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Transcript

- Hi there everybody.

Welcome to the rerun of Sono Sites

behind the scan webinar titled Diagnostic Shoulder Exams

Superior Shoulder.

My name is Chris Pennell

and I'll be moderating today's webinar.

This is the final part of a four-part series about shoulder

ultrasound and if you'd like

to check out the previous webinars in this series you,

you can visit our webinars page on sonosite.com.

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

We'll conduct a q and a session at the end

of the presentation and demonstration

and you can type those questions into the q

and a box in the toolbar located at the bottom

or the side of your screen.

And that's only for the participants on the Zoom webinar.

If you're on the YouTube webinar, you'll have

to get the link to the Zoom webinar in order

to get those questions asked.

This webinar will be recorded

and archived for future reference on our webinars page.

Here with us today is 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 SonoSite.

He now leads musculoskeletal market development

where he works to spread the word about the benefits

of point of care ultrasound.

We'll go ahead and get the recording started now.

Thank you so much for joining us.

- This is the last part of a four part series on

the superior shoulder.

There's not a lot going on on the superior shoulder,

so we'll throw in like an extra slide

or two about a couple of bonus structures in the area

that I found

to be really fun while I was scanning in the

superior shoulder region.

Anyways, but first we will stick

with the acromioclavicular joint

as a primary protocol structure of the shoulder.

It should be looked at anytime you're

evaluating shoulder pain.

So just to give you an idea of the journey we've been

through here, we started on the anterior shoulder,

worked our way down through the lateral structure such

as the main rotator cuff of the supraspinatus

and infraspinatus and subscapularis

and their various insertional variance

and what we look for.

And then we went to the posterior shoulder

for the infraspinatus and Terry's minor

and also looked at the lab and spinal glenoid notch.

Today we'll be looking at the top side of the shoulder,

the acromial clavicular joint,

and then while we're in that area we're just going

to translate the transducer a little bit anterior

and we're gonna aim the beam somewhat towards the corco

and we're going to be scanning the suprascapular notch.

So just knowing that that could contribute

to other pain generators in the area.

So we'll keep it short and sweet today

and rely heavily on q and a.

And and,

and just remember this is the last of a four part series.

If you missed any of the previous webinars,

they are posted@unasite.com

and you can check out those webinars in a recorded fashion.

Looking at the anatomy here,

we're we're scanning primarily over our

landmark of the acromion.

I think that's the easiest

to palpate if you're looking at a obese shoulder.

So I tell people to poke a finger down on the backside of

that transducer and feel for the acromion process

and then start from there.

Even if you have to go as lateral as the subacromial bursa

and then work your way up towards the anterior

lateral shoulder while the probe is standing

up about 12 o'clock.

And you should see a break in that acromion

and at that point you need to translate

and twist your transducer until you see the clavicle.

Something to keep in mind when you're doing

AC joint evaluations is that this space should have a normal

meniscal homolog inside, which is a fibro cartilage disc

that stays there when we're young

and it disappears when we're old.

So it can contribute to what looks like a loose body

or something clicking or popping

inside the joint when we do a dynamic exam.

And to stress this joint,

there's a few many areas we can do,

but the most common is here

where we have the patient touch their ipsilateral shoulder

or consala contralateral shoulder, sorry.

And we get those two bones to kind of clap together

and this way we wanna look for the joint symmetry.

Does the joint stay level, what's the integrity

of this ligament here?

The joint trying to sublux, is that little disc popping out?

Do we have osteophytes inside or osteolysis of the bone?

Do we just synovitis

or inflammation in the area that could be treated?

There's, there's a lot that could be discerned shoulder pain

at the AC joint level, it's very tender

and you want

to use some patient at this point if you suspect something

in the ligament or,

or something deeper on on the insertions of the ligament in

that fibro cartilage disc, you may wanna switch frequencies

to the linear 19 megahertz probe that will be scanning

with a little bit later if we have time.

You can also stress the elbow by pulling down on the elbow

and do kind of a weight bearing exam on the AC joint

and that can be helpful for AC separation.

Just checking out the stability of that ligament again

and seeing if the, if the joint opens up or gaps.

I'm gonna move on to the super scapular notch.

So this was a really fun structure to learn

and once I, once I had it taught to me it was kind of one

of those things that you, you can't

unsee while you're in the area.

You might as well just plop the probe a few more, like two

or three centimeters midline and aim the beam anteriorly

and just see what you can see

and look at the supraspinatus muscle,

which we discussed in the lateral shoulder webinar

and the posterior shoulder webinar for atrophy.

But if you have not explored the anatomy

of the supraspinatus fossa down at the bony surface,

this is a great time to kind of learn that landmark.

Instead of making this webinar three minutes long

and talking about the AC joint real fast,

I figured we would just explore one other thing.

So if it's not, if this is not an interest to you or

or whatever, that's okay, but there's, there is a lot

of people out there that they've explored the shoulder in in

pretty good detail, but maybe they're just one

or two things here and there that they would like

to learn just a little bit extra.

And I think this is one of those structures that does that.

So this is a really superior view.

Think of that, that netter's view of the rotator cuff.

We're looking down on the body,

we're looking down on the shoulder.

So here's the AC supraspinatus going underneath it

and the supraspinatus fossa, we can see the beam is,

is planted midline to the superspinatus,

which is like midal to the body plane.

Patient positioning doesn't really matter.

The patient can be nice and neutral for this exam.

And my tip,

and we will show this tip while we scan, is

to the posterior edge of the probe on the anterior edge

of the super or the spinous, sorry, I'm gonna again

of the scapular spine.

Anyways, I'll go over the live scanning

tips and how to find this.

Just know that we're looking for this structure at the,

at the supraspinatus faucet here, this little notch

and ligament and there's gonna be a

nerve that passes through there.

That's a suprascapular nerve.

You do want to throw on your colored doppler,

whether it's power doppler

or the directional flow, it doesn't matter.

But we want to locate this little artery,

the suprascapular artery

and find out if that artery goes above the ligament

or below the ligament because there are some anatomical

variations for that.

And you can do therapeutic injections

or you can do diagnostic injections at this level.

So this can be a part

of your shoulder diagnosis while not in a rotator cuff

protocol manner in a an ultrasound guided needle

injection around this nerve to see if

that patient's pain generator go away just at isolating

that superscapular nerve.

So this can be a great tool to kind

of pull outta your toolbox if you've run of other options.

So what we're gonna do now is just go over

to the live demonstration and then

after the live demo I just wanna let you know

that there's plenty of time for q and a

and if you guys wanna go ahead

and have any questions ready in the chat portal,

now's the time to start typing those.

But I'm gonna make this transition to the live scan

and just give me one second.

Okay, so now we'll begin

with the live shoulder demonstration.

Today we're gonna be looking at the superior shoulder,

just like we had in the PowerPoint will be the AC joint.

And then we will take a dive into the superscapular notch

and some of the other structures in that area.

We'll be scanning on the sono site PX ultrasound system

beginning with the L 15 to four 50 millimeter head

and then we'll move over to the L 19, which is a 19

to five very high frequency transducer.

So first we'll get started at the AC joint

and I'll talk a little bit about palpation first.

On most patients you can,

you can either start at the scapular spine

and work your way forward

until you can't feel anything else, so,

so right here I'm just kind of walking my fingers

until I reach a bone, a bony stopping point.

At that point the, the acromion is taking a slight turn

and the clavicle is meeting it at

that turn creating the the AC joint.

So we should be able to set the probe right down in front of

where I feel the spine of the scapula stop to do

that while I scan, I'm gonna keep the left side

of the screen to my patient's right.

I'm gonna hang a finger down on the backside

of the transducer and

and use it as a palpation point right there in

that little corner that I'm palpating right here.

So I'm gonna set that down and just place the transducer

right in front of that palpation point.

We'll get that really nice AC joint superficially.

So that's just a good starting point

by placing your finger back there.

You can leave your finger back there, that's fine, but,

but what we're gonna be looking at right now is a few

dynamic maneuvers to test this AC joint

and keeping your finger plopped down in

that area may also help keep you stable.

So screen right,

pull my arrow up here, there we go.

Screen right, I've got the clavicle side

and I can see the trapezium starting to come over

and invade the picture there.

And then screen left.

We have this, this bright cortical landmark which is the

acromion process

and then we can see the deltoid tendon attaching on

the acromion here.

So just under the deltoid here we could see the subacromial

space which was described in the lateral shoulder webinar.

So we won't go into too much detail here,

but if you wanted to confirm your placement there,

we could just have our patient do a slow kind

of chicken wing maneuver

and then watch that subacromial space glide really nicely.

Here's also a good time to see if that's contributing

to any clicking or popping around the AC joint.

That way that way you can kind of modify

or tailor your exam to also include that subacromial space.

So go ahead and relax. There we go.

Now let's go right back following

that acromion towards the clavicle here we can see

that very, very superficial structure, the AC ligament

and we're, we're gonna test the integrity of that ligament.

And there's also a little meniscal homolog here

right in the joint that will degenerate as we get older.

And right now I'm seeing a nice healthy joint space.

So what we're gonna do is see if that men medicinal homolog

inside the joint wants to protrude out

with any dynamic motion.

So what I'm gonna do now is have our patient just reach over

and touch her opposite shoulder

and let's watch those two bones.

Now notice they stayed nice

and level that's, that's normal, that's great.

What I don't wanna see is either of these bones kind

of sublux over the other.

I see the AC ligament is perched up high,

which is also normal and it's the ligament

and that meniscal homo logger bunched together.

So go ahead and relax. There we go.

And then the, the second maneuver I'm gonna do is try

to separate her AC joint

by pressing down on the forearm here

so she can just keep her arm in her lap.

And I'm just gonna use pressure

after the elbow bend and I'm just gonna press down.

There we go. And what

that does is help me pull on the actual elbow joint.

There we go. And I didn't see any separation.

So those are kind of the two main DI diagnostic maneuvers

you can do to test the integrity of the AC joint.

Let's take a closer look at this ligament here,

the AC ligament by switching over

to the 19 megahertz linear, which is a smaller footprint,

it's gonna be a little bit more zoomed in.

So this transducer, it begins zoomed out for perspective,

that way we don't get a little overwhelmed with

what we're seeing in the shot overly zoomed in.

There we go. And then we will slowly creep our depth up so

that we can appreciate all these little fibers.

But if we do suspect calcium deposits or little avulsions

or any other osteolysis,

this is the transducer that you want to use.

So I'm gonna bring my depth up

and my gain up just a little bit.

Got our arrow back up. We can see

that AC ligament really nicely.

We can see its insertion and origin also very nicely.

I don't see any calcium deposits or any avulsions.

That's something that I'm looking for.

You can redo those dynamic maneuvers at that point.

Also turning on your color tower doppler at the enthesis

or the origin of this ligament is very helpful if you

suspect some sort of avulsion

or other traumatic pathology in this area

at 19 megahertz, we can see the integrity

or the internal contents of

that meniscal home log very nicely

and just get a very, very close look at it.

Also for a procedure I would recommend this smaller

footprint transducer to kind of narrow your, your margin

of error when,

when doing an injection you can typically

do these out of plane.

We have a nice arrow right there on the center

of the screen, center of the transducer.

And I'm just gonna activate just a,

a center line here we go right there, center of the screen.

And that's gonna correspond with the

arrow underneath the transducer.

So it's, it's typically out a plane because it's so shallow.

Or what I also see a lot

of people do is build up a sterile gel on the lateral

side of the transducer here.

So you build up sterile gel,

you have your transducer covered

and then people will tilt the probe up

and just drive their needle here

through the sterile gel

and puncturing that ligament down into the joint if they

want to see the needle in its shaft

and bevel in its entirety.

That way once you pierce that ligament, you can spin

and go bevel down and

and watch the inject tape pour into the joint.

But I would say 90%

of the time most people just drop the needle out a plane.

But for those that really wanna see the,

the needle go in long access to their target,

this is the typical approach right here.

You can see my finger, it'll start coming in under the right

side of the screen, kind of representing the needle's path.

So from an AC joint standpoint, that

is the extent of the exam really there's not much

to see in cross-section of this joint

and so it, it's not typically done.

I'm gonna go back to my L 15

transducer which has a larger field of view

and we're gonna look at the suprascapular notch.

So I'm going to follow the scapular spine,

which was a great palpation point earlier.

I'm gonna set the transducer right on the scapular spine

so you can see that superficially right here,

nice scapular spine.

And I'm gonna aim the beam towards her corticoid.

I'm gonna keep the probe on the scapular spine

and I'm just gonna walk it towards the corco.

All right, so here you notice I don't have enough depth.

All I see is muscle.

This is trapezius, this is supraspinatus muscle.

I'm gonna turn the gain up just a little bit

and I wanna prove that superspinatus

by having our patient just do a little chicken wing maneuver

and we'll fire that supraspinatus in abduction

and then back down to the ribs.

Good, just hold that. So I need

to see the supraspinatus fossa.

I'm, I'm gonna fire the transducer down a little bit deeper.

Still aiming the probe slightly towards the OID process.

There we go. And I can see the bottom of

that superspinatus fossil.

If you're having a hard time seeing the bottom

of your patient supraspinatus fossa with, with good clarity,

I advise you to drop your frequency

for a linear array transducer going through a lot

of trapezius and then through the rest of

that depth on the neck,

sometimes you have to lower your frequency.

So on sono site PX and

or the MSK exam type, I'm gonna select gin mode

and you're gonna see the bottom

of the screen brighten up pretty good.

There we go. And I think that clarifies

that superscapular notch a little bit better.

So here's our notch

and then what I'm gonna do is just,

I'm gonna aim the probe anteriorly

and then I'm gonna sweep it posteriorly.

So anteriorly we see it fall off

'cause I, I'm just about at the corco process itself.

And then, and then I'm gonna go posteriorly until I see

that notch form in the fossa here.

That's where we should see a little sable artery

and we can check our, our work with the artery that

follows the suprascapular nerve

by throwing on our color powered.

But I'm gonna hit the C button on the PX here

and I'm gonna drop our color ROI right there.

And I have the directional color on by default.

I'm gonna switch that to color powered Doppler

with just a button press there

and it should be very dialed in

for musculoskeletal blood flow.

You shouldn't have to do a lot,

but what I like to do to make sure I'm getting the most

sensitive setting for my color power doppler is I bring my

gain up until I see noise underneath the bone.

So this is all just noise that we're seeing under the bone.

Get my arrow to move around.

All this little twinkling

that you see under the bone is not real flow.

I'm going, I'm, I'm gonna suspect

that this puls ital steady structure is above the bone

and just to check that I'm gonna reduce the gain

underneath the bone until that twinkling color goes.

And there we can see that suprascapular artery right there

in the notch really nicely

and we know that that suprascapular nerve is gonna border

that artery so that we could use that artery as a guide.

If you're gonna drop your needle down to this level,

you know what to hit and what not to hit.

If you're doing a deep procedure, this is also a good time

to activate the color compare feature on the sono site px.

I'm gonna select top bottom

so I activate the entire transducer,

but here you could drive your needle in real time

and see where the color was on the screen indicating

where the artery is versus

where your needle might be in gray scale so that

that ROI box and any flash artifact

that's showing up is not showing up in your

image on the bottom.

So the bottom is a live indicator

of what's happening on top.

And if you're doing a, a very detailed procedure

that requires some sort of arterial landmark,

I really do recommend using the the color compare tool

to drive your needle and also observe where not

to put your needle like in the superscapular an artery here,

that's the most common view.

But what I'm gonna do is just rotate the transducer left

side of the screen will be anterior.

We're gonna get a short axis shot.

I'm focusing on the bottom of the screen so I don't get all

that arterial flash

and I know that the, the screen left is anterior so I expect

that artery to show up right there

on that neck of the corticoid.

It's gonna start dropping itself right across that slope.

There it is of the the supraspinatus fo.

So here's that same suprascapular artery.

The angle we were taking earlier is leaning the transducer

from the spine of the scapula anteriorly into the wall

of the supraspinatus fossa, right as that super

suprascapular notch forms right here.

So we were taking a very hard oblique angle there

and it's kind of nice to see this top bottom where,

where the artery's not in my way.

If I were doing a procedure I would know what to miss

and also get a good clear shot of the needle.

I'm gonna turn off the color compare

so we can get a full screen.

There we go. And a nice look at that artery as well

as the nerve which is just resting on the bottom

of the screen here, there laying underneath the,

the muscle belly of the supraspinatus.

So this whole round structure here is

supraspinatus muscle belly.

This is a fascial plane that goes between the trapezium,

which is transverse here.

So this is all trapezium and or trapezius I should say.

And then here's trapeziums on the wrist,

trapezius muscle superficially

and then supraspinatus deep there

diagnostically if you're doing an exam on the supraspinatus

as we covered in the lateral shoulder

and posterior shoulder, I think we briefly touched on it,

this muscle should be nice

and dark all throughout all the

way up to that fascial plane.

You shouldn't see a dirty shadow

or rim around the muscle belly.

It should be nice and dark right up to the fashion.

So that kind of, that, that really concludes the majority.

What we do when we're looking at a superior shoulder exam

plus a little extra going into

that into the suprascapular areas kind of bonus.

It's one of those things that once you see it,

you can't unsee it kind of anatomy

and you, you do go kind of check

that area out every once in a while just to see if,

hey maybe there's, maybe there's something invading the

area, that suprascapular nerve

that you could go check out like a cyst, maybe a superior,

superior labral cyst

or something that might be spilling over

because here's that superior labrum right there.

You won't see that on everybody

but here's the shadow of the acromion.

Here's superior lab, kind of where the origin of the

proximal biceps is

and then here's the superior glenoid tubercle

and then here's that neck of the glenoid

and here's your superscapular notch.

I thank you for joining us.

That concludes the content of the webinar.

We'll move on to the q and a session.

If there's any questions,

we'll go ahead and answer those now.

- Alright, as Daniel said that is it for the recording

so we can move on to the q and a.

Now, just a reminder, you can put your questions into the q

and a box at the bottom or the side of your screen.

And in order to do that you'll have

to be on the the zoom screen here.

So Daniel, it looks like we do have a question already.

At what age do you lose the homolog?

- So that was a 2020 study I found in the Journal of

Orthopedic Research.

I think it was, I'll have Chris post it in the chat

to anybody that wants a copy of that.

But that would be about the age of 40 or 50.

There we go. I'm just gonna queue

that one shot up real quick

and drop the

question mark here while we get more questions dialed up.

Were you able to hear my audio okay Chris?

- Yeah we can. We can hear you just fine.

- Okay good. I'm just gonna ditch the wide shot there.

A little technical problem

but we can still see everything really, really nice.

Yeah, just as as a whole, you know

as we wrap up the the rotator cuff protocol,

I think it's good just to kind of go over those highlights

of the shoulder while we wait on any

of these other questions to come in.

So might as well just back

that camera up just a touch

and we'll just take a sweep

around the rotator cuff fairly quickly starting at the

biceps and if anybody has any questions feel

free to let 'em come on in.

Remember we had our palm up in the lap

and we take a look at that biceps tendon in its groove.

We've got lateral side

screen left kinda like you're looking at an MRI.

So we're looking at a right shoulder

and I've got the orientation marker facing lateral.

So that's a short axis biceps we have on the screen.

You take that on down to the pectoralis if you haven't found

any pathology, come back on up

into the inner part of the groove.

Keep following that short all the way into the

rotator cuff interval.

Everything still looks pretty normal from here.

We come back down into the groove,

keep your hand on the skin, rotate your transducer

with the other hand if you need to

and go long axis on that biceps tendon.

So if we go medial, we see lesser tuberosity as a bony peak.

If we go lateral, we see the rolling hill of

that greater tuberosity.

So that looked pretty good.

We go back to our short axis biceps groove

and we externally rotate the shoulder,

brings our subscapularis and long axis we wanna go down

and evaluate the inferior fibers and aim up

'cause we're scanning a ball.

Come on up to the top part of the subscap and aim down

and we're looking for volume loss, tendon retraction,

calcium deposits, tendinosis, compressible bursitis.

Get the corticoid in the shot by bringing the medial side

of the transducer a little bit more superior

and get that internal and external rotation of the shoulder.

- Looks like we have a little question here,

does she have a tear or was the dark area artifacts?

- It's an artifact in this shoulder.

The other shoulder's a different story

where she has injury from last year,

but now this artifact is called anti atropy.

It's an angle artifact

and anytime these fibers take a dive away from the

transducer, like that bird beak portion of the subscap,

let's have her externally rotate a little bit further

and we get the enthesis of that

to dive almost straight down into the bone.

It turns dark. And the way we can combat

that is you just chase your transducer out laterally

and go parallel with those fibers.

And also you have to confirm any pathology and short axis.

So here we are short axis over that lesser tuberosity

and we can see those musculo tendus slips between the heads

of the subscapularis really nicely.

And we want to go as far medial

as the scan will allow us,

which typically are gonna hit the corticoid.

So here's corticoid and one great shortcut is

to just go find the OID and aim your beam laterally

and you catch a really nice short axis subscap

and then you can chase the fibers from there

out to their antithesis.

So that's our short axis study of the subscap

and have our patient relax

and then go into our

abduction view here.

So we've got the acromion process up on the upper corner

here, screen right,

and then you've got greater tuberosity screen left here.

That shadow of the supraspinatus right there is our an

atrophy, so don't call that a a tear.

And then we have our subacromial space.

So before we put our patient into

that modified crass position

that we went over on part two on the lateral shoulder,

we might as well scan

and evaluate what we can see without stressing the tendon.

We got good volume through the supraspinatus and long axis.

And then I take the proximal corner of

that transducer up here by the acromion

and just put all your weight

of your transducer right there on top

of the acromion like we talked about.

And then we're gonna lay the rest

of the transducer right over the cuff structure

and have our patient chicken wing out

or abduct a little bit slowly.

Sometimes passively too is, is better,

but the reason we put our weight right on that acromion is

so the deloid doesn't bump your transducer.

It's really, really nice and smooth

and you don't compress any bursitis.

So after going through that

and evaluating for volume loss, it's pretty safe

to go modified crass

where the the hand is in the back pocket.

So a gutter hand in the back pocket elbow is slightly

towards the spine.

I like to start in a short axis

because that helps me evaluate the

volume of the tendon first.

So I, I tend to go short axis, find your biceps,

which is your, your lighthouse of your rotator cuff.

So we've got our biceps here, it's within the interval.

Here's the anterior margin of our supraspinatus.

We have corco humeral ligament fibers

and enveloping the anterior part of the cuff posteriorly.

Back here we've got infraspinatus supraspinatus here.

This anterior two thirds of supraspinatus,

this posterior two thirds is infraspinatus.

And then this middle third as we go distally

and see the superior facet meet the middle facet, that's

where you share a conjoin portion of the tendon

of the infraspinatus and the supraspinatus.

So infraspinatus fibers more

or less kind of overlap your supraspinatus fibers

and your supraspinatus fibers tuck under

your infraspinatus fibers.

And the anterior most shadow

that you're seeing right here is a corco humeral

ligament right there where my arrow is.

So after you assess for volume loss,

you can even wag the elbow a little

and look for bursal adhesions.

I don't see anything clicking, popping, snapping, dragging,

which is really nice.

Then I'm gonna take this slice here in long axis

and just rotate my transducer screen.

Left is lateral.

I've got our coronal mr equivalent here

and here's our supraspinatus and long axis.

Take that proximally as high as you can

and on some patients you can catch the labrum

and drop our frequency to gin mode and catch that anterior

or superior portion of the labrum right up top,

not a part of the protocol, just a bonus if you can see it.

And then we look for proximal

or most superior part of that glenoid tubercle

for any biceps pathology that we can see there.

And then proximal supraspinatus

should be passing right through here.

There we go. So that's the supraspinatus just

before it starts to tuck under the acromion

where we lose it, that's why we put our patient in

that modified crass position.

So long axis supraspinatus muscle here

and then I'm gonna come on out to the enthesis

little scanning tip is the anterior part

of the greater tuberosity has this inflection point

that's curved and that's just before you hit the interval.

So we have a curved greater tuberosity here

and if I go any more anterior,

I should hit the biceps tendon in the joint right there.

And just a few millimeters laterally,

I hit the anterior fibers of the supraspinatus right there.

So relatively speaking,

my transducers are very much laying right up against

that groove where your chest meets the shoulder.

Alright, and then watch this greater tuberosity flatten out.

As that flattens out, we hit the in infraspinatus here.

So if you see a flat greater tuberosity,

you've got yourself in infraspinatus.

If you see a curved greater tuberosity,

you're on the anterior most portion of it

where all the tears occur

and that is supraspinatus right there.

Very nice. Okay, let your patient relax,

maybe wiggle their arm around if they have to, if it's sore,

we're gonna turn and review that lateral

and posterior part of the shoulder infraspinatus.

So here we go. Maybe rotate a little bit more

and back the view out just a touch.

There we go. All right,

so she's fairly internally rotated

and I know the in infraspinatus goes all the way up here

where greater tuberosity meets superspinatus.

So here's Superspinatus

and then that posterior third

that I talked about was infraspinatus, right?

So that's our enthesis right there.

I can elongate it and I'm gonna chase that long axis tendon,

posteriorly, posteriorly, posteriorly.

And then a scanning pearl here is

that I'm gonna lean the top half

of my transducer up against the posterior point

of the acromion, that posterior edge

and just bump it right up against there.

And then you should just be able to lean the transducer into

the joint and catch a really,

really nice glenohumeral joint.

If you see a flat scapula here

and you wanna see the spinal glenoid notch,

you just wanna bring the medial side of the probe north

and you'll see that spinal glenoid notch deepen there.

And in the posterior shoulder webinar we talked about

dilating that vein and not calling that a cyst.

So we're gonna externally rotate the shoulder

and you see this big vein dilate right up in that notch.

You just don't wanna call that a spinal glenoid notch cyst

because a lot of those paral cysts will track down the

spinal glenoid notch causing entrapment on that

suprascapular nerve posteriorly.

So we're gonna have her patient relax, we can see

that infraspinatus really nicely

and we're gonna look at this joint capsule right here

as she externally rotates, as she externally rotates,

we see the joint capsule fold back over the labrum

and we're looking for any fluid debris,

calcium deposits that might be floating around in there.

And any of that is gonna

set right there in that little hump.

We're gonna internally rotate a little bit

and then externally rotate and get that dynamic evaluation.

Short axis is also very important.

So we're gonna internally rotate one more time.

Left side of the screen will go superior

until I see the scapular spine.

So now we have a short axis infraspinatus

and then further inferior we see a short axis,

Terry's minor, so

- We're gonna add a little bit of gel starting to run thin.

There we go. Okay,

so Terry's

- Minor should be about a third.

The size of the in infraspinatus,

we have the in infraspinatus in the spine

of the scapula here sitting in the infraspinatus fossa off

the base of

that scapula down here we see the triceps coming in.

That's a good landmark if you're taking measurements

of the Terry's minor muscle belly versus the infraspinatus.

But this is where we see the inferior margin of

that Terry's minor muscle belly.

We could follow that muscle belly out

until we hit the humerus, which looks like a hip

joint at this point.

And that's a great place to go. Long axis on Terry's minor.

So I'm gonna take the slice this way,

I'm gonna aim from inferior to superior

and we want to pinch this central tendon

between the humeral head and the skin.

So we have a good skeletal reference point.

So now I'm just gonna rotate the transducer,

keep the left side medial and aim superiorly

because of the angle that Terry's minor's diving,

I hope I'm just, I don't scan like this, like a stethoscope,

I don't want the camera to be able to see that acute angle

that we're having to take

to go long access to the Terry minor.

It's pretty sharp so you're scanning a ball

and we're on the undersurface of the ball aiming up

so we can keep that ske reference point

and we could externally rotate slowly

and see the Terry minor

- Tendon footprint come in and then internally rotate.

Good. All right, so that covers the basics of the

- Rotator cuff structures

and then recapping the AC joint right up top.

Supraspinatus fossa contents

or bonus, not a part of a protocol

but you might as well check up there

and see what you can see when it comes to cysts

and, and other,

- Other pain generators like things around the nerve.

Is the supraspinatus muscle belly nice

and healthy? Is it dark all the way

- Out to the rim?

Pretty important to have a nice healthy,

dark hypoechoic muscle.

Meet the hypoechoic fascia.

If I go short axis on this, you'll catch that kind of

supraspinatus fossa view.

When we look for a donut sign on things like MRI,

you would see a grainy rim around the muscle

and that would be fatty atrophy of the supraspinatus muscle.

But we don't see that here. We see nice dark fibers

that are consistent all the way

throughout that muscle belly.

And that's pretty much a review of the shoulder.

And in the future we do plan on having a diagnostic hand

and diagnostic foot

and then we will start our procedural webinars throughout

the remainder of 2024. Any questions?

- Yeah, it looks like we do have another question here.

Would you please show GH injection location?

- Okay, so I don't wanna give too much away

because we won't have much to talk about in

that webinar I just talked about.

But in general, the traditional approach,

and we covered this a little bit in the,

in the posterior shoulder webinar,

but in in general the traditional way to do this

by ultrasound is to take this view

of the glenohumeral joint.

Alright? And then I want you to bring half

of the humeral head to the side of the screen

so you're not throwing too much needle

and hitting the humeral head,

but your entry point at this

point, not where you would stand.

You don't stand where I'm standing

and you don't hold the probe like I'm holding,

but I just want you to see about

where we are on the on the shoulder is that you would enter,

there's a factory seam under the trans on the

side of the transducer.

You're gonna go out about a centimeter

and a half away from the probe

and you're gonna lay your needle down relatively flat

to the probe and then you're gonna align the syringe portion

of your, of your injection, align the syringe back

with the factory seam and that's gonna keep you in plain.

I also suggest that you put the patient in a lateral

decubitus position and have them face you

with the affected arm up

and their front would face your front

and then you get to hold the

transducer like a knee injection.

It's very efficient, very comfortable for you.

And if you have any vasovagal guys, big tough guys that seem

to pass out during injections,

they're already laying down very comfortable for everybody.

But you would just take your needle this way.

I'm gonna freeze the image and just show that trajectory.

And ideally what you end up with

is a needle landing right under the corner of

where the capsule meets the labrum

and your trajectory would be something about like this.

And don't forget your steep needle profiling software

to really highlight the needle

as you come in any steeper than about 10

or 12 degrees, your needle will start to disappear

until you activate that software.

I'm gonna hit 2D. There we go.

Hope that answered the gist of the question,

but stay tuned later in the spring

or early summer when we have the

shoulder injections webinar.

- Yeah, as Daniel said, you know, keep an eye out

for when we announce those hand webinars there.

Any other things that you wanna go over, Daniel?

- I think that was a good summarizing exam.

You know, we, we, we hit the superior shoulder

on the topics covered in the,

in the lecture we covered some scanning pearls about where

to put your hand and fingers

and finger pressure between scanning tips

and the actual protocol

and then recapping the whole rotator cuff quickly.

I, I think that was a pretty good

summarization of the shoulder.

If there are any questions, we will feel free to reach out

to me directly is fine,

daniel.Shelton@fujifilm.com and I'll get back to you

and anything else that we can help you with

or if you're interested in any other topics

that we haven't listed, go ahead

and feel free to email me those too

and how they would be beneficial to you and your specialty.

- Excellent. Well thank you all for joining us

for the Shoulder webinar series.

Like I said before, we'll be announcing some more webinar

soon, so keep an eye on the webinars page on sonos site.com.

Thank you so much, Daniel, for taking the time

to put together the original presentation

and also coming through for the q and a.

Let's see, we appreciate you sharing your expertise,

expertise with our audience

and thank you so much for joining us today,

everybody. We'll see you at the next one.

- Thanks Chris. Thank you everybody.

Watch an expert-led review of clinical images and Q&A session to discover how the expanded use of point-of-care ultrasound supports diagnostic superior 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 superior shoulder including the acromioclavicular joint with dynamic maneuvers
  • Learn indications for an evaluation of the superior 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.

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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.