Gonzalo Serrano-Belmar.
@GSERRANOB_MSK
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MSK radiologist at CLINICA ALEMANA SANTIAGO, Chile. Sharing knowledge in a didactic way. Amateur medical illustrator 🇨🇱+🇵🇹 #MSKRad
Santiago, Chile.
Joined March 2020
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We frequently see on MRI inflammatory changes of the suprapatellar or prefemoral fat pads, and we call it impingement. But few times we see it directly as in these case
Impingement with painful snapping between both fat pads during knee flexion-extension
💪 Dynamics
#mskrad
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DeQuervain Tendinopathy.
The presence of an intertendinous septum, forming a subcompartment for the EPB, is an essential element when evaluating the De Quervain's tendinopathy by US.
The septum is easily recognizable in both the transverse and longitudinal planes.
#mskrad
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Supraspinatus tendon tear.
Abduction against resistance can be a useful tool when assessing a supraspinatus tear, the muscle pulls the ruptured tendon, pulling it back and increasing the gap.
Here is a demonstrative example of the concept.
#mskrad
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Three examples of the volar plate of the fingers. 1. normal - 2. acute traumatic tear - 3. chronic tear with a swan neck deformity.
The dynamic and comparative study are priceless.
#MSKRad
#mskrad
#ultrasound
#ultrasonido
#volarplate
#radiology
#radiologia
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The Medial Collateral Ligament has a deep component made up of two ligaments—the meniscofemoral ligament (MFL) and the meniscotibial ligament (MTL).
The MFL is the most frequently injured, with its most likely site to rupture at the femoral insertion (+/- 80%).
The MFL
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The fibers of the supraspinatus tendon (bursal/intermediate/articular) have a tension that is maintained with an intact tendon.
This tension is partially or completely lost in a tear.
This tension can be evaluated with US, helping in doubtful cases.
Thanks G. Azulay
#mskrad
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Common extensor tendon tear of the elbow.
Maximum elbow flexion is extremely useful in better identifying tendon tears.
The tears usually have a longitudinal orientation; elbow flexion compresses the tendon like an accordion, opening these longitudinal tears.
"BUT," if you see
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Patellar tendon-lateral femoral condyle friction syndrome (PT-LFCFS).
-Also known as Hoffa's fat pad impingement syndrome.
-Anterior knee pain in active individuals.
-Relationship with patellar malalignment or vastus medialis/lateralis imbalance.
-Frequently associated with
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The soft tissue components of the biceps pulley system include:
•Subscapularis
•Supraspinatus
•The coracohumeral ligament (CHL)
•The superior glenohumeral ligament (SGHL)
The subscapularis has superficial and deep fibers that envelope the groove, creating the “roof” and
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Trigger finger.
US and Dynamic correlation.
Passive mobilization of the tendons shows restriction of their excursion at the A1 pulley, in addition to focal tendinosis of the FDS and FDP. In the second part, active flexion overcomes resistance, and snapping occurs.
#mskrad
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Quick Case.
Patient with a history of recent trauma. He was referred for an ankle ultrasound (normal).
Clearly, the problem is at the mid-foot.
Lisfranc injury, maneuvers are performed with stress, axial compression on the metatarsal with a fixed midfoot, and we can clearly
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Tear of the volar plate at the PIP, one month of evolution. Look at the retraction and how the tendons approach the bone plane, evident findings that clarifies the diagnosis. Comparing is essential, in addition to carrying out a previous clinical examination.
#mskrad
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The carpal tunnel (CT) fibro-osseous canal.
Content:
1. flexor digitorum superficialis tendons (S)
2. median nerve (MN)
3. flexor pollicis longus tendon (FPL)
4. flexor digitorum profundus tendons (D)
I will be posting a cool case of trigger wrist at the CT.
#mskrad
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-Neovascularization plays an important role in conditions such as tendinopathy.
-In chronic tendinopathies, such as patellar tendinopathy, neovascularization is commonly observed. This process is often accompanied by nerve ingrowth, which is believed to contribute to pain.
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Continuation of previous MRI case.
A 14-year-old boy with persistent discomfort and occasional joint effusion 3 months after a medial knee sprain of the deep component (same injury 3 years ago).
We have already seen the MRI.
Ultrasound confirms a residual proximal tear of the
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Rotator cuff tear shapes.
A ) Crescent-shaped tear.
B ) U-shaped tear.
C ) L-shaped tear.
D ) Massive tear.
#mskrad
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(Pseudo) Trigger finger secondary to a full-thickness/subtotal width laceration of the ulnar arm of the superficial flexor tendon engaging on the A1 pulley. Laceration at zone II level with the hitch happening with max flexion. The best part at the end !!
#mskrad
#mskultrasound
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Dynamic entrapment of the popliteal artery due to dynamic muscle compression, with proximal suboclusive thrombosis.
Heavy runner, with calf pain of 4-5 weeks of evolution. Exam requested to assess muscle injury.
#mskrad
#mskultrasound
#radiology
#radres
#orthotwitter
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MRI guide to locate the inferior calcaneal nerve, first branch of the lateral plantar nerve (Baxter’s nerve).
There are three possible entrapment sites:
1. Deep or adjacent to the fascial border of a hypertrophied abductor hallucis muscle.
2. Along the medial border of the
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- Carpal Tunnel transverse and longitudinal view.
- Ultrasound / Anatomical illustration.
#mskrad
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Cyclops injury. Also known as localized anterior arthrofibrosis, it is almost exclusively a complication of ACL reconstruction, with the appearance of an ovoid nodule most commonly located on the anterior aspect of the ACL graft near the tibial insertion.
Risk factors female
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Posterior interosseous nerve syndrome.
Symptoms ++. Thickening proximally and change of nerve caliber at the arcade of Frohse.
With pronation and some elbow flexion the nerve kinking usually becomes more pronounced.
Explore at the entrance until the distal edge.
#mskrad
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A nice example of the precision we can get when evaluating trigger fingers.
Trigger of the deep flexor tendon first and then the superficial flexor tendon in its proximal and then in its distal excursion to the A1 pulley.
Look as the pulley tilts from side to side.
#mskrad
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Traumatic tear of the radial arm of the sagittal band.
Usually, the diagnosis of sagittal band tears is made by inflammatory changes and distortion of/around the band, and we try to find indirect dynamic signs of rupture with tendon dislocation.
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In longitudinal split tears of the peroneus brevis, it is essential to perform dynamic maneuvers, or else the tear may appear less than it is or go unnoticed.
#mskrad
#mskultrasound
#radiology
#radres
#orthotwitter
#medart
#peroneusbrevis
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Illustrations of pronator teres syndrome on ultrasound.
The video case with the dynamic maneuvers I will upload it tomorrow.
The dynamics are a game-changer on the diagnosis.
#medianerve
#pronatorteressyndrome
#pronatorteres
#mskrad
#radres
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Persistent/ Recurrent trigger finger after a release of the A1 pulley. Triggering occur between the noose formed by the two slips of the FDS and the FDP at the Camper’s chiasm at the distal edge of the A2 pulley.
Always check for other possible points of conflict.
#mskrad
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Stener's injury. Video with the pillars in US diagnosis;
1. direct visualization of the torn and retracted ligament
2. mobilization of the add aponeurosis to corroborate the interposition and
3. Stress maneuvers with opening without stop
#mskrad
#mskultrasound
#orthotwitter
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Full thickness and partial width tear of the central indirect intramuscular tendon of the rectus femoris, with caudal extension through a fine longitudinal split.
There is no debate (for me) that MRI is the study of choice to adequately determine connective tissue involvement,
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Ultrasound-guided peri-sciatic infiltration and hydro dissection with a mixture of saline solution, local anesthetic, and corticosteroids in patients with deep gluteal syndrome refractory to conservative treatment is an alternative for symptom relief before surgery.
#mskrad
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Dorsal/extensor apparatus anatomy of the finger, illustration.
For a better understanding of the previous videos, and the next one.
#MSKRad
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Illustration / Ultrasound versus MRI full-thickness supraspinatus tendon tear.
Footprint irregularities and subcortical fibrocystic changes are indirect signs of cuff pathology/tearing.
I always check the x-ray before any US exam. You enter the room knowing you’l find a
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Intrasubstance medial delamination extension of the supraspinatus tendon can be difficult to assess on US, MRI, and arthroscopy.
“Water” (bursal or articular) is always an ally for exploration.
We force the entry of bursal fluid towards the laminar delamination of the tendon,
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The common extensor tendon is composed of the conjoined tendon (extensor carpi radialis brevis, extensor digitorum communis, and extensor carpi ulnaris) and the extensor digiti minimi.
An anatomical video showing the main components in short and long axis.
Part 2.
#mskrad
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Finishing up some illustrations that I was missing for my muscle injury talk for
@RadiologiaChile
.
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When looking for neovascularization in tendons, always look for its most relaxed state. In this case, a common flexor tendon of the elbow, going from forearm supination with an extended wrist to forearm pronation with a flexed wrist. Suddenly magic happens
#mskrad
#mskultrasound
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Jersey Finger.
When evaluating X-rays, it is important to always try to think about the soft tissue in order to make a more comprehensive evaluation of the images, "the bigger picture."
A fracture of the distal phalanx may divert attention from the “apparently” less important
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To assess muscle connective tissue in US, especially IM tendon expansion, it is very useful to tilt the probe from a perpedicular orientation of the tendon relative to the probe, to an "elongated" tendon parallel to the probe, and be able to evaluate them properly.
#mskrad
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Degloving injury
Separation between the inner and outer components of the RF muscle is demonstrated by the mobilization of the minimal amount of fluid at the interface by muscle hand-squeezing
Substantial difference in prognosis between a partial and a degloving injury
#mskrad
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What is your preferred approach to infiltrate the shoulder?
Mine is the approach through the rotator interval.
Glenohumeral joint, biceps sheath, and SA-SD bursa in the palm of your hand.
#mskrad
#mskultrasound
#radiology
#radres
#orthotwitter
#shoulder
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Tip.
When we infiltrate the sciatic nerve (or any nerve) in the deep subgluteal space we need the needle to pop into the fascial plane where the nerve resides.
When we are in the right place there is an immediate displacement of the nerve.
We fell and see the pop.
#mskrad
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Proximal iliotibial band syndrome is related to a strain injury of the enthesis of the iliotibial band, where it joins the iliac tubercle.
Although it can be due to trauma, it usually corresponds to an overuse injury.
There is a certain female predominance.
They consult with
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Nearly complete laceration of the radial arm of the FDS tendon and tear of approx. 30-40% of the radial aspect of the FDP tendon in zone II, associated with scar thickening of the distal half of the A2 pulley. US magic!
#mskrad
#mskultrasound
#radiology
#radres
#orthotwitter
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Spectrum of ultrasound findings of Hoffa's fat pad impingement syndrome.
Inflammatory changes in the superolateral aspect of Hoffa's fat, associated with dynamic snapping in the lateral trochlear ridge. Local pain.
#mskrad
#mskultrasound
#knee
#radiology
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An interesting case of pseudo trigger finger, rare and poorly reported.
Snapping syndrome of the lateral band of the extensor apparatus in PIPJ.
I have seen 3 cases, all in the little finger.
Dorsal subluxation of the lateral bands, with dynamic snapping.
#mskrad
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Mallet finger injury.
Spectrum of ultrasound findings:
•Loss of real-time movement of the tendon.
•Complete or partial extensor tendon tears.
•Fluid in the region of the extensor tendon insertion.
•Avulsion fracture.
#mskrad
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Illustrations and ultrasound images from volar plate injury case, swan neck deformity.
#mskrad
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Comparative images of Baxter’s nerve, MRI versus illustration.
The medial plantar branch (MPN) has an anterior location, and it must be differentiated from the lateral plantar branch (LPN), which is located posteriorly. Once the LPN has been identified, we follow it, and we
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When evaluating soleus injuries on US, concentrate on the "white lines" and not so much on "the meat". Focus around the lateral aponeurosis, medial aponeurosis, central tendon, anterior and posterior myofascial junctions, they are the key. They are not hard to find.
#mskrad
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Bursal side supraspinatus tendon tear with intrasubstance medial delaminative extension. Correlation Illustration/US versus MRI (from previous case)
The opportunity to correlate findings between different techniques is priceless; it allows us to learn a lot.
#mskrad
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Pronator teres syndrome on dynamic ultrasound.
Dynamic test: Resisted pronation of the forearm.
Imaging that kinking (sec 22 and 45) happening repeatedly in a heavy active person and we can understand why some people are predisposed to this entity.
#MSKRad
#mskultrasound
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Trigger finger at the wrist is an unfrequented condition
In this case triggering phenomenon of the annular finger with triggering point of the lumbrical muscle at the transverse carpal ligament, associated with regional inflammatory changes
Dynamic ❤️
#mskrad
#mskultrasound
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Quick case.
Coronal view.
Signs of disruption of the fibrous septa and subluxation of the plantar calcaneal fat pad with compression of the ultrasound transducer, reproducing a snapping of the fat pad.
Bibliography reference.
Skeletal Radiology
@SkeletalRadiol
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Meniscofemoral deep MCL full-thickness tear.
MRI versus Ultrasound.
*from dynamic video*
#mskrad
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Short video of the transverse dynamic anatomy of the dorsal apparatus at the level of the PIP. Central band and both lateral bands with their displacement during flexion and extension movement. This can help us locate them.
Next I will post a patologic case.
#mskrad
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Complement to the previous TFCC case.
This is what I came up with to obtain a coronal image of the TFCC to assess its peripheral insertion.
We perform a maximum flexion of the wrist; in this way, we move the triquetrum and create a small window through which we can support the
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The second and third metatarsals are more prone to stress fractures due to their central role in loading and repetitive strain during activities such as running and jumping.
These metatarsals absorb significant forces, especially in people with foot deformities or altered
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Scapholunate instability on US.
Normal. In ulnar deviation of the wrist, the scaphoid adopts a vertical orientation and there is an anterior translation of the proximal pole.
In radial deviation, the scaphoid flexes and there is a dorsal translation of the proximal pole.
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Scapular snapping syndrome is defined as an audible or palpable clicking of the scapula during movements of the scapulothoracic joint.
The US is not typically the study of choice, but I have seen several cases where we can give accurate information on the snap.
Evident snapping
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In-depth review, open access:
I am sharing with you an article on peripheral ulnar TFCC injuries that I wrote for the Journal of the Mexican Federation of Radiology and Imaging showing my experience.
👉 👈
This same approach applied in CT-arthrography
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Knowledge of variations in the branching pattern of the MN is important, particularly in surgical decompression
Any hand surgeon would be grateful for information on the branching pattern of the recurrent motor branch
Extraligamentous
Subligamentous
Transligamentous
#mskrad
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The "intraligamentous variant of the lateral femoral cutaneous nerve" occurs when the nerve passes through the inguinal ligament instead of below it, which is the typical anatomic route.
This variation can lead to meralgia paresthetica, which causes pain, numbness, or tingling
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Another example of my signature move "milking the bursa"👌🐄.
In this case, using the retrocalcaneal bursa to show a partial tear of the insertional anterior central fibers of the Achilles tendon.
Use what you have to your advantage.
#mskrad
#mskultrasound
#radiology
#radres
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The aponeurotic continuity between the gluteus minimus and the vastus lateralis is a connection that unites the aponeurosis of the gluteus minimus with that of the vastus lateralis. This connection facilitates the transmission of forces between both muscles, contributing to the
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Partial carpal tunnel release usually presents with exacerbation of clinical symptoms after surgery. Here is an example to understand why. Impressive !!
The mother of hourglass constrictions !
#mskrad
#mskultrasound
#carpaltunnel
#carpaltunnelsyndrome
#carpaltunnelsurgery
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P1. Weber's classification focuses on the integrity of the syndesmosis
P2. The shape of a fracture indicates the forces involved, it gives us a clue to understand the mechanism of injury
P3. The Lauge-Hansen system helps you maintain a logical order when evaluating the images
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Exciting projects for this year. A lot of work will be needed.
I share an anatomical drawing “in layers” of the intrinsic muscles of the hand.
#mskrad
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