<p begin="00:00:07.475" end="00:00:09.192" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.192" end="00:00:11.437" style="s2">with a musculoskeletal exam<br />type is used to perform</p>
<p begin="00:00:11.437" end="00:00:14.536" style="s2">an ultrasound examination of the medial</p>
<p begin="00:00:14.536" end="00:00:16.451" style="s2">and lateral meniscus.</p>
<p begin="00:00:16.451" end="00:00:18.503" style="s2">The patient is in a supine position</p>
<p begin="00:00:18.503" end="00:00:21.065" style="s2">with the knee flexed 90 degrees.</p>
<p begin="00:00:21.065" end="00:00:23.363" style="s2">The transducer is placed longitudinally</p>
<p begin="00:00:23.363" end="00:00:25.976" style="s2">just proximal to the fibular head</p>
<p begin="00:00:25.976" end="00:00:29.305" style="s2">with the orientation marker<br />directed to the patient's head.</p>
<p begin="00:00:29.305" end="00:00:32.353" style="s2">The lateral meniscus is<br />seen as a triangular-shaped</p>
<p begin="00:00:32.353" end="00:00:35.081" style="s2">object between the bright<br />hyperechoic signatures</p>
<p begin="00:00:35.081" end="00:00:37.628" style="s2">of the tibia and distal femur.</p>
<p begin="00:00:37.628" end="00:00:39.898" style="s2">The fibrillar lateral collateral ligament</p>
<p begin="00:00:39.898" end="00:00:42.227" style="s2">is superficial to the lateral meniscus</p>
<p begin="00:00:42.227" end="00:00:44.535" style="s2">and runs from the lateral<br />condyle of the femur</p>
<p begin="00:00:44.535" end="00:00:46.535" style="s2">to the fibular head.</p>
<p begin="00:00:46.535" end="00:00:48.768" style="s2">The meniscus should have a uniform pattern</p>
<p begin="00:00:48.768" end="00:00:51.208" style="s2">without surrounding anechoic fluid.</p>
<p begin="00:00:51.208" end="00:00:54.560" style="s2">Color Doppler can be used<br />to exclude hypervascularity,</p>
<p begin="00:00:54.560" end="00:00:58.096" style="s2">sometimes seen with inflammation<br />or significant trauma.</p>
<p begin="00:00:58.096" end="00:01:00.977" style="s2">To examine the medial meniscus,<br />the transducer is placed</p>
<p begin="00:01:00.977" end="00:01:04.011" style="s2">longitudinally over the medial joint space</p>
<p begin="00:01:04.011" end="00:01:05.699" style="s2">with the orientation marker directed</p>
<p begin="00:01:05.699" end="00:01:07.268" style="s2">toward the patient's head.</p>
<p begin="00:01:07.268" end="00:01:09.928" style="s2">The medial meniscus is<br />a wedge-shaped structure</p>
<p begin="00:01:09.928" end="00:01:12.677" style="s2">located between the bright<br />hyperechoic signature</p>
<p begin="00:01:12.677" end="00:01:15.213" style="s2">of the distal femur and proximal tibia.</p>
<p begin="00:01:15.213" end="00:01:17.680" style="s2">The medial collateral ligament overlies</p>
<p begin="00:01:17.680" end="00:01:20.824" style="s2">the medial meniscus and<br />has a fibrillar pattern.</p>
<p begin="00:01:20.824" end="00:01:23.205" style="s2">The meniscus should have a uniform pattern</p>
<p begin="00:01:23.205" end="00:01:26.922" style="s2">without surrounding anechoic<br />fluid, tracks or cysts,</p>
<p begin="00:01:26.922" end="00:01:29.326" style="s2">which indicate a meniscal tear.</p>
<p begin="00:01:29.326" end="00:01:32.536" style="s2">Color Doppler can be used<br />to exclude hypervascularity,</p>
<p begin="00:01:32.536" end="00:01:36.703" style="s2">sometimes seen with inflammation<br />or significant trauma.</p>

<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="00:00:07.317" end="00:00:08.978" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:08.978" end="00:00:12.109" style="s2">with a musculoskeletal exam<br />type is used to perform</p>
<p begin="00:00:12.109" end="00:00:15.195" style="s2">an ultrasound-guided injection<br />of the medial collateral</p>
<p begin="00:00:15.195" end="00:00:16.888" style="s2">ligament of the knee.</p>
<p begin="00:00:16.888" end="00:00:18.877" style="s2">The patient is in a supine position</p>
<p begin="00:00:18.877" end="00:00:21.545" style="s2">with the knee flexed 90 degrees.</p>
<p begin="00:00:21.545" end="00:00:25.073" style="s2">The transducer is placed<br />longitudinally over the inner knee</p>
<p begin="00:00:25.073" end="00:00:27.571" style="s2">at the joint space with<br />the orientation marker</p>
<p begin="00:00:27.571" end="00:00:29.959" style="s2">directed to the patient's head.</p>
<p begin="00:00:29.959" end="00:00:32.263" style="s2">The medial collateral ligament can be seen</p>
<p begin="00:00:32.263" end="00:00:35.025" style="s2">as a fibular patterned compact structure</p>
<p begin="00:00:35.025" end="00:00:38.035" style="s2">superficial to the bright<br />hyperechoic distal femur</p>
<p begin="00:00:38.035" end="00:00:40.155" style="s2">and proximal tibia.</p>
<p begin="00:00:40.155" end="00:00:43.123" style="s2">The medial meniscus is a<br />triangular shaped structure</p>
<p begin="00:00:43.123" end="00:00:45.288" style="s2">between the two bones.</p>
<p begin="00:00:45.288" end="00:00:47.754" style="s2">The medial collateral<br />ligament should be traced from</p>
<p begin="00:00:47.754" end="00:00:50.910" style="s2">insertion on the femoral<br />condyle down to the darker</p>
<p begin="00:00:50.910" end="00:00:54.390" style="s2">hypoechoic pes anserine tendon complex.</p>
<p begin="00:00:54.390" end="00:00:56.865" style="s2">The transducer is adjusted<br />so it is centered over</p>
<p begin="00:00:56.865" end="00:00:59.099" style="s2">the medial collateral ligament.</p>
<p begin="00:00:59.099" end="00:01:01.765" style="s2">The needle is inserted<br />in the skin just proximal</p>
<p begin="00:01:01.765" end="00:01:03.498" style="s2">to the transducer.</p>
<p begin="00:01:03.498" end="00:01:06.162" style="s2">The needle is slowly<br />advanced to lie in plane</p>
<p begin="00:01:06.162" end="00:01:08.783" style="s2">to the transducer beam<br />and is seen as a bright</p>
<p begin="00:01:08.783" end="00:01:11.277" style="s2">hyperechoic linear structure.</p>
<p begin="00:01:11.277" end="00:01:13.992" style="s2">The needle is slowly advanced<br />under direct ultrasound</p>
<p begin="00:01:13.992" end="00:01:16.988" style="s2">visualization until the<br />tip is seen in proximity</p>
<p begin="00:01:16.988" end="00:01:19.844" style="s2">to the ligament where an<br />injection can be done.</p>
<p begin="00:01:19.844" end="00:01:22.136" style="s2">After the procedure is finished, the area</p>
<p begin="00:01:22.136" end="00:01:24.615" style="s2">should be scanned to ensure<br />that there is no evidence</p>
<p begin="00:01:24.615" end="00:01:26.615" style="s2">of bleeding in the area.</p>

<p begin="00:00:07.393" end="00:00:09.023" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.023" end="00:00:11.914" style="s2">with the musculoskeletal<br />exam type is used to perform</p>
<p begin="00:00:11.914" end="00:00:15.626" style="s2">an ultrasound examination of<br />the medial collateral ligament</p>
<p begin="00:00:15.626" end="00:00:16.752" style="s2">of the knee.</p>
<p begin="00:00:16.752" end="00:00:18.666" style="s2">The patient is in a supine position,</p>
<p begin="00:00:18.666" end="00:00:21.420" style="s2">with the knee flexed 90 degrees.</p>
<p begin="00:00:21.420" end="00:00:24.672" style="s2">The transducer is placed<br />longitudinally over the inner knee</p>
<p begin="00:00:24.672" end="00:00:27.541" style="s2">at the joint space, with the<br />orientation marker directed</p>
<p begin="00:00:27.541" end="00:00:29.498" style="s2">to the patient's head.</p>
<p begin="00:00:29.498" end="00:00:31.804" style="s2">The medial collateral<br />ligament can be seen as</p>
<p begin="00:00:31.804" end="00:00:34.336" style="s2">a compact, fibrillar patterned structure,</p>
<p begin="00:00:34.336" end="00:00:37.058" style="s2">superficial to the bright<br />hyperechoic distal femur</p>
<p begin="00:00:37.058" end="00:00:39.061" style="s2">and proximal tibia.</p>
<p begin="00:00:39.061" end="00:00:41.334" style="s2">The medial meniscus is<br />a triangular-shaped,</p>
<p begin="00:00:41.334" end="00:00:44.520" style="s2">hyperechoic structure<br />between the two bones.</p>
<p begin="00:00:44.520" end="00:00:47.454" style="s2">The medial collateral<br />ligament has a superficial</p>
<p begin="00:00:47.454" end="00:00:50.053" style="s2">and deep layer that should<br />be scanned from insertion</p>
<p begin="00:00:50.053" end="00:00:53.227" style="s2">on the femoral condyle down<br />to the darker, hyperechoic</p>
<p begin="00:00:53.227" end="00:00:55.566" style="s2">pes anserine tendon complex.</p>
<p begin="00:00:55.566" end="00:01:00.054" style="s2">The transducer is then rotated<br />90 degrees counterclockwise</p>
<p begin="00:01:00.054" end="00:01:02.259" style="s2">to obtain a short axis view.</p>
<p begin="00:01:02.259" end="00:01:05.175" style="s2">The medial collateral ligament<br />appears as a bilaminate,</p>
<p begin="00:01:05.175" end="00:01:09.156" style="s2">sheet-like structure, with<br />a darker, hypoechoic middle.</p>
<p begin="00:01:09.156" end="00:01:12.171" style="s2">The ligament should be scanned<br />from its proximal origin</p>
<p begin="00:01:12.171" end="00:01:16.338" style="s2">to its distal insertion to<br />complete the examination.</p>

<p begin="00:00:09.660" end="00:00:12.635" style="s2">- Next we're going to examine<br />the patient's medial meniscus</p>
<p begin="00:00:12.635" end="00:00:14.523" style="s2">and medial collateral ligament.</p>
<p begin="00:00:14.523" end="00:00:17.067" style="s2">The medial collateral<br />ligament lies just on top</p>
<p begin="00:00:17.067" end="00:00:21.067" style="s2">of the meniscus and can<br />be seen on the same image.</p>
<p begin="00:00:21.067" end="00:00:22.351" style="s2">To identify this structure</p>
<p begin="00:00:22.351" end="00:00:24.887" style="s2">I'm going to place my tranducer</p>
<p begin="00:00:24.887" end="00:00:27.186" style="s2">in the longitudinal plane</p>
<p begin="00:00:27.186" end="00:00:29.269" style="s2">and palpate the patient's</p>
<p begin="00:00:30.736" end="00:00:32.982" style="s2">joint in the center.</p>
<p begin="00:00:32.982" end="00:00:35.482" style="s2">Place the probe over that area</p>
<p begin="00:00:36.889" end="00:00:40.236" style="s2">and center the meniscus<br />in my screen for viewing.</p>
<p begin="00:00:40.236" end="00:00:44.481" style="s2">The medial meniscus is<br />a wedge-like structure.</p>
<p begin="00:00:44.481" end="00:00:46.812" style="s2">To determine if there is acute trauma</p>
<p begin="00:00:46.812" end="00:00:50.060" style="s2">we can put color doppler on the meniscus.</p>
<p begin="00:00:50.060" end="00:00:52.372" style="s2">Here there's no significant trauma</p>
<p begin="00:00:52.372" end="00:00:55.582" style="s2">or suggestion of any<br />increased vascularity.</p>
<p begin="00:00:55.582" end="00:00:58.526" style="s2">In addition we can zoom<br />in to the meniscus.</p>
<p begin="00:00:58.526" end="00:01:01.955" style="s2">I do this by pressing the zoom button,</p>
<p begin="00:01:01.955" end="00:01:05.117" style="s2">squaring the image, centering it</p>
<p begin="00:01:05.117" end="00:01:07.945" style="s2">and pressing the zoom once again.</p>
<p begin="00:01:07.945" end="00:01:10.177" style="s2">And here I visualize the meniscus</p>
<p begin="00:01:10.177" end="00:01:12.937" style="s2">which appears healthy with<br />no significant trauma.</p>
<p begin="00:01:12.937" end="00:01:14.481" style="s2">Overlying the meniscus</p>
<p begin="00:01:14.481" end="00:01:17.833" style="s2">lies the medial collateral ligament.</p>
<p begin="00:01:17.833" end="00:01:20.865" style="s2">Which is a band-like<br />structure that we can see</p>
<p begin="00:01:20.865" end="00:01:23.782" style="s2">directly above the medial meniscus.</p>
<p begin="00:01:24.770" end="00:01:27.694" style="s2">I recommend starting<br />at the medial mensicus</p>
<p begin="00:01:27.694" end="00:01:30.698" style="s2">to identify the medial collateral ligament</p>
<p begin="00:01:30.698" end="00:01:33.441" style="s2">and then tracing the<br />ligament at it's proximal</p>
<p begin="00:01:33.441" end="00:01:35.769" style="s2">and then distal insertion.</p>
<p begin="00:01:35.769" end="00:01:39.211" style="s2">We begin by following<br />from the medial meniscus.</p>
<p begin="00:01:39.211" end="00:01:42.102" style="s2">Seeing the medial collateral ligament</p>
<p begin="00:01:42.102" end="00:01:45.674" style="s2">approximately to the femoral condyle.</p>
<p begin="00:01:45.674" end="00:01:47.685" style="s2">It's important to have<br />knowledge of the anatomy</p>
<p begin="00:01:47.685" end="00:01:48.705" style="s2">and know that the direction</p>
<p begin="00:01:48.705" end="00:01:51.983" style="s2">that the medial collateral<br />ligament travels.</p>
<p begin="00:01:51.983" end="00:01:52.922" style="s2">So we're going to travel</p>
<p begin="00:01:52.922" end="00:01:57.366" style="s2">the medial collateral<br />ligament approximately</p>
<p begin="00:01:57.366" end="00:02:01.183" style="s2">while looking at the screen<br />to maintain an accurate image.</p>
<p begin="00:02:01.183" end="00:02:04.262" style="s2">We see the medial collateral<br />ligament bending down</p>
<p begin="00:02:04.262" end="00:02:07.129" style="s2">and heading towards the attachment</p>
<p begin="00:02:07.129" end="00:02:09.605" style="s2">at its proximal end here.</p>
<p begin="00:02:09.605" end="00:02:11.348" style="s2">We're going to begin at our starting point</p>
<p begin="00:02:11.348" end="00:02:13.692" style="s2">which will be the medial meniscus</p>
<p begin="00:02:13.692" end="00:02:15.566" style="s2">and follow it distally</p>
<p begin="00:02:15.566" end="00:02:17.487" style="s2">along to its insertion.</p>
<p begin="00:02:17.487" end="00:02:20.173" style="s2">Following along here<br />you see the thick band</p>
<p begin="00:02:20.173" end="00:02:22.350" style="s2">of the medial collateral ligament.</p>
<p begin="00:02:22.350" end="00:02:25.115" style="s2">It actually inserts quite distally</p>
<p begin="00:02:25.115" end="00:02:28.425" style="s2">and what we can also see down<br />here are important structures</p>
<p begin="00:02:28.425" end="00:02:32.028" style="s2">known as the pes anserine tendons.</p>
<p begin="00:02:32.028" end="00:02:34.402" style="s2">These appear at the right of the screen</p>
<p begin="00:02:34.402" end="00:02:37.569" style="s2">as three discrete tendons of darkness.</p>