Msk Ultrasound

Media Library Type

Media Library Tag

Hip

Hip Ultrasound

Trochanteric Bursitis

Subtitles

- We're gonna examine the hip today,
this is her right hip and we'll look anteriorly
at the femoral acetabular joint,
and then we'll also look laterally
at the greater trochanter.
Positioning is important,
she is lying on her back with her leg extended
and slightly externally rotated.
This is the best position to see this joint.
I've chosen a C60 transducer.
There is a line here which corresponds
to the turquoise dot on the screen,
and this we usually, by tradition,
keep proximally or medially,
and that's the way I'll orient this image.
I'm trying to align the transducer
approximately parallel with the femoral neck,
and the left side of the screen,
the hyperechoic line is the acetabulum.
The curved structure, or circular structure,
is the femoral head.
It then drops down to the femoral neck,
and we can see the femur itself extending
parallel to the top part of the image,
out toward the right.
You can even see the joint capsule
and the cartilage on the femoral head,
and in the corner where the neck joins the ball
of the femur you can see the femoral joint space.
And that area right there at the base
is where you aim when you want to do an injection.
Before you do anything,
you want to identify the great vessels,
and I will turn the transducer transversely,
and look medially,
and we can see the anechoic structures that are pulsating.
I'll turn on the color.
Should be able to confirm that those are the vessels.
We want to, obviously, avoid those.
When I turn back longitudinally,
I see that those vessels are medial
to where I was looking before,
and now that area that I have examined
does not have blood vessels.
Sometimes it's a good idea to look
in this area,
because that's the direction the needle
is gonna be coming,
to make sure there are no branches
of the femoral artery or vein going in that direction.
If an effusion is present,
you'll usually see it right at that junction point
between the femoral head and the neck.
You'll see a bulge in the joint capsule,
it will be coming up and to the right,
and we'll usually move the iliopsoas muscle
and tendon dorsally, or superficially.
I'm gonna examine the lateral aspect of her hip,
the greater trochanter especially.
This would be an area that you can examine
with ultrasound in a symptomatic patient.
She's lying on her left side
with her hip extended.
Just slight flexion position.
I'm using a linear transducer now.
Sometimes in a person who has a
much deeper area to traverse,
I might use a C60.
This transducer has a linear mark here,
which corresponds to the turquoise dot on the screen,
and we keep that proximal,
or we keep that medial.
The hyperechoic curved line
is the superior edge of the greater trochanter.
There are muscles and tendons, then,
just beneath the skin.
Going distally, we see the rest of the greater trochanter
with tendinous insertions
of the gluteus muscles.
If we turn this transversely,
we can again see the bony outline
deep as a hyperechoic structure,
and above it,
a series of tendinous structures,
the gluteus muscles come in and attach
to the greater trochanter.
Anteriorly
and posteriorly
we can see these images around the greater trochanter,
and there are a series of bursae present there,
with fluid-filled sacs
visible in a person who would have bursitis.

Brightcove ID

5734020657001

https://youtube.com/watch?v=0Fu4R9mEoz4

How To: Ultrasound Guided Hand Injection

Read more about How To: Ultrasound Guided Hand Injection

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

Clinical Specialties

Media Library Type

Media Library Tag

Metacarpophalangeal Joint

Hand

Wrist

Extensor Tendon

Rheumatology Ultrasound

Rheumatoid Ultrasound

Subtitles

- So I'm going to show a technique for injection of fingers,
and we'll do on the Dorsal surface or Extensor surface,
a simulation of injection of either a PIP or MCP joint
and then turn the hand around on the Palmar surface,
and show you an injection approach for Flexor tendons.
I'm gonna use the L25 transducer.
Normally we would be dealing with a sterile field,
and a sterile gel, and most likely a transducer cover,
which is also sterile, but for the purposes of this,
we're just showing you an approach.
If the joint is swollen and has Synovitis,
or a joint diffusion, it's quite easy to see the space
that you're aiming for.
This particular exam, we don't have that finding.
Normally for an injection into a small joint like this,
I like to approach the joint with the transducer placed
transversely, in this type of a plane, and then have
the needle in the same direction parallel, or in plane
with the transducer, so my needle and my transducer are
parallel, and I'm going as superficial as possible,
with a very small needle so it doesn't hurt,
and trying to place the needle into the skin,
and in the one millimeter ultrasound beam,
into the target this way.
On the other side, we'll be looking at a Flexor tendon,
which travels in this direction.
I will place the transducer longitudinally,
and approach with the needle in this direction.
If you keep the needle parallel to the surface
of the transducer, it shows up the best.
The insertion point can be quite close
to the transducer's edge, especially if you're going
very superficially; in a small area like a finger,
or a tendon around here, you don't have a lot of space
and so you have to go very close, and can insert
the needle very flat and superficially.
Because there's very little space between the skin surface
and the tendon, and here it's probably
about two or three millimeters.
And watch exactly where the tip of the needle
and the bevel goes.

Brightcove ID

5751328215001

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

How To: Hand Exam

Read more about How To: Hand Exam

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

Clinical Specialties

Media Library Type

Media Library Tag

Metacarpophalangeal Joint

Hand

Wrist

Extensor Tendon

Rheumatology Ultrasound

Rheumatoid Ultrasound

Synovial Prolipheration

Subtitles

- 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

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

Clinical Specialties

Media Library Type

Media Library Tag

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

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

Clinical Specialties

Media Library Type

Media Library Tag