Musculoskeletal Ultrasound Marnix T van Holsbeeck, Joseph H Introcaso
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fm1Musculoskeletal Ultrasoundfm2
fm3Musculoskeletal Ultrasound
Third Edition
Marnix T van Holsbeeck MD Division Head of Musculoskeletal Radiology Henry Ford Health System Detroit, Michigan and Professor of Radiology Wayne State University School of Medicine Detroit, Michigan, USA Joseph H Introcaso MD DMD Radiology Associates of the Fox Valley Director of Clinical Neuroscience Programs Ministry Healthcare Eastern Region Appleton, Wisconsin, USA Foreword David J Collon MD
fm4
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© 2016, Marnix T van Holsbeeck, Joseph H Introcaso
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Musculoskeletal Ultrasound
First Edition: 1991 (Published by Mosby-Year Book, Inc.)
Second Edition: 2001 (Published by Mosby, Inc.)
Third Edition: 2016
9789351529330
Printed at:
fm5Dedicated to
Beatrice, Lodewijk, Elise, Annabel, Andy,
Hendrik, Adelyn, Charlotte, Mona, and Louis
— Marnix T van Holsbeeck
Susan, Katie, Charlotte,
Marian, Joseph, William, and Mary
— Joseph H Introcaso
Thank you to the many people who
have made this book possible
we could not have done it without
the patience and support of our families. fm6
fm7Contributors fm8 fm9Foreword
I am pleased to have been asked to contribute a foreword to Drs van Holsbeeck and Introcaso's book on Musculoskeletal Ultrasound. In the present atmosphere of rapidly advancing techniques in imaging, with increasing pressure for cost containment and with an emphasis on keeping radiation ‘As Low as Reasonably Achievable’ (ALARA), this is an extremely timely work.
Vast areas of investigation have been opened as a result of the development of ultrasound as an imaging tool. In the past 25 years, there have been dramatic advances in imaging in the form of computerized tomography (CT) and magnetic resonance imaging (MRI). These have developed, however, as expensive procedures with fixed facilities and high operating expenses. By contrast, ultrasound provides economic, non-invasive imaging of tissues in static and dynamic states, and in serial studies where indicated. Its capacity to offer ‘Point of Care’ imaging adds to its value.
These unique aspects of imaging have made ultrasound especially valuable in the field of sports medicine. Ultrasound meets two very specific needs in sports medicine created by the pressure in professional athletics to return the athlete to competition as quickly as possible. First, it allows immediate identification of problems, thereby avoiding many diagnostic surgical procedures. Secondly, it allows for the study of lesions, which only manifest during physical activity. These same attributes also enhance the study of inflammatory diseases including infections, trauma including fractures and dislocations, and neoplastic conditions.
Drs van Holsbeeck and Introcaso, two of the premier authorities on ultrasound, have provided a text equally valuable to the clinician and to the radiologist. In a concise manner, the book describes the clinical indications for ultrasound imaging. The authors also provide information about theory and technique for the benefit of the practicing radiologist or sonographer. The book is a valuable text in an important and expanding field. I compliment Drs van Holsbeeck and Introcaso for an excellent job and a fine accomplishment.
David J Collon MD
President
Michigan Orthopaedic Institute
Southfield, Michigan, USA
fm10 fm11Preface
Since the publication of the first and second editions of this text, ultrasound equipment has continued to evolve and improve, helping to provide a better understanding of sonographic musculoskeletal soft tissue anatomy. At the same time, our health care system has also evolved and contributed to growing interest in ultrasound of the musculoskeletal system. Cataclysmic change has seized the publishing industry, changing the way you interact with a book. The time is right to publish a follow-up to our prior work in digital format.
Soft tissues such as fibroconnective tissue, fat, and muscle make up more than 50 percent of the mass in the human body. Despite the importance of the soft tissues of the musculoskeletal system, the pathology of these tissues remains poorly understood. Magnetic resonance imaging (MRI) has improved the diagnosis of musculoskeletal pathology and has resolved some of the difficulties in diagnosis of internal joint derangement. However, the diagnosis of chronic repetitive injury, work-related injury, inflammation, and infection in soft tissues has not changed significantly during the explosive growth of MRI. Ultrasound shows great promise in this realm and its role is continually expanding.
Ultrasound shows us musculoskeletal anatomy from a new and unique perspective. The backbone of fibroconnective tissue consists of a collagenous framework. This matrix can be viewed as the microskeleton of muscles, tendons, ligaments, and nerves. Reflection of the sound beam by this collagenous framework displays structure that is imperceptible with other imaging techniques. Lesions that disrupt this framework become very obvious when examined sonographically. The physical properties of tissues change so dramatically in diseases like tendon tear, septic arthritis, osteomyelitis, and heterotopic bone formation, making ultrasound better suited than any other imaging technique in detecting these processes early.
A better understanding of the principles of musculoskeletal ultrasound has led to anisotropic imaging (i.e. image reconstruction based on anisotropic characteristics of collagen in connective tissue). In addition to tissue anisotropy, musculoskeletal anatomy is singular in its capability to form fluid through the synovial membrane. Ultrasound shows fluid because of the uniformity of its acoustic impedance. The capability of ultrasound to demonstrate fluid with great sensitivity and specificity proves extremely useful in the diagnosis of osteoarticular diseases. Anisotropic imaging characteristics of mesoderm, in addition to the unique acoustic impedance of fluid, represent the physical principles on which successful musculoskeletal ultrasound is based.
With the diagnostic success of ultrasound so tightly related to the demonstration of internal tissue architecture, we have organized the text according to anatomy. As in the first and second editions, we divided the book into chapters on pathology according to tissue type (histology) and according to more regional anatomy (topographic anatomy). Some chapters of the electronic version of this book are introduced with a small three-dimensional illustration. You as a reader are encouraged to play with this model so that the topographic anatomy and pertinent skeletal landmarks that you will be required to recognize during scanning will be at your fingertips.
New chapters have been added to this edition of our book: one on post-surgical imaging and one on the developing role of musculoskeletal ultrasound in telemedicine. Important new insights in the mechanisms of disease are highlighted in Chapter 8. Chapter 15 on interventional musculoskeletal ultrasound covers a subject that represents the fastest growing share of our ultrasound referrals—invasive procedures under ultrasound guidance. This chapter will be useful to those who have already started musculoskeletal ultrasound but would like to expand their scope of services. This new edition emphasizes the use of color Doppler, power color Doppler, and real-time video material stressing the importance real-time ultrasound plays in looking at living anatomy dynamically. Exquisite line diagrams and animations that teach a virtual approach to joints represent new features of this work.
This third edition, intended as an electronic book, combines text, static and dynamic ultrasound images, line drawings, 3-D animations, and variable combinations of audio and video. The glossary and search functions now replace the old index. The glossary contains crucially important terminology often illustrated by graphic material. it is worth browsing the glossary before starting to read the text, especially if you are relatively new to the practice fm12of musculoskeletal ultrasound. In updates, this glossary will continually improve in part by your direct feedback. A truly interactive feature will be the Continuing Medical Education (CME) offering of this book, which will be available shortly as a downloadable upgrade. To make sure you do not miss out on this opportunity, please email us at MedEd3D@comcast.net so that we can keep you up-to-date on this latest feature. This is a modest beginning for a dialogue between authors and readers.
This third edition contains more information on ultrasound anatomy, indications for musculoskeletal ultrasound examinations, and information on pathology and ultrasound signs of disease. Positioning represents the most dynamic aspect of musculoskeletal ultrasound, and more advanced techniques develop continuously. Those just starting in the field should be aware that it is vital to stay in touch with the latest developments. An excellent way to stay current on the latest techniques is to participate in the activities of the Musculoskeletal Ultrasound Society (www.musoc.com). You will also find updated material on imaging protocols and technique on our facebook page (Musculoskeletal Ultrasound).
Thirteen years have passed since the publication of our second edition. This new edition shows more maturity in part because the field has finally gained widespread acceptance. The recent rapid growth of this technique and evidence of an ever-increasing number of followers prove that musculoskeletal ultrasound represents an important tool in the hands of the contemporary musculoskeletal practitioner.
Marnix T van Holsbeeck MD
Joseph H Introcaso MD DMD
fm13Acknowledgments
One of the most significant additions to the third edition is the inclusion of superb 3-D animations, videos and digital illustrations made possible by the work of Dr Elise van Holsbeeck. Her skills as both physician and artist have greatly enhanced the value of these multimedia pieces. Her work with Adobe Illustrator, Photoshop, Final Cut Pro, Autodesk Maya, and Apple iBooks Author provide a markedly improved reader experience, especially in the electronic format of the book. Dr Elise van Holsbeeck received her medical degree from the Michigan State University of Osteopathic Medicine, Michigan, USA and completed a traditional residency at the Michigan State University Kalamazoo Center, Michigan, USA for Medical Studies. Her training also included Physical Medicine and Rehabilitation at the Detroit Medical Center, Michigan, USA. We greatly appreciate all of the skill and effort she has put into this project and hope that you will take time to fully explore these creations.
Finally, we would also like to thank Mr Jitendar P Vij (Group Chairman), Mr Ankit Vij (Group President), Ms Chetna Malhotra Vohra (Associate Director), Ms Sheetal Arora Kapoor (Development Editor), and the production team of Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India.fm14