Flexor Digitorum Tendons - Ventral Side - Normal Ultrasound Anatomy of the Musculoskeletal Syst

5.1 Ventral Side

5.1.2 Flexor Digitorum Tendons

menced at the carpal tunnel level (see above).

The changing relationship between superficial and deep flexor tendons (Figs. 5.2a, b) can be appreciated moving the transducer distally with axial scans (Figs. 5.3a, b).

from long tendons that enter the carpal tunnel and then insert on the fingers. In partic- ular, deep tendons run straight up to the distal phalanges, where they insert on the bases. Conversely, superficial tendons run up to the middle of the proximal phalanges, where they split into two branches that sur- round the deep tendons and insert on the head of the middle phalanges. The superficial and deep tendons have common tendon sheaths. Note that the flexor digitorum superficialis tendon of the little finger can frequently be absent.

Fig. 5.2aAnatomical scheme of flexor digitorum tendons. *, flexor digitorum profundus tendon; circles, flexor digitorum superficialis tendons; M,metacarpal bone; P1, P2, P3, proximal, middle and distal phalanges, respectively

Fig. 5.2bAnatomical scheme of axial section over the metacarpal heads. M, metacarpal bones; FDS, flexor digitorum superficialis tendon; FDP, flexor digitorum profundis tendon; L, lumbrical muscles; IO, interosseous muscles;

N,common digital nerve; A, common digital artery

Fig. 5.3bUS axial scan of the hand palm. FDS, flexor digitorum superficialis tendon; FDP, flexor digitorum profundus tendon; M, metacarpal bone; L, lumbrical muscle; white arrowheads, common digital nerve; void arrowheads, common digital arteries (Doppler signal in red); *, interosseous muscles

Fig. 5.4aProbe position to evaluate the flexor digitorum tendons on the long axis

Fig. 5.4bUS longitudinal scan of the third flexor digitorum tendon. FDS, flexor digitorum superficialis tendon;

FDP, flexor digitorum profundus tendon; M, metacarpal bone

Fig. 5.5bLongitudinal scan of the metacarpophalangeal joint, palmar side. M, metacarpal head; P1, proximal phalanx; T, flexor tendons; *, palmar plate; circle, proximal synovial recess; arrowheads, A1 pulley

Fig. 5.6aProbe position to evaluate the interphalangeal joint on the long axis

Fig. 5.6bProximal interphalangeal joint longitudinal scan, palmar side. P1, proximal phalanx; P2, middle phalanx;

T, flexor tendons; *, palmar plate

Fig. 5.6c Distal interphalangeal joint longitudinal scan, palmar side. P2, middle phalanx; P3, distal phalanx; T,flex- or digitorum profundus tendon

Fig. 5.7bUlnar collateral ligament of the thumb. M, metacarpal head; P1, proximal phalanx; arrowheads, ulnar collateral ligament of the thumb

5.2 Dorsal Side

Dorsal compartment can be assessed with the hand lying on the table, with the palm facing down (Fig. 5.8). Anatomical scheme of dorsal compartment of fingers is shown in Fig. 5.9.

5.2.1 Extensor Digitorum Tendons

Extensor digitorum tendons can be assessed using axial scans, moving the transducer from the carpus distally to the fingertips. Tendons become very thin distally, then transform into lamina extensoria (Figs. 5.10a-c, Figs. 5.11a-c).

Fig. 5.8Probe position to evaluate the dorsal compartment of the hand

Fig. 5.9Anatomical scheme of the dorsal compartment of the hand. Void arrowheads, extensor digitorum communis tendon;

white arrowheads, extensor digitorum superficialis tendon; *, extensor digitorum rpofundus tendon; M, metacarpal bone;

P1, proximal phalanx;

P2, middle phalanx

Fig. 5.10bMetacarpophalangeal joint longitudinal scan, dorsal side. M, metacarpal head; P1, proximal phalanx;

arrowheads, extensor tendon

Fig. 5.10cLongitudinal scan, dorsal side. Arrowheadsindicate the course of the extensor tendon. P2, middle phalanx

Fig. 5.11aProbe position to evaluate the proximal and distal interphalangeal joints

Fig. 5.11bProximal interphalangeal joint longitudinal scan, dorsal side. P1, proximal phalanx; P2, middle phalanx;

arrowheads, extensor tendon

Fig. 5.11cDistal interphalangeal joint longitudinal scan, dorsal side. P2, middle phalanx; P3, distal phalanx; arrow- heads, estensor digitorum profundus tendon

The hip is divided into four compartments:

anterior, medial, lateral and posterior.

6.1 Anterior Hip

The patient lies supine, with the lower limb in a neutral position (Fig. 6.1).

• Femoral Neurovascular Bundle

• Coxo-Femoral Joint 6.2 Medial Hip

6.3 Lateral Hip 6.4 Posterior Hip

• Ischiocrural Tendons (Hamstrings)

• Sciatic Nerve

E. Silvestri, A. Muda, L. M. Sconfienza, Normal Ultrasound Anatomy of the Musculoskeletal System, 75

Fig. 6.1Lower limb position to evaluate the anterior hip

6.1.1 Sartorius and Tensor Fasciae Latae

With the patient supine, find the anterior-supe- rior iliac spine (ASIS)with palpation and place the probe on it in an axial position (Fig. 6.2a).

See the typical “pseudo-thyroid” aspect (Fig.

6.2b) with the hyperechoic ASIS at the centre, next to the short tendinous insertions of the sar- torius (medial) and the tensor fasciae latae (lateral) muscles. The tensor fasciae latae muscle courses distally on the lateral side of the thigh, whereas the sartorius muscle can be seen with medial orientation, superficially to the rectus femoris muscle (Fig. 6.2c). Examine the muscle bellies using both axial and longitudinal scans.

6.1.2 Rectus Femoris

Starting from the position previously described at ASIS level shift the transducer caudally to reach the anterior-inferior iliac spine (AIIS) (Fig. 6.3a). There, the direct tendon of the rectus femoris muscle inserts on the lateral side, deeper than the iliopsoas muscle (Fig. 6.3b).

From this position, translate the transducer caudally to reach the muscle belly of the rectus femoris (Fig. 6.3c).

Rotate the transducer by 90° to evaluate, by longitudinal scans, the myotendinous junctions of the rectus up to the insertion onto the AIIS (Figs. 6.4a, b).

Evaluate the direct andindirect tendon of the rectus femoris (Fig. 6.5), using longitudinal (Figs. 6.6a, b) and axial scans (Figs. 6.7a-d).

The rectus femoris muscleis characterized by a complex organization of proximal insertions, consisting of a direct tendon inserting on the AIIS and an indirect ten- don running distally as an aponeurosis into the muscle belly. Proximally it runs under the direct tendon then proceeds more externally, with an oblique trend compared to the overhanging direct tendon that inserts into the acetabular tubercle. The third small tendon anchors the insertional complex of rectus reflecting distally in the proximity of the greater tuberosity (reflected tendon).

Fig. 6.2aProbe position to evaluate the sartorius and tensor fasciae latae insertions

Fig. 6.2bUS scan shows the tendinous insertions of sartorius (Sa) and tensor fasciae latae (TFL) muscles on the anterior-superior iliac spine (ASIS)

Fig. 6.2cAnatomical scheme: proximal insertion of sartorius (Sa) and tensor fasciae latae (TFL) and respective muscle bellies anterior-superior iliac spine (ASIS)

Fig. 6.3bThe axial scan shows the tendinous insertion of the rectus femoris (arrowheads) into the AIIS. Ps, iliopsoas muscle; AIIS, anterior-inferior iliac spine

Fig. 6.3cAnatomical scheme: proximal insertion of rectus femoris (RF) and its connections with psoas muscle (Ps). AIIS, anterior-inferior iliac spine; F, femur Fig. 6.3a Probe position to evaluate the rectus

femoris proximal insertion

Fig. 6.4aProbe position to evaluate the rectus femoris tendon insertion onto the AIIS

Fig. 6.4bThe ultrasound scan shows the tendinous insertion of rectus femoris (arrowheads) onto the AIIS. RF, muscle belly of rectus femoris; Ps, psoas muscle;

AIIS, anterior-inferior iliac spine

Fig. 6.5Anatomical scheme: tendons of the rectus femoris muscle. d, direct tendon; i, indirect tendon; r, reflected tendon; RF, rectus femoris muscle; F,femur

Fig. 6.6aProbe position to evaluate the rectus femoris tendon with longitudinal scans

Fig. 6.6bThe longitudinal scan shows the direct (arrowheads) and indirect (*) tendons of the rectus femoris muscle. Note the hypoechoic appearance of the indirect tendon cranial portion, determined by the change in orientation of the tendon (anisotropy), which courses externally and obliquely compared to the direct tendon

Fig. 6.7aProbe position for the axial evaluation of the rectus femoris direct and indirect tendons

Fig. 6.7c Probe position to evaluate the rectus femoris distal aponeurosis

Fig. 6.7bAxial evaluation of the direct (arrowheads) and indirect (*) tendons of the rectus femoris muscle. Sa, sartorius; F, femur

Fig. 6.7dThe axial scan shows the distal tendinous aponeurosis (arrowhead) of the rectus femoris muscle (RF) shaped like a “C”. Vi, vastus intermedius muscle; F, femur

6.1.3 Iliopsoas

The iliopsoas musclecan be seen by means of a series of axial scans, medial to the rectus femoris. On these images, the hyperechoic tendon is located in an eccentric posterior-medial position within the muscle belly (Figs. 6.8a, b).

The muscle can be followed using both axial and longitudinal scans up to the insertion into the lesser trochanter.

Theiliopsoas muscleis often considered as the only biarticular muscle, located in the lumbo-iliac region and in the anterior region of the thigh. Actually, it is formed by two distinct portions: the psoas major muscle, and the iliacus muscle. It arises from the lateral side of the body of the last thoracic vertebrae, from the first four lumbar vertebrae and the interposed disc, and from the base of the transverse processes of the first four lumbar vertebrae. The muscle belly runs obliquely down and outwards; it passes under the inguinal ligament and ends on the apex of the lesser trochanter on the thigh.

The femoral nerve runs between the iliacus muscle and the psoas major.

The iliopsoas bursa is located anteriorly between the joint capsule and the posterior surface of the iliopsoas muscle. This is the largest synovial bursa of the human body, which communicates with the joint space in 15% of cases.

6.1.4 Femoral Neurovascular Bundle

Medial to the rectus femoris muscle, the neurovascular bundle can be identified using axial scans: lateral to medial, the femoral nerve, the common femoral artery, and the common femoral vein can be seen (Figs. 6.9a, b).

6.1.5 Hip Joint

Medially and distally to the ASIS, thehip joint can be seen by an oblique sagittal scan to assess the femoral acetabulum with the anterior portion of the labrum, the anterior capsular profile and the femoral head covered by the articular cartilage (Figs. 6.10a, b). At the bottom of the femoral there head is the anterior synovial recess that is not detectable when normal.

Conversely, the anterior capsular profile is almost always visualized as a hyperechoic linear structure superficial to the joint space.

The joint capsule inserts proximally onto the border of the acetabulum and the acetabular labrum, distally onto the inter-trochanteric line, and posteriorly onto a line located at the border between the medium and lateral third of the femoral neck. Therefore, the anterior face of femoral anatomical neck is intracapsular, whereas the posterior side is only partially intracapsular.

Fig. 6.8a Probe position to evaluate the psoas muscle myotendinous junction

Fig. 6.9aProbe position to evaluate the femoral neurovascular bundle

Fig. 6.8bThe axial scan shows the myotendineous junction (*) of the psoas muscle (Ps). F,femoral head

Fig. 6.9b The axial scan shows the femoral neurovascular bundle: fA, femoral artery; fV, femoral vein and fN, femoral nerve. Pe, pectineus muscle

Fig. 6.10aProbe position to evaluate the coxo- femoral joint

Fig. 6.10bThe scan shows the femoral head (F)covered by the articular cartilage, the acetabulum (Ac), the acetabular labrum (*), and the anterior capsular profile (arrowheads). Ps, psoas muscle

Fig. 6.11Lower limb position for medial hip evaluation

Fig. 6.12 Anatomical scheme: adductor muscles. The adductor longus (AL) is the most superficial and it is represented in shadow. The adductor brevis (AB) and magnus (AM) are shown deeply. F, femur; P, pubic ramus

Fig. 6.13aProbe position to evaluate the adductor muscles’ proximal insertion

Fig. 6.13bThe longitudinal scan shows the tendon insertion (*) of the adductor longus (AL), adductor brevis (AB), and adductor magnus (AM) muscles in correspondence with the pubic symphisis

6.3 Lateral Hip

6.3.1 Gluteus Tendons and Muscles

With the patient lying on the contra-lateral hip (Fig. 6.14), find the greater trochanter with an axial scan and then slightly shift the probe cranially (Fig. 6.16a). Similar to the shoulder rota- tor cuff analysis, three muscles can be encoun-

Fig. 6.14Patient in the lateral position for the lateral hip evaluation

tered with their myotendinous junctions: from the front to the back, the gluteus minimus muscle (deep), the gluteus medius muscle, and the gluteus maximusmuscle (more superficial) (Figs. 6.15 and 6.16b). Superficial to these is the tendinous portion of the tensor fasciae latae, which has a ribbon-like hyperechoic appearance and is separated from the cuff by asynovial bursa and adipose cleavage planes (Figs. 6.17a, b).

Fig. 6.16aProbe position to evaluate the gluteus muscles’

insertion onto the greater trochanter

Fig. 6.16bThe axial scan shows the tendinous insertion of the gluteus minimus (*), medius (arrow), and maximus (star) into the femoral greater trochanter (GT). Arrowheads, tensor fasciae latae tendon

Fig. 6.17aProbe position for the longitudinal evaluation of the tensor fasciae latae tendon

Fig. 6.17bThe longitudinal scan shows the tensor fasciae latae tendon (arrowheads) superficial to the greater trochanter (GT)

6.4.1 Ischiocrural Tendons (Hamstrings)

Patient lies prone with the lower limb in a neutral position (Fig. 6.18). Anatomical scheme of ischiocrural tendons is presented in Fig. 6.19.

6.4.2 Sciatic Nerve

Lateral to the hamstring insertions, also examine the sciatic nerve axially and then longitudi- nally (Figs. 6.22a-c).

Fig. 6.18 Lower limb position for posterior hip evaluation

Fig. 6.19 Anatomical scheme: ischiocrural tendon insertion into ischiatic tuberosity and course of sciatic nerve. BF, biceps femoris; SM, semimembranosus; ST, semitendinosus; S,sciatic nerve; IT, ischiatic tuberosity; F, femur

Fig. 6.20a Probe position to evaluate the hamstrings’ insertion into the ischiatic tuberosity on an axial plane

Fig. 6.21a Probe position to evaluate the hamstrings’ insertion into the ischiatic tuberosity on a longitudinal plane

Fig. 6.20b The axial scan shows the tendinous insertion of the long head of the biceps femoris (1), semitendinosus (2) and semimembranosus (3)muscles. IT, ischiatic tuberosity

Fig. 6.21b The longitudinal scan shows the tendinous insertion (*) of the semitendinosus (St) and semimembranosus (Sm) tendons into the ischiatic tuberosity (IT)

Fig. 6.22a Probe position to evaluate the sciatic nerve on an axial plane

Fig. 6.22c Longitudinal scan of the sciatic nerve (arrowheads);

ST, semitendinosus muscle belly; BF, biceps femoris muscle belly

The knee can be divided into four compartments: anterior, medial, lateral and posterior.

7.1 Anterior Compartment

The patient lies supine with the knee flexed at about 30–45° to correctly stretch the patellar and the quadriceps tendons (Fig. 7.1).

Anatomical scheme of the anterior compartment of the knee is reported in Fig. 7.2.

7.1.1 Quadriceps Tendon

The quadriceps tendon must be scanned on

both a long and short axis. The longitudinal view is obtained by orienting the probe on a sagittal plane and placing the distal edge on the patella (Figs. 7.3a, b). The typical multi-layered appearance of the tendon is due to the overlap of the different tendinous aponeuroses that concur to build the quadriceps tendon (Figs. 7.4a, b). This appearance may be more or less clear close to the insertional region, as the amount of adipose tissue interspersed between tendon layers may vary.

Moving the probe cranially, the myotendinous junctions of the quadriceps femoris can be seen. Note that the rectus femoris junction is located more proximally than the others (Figs.

7.5a, b).

Knee 7

Contents

7.1 Anterior Compartment

• Quadriceps Tendon

• Suprapatellar and Paracondylar Recesses

• Femoral Trochlea

• Patellar Retinacula

• Patellar Tendon or Ligament 7.2 Medial Compartment

• Medial Collateral Ligament

• Goose’s Foot Tendons 7.3 Lateral Compartment

• Iliotibial Tract

• Lateral Collateral Ligament 7.4 Posterior Compartment

• Medial Tendons

• Semimembranosus Bursa

• Popliteal Neurovascular Bundle

• Posterolateral Corner and Biceps Femoris

• Peroneal Nerve

E. Silvestri, A. Muda, L. M. Sconfienza, Normal Ultrasound Anatomy of the Musculoskeletal System, 93

Fig. 7.1Lower limb position to evaluate the anterior compartment of the knee

Fig. 7.2Anatomical scheme of quadriceps (QT) and patellar tendons (PT). F, femoris; T, tibia; Fi, fibula;

P,patella (under PT)

Fig. 7.3a Probe position to evaluate the quadriceps tendon on a longitudinal scan

Fig. 7.3b US scan shows the characteristic layered appearance of the quadriceps tendon (arrowheads). P, upper pole of patella

Fig. 7.4aPosition of the probe for evaluation of quadriceps tendon along the short axis

Fig. 7.4b Quadriceps tendon on its short axis (arrowheads). F,femur

Fig. 7.5a Probe position to evaluate the quadriceps femoris myotendinous junctions

Fig. 7.5b Quadriceps femoris myotendinous junctions.VL, vastus lateralis; RF, rectus femoris; *, rectus femoris myotendinous junction; VM, vastus medialis;

VI, vastus intermedius ; F,femur

7.1.2 Suprapatellar and Paracondylar Recesses

The lower limb must be kept in the same position described above to evaluate the quadriceps tendon.

The suprapatellar fat pad(Figs. 7.6a, b) is located under the quadriceps tendon and proximally to the superior pole of the patella. The suprapatellar synovial recess can be seen as a large hypoechoic space between the suprapatellar fat pad and the prefemoral fat pad that lies deeply, over the distal third of the femur.

In physiological conditions, the amount of synovial fluid contained within the suprapatellar synovial recess is very low. To detect the presence of intrarticular effusion, dynamic scans can be performed, asking the patient to flex the knee completely or to contract the quadriceps muscle. Paracondylar recesses can be assessed performing longitudinal and axial scans of the lateral and medial sides of the quadriceps tendon (Fig. 7.6c).

7.1.3 Femoral Trochlea

The knee must be positioned in full flexion. On the axial scan, the femoral trochlea and the overlying articular cartilage(Fig. 7.7a) can be seen. When normal, the articular cartilage is characterized by a hypo/anechoic and homoge- neous echotexture, while the bony surface of the trochlea is represented by an underlying hyperechoic line (Fig. 7.7b).

7.1.4 Patellar Retinacula

Anatomical scheme of the patellar retinacula is showed in Fig. 7.8. Medial and lateral retinacula can be evaluated by axial scans on the medial and lateral side of the patella, respectively. They appear as bilayered structures that can hardly be differentiated from the underlying joint capsule (Figs. 7.9a, b).

Fig. 7.6a Probe position to evaluate the suprapatellar recess

Fig. 7.6bThe sonogram shows the physiological fluid distension of the suprapatellar recess (*) under the quadriceps femoris tendon (arrowheads).

F, femur; P, proximal patellar pole;

ffp, prefemoral fat pad; pfp, suprapatellar fat pad

Fig. 7.6cParacondylar recess (arrow- heads) distended by a minimal amount of fluid. C, femoral condyle

Fig. 7.7b The sonogram shows the femoral trochlear cartilage (arrowheads). TF, femoral trochlea

Fig. 7.8Anatomical scheme of patellar retinacula.

MR, medial retinaculum; LR, lateral retinaculum;

PT, patellar tendon; F, femoris; T, tibia; F, fibula;

P,patella (under PT).

Fig. 7.9a Probe position to evaluate the lateral and medial retinacula

Fig. 7.9bThe sonogram shows the medial retinaculum (arrowheads). P, patella;

mfc, medial femoral condyle; ifc, lateral femoral condyle

Fig. 7.11a Probe position to evaluate the patellar tendon on the short axis

Fig. 7.11b Patellar tendon scan on its short axis (arrowheads). The tendon has a typical oval elongated section (lateral-medial is larger than the antero-posterior one)

Fig. 7.10 Anatomical scheme of quadriceps (QT) and patellar (PT) tendons. F, femoris; T, tibia; Fi, fibula;

P, patella (under PT)

Fig. 7.12a Probe position to evaluate the patellar tendon on its long axis

Fig. 7.12b Two coulplead images showing the patellar tendon in all its extension (arrowheads). P, lower patellar pole; T, anterior tibial apophysis; HFP, Hoffa’s fat pad

from the medial femoral condyle anteriorly to the medial tibial aspect posteriorly. The probe must be placed on a coronal oblique scan to assess the ligament along its extension. Both superficial and deep portions of the ligament (meniscus-femoral and meniscus-tibialis bun- dles) must be assessed (Figs. 7.15a, b).

7.2.2 Goose’s Foot Tendons

Anatomical scheme of goose’s foot tendons is reported in Fig. 7.16. Slightly anterior to the distal insertion of the medial collateral ligament, the three tendons (sartorius, gracilis,

medial tibial tubercle, where its fibers melt with those belonging to the gracilis and semitendinosus muscle

The gracilis lies in the medial region of the thigh, deep to the adductor longus and magnus. It arises from the pubic symphysis and inserts on the medial tibial tubercle.

Thesemitendinosus is a superficial muscle located in the posterior medial region of the thigh. It arises from the ischiatic tuberosity with a tendon in common with the long head of biceps femoris and inserts on the medial tibial tubercle.

Fig. 7.13 Anatomical scheme of the medial collateral ligament (arrowheads). ME, medial epicondyle;

P, patella; T,tibia; Fi, fibula

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