol on.

You can't just do a limited shoulder.

So all the other structures you can, you can tailor it

to the site of clinical interest,

but the shoulder very specifically is the only one.

It's required that you do not do a focused exam.

So that's why we really want to show a thorough exam and,

and give everybody just some sort of groundwork here.

So make sure you're here for the lateral shoulder.

There's a lot more going on in the lateral shoulder

as you can imagine from supraspinatus

and rotator cuff interval.

And the ligaments that that are, that are around that

and the subacromial bursa and impingement

and a little bit of in infraspinatus,

that ties into the lateral shoulder as well.

So don't miss that.

These, these will get better also with your feedback too.

So great questions.

I think you'll get a survey

after this, make sure you fill that out.

It helps us make these better.

And thank you for your time

today and I hope you have a great week.

- Thank you Daniel. And just for a moment,

I'm gonna share my screen

and show the link to the upcoming webinars

'cause a couple people have asked about that.

So let me do that really quickly one more time.

So this shows the link right here at the bottom,

secure do sono.com/behind the scan.

And also if you go to sonosite.com

and click on the education tab,

you can find it there as well.

Thank you so much for joining us everyone.

We will end the call today

and we look forward to seeing you at future webinars.

Join us for an expert-led review of clinical images and live Q&A session to discover how the expanded use of point-of-care ultrasound supports diagnostic anterior shoulder exams. Learn more about this trending topic, including best practices for positioning patients, identifying possible pathologies and assessing for abnormalities.

What You'll Learn

  • Review basic principles of MSK ultrasound such as anisotropy
  • Identify the anatomy within the anterior shoulder including the biceps tendon and groove, subscapularis tendon, and lesser tuberosity
  • Learn indications for an evaluation of the anterior shoulder
Daniel Shelton
Presenter: Daniel Shelton, RT(R)
Job title: Director, Musculoskeletal Market Development, FUJIFILM Sonosite

Daniel Shelton, RT(R) is the Director of Musculoskeletal Market Development for FUJIFILM Sonosite. Daniel spent 18 years as a dedicated musculoskeletal sonographer and 12 of those years have been here at Sonosite. He now leads musculoskeletal market development, where he works to spread the word about the benefits of point-of-care ultrasound.

Related

This educational webinar is intended for healthcare professionals and not for patients or consumers. The material is provided for general educational purposes, as a reference and a supplement to professional experience, education and training, and should not be considered the exclusive source for this type of information. This educational webinar is not intended to recommend any device for a particular indication or to provide indications for use for any device. At all times, it is the professional responsibility of the practitioner to exercise independent clinical judgment in each particular situation. Fujifilm assumes no responsibility or liability for any misuse of the information imparted in this webinar. This educational webinar does not supplement, replace, or supersede device labeling, including instructions for use, which accompanies any FUJIFILM Sonosite product.