Basic MSK Ultrasound :

Introduction, lnstrumentation,
Technique,Normal sonoanatomy

of MSK structures

Tertianto Prabowo

Workshop Basic Musculoskeletal Ultrasound – Jakarta, 7-8 Oktober 2015

 INTRODUCTION
Interpretation of ultrasound images
depends on :
•the echogenicity : the brightness of
the image,
•the degree of reflection of the
ultrasound waves. Terms used
include hyperechoic,isoechoic,
hypoechoic, and anechoic.

Workshop Basic Musculoskeletal Ultrasound – Jakarta, 7-8 Oktober 2015

Limitation of Ultrasound
• Relatively superficial
structures could be
examined.

• Operator dependent.
(experiences, skills and
knowledges)

• Relatively machine
dependent (the quality of
transducer or probe)

• Long learning and practice.

(‘’Hundred times seen not
as once performed’’)

Workshop Basic Musculoskeletal Ultrasound – Jakarta, 7-8 Oktober 2015

 INSTRUMENTATION
• Interface

• Control Panel

• Scanner

Workshop Basic Musculoskeletal Ultrasound – Jakarta, 7-8 Oktober 2015

 INSTRUMENTATION

Workshop Basic Musculoskeletal Ultrasound – Jakarta, 7-8 Oktober 2015

1. Some important things first : GETTING THE BEST
IMAGE
2. Once we’ve got it, how do we read it : LOOKING
AT
LANDMARKS AND LAYERS
3. Recognizing specific structures :
SONOGRAPHIC
APPEARANCES
4. High index of suspicion : STEPS TO GETTING IT
RIGHT
5. Pitfalls in Musculoskeletal ultrasound imaging

Workshop Basic Musculoskeletal Ultrasound – Jakarta, 7-8 Oktober 2015

1. GETTING THE BEST IMAGE
a. Transducer selection
b. Depth
c. Focal zone
d. Gain

Workshop Basic Musculoskeletal Ultrasound – Jakarta, 7-8 Oktober 2015

 1.a. Transducer
• Determines image quality
• High Frequency :
– Greater resolution,
Linear (12-5 MHz) shallow penetration
– Best for more superficial
structures
• Low Frequency
– Lower resolution, greater
Curvilinear (9-4 MHz) penetration
– For deeper structures
Compact linear (15-7 MHz)
Workshop Basic Musculoskeletal Ultrasound – Jakarta, 7-8 Oktober 2015
 1.a.Transducer
Transducer positioning
• the transducer is stabilized
with simultaneous contact
of the transducer, the skin
surface, and the
examiner’s hand

Workshop Basic Musculoskeletal Ultrasound – Jakarta, 7-8 Oktober 2015

 Transducer relative to target
• LAX : Long axis
(longitudinal): The
transducer is parallel to
the normal anatomic
alignment of the target
structure (eg, the tendon
fibers are running across
the screen).
• SAX : Short axis
(transverse): The
transducer is
perpendicular to the
target structure

Workshop Basic Musculoskeletal Ultrasound – Jakarta, 7-8 Oktober 2015

 Transducer positioning for USG
procedures.
• Translation: The • Stand-off oblique:
transducer is moved in Build up the gel under
one orthogonal one end of the
direction (long axis or transducer. This
short axis) in reference oblique technique
to the target structure. allows the needle to
• Rotation: The pass through the gel
transducer is spun and decreases needle
• Compression: anisotropy (similar to
the Heel-Toe effect)
Increasing or
decreasing the direct
physical pressure with
the transducer.

Workshop Basic Musculoskeletal Ultrasound – Jakarta, 7-8 Oktober 2015

 Transducer positioning for USG
procedures.
• Heel-Toe: The
transducer is angled
in the long axis
• Tilt/Wag: The
transducer is angled
in the short axis

Workshop Basic Musculoskeletal Ultrasound – Jakarta, 7-8 Oktober 2015

 1.b. Depth
• Adjust depth to place
image at middle to
bottom of screen
• Decreases
attenuation, increases
resolution
• Scale allows
localization

Workshop Basic Musculoskeletal Ultrasound – Jakarta, 7-8 Oktober 2015

 1.c. Focus
• User controlled focal zones are important controls
and must be adjusted to the depth of interest
• Be aware of the position and range of the focal
zone
• On most systems it is possible to expand the
number of zones allowing focusing over more of
the image
• This is about optimizing resolution
• Practice changing number & position of focal
zones & watch the effect on image

Workshop Basic Musculoskeletal Ultrasound – Jakarta, 7-8 Oktober 2015

Workshop Basic Musculoskeletal Ultrasound – Jakarta, 7-8 Oktober 2015
 1.d. Gain
Time Gain Compensation ( TGC )
Sound beam is attenuated (loses energy) as it passes through tissue
- Echoes received from deep structures are weaker
- Applying gain to the returning deep echoes compensates for this
- The operator decides at what rate this gain will be applied by using
the TGC controls
SKIN LINE

DEPTH OF
FIELD

Workshop Basic Musculoskeletal Ultrasound – Jakarta, 7-8 Oktober 2015

 2. LOOKING AT LANDMARKS AND LAYERS

• Looking at ‘LAYERS’

– How do we ‘work out’ what we are seeing ?

– This is where the ‘Layers’ approach is useful
– Firstly, optimise the image (depth, focus,TGC)
– Secondly, find a structure you recognise (skin or
bone)
– Thirdly, either start at the bone and work up to the
skin or start at the skin and work down to the
bone
– What can you see ? What are the layers ?

Workshop Basic Musculoskeletal Ultrasound – Jakarta, 7-8 Oktober 2015

2. LOOKING AT LANDMARKS AND LAYERS

SKIN

SUBCUTANEOUS FAT

MUSCLE

BURSA
TENDON

CARTILAGE

BONE

Workshop Basic Musculoskeletal Ultrasound – Jakarta, 7-8 Oktober 2015

 2. LOOKING AT LANDMARKS AND LAYERS
FAT LOBULES

DERMIS

FIBROUS SEPTA

SUBCUTANEOUS

MUSCLE FASCIA

MUSCLES

Workshop Basic Musculoskeletal Ultrasound – Jakarta, 7-8 Oktober 2015

 3. SONOGRAPHIC APPEARANCES
• Terminology- Echotexture • Terminology-Echogenicity
– Refers to the internal pattern – Hyperechoic
of echoes • More soundwave reflected
• Coarseness – Isoechoic
• Homogeneity and heterogeneity • Same amount of soundwave
reflected
– Hypoechoic
• Fewer soundwave reflected
– Anechoic
• No soundwave reflected

Workshop Basic Musculoskeletal Ultrasound – Jakarta, 7-8 Oktober 2015

3. SONOGRAPHIC APPEARANCES

Workshop Basic Musculoskeletal Ultrasound – Jakarta, 7-8 Oktober 2015

Workshop Basic Musculoskeletal Ultrasound – Jakarta, 7-8 Oktober 2015
Workshop Basic Musculoskeletal Ultrasound – Jakarta, 7-8 Oktober 2015
Workshop Basic Musculoskeletal Ultrasound – Jakarta, 7-8 Oktober 2015
Workshop Basic Musculoskeletal Ultrasound – Jakarta, 7-8 Oktober 2015
Workshop Basic Musculoskeletal Ultrasound – Jakarta, 7-8 Oktober 2015
Workshop Basic Musculoskeletal Ultrasound – Jakarta, 7-8 Oktober 2015
Workshop Basic Musculoskeletal Ultrasound – Jakarta, 7-8 Oktober 2015
• The term artifact is used to describe
imaging findings that do not accurately
represent the anatomic structures being
evaluated

Workshop Basic Musculoskeletal Ultrasound – Jakarta, 7-8 Oktober 2015

Workshop Basic Musculoskeletal Ultrasound – Jakarta, 7-8 Oktober 2015
Workshop Basic Musculoskeletal Ultrasound – Jakarta, 7-8 Oktober 2015
Workshop Basic Musculoskeletal Ultrasound – Jakarta, 7-8 Oktober 2015