SHOULDER ULTRASOUNDPersonal protocols

Caitlin Gardiner

INTRODUCTION

The practice I did the majority of my training with in my first year of clinical ultrasound performs little MSK ultrasound. I have just commenced work in the past few weeks at a general radiology practice where I am already exposed to a significant degree more MSK ultrasound that ever before. At this stage, I’m scanning MSK with another sonographer and the plan is to slowly add various scans to my list as I gain competency. Shoulder ultrasound is challenging due to the large number of tendons very proximal to one another and unique scanning plane. Using my images I submitted for homework, this is a summary of what I know so far with the feedback I have been given by my tutor.

BICEPS

Ipsilateral hand of the shoulder placed on the knee with palm upwards.

Observe in Trans -?surrounding fluid Observe it Long

?regular fibers Any hypoechoic/thickening

Ensure visualization from upper biceps muscle to very superior segment

Assess groove <3mm= shallow Transverse bicep central/medial

edge(subluxed)/out of the groove (dislocated)

Assess pop-eye sign, to aid biceps rupture

Patient Position/Manoeuvre

Assessment of Structure

BICEPS- SUBMITTED IMAGES AND FEEDBACK

Lovely

SUBSCAPULARIS

Place probe in transverse, fully rotate the arm externally

Assess subscupularis like this and then visualize in mild extension and partial external rotation

Assess all fibres, including those adjacent to the bicep tendon (utilise manoeuvres)

Ensure observation of subscapularis sliding under coracoid (?entrapment)

Visualise fibrillar pattern and any bursal thickening

Mild bony irregularly is acceptable

Patient Position/Manoeuvre

Assessment of Structure

SUBMITTED IMAGES AND FEEDBACK

Image with internal rotation does not have subscapularis in it

CA LIGAMENT

Maintain external rotation of the arm. Slide the probe medial to visualize the clavicle and angle the lateral end of probe superior to around 45° to see acromium.

Patient Position/Manoeuvre

Assessment of Structure

SUBMITTED IMAGES AND FEEDBACK

Lovely

AC JOINT

‘Plonk’ probe on top, in line with the clavicle

Is there any focal tenderness?

Any separation of the two bones (can get patient to pull from underneath of bed to apply pressure)

Any cysts or bony spurs

Patient Position/Manoeuvre

Assessment of Structure

SUBMITTED IMAGES AND FEEDBACK

Lovely.

SUPRASPINATUS

Place the ipsilateral hand on the ipsilateral hip with elbow posterior. Visualize the bicep in transverse in the most medial side of the screen. Slide the probe backwards to visual is transverse. Rotate 90°to view tendon in longitudinal.

Consider various positions (eg, hand behind back/neutral) throughout to maximize assessment

In true transverse, assess from anterior to posterior ensuring visualisation adjacent to biceps tendon Regular contour (?thinning,

flattening) In longitudinal, image from

medial to lateral fibrillar pattern Bony irregularity (?

enthesopathy) Bursal thickening Note any calcifications and

associated hypervascularity

Patient Position/Manoeuvre

Assessment of Structure

SUBMITTED IMAGES AND FEEDBACK

None of trans images have biceps in them, therefore most anterior portion is not imaged. Mid and post long images are a little oblique.

INFRASPINATUS

Place hand on contralateral shoulder. Position probe on posterior of shoulder (not too far back).

Mild bony irregularity is acceptable

Significant bony irregularity/Hill-Sachs deformities indicate dislocation

If need to differentiate from supraspinatus, refer to previous position where the infraspinatus fibres run oblique

Patient Position/Manoeuvre

Assessment of Structure

SUBMITTED IMAGES AND FEEDBACK

Lovely.

POSTERIOR JOINT

Drop field of depth from infraspinatus and slide probe slightly medial

Ask patient to slowly tap ipsilateral shoulder and observe any joint fluid.

Appears as an echogenic triangle

?fluid ?cysts

Patient Position/Manoeuvre

Assessment of Structure

SUBMITTED IMAGES AND FEEDBACK

No feedback.

SPINOGLENOID/SUPRASCAPULAR NOTCHES

Spinoglenoid notch- move probe more medially

Suprascapular notch- position probe between the superior scapula and the posterior border of the lateral clavicle

Exclude ganglion and cysts

Patient Position/Manoeuvre

Assessment of Structure

SUBMITTED IMAGES AND FEEDBACK

?Mislabelled

ABDUCTION

Patients arm is bent beside their torso with their palm up. Abduct slowly.

Observe anterior and mid supraspinatus under CA Ligament

? Bunching of the supraspinatus

?bunching of the bursa

Patient Position/Manoeuvre

Assessment of Structure

SUBMITTED IMAGES AND FEEDBACK

Good.

REFERENCES

Ideas extracted from McNally E, 2005. Practical Musculoskeletal

Sonography. Elevisier Churchill Livingstone, Philadelphia

Coombs P, 2005. Shoulder Ultrasound: a discussion paper. Soundeffects; 3:18-25