Lung Point

- I'm going to examine the MCM and PIP joints now.
We'll be looking at the dorsal, or extensor, surfaces,
as well as the palmar surface of the MCPs
and just take a brief look at the PIP.
The best transducer for this exam is the L25,
which has a small footprint and it allows you
to retain contact with the skin's surface.
There is a marker on the transducer, which represents
this turquoise dot, so in keeping your orientation straight,
you always want to keep this proximal, so this is held
that way for longitudinal images, and medial,
so this marker should be on the outside.
As a rheumatologist, we're going to be looking for
boney detail tendon anatomy, and the presence
or absence of synovitis and erosions.
I'll look, today at the second and third MCPs,
both in the transverse and longitudinal planes,
and we'll take a brief look at the PIP
and then the palmar surface of the second MCP.
We'll look longitudinally over the second MCP first
and see the skin surface on the top.
The bones, this is proximal, so this is
the end of the 2nd Metacarpal.
Here's the Articular Surface, and then here is
the proximal portion of the 1st Phalanx.
The black anechoic surface, here, is Cartilage,
and there's some cartilage here,
and this is a normal joint structure at the second MCP.
There is frequently a small articular cortical defect
on the dorsal surface of this metacarpal.
That is not an erosion.
An erosion would appear elsewhere
with this type of an appearance.
We can also see the Extensor Tendon superficially
right under the surface of the skin.
Could you move your finger just up a little bit,
and you can see that tendon moving and the joint moving.
We'll then take a transverse image and see
a transverse oval image of that Extensor Tendon.
We're going to look for hyperechoic
or anechoic fluid or synovium around it.
In this case, none of that is present.
We can also now look at the third MCP.
Here, again, we see the extensor tendon, the joint
is V-shaped structure.
This is anechoic where the cartilage is and hypoechoic
where the actual joint material is within the capsule.
The joint extends from approximately here
all the way over to here.
That's quite normal.
We'll look at the PIP.
This is the distal end of the 1st Phalanx.
The Joint is this space, here, and she happens
to have a small amount of osteoarthritis, here,
with some Irregularity of this Cortical surface.
I can slip my finger in here and show you where
this is actually moving and you can see
that joint flexing and extending.
We'll look at the flexor surface of the second MCP.
These tendons are quite a bit bigger.
We see the Flexor Tendon moving very nicely
as she flexes and extends her finger, and you can see
the superficial border between the tendon and the
Subcutaneous Tissues, and you can see
the Joint very nicely, here.
This Hypoechoic area is the A1 pulley,
which is just proximal to this joint.

Brightcove ID

5751328211001

https://youtube.com/watch?v=vjkspg2Esq0

How To: Foot Injection

Read more about How To: Foot Injection

/sites/default/files/Coach_pollock_foot_injection_thumb.jpg

Dr. Scott Pollock demonstrates how to perform an ultrasound guided foot injection.

Clinical Specialties

Physical Med & Rehab

Media Library Type

How To Videos

Media Library Tag

Msk Ultrasound

Musculoskeletal Ultrasound

Subtalar Joint Injection

Podiatry

Subtitles

- Injection or aspiration of fluid from the ankle
is best obtained most of the time anteriorly.
But it really depends on where the fluid
is most easily visible
where the blood vessels are and what the best approach is
for the angle of the needle.
This is the joint that we would be aiming for
right at the base of that v.
And if there were fluid there
we would see it as a black area
filling in the base of the v.
This can approached then with a needle and syringe
using sterile technique
and obviously here do not have sterile gel
or sterile preparation
it's just for demonstration purposes.
The needle can be placed in this way.
Sometimes this is very easy to do
especially when a person has full mobility of the ankle
and the ankle can be
kept in this orientation.
Sometimes it's necessary to visualize the effusion this way
holding the transducer transversely.
And then injecting or aspirating
with the needle parallel to the transducer
with the approach this way.
It's very important to watch for arteries
and you can see the artery pulsating
in the center of the field.
When the tranducer's in the longitudinal plane
it's important to look for blood vessels
and this large vessel that's most likely
the dorsalis pedis artery is right superficial
to that structure.
It would be very important for me to move either
medially or laterally to avoid that artery.
This can also be checked by switching on the color
and seeing the artery pulsating right there.
So I would move this over a little medially
and then enter here
relatively close to the transducer edge
and going in at an angle sufficient
to get down to the depths where the effusion is.
This joint is approximately
one and a half centimeters deep
and so I'm gonna to have to angle this syringe
such that the tip of the needle
goes to the depth of two centimeters.
So here is an image of
taken of a person with an ankle effusion.
This is a transverse image.
So we don't really see the tibiotalar joint
with that classic v presentation
but we see the bone here
and we see an artery probably
the dorsalis pedis artery here
and this hypoechoic and anechoic black area
is all joint effusion
with synovial proliferation.
In this still image you can see the needle coming down
and as I turn on the video
you'll see the needle advanced in injected material
which you can see circulating around.
You can see the artery pulsating.
In this image
this is a person with acute gout.
We have a transverse image of the left first
metatarsal phalangeal joint
and this is the bone surface.
This is the distal end of the metatarsal
and this area of hypoechoic and anechoic
black appearance is fluid in that joint.
There's a digital artery over here
and the needle can be seen coming down
from the left side of the screen.
You can see the bevel on the needle.
Right now the end of the needle is caught
in a small amount of synovial tissue
and there is steroid injected in.

Brightcove ID

5751505197001

https://youtube.com/watch?v=MkEuZklbJ9I

How To: Foot Exam

Read more about How To: Foot Exam

/sites/default/files/Coach_pollock_foot_exam_thumb.jpg

Dr. Scott Pollock demonstrates how to perform a foot exam.

Clinical Specialties

Physical Med & Rehab

Media Library Type

How To Videos

Media Library Tag

Msk Ultrasound

Musculoskeletal Ultrasound

Subtalar Joint Injection

Podiatry

Subtitles

- We're going to exam the ankle.
She's lying down on her back with her knee flexed
and ankle in approximately this position.
I've selected an L25 transducer
because it has a small footprint.
It's easy to get around the curves in the ankle.
On the Sonosite M-Turbo,
I've set for its factory preset for Msk.
For orientation, this mark on the transducer
corresponds to the turquoise dot
on the upper left portion of the screen.
And I'll examine the anterior portion
of the true ankle joint first.
And on the left side of the screen is the tibia.
And in this view, you see the tibiotalar joint.
There is a hypoechoic, or anechoic, stripe
over the talus, which is cartilage.
And there are vessels and tendons superficially.
This would be one of the best views
for a rheumatologist to find an ankle effusion.
And that can be seen as an anechoic area in that V
between the two bones.
The lateral aspect of the ankle joint can also be examined.
The fibula is the bony structure underneath the marker.
And the talus is to the right.
You can see an effusion again, between those bones as well.
Transverse images are very good
for looking at extensor tendons,
and for tendon abnormalities.
You might see anechoic fluid around the tendon
or synovitis.
And also see in the middle of the screen,
the dorsalis pedis artery pulsating.
It's very important to identify the position
of the arteries so that when you do injections,
so you'll be able to avoid them.
Next I'm going to examine the medial aspect of the ankle.
The medial tendons, three of them,
run just inside, or just posterior,
to that medial malleolus.
It's best to examine these initially
in the transverse plane.
And we can see two of those tendons very clearly,
right superficial to the tibial bone.
As a rheumatologist, you can see peritendinous processes
with fluid and synovial proliferation.
You can also find large tears or tendinopathy.
A longitudinal image of those tendons is also very easy
to obtain because they're so superficial.
We can look at the lateral aspect of the ankle.
The peroneus tendons are present here.
And just posterior
to the lateral malleolus are the peroneus tendons.
You can see them on the screen just
to the right of the bone.
There are two tendons there.
For examination of the Achilles tendon,
it's best to have the patient in the prone position,
and have the Achilles tendon lined up.
The image that you see on the screen,
the bony structure is the calcaneus.
The Achilles tendon is inserting
into the calcaneus distally.
This is a frequent zone of calcification.
And then going proximally,
you can get a very nice view both medially and laterally
of this Achilles tendon.
The structures deeper to the tendon include a bursa
and some fatty tissue.
This is the area where many tendon tears occur.
We also should then
examine the Achilles tendon transversely.
And this can be done all the way distal,
to the point where this Achilles tendon
gets smaller and smaller,
and inserts on the bone.
Or as we move proximally,
you might be able to see areas of tendinosis,
or tendonitis, or rupture here.
There are a number of appropriate measurements
that are frequently taken for the size,
accessing the size of the Achilles tendon.
These can be done
both in the transverse and longitudinal plane.
And usually we go just to the border
where the calcaneus ends,
and freeze the image.
And then using the calipers,
and place
one on this side
and one on this side for getting a measurement
from medial to lateral.
You can then get another measurement of thickness
from the superficial to the deep.
You can also measure an area.
Probably the best way to do it is manual.
And so then this gives us an area of the tendon,
in a cross section,
and that area is .85 centimeters squared.
You can also take measurements of the Achilles tendon
in the longitudinal plane.
And measure the thickness
at the edge of the calcaneus.

Brightcove ID

5751496699001

https://youtube.com/watch?v=CKcM5zFZk_g

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