<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="00:00:07.374" end="00:00:09.089" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.089" end="00:00:12.017" style="s2">with a musculoskeletal exam<br />type is used to perform</p>
<p begin="00:00:12.017" end="00:00:14.388" style="s2">an ultrasound examination of the Lateral</p>
<p begin="00:00:14.388" end="00:00:16.672" style="s2">Collateral Ligament of the Knee.</p>
<p begin="00:00:16.672" end="00:00:18.568" style="s2">The patient is in a supine position</p>
<p begin="00:00:18.568" end="00:00:21.341" style="s2">with the knee flexed 90 degrees.</p>
<p begin="00:00:21.341" end="00:00:23.742" style="s2">The transducer is placed longitudinally</p>
<p begin="00:00:23.742" end="00:00:25.916" style="s2">over the outer knee at the joint space</p>
<p begin="00:00:25.916" end="00:00:27.753" style="s2">with the orientation marker directed</p>
<p begin="00:00:27.753" end="00:00:29.563" style="s2">to the patient's head.</p>
<p begin="00:00:29.563" end="00:00:32.682" style="s2">The fibular head is a<br />bright, hyperechoic structure</p>
<p begin="00:00:32.682" end="00:00:35.641" style="s2">where the biceps femoris muscle attaches.</p>
<p begin="00:00:35.641" end="00:00:37.553" style="s2">The transducer should be translated</p>
<p begin="00:00:37.553" end="00:00:39.726" style="s2">in a windshield wiper type maneuver</p>
<p begin="00:00:39.726" end="00:00:42.375" style="s2">to connect the fibula<br />and the femoral condyle</p>
<p begin="00:00:42.375" end="00:00:45.671" style="s2">to identify the Lateral<br />Collateral Ligament.</p>
<p begin="00:00:45.671" end="00:00:47.588" style="s2">The ligament can be seen as a packed,</p>
<p begin="00:00:47.588" end="00:00:50.143" style="s2">fibular patterned, tight,<br />elliptical structure</p>
<p begin="00:00:50.143" end="00:00:52.167" style="s2">arising from the lateral condyle,</p>
<p begin="00:00:52.167" end="00:00:54.630" style="s2">and inserting on the fibular head.</p>
<p begin="00:00:54.630" end="00:00:57.277" style="s2">The transducer is then rotated 90 degrees</p>
<p begin="00:00:57.277" end="00:01:00.799" style="s2">counterclockwise to<br />obtain a short-axis view.</p>
<p begin="00:01:00.799" end="00:01:02.914" style="s2">The Lateral Collateral Ligament appears</p>
<p begin="00:01:02.914" end="00:01:05.520" style="s2">as a sheet-like structure,<br />which should be scanned</p>
<p begin="00:01:05.520" end="00:01:07.742" style="s2">from its proximal to distal insertion</p>
<p begin="00:01:07.742" end="00:01:10.159" style="s2">to complete the examination.</p>

<p begin="00:00:07.292" end="00:00:08.981" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:08.981" end="00:00:11.121" style="s2">with a musculoskeletal examine type</p>
<p begin="00:00:11.121" end="00:00:13.777" style="s2">is used to perform an<br />ultrasound guided injection</p>
<p begin="00:00:13.777" end="00:00:16.673" style="s2">of the knee using a lateral approach.</p>
<p begin="00:00:16.673" end="00:00:18.782" style="s2">The patient is in a supine position</p>
<p begin="00:00:18.782" end="00:00:20.520" style="s2">with the leg extended.</p>
<p begin="00:00:20.520" end="00:00:23.616" style="s2">The transducer is placed<br />just proximal to the patella</p>
<p begin="00:00:23.616" end="00:00:25.906" style="s2">in a long-axis fashion.</p>
<p begin="00:00:25.906" end="00:00:28.317" style="s2">The fibular pattern of<br />the quadriceps tendon</p>
<p begin="00:00:28.317" end="00:00:31.276" style="s2">in seen above the rounded,<br />bright hyperechoic surface</p>
<p begin="00:00:31.276" end="00:00:33.983" style="s2">of the distal femur and patella.</p>
<p begin="00:00:33.983" end="00:00:36.301" style="s2">The suprapatellar fat-pad and the darker</p>
<p begin="00:00:36.301" end="00:00:38.897" style="s2">hypoechoic suprapatellar bursa</p>
<p begin="00:00:38.897" end="00:00:40.829" style="s2">can be seen in this image.</p>
<p begin="00:00:40.829" end="00:00:43.760" style="s2">The transducer is rotated<br />90 degrees clockwise</p>
<p begin="00:00:43.760" end="00:00:46.149" style="s2">for a short-axis view of the bursa,</p>
<p begin="00:00:46.149" end="00:00:47.922" style="s2">which lies below the patellar tendon</p>
<p begin="00:00:47.922" end="00:00:50.137" style="s2">and above the bony cortex.</p>
<p begin="00:00:50.137" end="00:00:52.601" style="s2">The transducer is<br />adjusted so it is centered</p>
<p begin="00:00:52.601" end="00:00:55.199" style="s2">over the superapatellar bursa.</p>
<p begin="00:00:55.199" end="00:00:56.947" style="s2">The needle is inserted in the skin</p>
<p begin="00:00:56.947" end="00:00:58.889" style="s2">just proximal to the transducer,</p>
<p begin="00:00:58.889" end="00:01:01.243" style="s2">opposite the orientation marker.</p>
<p begin="00:01:01.243" end="00:01:03.766" style="s2">The needle is slowly<br />advanced to lie in-plane</p>
<p begin="00:01:03.766" end="00:01:06.557" style="s2">to the transducer beam,<br />and is seen as a bright,</p>
<p begin="00:01:06.557" end="00:01:09.116" style="s2">hyperechoic, linear structure.</p>
<p begin="00:01:09.116" end="00:01:11.776" style="s2">The needle is slowly advanced<br />under direct ultrasound</p>
<p begin="00:01:11.776" end="00:01:13.807" style="s2">visualization until the tip is seen</p>
<p begin="00:01:13.807" end="00:01:15.380" style="s2">to lie within the bursa,</p>
<p begin="00:01:15.380" end="00:01:19.297" style="s2">where the injection or<br />aspiration can be done.</p>

<p begin="00:00:09.866" end="00:00:11.390" style="s2">- Next, we're gonna move laterally</p>
<p begin="00:00:11.390" end="00:00:13.801" style="s2">and examine the patient's lateral meniscus</p>
<p begin="00:00:13.801" end="00:00:17.193" style="s2">and lateral collateral ligament.</p>
<p begin="00:00:17.193" end="00:00:18.361" style="s2">It's an important landmark</p>
<p begin="00:00:18.361" end="00:00:19.832" style="s2">so we're gonna hold the transducer</p>
<p begin="00:00:19.832" end="00:00:22.582" style="s2">with the notch facing superiorly.</p>
<p begin="00:00:23.920" end="00:00:27.073" style="s2">An important landmark on the<br />patient is the fibular head.</p>
<p begin="00:00:27.073" end="00:00:30.548" style="s2">I'm going to palpate the fibular head</p>
<p begin="00:00:30.548" end="00:00:32.327" style="s2">and place the transducer so that</p>
<p begin="00:00:32.327" end="00:00:34.265" style="s2">the bottom edge of the transducer</p>
<p begin="00:00:34.265" end="00:00:36.827" style="s2">is in contact with the<br />patient's fibular head.</p>
<p begin="00:00:36.827" end="00:00:38.922" style="s2">And that should give us a direct view</p>
<p begin="00:00:38.922" end="00:00:40.852" style="s2">of the lateral meniscus.</p>
<p begin="00:00:40.852" end="00:00:42.158" style="s2">It's important to keep your image</p>
<p begin="00:00:42.158" end="00:00:45.175" style="s2">at the center of the screen<br />to get the best view.</p>
<p begin="00:00:45.175" end="00:00:48.327" style="s2">Here we can see the<br />patient's lateral meniscus.</p>
<p begin="00:00:48.327" end="00:00:49.727" style="s2">Overlying the meniscus is</p>
<p begin="00:00:49.727" end="00:00:53.903" style="s2">the lateral collateral ligament<br />which we'll look at next.</p>
<p begin="00:00:53.903" end="00:00:56.711" style="s2">The meniscus appears as<br />a wedge-shaped structure</p>
<p begin="00:00:56.711" end="00:00:59.816" style="s2">with a homogeneous pattern throughout.</p>
<p begin="00:00:59.816" end="00:01:04.339" style="s2">A tear may show dark<br />patterns within the meniscus</p>
<p begin="00:01:04.339" end="00:01:09.184" style="s2">as well as fluid leaking into<br />the surrounding joint space.</p>
<p begin="00:01:09.184" end="00:01:11.516" style="s2">If we suspect meniscal trauma,</p>
<p begin="00:01:11.516" end="00:01:13.665" style="s2">sometimes we'll use color Doppler</p>
<p begin="00:01:13.665" end="00:01:16.097" style="s2">and see if there's an acute inflammation</p>
<p begin="00:01:16.097" end="00:01:19.267" style="s2">or significant injury demonstrated.</p>
<p begin="00:01:19.267" end="00:01:22.350" style="s2">To do this, I activate color Doppler.</p>
<p begin="00:01:25.350" end="00:01:28.155" style="s2">And if there was any acute trauma,</p>
<p begin="00:01:28.155" end="00:01:30.919" style="s2">once the probe is<br />stabilized and not moving,</p>
<p begin="00:01:30.919" end="00:01:32.955" style="s2">we'd see the increased vascular activity,</p>
<p begin="00:01:32.955" end="00:01:34.288" style="s2">which we do not.</p>
<p begin="00:01:35.621" end="00:01:38.470" style="s2">An additional feature<br />that we may be able to do</p>
<p begin="00:01:38.470" end="00:01:40.719" style="s2">is to zoom in on a structure.</p>
<p begin="00:01:40.719" end="00:01:43.052" style="s2">To do this, I'll press zoom.</p>
<p begin="00:01:45.507" end="00:01:47.587" style="s2">Center over the desired region</p>
<p begin="00:01:47.587" end="00:01:49.337" style="s2">and press zoom again.</p>
<p begin="00:01:51.009" end="00:01:52.866" style="s2">And now I see a blown up image</p>
<p begin="00:01:52.866" end="00:01:55.071" style="s2">of the patient's lateral meniscus.</p>
<p begin="00:01:55.071" end="00:01:58.320" style="s2">As well as the surrounding<br />lateral collateral ligament,</p>
<p begin="00:01:58.320" end="00:02:02.165" style="s2">which is the band seen<br />at the top of the screen.</p>
<p begin="00:02:02.165" end="00:02:04.623" style="s2">Again, seeing a homogeneous<br />image of the meniscus</p>
<p begin="00:02:04.623" end="00:02:07.123" style="s2">with no indication of tearing.</p>
<p begin="00:02:08.308" end="00:02:09.678" style="s2">The next structure to image</p>
<p begin="00:02:09.678" end="00:02:12.572" style="s2">lies just above the lateral meniscus,</p>
<p begin="00:02:12.572" end="00:02:15.170" style="s2">which is the lateral collateral ligament.</p>
<p begin="00:02:15.170" end="00:02:17.776" style="s2">Maintain the transducer<br />in the superior position</p>
<p begin="00:02:17.776" end="00:02:21.327" style="s2">with the notch facing<br />towards the patient's head.</p>
<p begin="00:02:21.327" end="00:02:23.989" style="s2">An important landmark is the fibular head.</p>
<p begin="00:02:23.989" end="00:02:25.368" style="s2">I like to keep the fibular head</p>
<p begin="00:02:25.368" end="00:02:28.179" style="s2">in the center of the<br />transducer beneath it.</p>
<p begin="00:02:28.179" end="00:02:30.846" style="s2">Which will allow me to visualize</p>
<p begin="00:02:31.707" end="00:02:35.461" style="s2">the distal attachment of the<br />lateral collateral ligament.</p>
<p begin="00:02:35.461" end="00:02:36.933" style="s2">Here we can see fibers of</p>
<p begin="00:02:36.933" end="00:02:38.409" style="s2">the lateral collateral ligament</p>
<p begin="00:02:38.409" end="00:02:40.868" style="s2">attaching on the fibular head.</p>
<p begin="00:02:40.868" end="00:02:43.858" style="s2">Next what we do is trace this<br />lateral collateral ligament</p>
<p begin="00:02:43.858" end="00:02:47.616" style="s2">up to its attachment on the<br />lateral femoral condyle.</p>
<p begin="00:02:47.616" end="00:02:50.415" style="s2">We follow the lateral collateral ligament</p>
<p begin="00:02:50.415" end="00:02:53.374" style="s2">as it continues to pass above the condyle.</p>
<p begin="00:02:53.374" end="00:02:57.541" style="s2">And eventually we'll taper<br />back onto the upper condyle.</p>