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https://www.youtube.com/watch?v=TeFrB4pv6Xs
Transcript

- Thanks everybody for joining us today.

Hi 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 one, the Anterior Knee.

Now this is the first in a three part series on the knee

and we'd love it if you come to the other reruns as well.

We'll be showing part two, the lateral

and medial knee on the April 23rd

and part three, the posterior knee on May 7th.

And those are both at the same time as today.

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're 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 in the toolbar located at the bottom

or the site of your screen.

And feel free to send those in as the presentation is going.

We'll get to those after the presentation.

This webinar will be recorded

and archived for future reference on our

webinars page as well.

Here with us 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 Sonos site.

He now leads musculoskeletal market development

where he works to spread the word about the benefits

of point-of-care ultrasound.

All right, I'll go ahead and get the

presentation started now.

Enjoy and we'll see you at the q and a.

- Thanks Chris for that introduction.

We'll go ahead and get started. This is part one

as we mentioned of a series today we're gonna talk about

the anterior knee.

The objective of this, this webinar are not comprehensive,

but we will be identifying the major tendons

and ligaments of the knee.

We should be able to detect a joint effusion,

identify injection locations,

and also identify the outlines of the super patella recess.

We'll be describing various pathologies of the tendons,

the joint re recess itself

and the cartilage in this particular part one.

Today we're gonna talk about the super patella region,

the quadriceps tendon complex,

the supra patella bursa slash recess of the fat pads,

and the infra patella tendon office fat pad as well.

First, as you can see in the photograph,

we're just gonna start at the patella

and then we're primarily just focusing on this midsagittal

shot to assess the quadriceps tendons complex.

And we're really looking at the enthesis here,

right along the patella, there's three distinct almost

flat facets on, on the superior part of the patella.

It's prominent and just about everybody I come across,

but not all the way across the patella, just in one segment,

and we'll cover that in the live scan here.

But the most superficial component here

is number three here, which is the rectus fems.

The number two here is the complex

of the ssus lateralis and medias.

And then number one here is the, the deepest layer

of the quadriceps tendon complex,

which is vasts intermediates.

Moving down to number four,

this is the trochlear lene cartilage

and it is koic, it's not compressible,

so don't com confuse that for fluid.

And note here the, the photograph is not quite as bent

as we need and we'll show that in the live scan.

But to get a good tight tendon, it, it's important

to go ahead and put the knee into quite a bit

of flexion if the patient can tolerate that.

But also in this image here we have the distal femur

and the proximal patella.

Now let's talk more about the recess itself.

This cadaver slice was, was probably the most illustrative

for me to learn and just show how large and

and far approximately running this recess is.

So the knee joint is a, a large target,

but there's no need to run a needle near the Lene cartilage.

Whether you're going sub patellar with your needle

or if you're going infra patellar

and driving the needle under hoffa's fat pad, hoping to hit

the recess there, you know,

you could be scuffing cartilage at that approach too.

So we stay in the super patella recess for knee injections

and we'll actually cover ultrasound guided procedures

including knee injections

and a subsequent subsequent webinar later in the quarter.

But for today's purposes, I do want to outline

and get everybody comfortable

and confident with super patella recess anatomy here.

So number one, back to review the patella.

Number two is the shaft of the femur.

Number three, not quite seen in the ultrasound image here,

but that is the hidden trochlear cartilage.

As you can see, it's over relied here in the,

the cadaver slice by the patella

and here partially overlayed by the patella here,

depending on the flexion of the knee

and dynamically positioning the knee

to show the maximum amount

of fluid is something we'll cover in the LifeScan.

But it's very beneficial

to put this knee into slight flexion

quadriceps tendon, which we already covered.

We also have a quadriceps fat pad,

this little triangular wedge here.

So I, I prefer cadaver anatomy references

over illustrations.

For example, if you look, if you look back at some

of the older illustrative knee

diagrams from more prominent illustrators in anatomy,

you'll notice that these two fat pads are virtually swapped

out where number six is is quite small in some

of the illustrations of the past.

And number five here is is quite large.

So go back and take a look at some of those references

and see the difference between cadaver and,

and show how accurate ultrasound actually

depicts this anatomy here.

So the pre femoral fat pad is this large guy here just

enveloping the distal femur.

And then all of this fluid here depicted up in the recess

of the cadaver image,

but not in the ultrasound

for some reason is the S patella recess itself.

So this does communicate all the way into the knee joint

under the patella and it's not isolated as some sort

of external bura.

Let's talk about cartilage and what it looks like.

In a normal case, you can see that the surface

of the cartilage is nice

and parallel with the surface of the distal femur.

They, for, for example, if we did see damage here,

I would see soft tissue structures dipping

and herniating towards the cortex of the femur.

So this is normal

where the arrows are pointing it out long axis.

And then short axis we can see the sunrise view

that you traditionally look at for radiography.

We actually see the cartilage really, really nicely

underneath the quadriceps tendon and transverse.

Just a quick scanning note,

we'll cover this in the live scan,

but I can tell just by looking at this image, this is medial

and this is lateral.

So I can tell that because the vastus medias is a large

muscle mass that extends far more distal than the vastus

lateralis not seen in the image here.

So just glancing at the image, you'll always be able to tell

that this is vastus medias versus lateralis as well

as this trochlea here on the lateral aspect of the epi.

Troia is is always more superficial than the medial side.

Medial side is always deeper

and the lateral side is always more superficial

and that's really important for your knee injections,

for your needle guidance so that you go proximal enough

to avoid smacking your needle across this

cortex on the lateral side of the knee.

So there's your normal look at cartilage.

Now let's look at abnormal.

If you see kind of a delamination mid layer between these

layers of the trochlear cartilage,

then then you have an issue.

You have to scan further. You have pathology there.

But this was a, this was actually an injury, a contusion

of somebody coming down on their knee

and probably delaminated some sort of

cartilage interface there.

Here we have cp,

the calcium pile of phosphate crystal deposition

all within the cartilage.

Okay, so it's not coating the exterior part

of the cartilage, it's,

it's on the internal part of the cartilage.

So this would be more of a pseudo gout versus actual gout.

So what would an osteochondral defect look like?

Basketball player, young high school,

constant patellar dislocations

and acute injury here causing an osteochondral

defect coming down on his knee.

So there's no telling exactly what the undersurface

of the patella looks like here.

It's very hard to image with ultrasound.

That is a limitation of ultrasound.

So don't hang your hat on looking at

the cartilage underneath the patella.

But we can see pretty much depending on

how the knee is positioned, we can see most

of the the trochlea cartilage of the femur.

And this is what osteochondral defect would look like

after an acute injury.

Okay, next slide there.

So also an acute injury when you see blood

coagulating and causing a fluid level within the super

patella recess, we can see this was a injury of somebody

who fell on ice, slipped and landed on their knee.

Everybody just seems to land on their knees.

And what we have here is a, a fluid line

between synovial fluid and blood.

And as if we were to let that rest for quite a bit,

you would see a linear line right across the joint line

where wherever gravity would have that, have that settle.

But as of right now, fresh, probably 20, 30 minutes

after the injury, you put the transducer down

and we can still see that blood all throughout the

articular, high articular joint fluid there.

A simple effusion will just be koic

or zero echoes, very easily compressible.

And you should expect just the typical synovial

fluid on aspiration.

Here's a needle. The focus of this talk is not necessarily

to go over all the knee injections,

but this would be the, the traditional approach.

This would be lateral to medial by ultrasound.

Alright, so before we go on to the infra patella tendon,

we're gonna break out

and scan real quick, that super patella recess and

- The quadriceps tendon.

All right, hoping my audio is still coming through good,

but we're gonna get started just

on the super patella recess.

I like to scan with the cable wrapped

around my wrist. Not only will

- That help us with the camera angle here today,

but it keeps things from pulling

and tugging on your transducer as you're scanning.

So as I'm scanning super patella, I always start

with the distal portion, which will be screened right

of the transducer on the patella

and I don't really let it leave the patella.

And then I fire the thumb orientation marker,

which will be the left side of the screen towards the

rest of the femur proximally.

And then when we get into these dynamic maneuvers,

I will traditionally place my palm down here on the

infra patellar tendon. Just kind of

- Noticing a camera shift might help you guys

see a little bit better.

There we go. Sorry for the delay

as it would happen, right? All right, so I'm placing

- My palm on the, on the distal portion of the patella

and then I'm just gonna rest the transducer.

And you notice my fingers are back here laid down on the

rest of the leg and that that will help me not compress

any pathology that might just be immediately visible.

So if I were to start by just mashing down on the tissues,

I might collapse a joint effusion and,

and I don't wanna do that either.

So let's get an arrow up on the screen.

Here we go and start pointing out some anatomy.

So right up here would be my palm transducer

side way over here.

And then here's the cortical landmark

of the proximal patella.

And we always start with bones

and musculoskeletal ultrasound

'cause the soft tissue can change.

So here's the distal femur

and I can't see the distal most tr

because it's overshadowed by the patella.

So I can't see through the patella.

It cast this shadow and

therefore I can't see the rest of this pre femoral fat pad.

For example, I can't see the distal femoral trochlea

and evaluate the cartilage in this position.

And when the knee is more relatively straight,

it's about a 20 degree flexion.

Some of your quadriceps inserts

can appear hypoechoic and diseased.

And so to eliminate that,

what we're gonna do is just have our model here slowly flex

her knee up like this

and notice that I kept my palm on the patella, okay?

By keeping my palm on the patella, I was able to kind

of chase, chase that that patella

with the transducer and not lose it.

And we're gonna keep our model's knee

extending up even higher.

And just like you saw on the slide, here we are.

So we've got that, that tendon now in maximum tension

and that's gonna help us identify any

retractions in these layers.

And then as mentioned, a lot of times

on most people you can,

you can notice these little facets on the patella

and they'll delineate, hey, this is rectus femes, this is

that blended layer here between the intermedius

or sorry, lateralis and medias.

And then the deep layer here be intermedius.

And then when the knees in this maximum flexion,

we can really see that hyper echoic quadriceps fat pad.

Very important underneath that, especially in this position,

not to call this a joint effusion, this is just cartilage,

this is koic,

it's not compressible if I give it transducer

pressure, okay?

That is not compressing that it is

what fluid would look like, but fluid would be compressible.

And then this is the, this is the chondral

or the the cortex of the distal femur trochlea.

Okay, so if I were to take this shot here

and now go short axis, I'll slice through the quads,

we're gonna lose the patella.

In fact, let's start on the patella.

I'm gonna go left side medial, rotate the transducer

and let's look at the variant thesis of these tendons.

So if we did suspect anything like a tear calcium,

especially calcium deposits,

I see bone spurs here all the time,

especially in long-term runners, degenerative changes,

tendinosis always occurs it seems right here at this most

thin line, that's where I'm starting.

So what I'm doing now is you'll notice I sweep the

transducer proximally, I lose the tendon fibers,

they're turning koic

and that's that anisotropy artifact

that we covered in the in the shoulder workshop.

But watch, when I tilt the transducer,

those fibers should fill in.

Okay, cool thing about that artifact.

It really only works on healthy tendons.

So if I were to tilt back

and I get a completely anti coic tendon like

that, that's a good thing.

That means this entire quadriceps is healthy.

If I start to see little invading, hypoechoic

homogeneous portions of the tendon that do not respond

to angle artifact, you should be highly suspicious

of those being some sort of tendinopathy.

Because once the tendons lose their linear longitudinally

arranged fiber or appearance

and they start to blend in a homogeneous way that's dark

and hypoechoic

and diffuse, that's when tendon disease is easy to pick up.

So nice healthy quadriceps tendon here, it's this oval.

Here's the fat pad underneath it, the quadriceps fat pad.

And I'm gonna climb more proximally again.

Here we have the distal femoral trochlea.

And then right off the bat, check it out.

I can tell again, left side is medial.

I always see that more distal musculotendinous portion

of the vast medias oblique.

And then lateralis hasn't even come into the shot yet.

It's all tendonous. Okay, so if I were to

turn my probe a little bit here

and climb laterally, I could evaluate the quadriceps tendon

of the vastus lateral is more proximally

and laterally over here.

So I'm gonna go back over to the main quadriceps,

right over the distal femoral trochlea.

And this looks like that sunrise view

that you get in radiography.

And we can keep evaluating that proximally and distally.

If we wanted to evaluate more of it,

we could put the knee into a little bit more flexion

and any further distal,

I'll show you a cool trick in the infra patellar exam.

We can further evaluate the rest of the anterior part

of the trochlea on the infra patella

view when we straighten the knee.

And we'll go over that in just in a minute.

Things I'm looking for is the parallel

nature of this cartilage.

Okay? I don't see any divots in the cartilage.

I don't see soft tissue like tendon

or fat trying to herniate through the cartilage.

I don't see the crystal deposition

that we saw in the PowerPoint.

And the cortical surface looks nice

and smooth and continuous.

I don't see any erosive looks.

I'm letting up on my transducer pressure

to make sure there's no fluid

collection above the cartilage.

Now let's travel more proximally.

Now that I feel good about the cartilage

and the quadriceps tendon integrity,

I'm just gonna have our model straighten her knee out,

relatively speaking to that more 20 degree flexion.

Okay, I'm gonna hold the leg here

and passively, let's take a look at the super patella recess

in its various waves we can, we can identify it

because here today we have a, we have a pretty dry knee

and this can be very frustrating in your knee injections.

And we will have a more comprehensive knee injection

demonstration with a guest speaker later in the year.

But I do wanna show you a few tricks that you can do

to access the, the knee joint.

So here I can tell this is pre femoral fat,

this is the quadriceps fat, this little triangle here.

And then check out this sliver

of a hypoechoic line right there as it

as it climbs up proximally

underneath the quadriceps tendon here.

This is the super patella resets.

And we can tell that dynamically just by doing more passive

flexion and extension right there,

I'm getting those two fat pads to oppose each other.

Okay? So right there we even, we even force a small

triangular wedge of joint effusion.

And then I always find that slightly more lateral

of midline, more lateral.

I catch it just a bit more

of the super patella recess than if I were

to hang the transducer over medially.

Okay? So dynamically, that's one way to tell

where the super patella recess is in a dry knee.

Another way is to have the patient actually tighten their

quad and you can see that same recess

and oftentimes this tensioning here

of the quad tendon will pull up

and cause kind of a syringe like vacuum

and actually pull some of the fluid into the

super patellar pouch.

So we don't see that here today.

Normal healthy knee, I think we saw

that in the cartilage exam.

Go ahead and relax. Other ways we can evaluate for

where that recess is for needle target location is

to go short axis, okay?

Left side medial. And you wanna get away from the cartilage

here because we're gonna, we're gonna tee up

for a joint injection, right?

So here's the quadriceps tendon.

And remember in that cadaver slice we saw immediately

beneath the quad tendon when we're proximal

to the quadriceps fat pad is the supra patella recess.

And I still don't see it here in short axis very

confidently, but if you palpate the IT band

and just poke a little above it with your finger, okay,

we're causing this lateral media lateral motion

of the pre femoral fat

underneath the quadriceps tendon here.

And we're gonna identify

that synovial recess right there where my arrow is.

And that's just one other way to identify it.

If I bring my probe out even more laterally,

I can kind of see sometimes a joint effusion kind

of wrinkle up over there laterally, but not today.

And then the fourth way is really to ano palpate.

We're gonna push into the quad here with the transducer

and get that pad to displace medially

and laterally with my pressure.

And there I can further delineate, Hey, anything

that's mobile is fat.

So we wouldn't want to call this part right here.

That's not the joint recess, that's part of the fat,

it's a little oil dense pocket, it's part

of the fibro adipose tissue.

And I can tell that when I, when I squish it's

mobile and it all moves.

So it's the interface above that right here.

And we're causing just a slight bit maybe of the effusion

to leak out into one little interface there.

But she doesn't have an effusion.

So what you would want to do there is just drive your needle

right under the quad laterally

and this direction here, drive your needle

above the IT band right here.

And then we're gonna aim slightly towards the

transducer, okay?

And then we're just gonna drive the needle from lateral

to medial and plop it right there under the quad.

And then give a test injection.

If the injection were to ball up

and blister up around your needle, then you would be

missing the knee joint.

You would be in the fat pad.

That injection should spread from medial

to lateral in a, in a vacuum plane.

So very important to identify that, that it's not collecting

around your needle to verify your, your location in the

super patella recess medially.

Let's come over here medially to the vasts medias oblique.

Okay? And then it's bordering some of the superior

Retin aum, the patella femoral RET ulu here.

So we can see the patella medially

going a little bit off the slides here,

but here's that, that re aum

and you can see how far approximately it

extends underneath the VMO.

So here's VMO, here's more of the rein AUM

and it'll go all the way over here to the adductor tubercle,

which we'll get into on the medial part of the,

of the knee later in the month.

So VMO is really cool one to image, especially in front

of your patients because it just looks like a

big piece of meat.

And here in short axis, you, you recognize

that the fibers are going from proximal to distal

but not straight up and down.

They take an immediate abrupt curve up towards the patella.

And this is a cool image

to teach musculoskeletal ultrasound, especially

to beginners, how to follow fibers in their short axis and

and follow them as they traverse through their planes.

But I'm looking for volume loss, I'm looking for divots

and soft tissue mass herniations from the superior

portion in the inside.

I'm looking for irregularities looking

and I just don't see any there long axis.

You can see where I am in short axis, relatively speaking,

I'm, I'm gonna go this way

and just turn the probe oblique there.

And we see really, really nice longitudinally oriented

fibers of the VMO.

That's one of the more awesome muscles

to image in the knee just

because it's so prominent, it's such a medial landmark.

It kind of tells you where you are.

Now we're gonna go over here laterally.

We're gonna roll the knee over. Same logic applies.

We're gonna look at the the VAs laterals.

Now this more superficial bate muscle right here,

it does taper off much quicker, here we go.

And I'm just gonna rotate the transducer long axis to it

and it has a much longer musculo tendus junction than the

VAs medias, which was a real short stumpy

musculo tendonous junction.

But you can see my, my transducer plane

and how lateral it is upward sloping towards the patella.

Here we go. Here's the ssus lateralis

and you can see it's central tendon

and it's bi penate feather looking

classic muscular architecture here.

All right, and then last

but not least, vastus, well not last actually.

We still have rectus femes to kind

of cover going off slides again,

but here's your rectus femes.

This, this oval shaped structure here kind

of sits like an hourglass on top of the vastus intermedius.

So this structure here always kind of reminds me

of this big hourglass landmark, A figure eight

where we see one on top of the other.

If you're evaluating for atrophy, I will say don't go off

of one slice when you're comparing this tendon,

or sorry, this muscle to its surroundings,

they run at slightly different angles.

Okay, so if I'm cutting the the rectus fems

and short axis perfectly perpendicular,

that means your ssus intermedius is at a slightly different

angle unless you're really compressing the two together.

So you have to tilt and you'll get the distal more,

or sorry, the deeper ssus intermedius here, you'll get it

to highlight really nicely over the femur,

but not all the time will you get the rectus femoris

to highlight really nicely there.

So it's one or the other.

So ssus intermedius, we're looking at it here.

Nice short axis, no atrophy,

no muscle injury, good lean muscle.

I'm gonna tilt the probe

and show the rectus femoris in a similar fashion here.

So that's how you kind of navigate your

way through these quads.

And there you are. You can see that quad nature.

So here we have the

1, 2, 3, 4 all in one slice.

It's a 50 millimeter transducer head,

it's already very wide all the way from the shallow part

of the image to the deep part of the image.

So we can capture all these in one shot

and we'll have to keep your questions for

after the next portion.

We're gonna go over the infra patell next, hang on

to your questions and we'll we'll answer those right

after the infra patell portion.

So I'm just gonna make a switch over to presentation

- And go - There.

All right, we'll get going with the intra patella tendon.

This should be pretty quick.

And then we'll get back to live scanning

and answer your questions live if you have any.

So have 'em ready, type them in the chat portal as we come

to a close on the live scanning portion

and we will circle back around

and be able to answer your questions live

with scanning if if needed.

Alright, so infra patellar tendon.

Very straightforward, probably my favorite tendon

to really show beginners where to start scanning

because you can easily palpate your patella

and you can easily palpate the tibial tuberosity.

So it's only natural to, to set the proximal aspect

of the probe over the patella

and the distal aspect of the probe over the tib tibial

tuberosity and expect to see a tendon and it,

and it's fairly straightforward.

So from there it's just a matter of, you know,

proper angulation, making sure you're very thorough,

sweeping the transducer medial to lateral.

And we'll cover those scanning tips in the wive scan here.

But let's, let's go over our bony landmarks first.

So number one, we have the distal patella.

Number two, we have the tibial tuberosity.

Number three, we have the infra patella tendon.

This big guy right here, like a classic tendon drawing

on illustration and then distally here.

Most of this is overlap.

It's a quite, quite a large transducer.

50 millimeters will capture all of the body of the tendon.

If you were to set the pro right down the middle,

the image would begin about here and end about here.

But I think it's important when describing this anatomy

to show the very, very most origin

of the patellar tendon right here

and the distal motion inthe

and how far down the tibial tuberosity it actually goes.

A little trivial question here,

why do we call this a tendon if it appears

to go from bone patella to a bone tibia?

And just depends on, I guess how you were brought up,

tomato, tomato kind of thing or how you were taught.

But some, some schools

of thought would consider the patella moid

and that would make this an extension

of the quadriceps tendon.

So we have the patella tendon just being an extension

of the quad, which is enveloping as s moid.

The patella classifying the rest of this structure

as a, as a tendon.

If you would consider the patella an independent bone,

then we have a bone to bone connection here

and this becomes the infra patella or patella ligament.

Either way is fine with me. I just think it's fun.

And it was fun when I learned this to, to show that

that distinct difference.

And I will say ultrasound makes it really fun

because if you, and we'll do this on the live scan if you

want, but if you were

to follow this really thin hyper EIC line right here,

the superficial most aspect

of these fibers approximately all the way to the quad

and almost seen on this MRI, they they, they tend

to fade off right here.

You would notice that a lot of these fibers are contiguous

with that most superficial portion of the quadriceps.

Further strengthening that relationship

of this being a large sesamoid,

protecting the distal femur

and an extension of the quadriceps tendon.

So if that's the case, we have strong evidence of

that on ultrasound and less detailed on MRI.

But when you really look at it on ultrasound,

it's really neat to see that communication,

what happens when things go wrong in that area.

So we see a lot of acute patellar tendinosis, tendinosis,

tendonitis, which is imaged over here

with the color powered doppler.

I can't emphasize enough, all the pathology

that you find in Ms K ultrasound,

throw on your color powered doppler.

It's very important. Here we're showing a feature

called color compares.

So if you're doing procedures or you just wanna go ahead

and get that simultaneous image with

and without color live at the same time,

and we can do that on the live skin as well.

This is what it'll look like. But here we have this koic

part of the tendon, no matter how I tilt

or rock the transducer, it's not filling.

In previous webinars we spoke about the artifact called

anisotropy, which is angle artifact

where if a tendon is oblique to the transducer,

it just does not reflect the fiber angle back to the probe.

So very important to know about that artifact.

And that's not what we're seeing here.

If we were to press down on this,

it would probably collapse this small partial tear.

These tears typically occur on the undersurface

of the tendon, not necessarily superficially,

not very often at least, but I tend to see more jumper's,

knee pathology right there on the,

the most posterior surface

of the tendon right at the distal patella.

Throw on your color powered doppler to confirm

that there are a normal group of vessels

that just line the underbelly of the tendon here,

but they typically don't invade the architecture

of the tendon like we're seeing here.

Also note the the fiber geometry

that we're seeing here looks more like a loaded paintbrush

than a normal tendon.

So underneath, let's just take a look at

this older picture here.

This is a normal patella tendon distal patella.

Note that the fibers are nice and parallel with each other.

The posterior surface

and the su, the superficial surface

of these fibers are nice and parallel.

And you come over here where we have tendon notice

tendonosis and you notice that these fibers tend

to fan away from each other

because they're loaded with fluid

or degenerated architecture

that no longer is longitudinally oriented fibers.

So within the structure here, we have a loss of fiber detail

right down the center of the area of concern.

Surrounding that we have normal fibers, which is good,

but we have this diffuse echogenic pattern right down the

core of the tendon leading all the way up to the tear site.

And that would be consistent with tendinosis.

We've lost our fiber architecture if we did see normal

fibers but they were not, if they were normal

and loaded with fluid, we'd call that more of a tendonitis

coming over here to more just an

undersurface patellar tendon tear.

Very common we see a little calcium there.

It might have been a fleck pulled off through an avulsion.

We also see that here and long

and short axis on the bottom right.

So always confirm these in short axis and we'll do long

and short axis scanning in the LifeScan.

Thank you very much. And while we get switched over on

video, I just wanna remind everybody we have medial

and lateral knee evaluation coming up next in the series.

This is a three part series.

We're gonna cover medial lateral

because they scan very similarly.

We will cover dynamic valgus, various stress maneuvers

and how to stress the knee and those limitations.

So you wanna look at meniscal pathology.

Is that easy to see? Is it not easy to see?

Where are the limitations?

Where are the strengths of ultrasound?

I think it's very important to have that conversation.

I'm gonna turn it over to the studio now

and we're gonna go with the live scanning demonstration.

So if you'll just gimme one second to get

that set up. We'll get started

- On the live demo and your questions.

- Alright, well that's the presentation.

Looks like we're going

to get Daniel set up in his studio here

and you should be able to access the q

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

You can use that to ask questions while Daniel is getting

set up here, it looks like he's getting

to work on it here.

- Alright Chris, can you hear me okay?

- Yep, I can hear you. - Perfect.

Let's get going with our, our live demo with q and a.

So you may notice we've changed a few things in the room.

I've switched over to the new SonoSite st

so you can see the live scan

that was in the pre-recording was with the SonoSite px.

And today we'll just give you a chance to see

the differences, the new form factor of this all touch panel

and maybe how it compares, which it's running much

of the same hardware but from cleanability.

It's very nice. So I'll be using this SonoSite st

during the the live q and a today.

- Daniel, what are the differences kind of

between using the ST

and the other sono site machines that we have?

- That's a great question.

This is all touch screen,

which is really nice for cleanability.

It's also we, we've changed a few of the button layouts

and there's no tactile buttons

and there's a tray on the back which is really nice

for procedural setup.

And then on the sides you can,

you can see we have transducer holders just off

to the side on the back of the machine.

So if you're behind the machine setting up your sterile area

or whatever, you can use that tray

and you have the transducers being held

by these little arms, which is nice if you're a solo artist

and there's nobody in the room to help you cover the probe.

These act as little hands holding your

transducers out for you.

So it's really nice. It's a very procedure driven machine.

So there are a few less features

and settings then on the PX and on the sono side lx.

But from an image quality standpoint, I think you'll find

that it's, it's definitely comparable.

We have two transducer reports instead of three built in

and this does not come off the stand like the px.

So the PX would come off the stand.

I would say those are the, the majority

of the differences there, but I think you'll find the image

quality is no compromise there

and we'll easily get

through our demonstration today going over all the same

things that were covered in the PowerPoint.

- Awesome. Alright, looks like we got a couple

questions coming in.

Great. The first one is for the last demonstration

of the patellar tendon is the difference between anisotropy

and an actual patellar tendon lesion that with the movement

of the transducer, the lesion remains,

but the an atropic artifact goes away.

- Basically you're gonna use the an isotropic

artifact to your advantage.

I'm gonna slice this patellar tendon in half here.

So we should get this kind of hamburger patty looking

this this guy right here.

So here's our patellar tendon

and if a part of it was diseased or or scarred up

and no longer had longitudinally arranged collagen fibers

as I tilt the probe, a portion

of the tendon would remain hyper coic

as if I was getting full reflection of

collagen fibers in their fiber or direction.

But when they, when they remain solid hyper coic in here,

they've lost their longitudinally organized state.

And that means a tendon has lost its linear

orientation where it should normally

be longitudinally S strided.

You would check that in both planes

and make sure that it doesn't look longitudinally

oriented in long axis.

You would just see this, this kind of backfill

of tissue kinda like we see.

I wouldn't call this necessarily

degeneration,

but I do see a lack of filar fibers right here in this area.

Okay, so this is at the base of the patella here

and if I were to maybe zoom in on that just to kind

of show that,

- Let's get outta here and we're going

to hit freeze and zoom in.

- There we go. So I'm looking at this zone right here.

I'm gonna unfreeze and I'm gonna go into short axis

and let's just see how it acts.

Does that zone stay hyper coic? And I'd say it does.

The whole base there remained hyper coic right here.

So this portion is not longitudinally oriented,

but this portion that is responding to angle artifact is

whereas if you're just cutting the whole thing at 90

degrees, it may all look the same.

So anytime you're scanning an MSK,

you're gonna sweep a tendon, you're gonna tilt, sweep tilt,

sweep tilt

and remaining.

This is kind of neat to see the little inter tendonous

digitation at the enthesis following that same logic

of a tendon losing its longitudinal fibrillar architecture.

So we're actually seeing these vertical slips of tendon

as it starts to splay out

and attach on the tibial tuberosity,

you'll see these little vertical striations

that don't quite behave like the rest of the tendon.

And you can see that with the angle artifact really nice

right there.

These little guys, I wouldn't call those pathologic it,

I see 'em on everybody and it just seems to be

where the tendon starts to diverge out to its thesis or its,

or its footprint to a broader attachment,

kinda like a subscapularis in the shoulder.

You get those inter inter tendon digitizations.

We don't talk about that here in the patellar tendon ever,

but you will notice

that pattern in short axis if you use this rocking method

as you go to the insertion.

Now if I let up my pressure,

we can see in our model here today, we've got

that little bit of patellar deep in for patellar bursa.

She's a runner. So I expect

to find these popping up every once, once in a while.

But just to make sure you're not collapsing it,

what I'm gonna do is just let up pressure here

and I can see that rectangle where my transducer was

and then I'm just gonna get all the air out

of the gel bottle and I'm gonna follow that rectangle.

Oh man, had a little air bubble.

Okay, so I'm gonna use that as a gel standoff.

I'm gonna use my fingers as stilts so that I don't,

I don't compress the gel first,

then we're just gonna float right into it

and we will see the bursa show itself a little easier

and it always seems to be lateral.

You hardly ever see these go medial.

And a good sign that I'm not compressing also is

that I'm not compressing these little geniculate

lateral inferior ICT vessels either.

And I can see the gel on both sides.

So if there were a superficial infra patella bursa,

I wouldn't be collapsing that either,

as long as I can see the gel.

But anytime you suspect a pathologic fluid collection like

that right there, give it a compression, see if it's solid

or cystic and if it's really big

maybe it needs to be drained.

There we go. I hope

that answered the angle artifact question though,

so you could, you could apply the same thing to the quads.

So we'll come over here and go down in our depth

a little bit more.

There we go. There's the femur at the bottom of the screen

and which is quad, which is fat pad.

So that's kind of a good injection technique too if just

wanna find out what's what.

You can see the quad tendon will change echo texture here

and then the fat starts here.

So this is pre femoral fat

from this layer all the way to the femur.

Pretty much there's a little muscle deep down here we don't

talk about, but it's there.

And then all of that kind of blends together right there.

And we could test that moly too.

I can compress and see where tissues move.

And you can see that right under the angle artifact.

If I push laterally, you can see

that pre femoral fat gliding right under the

an isotropic artifact.

Just a couple ways to just fail safe, check yourself,

make sure you're not gonna land a needle in

a, in a pocket of fat

- And take off arrow.

- Okay, so we covered angle artifact.

We covered what tendons look like, how to do a gel standoff

and make sure we're not compressing possible pathology.

- Right. We got another question coming in.

Do you use sterile transducer gel for injections?

And do you use a sterile cover

for the transducer for injections?

- We recommend that you do.

I would say that from many angles we'll have an injection

presentation later in the year.

So watch out for that and it'll cover

all those different techniques.

But I would just say as a general rule of thumb,

especially if you're just starting out with these,

keep everything covered, keep everything sterile

because you don't know when you're gonna drift your

transducer into the sterile field.

So even though your,

your procedure may be far away from the probe

as you get going, you might learn that some

of this gel might drip down into your procedure site.

That's something to be cautious of

if you're using ethyl chloride spray for example, and,

and you haven't broken the habit

of spraying it near a transducer, that

that spray will very much damage the housing on all

transducers in the market.

So having a sterile cover,

that thicker cover will apply an of your transducer.

So I do recommend that you can spray ethyl chloride,

let it work and then set the transducer down.

But oftentimes people get impatient

and they will let the ethyl chloride spray pull up

around the indentation of that the transducer leaves.

And when that stuff rests up against the plastic

and it has its chemical reaction to room air,

it can completely dissolve

and separate some of the linings in a transducer.

So I recommend protecting your transducer with

that over a tegaderm.

For example, if you're gonna use a tegaderm

and ethyl chloride spray,

you're gonna wanna back off tegaderms on the transducer.

We don't recommend using a tegaderm,

but we know, we know that's what people do.

I don't recommend using a tegaderm for this purpose.

People traditionally use ethyl

chloride spray for these injections.

So ethyl chloride spray will melt to your transducer,

the tegaderm and it can be impossible to get off.

So I just recommend, at least in the beginning when you're

learning and getting your pace built up to cover it

with a fully functional transducer cover,

it will protect your transducer and keep the area sterile.

You're gonna use sterile gel because that gel may slide down

and slide down the skin into your procedure

site too and you don't want that.

So that's definitely our recommendation and,

and different ways to do it.

- Alright, are there any other areas of this part

of the knee that people usually have trouble

scanning for first time?

- I think it's, it's a matter of just keeping your,

your hands on the skin.

I base my hand around the patella as an island so

as I'm scanning, I'm always keeping a finger down

and palpating down the side of the transducer

so I don't lose my spot.

You wanna base your hand up, try to get rid

of this excess cord.

I'm, I like to wrap it around my arm one time

and that takes the weight of the cord off

that trans, okay.

So I think that's what makes scanning the knee in

particular a little bit tricky.

And if they will just kind of keep in mind

that we're scanning a cylinder and the femur

and the tibia are centrally located

and we have to stay 90 degrees to the cylinder.

So what you don't wanna do is scan out medially

and forget to tilt back into the femur

or scanning out laterally and forget to tilt.

So just keep in mind we're trying to scan to the center of

cylinder and that's what's gonna keep all your,

all your tissues nice and bright.

So as you're scanning, you wanna make sure

that the bone is nice and bright above everything else.

First, make sure you have good hyper coic bony cortex

and then worry about the rest of the layers on top.

Because this is musculoskeletal

and everything's angle dependent, as long as your

your bone is nice and bright, the structure's wrapped

around the bone will be being cut at 90 degrees as well.

So as I transition to a lateral knee survey, I'm,

I'm still just focusing on the femur first.

So femur comes first

and then I worry about the stuff on top.

'cause if the femurs kind of fuzzy then your muscle can get

kind of fuzzy and so can your tendons.

That goes for anything that's cylinder like your elbow,

your wrist, ankle.

If you just treat that central centralized bone

as your reference point, all of this becomes much easier

to navigate and to make the tissues move.

I can't emphasize that enough.

So if you come across the dry knee,

I think this frustrates a lot of people.

The most out of all knee scan is

where is that joint capsule.

So even here on a healthy knee with no joint effusion,

you need to know your, we need to know where the femur is,

we need to know where the patella is.

Okay, we need to know where the quad is, we need to know

where the undersurface of the quad is

because that's gonna tell us where the recess is gonna be.

But there's two fat pads, if you remember

from the beginning of the slides.

So we have the quadricep fat pad, it's triangular wedge

that responds differently to angle artifact

so you can use that to your advantage.

And we have the pre femoral fat pad here.

So with the pre femoral fat pad,

we can make these two move away from each other like we did

earlier in the live demo where we can have our

patient tighten her quad.

There you go, perfect. And it's just that tissue motion.

So slowly tighten and then relax.

Okay, now relax slowly

and we can see that capsule start to move

and oppose the two fat pads.

So make the tissues move.

I would say that's the other thing that trips people up.

Just coming across the dry knee can be very frustrating.

So do everything you can

and scanning MSK to make the tissues move

that's anywhere in the body.

But even here I'm just rocking that fat pad

to find its margins

and I can see the mobile margins of that fat pad right here.

I can use my finger and poke it right there.

I'm just using transducer pressure now

and just kind of squirting the fat pad back and forth.

Some of it's going all the way under it

and VAs laterals almost,

which we'll get to in the next webinar.

How to scan those in detail.

Penetration can be a problem if they have really dry knees,

dry kneecaps for example, where this,

this goes for the heel too.

And elbows in particular dry skin can

destroy your ultrasound beam.

So air is the enemy of sound.

So if you moisturize the skin

before you start your scan, you'll be a lot less frustrated

with penetration problems.

If that's not doing the trick,

then try dropping your ultrasound frequency.

So if I wanted to see more detail down in the lower part

of this image, let's see, let's take off our other tools.

I'm just gonna go down here to the bottom of your screen.

You see we're in resolution mode.

So at the top end of the frequency on larger legs in

particular or people with really, really dense dry skin,

drop your frequency to gin mode

and just watch how the image changes

and it's a very, very powerful change to the image.

So I'm gonna go back to res, it's more fine, more resolute,

but it lacks the penetration sometimes.

So if I wanna see the femur

and detail around the femur more,

especially on a larger leg, like if I were

to jump up on the table, then we'd

i'd, I'd put it in gin mode.

There you go. So keep that in mind.

Your machine has a few more buttons.

They're typically so easy to use, you never have

to push 'em, but it is good to know that

that tool is in your toolbox when you need it.

I see people do deeper studies,

more advanced study would be an ACL,

which we're not here teaching today,

but if we were to do one now just for fun,

you would flex the knee up like this

and this is where I get into if it's pathological,

this is gonna hurt anyways.

So you know, gotta, there we go.

Gonna see if I can get a, an upper camera shot.

Probably not. So just ignore

that top frame and let's go here.

If I needed more penetration for this kind of ACL shot,

we'll use our arrow down here.

We're looking for this deep diving shadow

to go from the tibial plateau

and I'm just lacking the penetration.

Then what I'm gonna do is go back to gin.

So let's look at the deep part of the image

and hit gin and you'll see it light up.

And now I can see that vertical shadow climbing up

to the tibial plateau.

That's a just another example where penetration kind

of matters no matter which body habitus you're scanning.

Curvilinear probes do really good for this too.

I mean we can even see a bit of meniscal root here

of medial meniscal root down at the bottom

as I go oblique, let's go ahead and straighten your knee.

Very good. Excellent question.

Just troubleshooting the knee, what are the challenges?

I'd say the dry knee, not only the dry super patella recess,

but dry skin.

- All right. Next question is the last demonstration

of the patella tendon, the one

with the patella tendon lesion.

It appeared as if the bony cortex

where the tendon was attaching was irregular.

Is that correct or

and is it typical to see both the tendon lesion

and the cortical irregularity?

- Usually most tendinopathies accompanied

by cortical irregularity.

So especially in the shoulder,

that's your number one dead giveaway.

It's about 90% certain they're gonna have a cuff tear if you

see a cortical irregularity at the footprint.

So I'm looking for cortical irregularities at the tendon

and thesis, not just cortical irregularities in general.

So if I slide too far medial

or lateral, then you can come across nutrient

foramen for example.

I would not call that a cortical irregularity here.

That's a nutrient foramen.

And that is one of the diving points for our,

and this case inferior medial geniculate artery.

So I'm looking for divots in a tendon footprint

like that to be within the substance of the flat facets

of tendon and,

and these, so if I see a divot mid footprint

that looks like one of these little pits in the bone,

then that's what I would consider a cortical irregularity.

But just not out here where,

where nothing's really attaching sounds like common sense,

I know, but I've seen people call cortical irregularities

all kinds of things when there are some normal ones out

there that can throw you off.

And if that's the case, for example,

if we think there's a nutrient framing,

then you just throw your color doppler on

and and see if you can pick it up.

And it's good training for testing your color Doppler

sensitivity to, so if I were to go back over here

to this medial inferior ICT here

and then throw on the C button for color

and even switch to CPD, I could see that

that artery is in fact diving straight into the

cortex at that point.

There's more branches, this one climbs up

and makes its way under the entire infra patella tendon

and then other branches climb up over the meniscus.

It's, it's kinda like a tree,

but anytime you see one of these nutrient foramen,

it's also a good place to calibrate your color

for pathology.

'cause it'll be around the same level

of flow, low level flow.

- But yeah.

Alright, well

- We shouldn't see any flow within a tendon.

That's another thing to troubleshoot.

So I don't see any doppler flow within the substance

of the tendon, so that's good.

We don't catch that on normal tendons,

but on pathologic tendons we will start to see the

infiltration of neo vessels when the healing

process tries to take over.

- Alright, well it looks like that's all the questions

that we have and we're about running out of time here.

We're getting pretty close to the top of the hour.

So I'd like to thank everybody for joining us

for this new webinar, Whitney, sorry, new webinar series

If you'd like to.

We'll also be rerunning the other webinars in the knee

series with the medial

and lateral knee happening on April 23rd

and the posterior knee happening on May 7th.

And we'll also be announcing some more webinars soon.

So keep an eye on sonosite.com/behind the scan

webinar for more details.

Thanks again, Daniel, for putting together the original

presentation and coming in for the q and a session as well.

We had some really good questions

and we really appreciate that.

For everybody else, thank you so much for joining us

and we'll see you at the next webinar.

Join this webinar to review normal sonoanatomy of the suprapatellar and infrapatellar regions of the anterior knee. Our expert presenter will demonstrate a dynamic evaluation of the knee and review how to assess the knee joint for effusion and the infrapatellar tendon for structural changes and bursitis. Injection targets will also be discussed. A live Q&A at the end.

What You'll Learn

  • Evaluate the knee joint for effusion
  • Identify intra-articular knee joint injection/aspiration anatomy Assess the infrapatellar tendon for structural changes and bursitis
  • Perform a dynamic examination of the knee as well as transducer handling tips
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.