<p begin="00:00:07.468" end="00:00:08.913" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:08.913" end="00:00:10.790" style="s2">with a musculos-skeletal exam type is used</p>
<p begin="00:00:10.790" end="00:00:14.145" style="s2">to perform an ultra sound<br />guided kneed injection.</p>
<p begin="00:00:14.145" end="00:00:15.682" style="s2">Using a medial approach.</p>
<p begin="00:00:15.682" end="00:00:19.428" style="s2">The patient is in a supine<br />position, with the leg extended.</p>
<p begin="00:00:19.428" end="00:00:23.144" style="s2">The transducer is placed<br />just proximal to the patella.</p>
<p begin="00:00:23.144" end="00:00:26.950" style="s2">In a long axis fashion, the<br />fibular pattern of the patellar</p>
<p begin="00:00:26.950" end="00:00:28.902" style="s2">tendon is seen above the rounded bright</p>
<p begin="00:00:28.902" end="00:00:32.923" style="s2">hyperechoic surface of the<br />distal femur and patella.</p>
<p begin="00:00:32.923" end="00:00:36.218" style="s2">The supra patellar fat pad<br />and the darker hyperechoic</p>
<p begin="00:00:36.218" end="00:00:39.746" style="s2">supra patellar versa can<br />be seen in this image.</p>
<p begin="00:00:39.746" end="00:00:43.687" style="s2">This versa may not be visible<br />in the absence of an infusion.</p>
<p begin="00:00:43.687" end="00:00:47.323" style="s2">The transducer is rotated<br />90 degrees clockwise</p>
<p begin="00:00:47.323" end="00:00:49.557" style="s2">for a short access view of the versa</p>
<p begin="00:00:49.557" end="00:00:52.314" style="s2">which lies below the patellar tendon.</p>
<p begin="00:00:52.314" end="00:00:55.459" style="s2">And above the bony cortex,<br />the transducer is adjusted.</p>
<p begin="00:00:55.459" end="00:00:59.185" style="s2">So it is centered over the<br />anechoic supra patellar versa.</p>
<p begin="00:00:59.185" end="00:01:01.457" style="s2">The needle is inserted in the skin,</p>
<p begin="00:01:01.457" end="00:01:03.366" style="s2">just proximal to the transducer.</p>
<p begin="00:01:03.366" end="00:01:05.224" style="s2">The needle is slowly advanced</p>
<p begin="00:01:05.224" end="00:01:07.961" style="s2">to lie in plane to the transducer beam.</p>
<p begin="00:01:07.961" end="00:01:11.207" style="s2">And is seen as a bright<br />hyperechoic linear structure.</p>
<p begin="00:01:11.207" end="00:01:12.807" style="s2">The needle is slowly advanced</p>
<p begin="00:01:12.807" end="00:01:15.253" style="s2">under direct ultrasound visualization.</p>
<p begin="00:01:15.253" end="00:01:17.750" style="s2">Until the tip is seen to lie in the versa,</p>
<p begin="00:01:17.750" end="00:01:21.500" style="s2">where an injection or<br />aspiration can be done.</p>

<p begin="00:00:06.069" end="00:00:08.233" style="s2">- [Voiceover] This video<br />describes pathology</p>
<p begin="00:00:08.233" end="00:00:10.430" style="s2">to the lateral elbow, specifically at the</p>
<p begin="00:00:10.430" end="00:00:12.440" style="s2">common extensor tendon.</p>
<p begin="00:00:12.440" end="00:00:15.261" style="s2">The bony anatomy review<br />will be as follows:</p>
<p begin="00:00:15.261" end="00:00:19.730" style="s2">highlighted here is the<br />anterior surface of the humerus,</p>
<p begin="00:00:19.730" end="00:00:24.280" style="s2">the anterior lateral<br />surface of the radial head,</p>
<p begin="00:00:24.280" end="00:00:26.762" style="s2">and the anterior surface of the ulna,</p>
<p begin="00:00:26.762" end="00:00:29.486" style="s2">which will not be described in this video.</p>
<p begin="00:00:29.486" end="00:00:33.130" style="s2">Highlighted in blue is the<br />common extensor tendon insertion</p>
<p begin="00:00:33.130" end="00:00:34.866" style="s2">to the lateral epicondyle.</p>
<p begin="00:00:34.866" end="00:00:37.199" style="s2">In green is the radial head.</p>
<p begin="00:00:39.513" end="00:00:43.768" style="s2">Over at the radial neck will<br />be the supinator muscle.</p>
<p begin="00:00:43.768" end="00:00:48.448" style="s2">Over the supinator muscle will<br />be common extensor tendon.</p>
<p begin="00:00:48.448" end="00:00:50.876" style="s2">And then over the common<br />extensor tendon would be</p>
<p begin="00:00:50.876" end="00:00:52.568" style="s2">the brachioradialis.</p>
<p begin="00:00:52.568" end="00:00:57.092" style="s2">In this clip, the probe position<br />is as shown on the screen.</p>
<p begin="00:00:57.092" end="00:01:00.559" style="s2">This image shows a normal<br />common extensor tendon insertion</p>
<p begin="00:01:00.559" end="00:01:04.450" style="s2">through the lateral epicondyle<br />which is highlighted here,</p>
<p begin="00:01:04.450" end="00:01:08.246" style="s2">followed by a highlighted<br />lateral aspect of</p>
<p begin="00:01:08.246" end="00:01:11.518" style="s2">the radial head highlighted here,</p>
<p begin="00:01:11.518" end="00:01:13.940" style="s2">followed by the common extensor tendon,</p>
<p begin="00:01:13.940" end="00:01:16.107" style="s2">which is highlighted here.</p>
<p begin="00:01:18.448" end="00:01:21.198" style="s2">Observe the only insertion is taking place</p>
<p begin="00:01:21.198" end="00:01:24.610" style="s2">in the highlighted segment in blue.</p>
<p begin="00:01:24.610" end="00:01:28.087" style="s2">A transverse image of the<br />common extensor tendon</p>
<p begin="00:01:28.087" end="00:01:30.589" style="s2">over the level of the radial head</p>
<p begin="00:01:30.589" end="00:01:33.683" style="s2">shows a thin, dark hypoechoic line</p>
<p begin="00:01:33.683" end="00:01:36.433" style="s2">representing articular cartilage.</p>
<p begin="00:01:37.790" end="00:01:41.319" style="s2">Superficial to that would be<br />the common extensor tendon.</p>
<p begin="00:01:41.319" end="00:01:45.341" style="s2">Highlighted here is the<br />articular cartilage,</p>
<p begin="00:01:45.341" end="00:01:48.599" style="s2">giving us an idea what part<br />of the common extensor tendon</p>
<p begin="00:01:48.599" end="00:01:49.657" style="s2">we're viewing.</p>
<p begin="00:01:49.657" end="00:01:54.052" style="s2">In this image we can clearly<br />see a large join effusion.</p>
<p begin="00:01:54.052" end="00:01:56.635" style="s2">Here is the lateral epicondyle,</p>
<p begin="00:01:57.802" end="00:02:01.888" style="s2">followed by the lateral<br />aspect of the radial head.</p>
<p begin="00:02:01.888" end="00:02:04.869" style="s2">And then something we did<br />not see in our normal images,</p>
<p begin="00:02:04.869" end="00:02:08.834" style="s2">highlighted here in blue<br />would be the effusion.</p>
<p begin="00:02:08.834" end="00:02:11.405" style="s2">Less noticeable is the full thamus tear</p>
<p begin="00:02:11.405" end="00:02:13.437" style="s2">to the common extensor tendon.</p>
<p begin="00:02:13.437" end="00:02:17.489" style="s2">Upon compression, the<br />brachioradialis muscle</p>
<p begin="00:02:17.489" end="00:02:20.480" style="s2">herniates into the void<br />that is created by the</p>
<p begin="00:02:20.480" end="00:02:21.897" style="s2">full thamus tear.</p>
<p begin="00:02:23.080" end="00:02:25.413" style="s2">In this image, the<br />fibrillar pattern of the</p>
<p begin="00:02:25.413" end="00:02:29.507" style="s2">common extensor tendon is<br />now dark and hypoechoic</p>
<p begin="00:02:29.507" end="00:02:31.400" style="s2">and loses organization.</p>
<p begin="00:02:31.400" end="00:02:34.452" style="s2">Also inside are large calcifications</p>
<p begin="00:02:34.452" end="00:02:38.147" style="s2">peppering the insertion of<br />the common extensor tendon</p>
<p begin="00:02:38.147" end="00:02:39.680" style="s2">to the lateral epicondyle.</p>
<p begin="00:02:39.680" end="00:02:41.825" style="s2">In this picture this clearly represents</p>
<p begin="00:02:41.825" end="00:02:44.158" style="s2">diffuse calcific tendonosis.</p>
<p begin="00:02:46.715" end="00:02:49.683" style="s2">The next image shows a<br />large full thamus tear</p>
<p begin="00:02:49.683" end="00:02:53.379" style="s2">of the common extensor tendon<br />to the lateral epicondyle.</p>
<p begin="00:02:53.379" end="00:02:56.193" style="s2">Here we also see a bony irregularity</p>
<p begin="00:02:56.193" end="00:02:59.963" style="s2">such as an osteophyte or loose body.</p>
<p begin="00:02:59.963" end="00:03:03.884" style="s2">Obtaining a transverse image<br />of this tear is also important</p>
<p begin="00:03:03.884" end="00:03:05.801" style="s2">to confirm volume loss.</p>
<p begin="00:03:07.042" end="00:03:09.611" style="s2">Highlighted here is the lateral epicondyle</p>
<p begin="00:03:09.611" end="00:03:13.574" style="s2">using this hyperechoic bony osteophyte</p>
<p begin="00:03:13.574" end="00:03:16.740" style="s2">as a landmark, we turn the probe</p>
<p begin="00:03:16.740" end="00:03:19.407" style="s2">for a long-access to transverse,</p>
<p begin="00:03:19.407" end="00:03:22.324" style="s2">also indicating a full thamus tear.</p>