The main focus of our clinic is the treatment and rehabilitation of joint diseases of any level of complexity, including surgical intervention.
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Articular cartilage is an integral part of most joints. It lines the surfaces of the bones facing the cavity, and that is why it is so inextricably linked with them. It does not have its own blood vessels and contains a large amount of water (up to 75%). It receives nutrients from the underlying layer of bone (subchondral), as well as from synovial fluid. Its structure consists of main cells - chondrocytes - and an intercellular matrix, consisting mainly of collagen protein and glycosaminoglycans (hyaluronic acid, chondroitin sulfate and keratan sulfate), interconnected. It is the structure of the matrix that provides cartilage tissue with its elasticity and resilience. Articular cartilage that has a homogeneous matrix structure is called vitreous or hyaline. Experiencing stress at rest and during movement. Its function is shock absorption and protection. Due to its elastic and elastic structure, it reduces the load on the bones of the joints, preventing them from hitting each other and causing damage.
Anterior approach
The patient is in the supine position, the knee is bent 30-45°. The anterior approach evaluates the quadriceps tendon, suprapatellar bursa and bursa, contour and cartilage of the femoral condyles, patella and subcutaneous bursa, patellar ligament proper, superficial and deep infrapatellar bursa, and fatty body of the knee joint.
Quadriceps tendon on ultrasound
The sensor is placed above the patella in the projection of the quadriceps tendon. The tendon consists of four bundles that connect distally to the rectus, intermediate, lateral and medial heads of the muscle. It is important to examine the entire length of the tendon from its insertion at the superior edge of the patella to its transition to the muscle.
Task. Ultrasound shows a longitudinal section through the quadriceps tendon: a fibrous structure of increased echogenicity shadows from the upper edge of the patella (PA) (between the arrows); the edge of the tendon is hyperechoic, as there is no synovial membrane; a thin hyperechoic separation layer can be seen between the fascicles for the rectus, intermediate, lateral and medial heads of the muscle.
Task. Ultrasound shows a transverse section through the quadriceps tendon: the hyaline cartilage of the femoral condyles is hypoechoic, homogeneous echostructure, uniform thickness; the structure of the four quadriceps muscle bundles is studied proximally.
Task. Ultrasound shows a hypoechoic zone at the site of attachment of the quadriceps femoris tendon to the patella, a small tear in the posterior sections (arrow), a hyperechoic inclusion, and increased vascularization. Conclusion: Tendinosis of the distal quadriceps tendon.
Task. After falling on my knee, acute pain appeared; the patient cannot straighten his leg. On ultrasound, at the site of the quadriceps tendon, there is a heterogeneous hypoechoic zone with an uneven contour; tendon fibers are not identified. Conclusion: Rupture of the quadriceps tendon. Hematoma.
Task. Ultrasound shows avulsion of the tendon of one of the heads of the quadriceps femoris muscle: complete avulsion of the tendon and retraction of the rectus muscle; behind the rectus muscle, the intermediate muscle is of normal echogenicity and echostructure, the tendon is not broken.
Suprapatellar bursa on ultrasound
Under the quadriceps tendon, the suprapatellar bursa is located on a pad of fat; normally, a small amount of fluid can be seen in it.
Until the end of the 4th month of intrauterine development of the fetus, the cavity of the knee joint is separated from the suprapatellar bursa by the suprapatellar fold; by the end of the 5th month it is partially or completely reduced.
Degree of reduction of the suprapatellar fold: closed suprapatellar bursa; the suprapatellar fold has one or more openings; a residual connective tissue cord is visible, often on the inside; complete involution of the suprapatellar fold.
Task. Ultrasound shows a heterogeneous effusion in the suprapatellar bursa with a level of fine suspension; The bursa is separated from the joint cavity by a connective tissue linear structure (arrow)—the suprapatellar fold. Hemorrhagic fluid without signs of inflammation was aspirated from the suprapatellar bursa.
Task. Ultrasound shows longitudinal (1) and transverse (2) sections of the suprapatellar bursa: effusion is detected, the synovial membrane is thickened, vascularization is enhanced, the central septum is visible. Conclusion: Suprapatellar fold syndrome, local synovitis.
In 85% of cases, the suprapatellar bursa communicates with the anterior patellar inversion of the joint. Then the fluid in the suprapatellar bursa indicates effusion in the joint cavity - exudative synovitis, proliferation of the synovial membrane - exudative-proliferative synovitis.
If there is effusion in the suprapatellar inversion and bursa, it is important to examine the medial and lateral inversions of the joint; the sensor is placed transversely inward and outward from the patella.
Task. On ultrasound, effusion in the suprapatellar bursa: with normal sensor pressure, an echo picture of simple exudative synovitis; when the sensor pressure is excessive, the bag narrows and the illusion of an unevenly thickened synovial membrane appears - an echo picture of exudative-proliferative synovitis.
Task. Girl aged 10 months. On ultrasound, the patella and condyles are cartilaginously dense, growth zones are visible; in the suprapatellar volvulus there is effusion, the synovium is thickened, and vascularization is noticeably increased (2, 3, 4). Conclusion: Synovitis is exudative-proliferative.
Lipohemarthrosis occurs as a result of the extrusion of fat and blood from the bone marrow into the joint space after an intra-articular fracture. 97% of patients with intra-articular knee fracture have lipohemarthrosis.
Task. After falling from a wall, swelling, pain, and limited movement occurred in the knee joint. Ultrasound two days later showed no damage to the quadriceps tendon; in the suprapatellar volvulus and bursa there is a significant effusion from the alternation of hyper- and anechoic layers. Conclusion: Lipohemarthrosis of the knee joint, intra-articular fracture is likely. CT shows lipohemarthrosis; the patella is displaced laterally, there is a large defect in the medial edge; defect of the lateral edge of the distal femoral condyle; bone fragments in the surrounding tissues.
Task. Pigmented villonodular synovitis is a slow proliferation of the synovial membrane of large joints; nodular and villous outgrowths are formed, which can separate and form “articular mice”; accompanied by accumulation of hemorrhagic effusion, deposition of hemosiderin and the development of reactive synovitis; prolonged course leads to the appearance of degenerative changes in articular cartilage.
Hyaline cartilage of the femur on ultrasound
Task. To examine hyaline cartilage on the femoral condyles, the knee is flexed to 90° with the probe in the transverse plane above the patella. On ultrasound, the thickness of the cartilage on the femoral condyles is assessed on a transverse section: an avascular, homogeneous hypoechoic structure over the femoral condyles; The thickness of the cartilage decreases slightly from the center to the periphery.
Degenerative-dystrophic changes in cartilage on ultrasound
0-1 degree 2 degree 3 degree 4 degree
Osteophytes in the area of the medial condyles on ultrasound
with deforming osteoarthritis: moderate or absent swelling; hyaline cartilage unevenly thins, hyperechoic inclusions appear; the synovial membrane is focally thickened to 1-3 mm; moderate amount of effusion with homogeneous echostructure; the articular surfaces are grossly deformed by osteophytes.
for rheumatoid arthritis: severe swelling; hyaline cartilage in the initial stages may remain normal and even thickened due to swelling, then it becomes evenly thinner, cysts, erosions and ulcers appear; the synovial membrane is locally or diffusely thickened to 5-8 mm, fringed growths; there is a lot of effusion - fine and medium-dispersed suspension; the articular surfaces are flattened and significantly deformed.
Patella on ultrasound
Problem Double patella
Prepatellar bursitis - this type of bursitis is located directly under the skin on the patella and does not communicate with the cavity of the knee joint. If there are abrasions or wounds on the skin of the patella, then this type of bursitis becomes easily infected. Task. Prepatellar bursitis.
Task. Prepatellar bursitis
Task. Prepat hemorrhagic bursitis
Proprietary patellar ligament on ultrasound
The sensor is placed below the patella in the projection of the patellar ligament. The entire length of the ligament is examined from the place of attachment at the lower edge of the patella to the tibial tuberosity, while the condition of the fat body of the knee and subpatellar joint capsules is assessed.
Task. Ultrasound shows longitudinal and transverse sections of the patellar ligament (between the arrows): a fibrous structure of increased echogenicity stretches from the lower edge of the patella to the tibial tuberosity; above the patella, fibers from the quadriceps tendon to the patellar tendon (patella - sesamoid bone); behind the ligament is the fatty body of the knee joint and the deep infrapatellar bursa.
Task. Tendinosis of the proximal patellar ligament tendon with a thickened hypoechoic lesion with neovascularity.
Task. The jumper's knee is a patella with an uneven contour. On examination, there was no visible knee effusion and he had full range of motion; There is slight pain on palpation of the proximal insertion of the patellar tendon. On ultrasound, in the patellar ligament proper, at the site of attachment to the lower pole of the patella, there is a hypoechoic zone with hyperechoic inclusions, noticeable vascularization; The cortical layer of the patella is uneven. Conclusion: Patellar tendinopathy.
Task. Hoffa body injury
Task. Distal part of the patellar ligament.
Schlatter's disease on ultrasound
Infrapatellar bursitis – This bursitis is located under the patella, just behind the ligament. The bursa is protected by a ligament, so damage to the ligament leads to inflammation of the bursa.
Task. Schlatter - tuberosity with an uneven contour, tendinosis, bursitis.
Task. Schlatter
Task. A patient diagnosed with Osgut-Schlater disease complains of pain in the tibia. History of knee injury 10 years ago. On ultrasound, in the distal part of the patellar ligament there is a small hyperechoic structure with a posterior acoustic shadow, size 0.5x0.7 cm; echo signs of tendon tear and infrapatellar bursitis are not detected, the vascularization of the ligament and surrounding tissues is not changed. Conclusion: Bone fragment in the distal patellar ligament. X-ray data reveals a bone fragment, which can be interpreted as a consequence of an avulsion fracture, taking into account the history of the injury.
Medial access
This approach provides visualization of the medial collateral ligament, the body of the medial meniscus, and the medial part of the joint space.
The patient is in a supine position, the limb is straightened. The sensor is installed on the medial surface of the joint, in a longitudinal position, along the midline in relation to the joint space. When the sensor is installed correctly, the joint space should be clearly visible on the monitor screen. Improved visualization of the meniscus can be achieved by bending the leg at the knee joint to 45-60 degrees.
The condition of the joint space, the contours of the femur and tibia, the thickness and condition of hyaline cartilage, and the presence of effusion in the joint cavity are assessed.
Above the joint space, fibers of the medial collateral ligament are visible, which originate from the proximal part of the medial femoral condyle and attach to the proximal part of the tibial metaphysis. To improve visualization of the body of the internal meniscus, the limb must be rotated outward, in this case a divergence of the joint space occurs, and the meniscus is located posterior to the medial collateral ligament.
From the medial approach it is sometimes possible to visualize the anterior cruciate ligament. To do this, the patient is asked to bend the leg at the knee joint as much as possible. In this case, the sensor is placed below the patella and the scanning plane is directed into the joint cavity. The bony landmarks are the condyle of the femur and the epicondyle of the tibia. The fibers of the anterior cruciate ligament are partially visualized. Due to the anisotropy effect, the ligament may be hypoechoic, and only part of the fibers located perpendicular to the ultrasound beam will be hyperechoic.
Anserine bursitis (pes anserine bursitis) - the bursa is very small, but extremely painful. The tendons of three muscles (sartorius, gracefulness and semitendinosus) attach to the tibia at one point, resembling the foot of a goose. This zone is located 4 cm below the gap of the knee joint on the inner surface. Upon examination and palpation, it turns out that this is a pathology not so much of the joint as of the area of the crow's foot. Pain with anserine bursitis intensifies when going up stairs, and with arthrosis - when going down. This type of bursitis is characterized by “starting pain” - pain at the beginning of walking after prolonged sitting.
Menisci -
Meniscal injuries on ultrasound
Med meniscus
Task. Meniscus cyst. Lateral knee pain. There were no previous injuries, but discomfort persisted, especially when extending the knee. On examination, there was no effusion, a cystic, noncompressible, nonvascular, anechoic lesion on the lateral joint line that appeared to be associated with the lateral meniscus and joint line. The patient may have local swelling and discomfort in the joint area, and may have reduced range of motion. A meniscal cyst is a well-defined cystic lesion located along the peripheral edge of the meniscus and is often associated with horizontal meniscal tears. Meniscal cysts can be managed using guided aspiration, but are likely to be associated with meniscal pathology, which should be considered. On MRI, there is high signal in the anterior horn, and the body of the lateral meniscus extends into the lobular region of the fluid signal anteriorly and laterally, consistent with a meniscal tear and cyst. Several partitions are visible in this one.
Drawing.
Symptoms
Elbow pain is the most common symptom of elbow arthrosis, and can radiate down into the forearm or up into the shoulder. Often, a grinding sound may also be noted that accompanies movements in the elbow joint, which is the result of a violation of the smooth surface of the hyaline cartilage. As arthrosis progresses, loose pieces of cartilage or bone can become lodged in the elbow joint and cause significant limitation of movement (locking). Due to the small intra-articular space, the accumulation of synovial fluid can lead to compression of the ulnar nerve, which can manifest itself as a pins and needles sensation in the little and ring fingers. Patients with arthrosis of the elbow joint often “overdo it” with stress during sports or during work, and in such cases there is a sharp aggravation in the joint where there are degenerative changes. This flare-up can last up to 48 hours and usually results in stiffness (particularly in the morning) and pain in the affected joint. The exacerbation decreases with rest and use of NSAIDs (non-steroidal anti-inflammatory drugs) as prescribed by a doctor. Applying ice may also be helpful. A significant period of time may pass before the next exacerbation episode, but, as a rule, each subsequent episode is more intense. The time interval between episodes shortens and eventually the patient will have pain even at rest. As arthrosis progresses, symptoms that are initially triggered by exercise may later also be associated with periods of immobility. Thus, if in the early stages of arthrosis rest and unloading of the joint is necessary, in the later stages long-term unloading of the joint can only aggravate the problem.
In later stages of arthrosis, in the presence of persistent pain at rest and at night, as well as when joint mobility is limited, it is advisable to consider surgical intervention. Moreover, arthroscopic operations are currently used for this. These minimally invasive techniques remove loose bone and cartilage tissue and restore normal elbow function.
Lateral access
This approach provides visualization of the distal fascia lata, popliteus tendon, lateral collateral ligament, distal biceps femoris tendon, body of the lateral meniscus, and lateral joint space.
The patient is in a supine position, the leg is bent at the knee joint at an angle of 30-45 degrees, internally rotated. The sensor is installed on the lateral surface of the joint, in a longitudinal position, along the midline in relation to the joint space. The bony landmarks are the head of the fibula, the tubercle of Gerdian of the tibia, and the lateral condyle of the femur.
Scanning in the cranial direction allows you to examine the fibers of the fascia lata. The bony landmark for the attachment of tendon fibers is the tubercle of Gerdian on the anterolateral surface of the tibia.
Between the Gerdian tubercle of the tibia and the lateral condyle of the femur in the notch is the popliteus tendon, which is attached to the posterior surface of the tibia. Part of this tendon can be visualized by scanning the lateral collateral ligament.
The fibers of the lateral collateral ligament pass over the joint space. The lateral collateral ligament originates from the lateral femoral condyle, passes over the popliteus tendon, and attaches to the head of the fibula, merging with the fibers of the tendon of the lateral head of the biceps femoris.
With a fixed position of the sensor in the area of the head of the fibula and rotation of the proximal end of the sensor downward, the tendon of the lateral head of the biceps femoris is determined.
To assess the body of the lateral meniscus or determine the integrity of the fibers of the lateral collateral ligament, the limb must be rotated medially, with the meniscus located posterior to the lateral ligament and separated from its fibers by the popliteus tendon.
How else to help cartilage
The rate of restoration of damaged cartilage tissue depends on the number and activity of chondrocytes. Therefore, they need to be provided with adequate nutrition through synovial fluid, as well as to speed up their metabolism. Active movements contribute to this in the best possible way.
The more you move, the faster cartilage tissue is restored
Prolonged immobility leads to muscle atrophy and reduction of cartilage tissue, since it does not receive enough nutrients. Therefore, the least you can do with arthrosis is to ensure that a sufficient amount of fluid enters the body and move - of course, without fanaticism, to the best of your ability!
Rear access
With this approach, the neurovascular bundle of the popliteal fossa, the medial and lateral heads of the gastrocnemius muscle, the distal part of the fibers of the semimembranosus tendon, the posterior horn of the internal meniscus and the posterior horn of the external meniscus, and the posterior cruciate ligament are visualized.
The patient is in a prone position. The sensor is located transversely to the long axis of the limb in the popliteal fossa. The neurovascular bundle is displaced laterally in the popliteal fossa. The popliteal artery is located behind the vein; the muscle bundles of the popliteal muscle are visualized below. With a panoramic scan using energy mapping, the course of the popliteal artery can be traced.
The tendons of the medial and lateral heads of the gastrocnemius muscle arise from the corresponding condylar surfaces of the femur. The semimembranosus tendon inserts on the posteromedial surface of the proximal tibia.
Between the semimembranosus tendon and the medial head of the gastrocnemius muscle is a small bursa that usually contains the neck of a Baker's cyst. Landmarks for visualizing this bursa during transverse scanning are: the posterior surface of the medial condyle of the femur, covered with hyaline cartilage, the semimembranosus tendon, and the fibers of the gastrocnemius muscle.
When scanning the popliteal fossa longitudinally, the sensor is shifted laterally and rotated according to the plane of the joint cavity. In this case, the posterior horn of the external meniscus is visualized. The posterior cruciate ligament is also visualized from this position, with the probe rotated 30 degrees counterclockwise when examining the right limb and 30 degrees clockwise when examining the left limb. The posterior cruciate ligament, like the anterior ligament, is partially visualized. Due to the anisotropy effect, its fibers are hypoechoic.
To assess the posterior horn of the medial meniscus, it is necessary to move the transducer medially in the popliteal fossa and image the tendon fibers of the medial head of the biceps femoris muscle, which attach to the medial epicondyle of the tibia. From this position the body of the medial meniscus is visualized.
From the posterior approach, one can also evaluate the peroneal nerve, which, leaving the lateral part of the sciatic nerve in the distal thigh, follows laterally and downwards along the posterior surface of the distal biceps femoris tendon before passing to the popliteal region, then around the head of the fibula to the anterior surface of the leg. In this area, nerve damage often occurs between the fibers of the fibrous tunnel.
Popliteal bursitis (Baker's cyst) is located on the back of the knee in the popliteal fossa. On the inside of the knee there is a popliteal bursa known more commonly as a Baker's cyst. Visible only when the knee is bent; as soon as the leg is bent, the cyst disappears. Rarely occurs as an independent cavity, it usually communicates with the joint cavity through a valve connection, the fluid can flow only in one direction, from the joint to the bag, where it is usually absorbed. With this bursitis, there is pain in the knee, which intensifies when squatting, and there will be limited mobility in the knee joint.
Baker's cyst on ultrasound
Task. Patient with discomfort in the popliteal fossa. Ultrasound shows a Baker's cyst with septations, increased vascularization around the perimeter. Conclusion: Baker's cyst.
Treatment
Conservative treatment
In almost all cases, doctors first prescribe conservative treatment. The goal of conservative treatment is to reduce pain and maintain sufficient joint function. Non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen, which can reduce swelling and pain, can be recommended for medical treatment. Various methods of physiotherapy (electrophoresis, phonophoresis, laser, etc.) are widely prescribed, which also helps reduce pain. Exercise therapy plays an important role in the conservative treatment of arthrosis, which helps preserve the functionality of the joint. In case of severe exacerbation, the use of an orthosis for a certain period of time may be recommended.
In some cases, the patient needs to change or limit physical activity, especially when it involves stress on the arm.
Cortisone injections into the elbow joint may provide temporary relief. Cortisone is a powerful anti-inflammatory drug and can be very effective in relieving pain and swelling. The effects of cortisone (or other steroids) are temporary, lasting from several weeks to months. There is a small risk of infection with any joint injection, and cortisone injections are no exception. In addition, steroids should not be administered frequently, as they themselves lead to damage to cartilage tissue.
Soft tissue neoplasms on ultrasound
Task. Vascular malformation of the knee
Task. 6 months of anterior knee pain with background history of ACL reconstruction. pain in the tibia area. They did recall an occasional smaller area of swelling appearing on the front of the lower leg in recent months. There was full range of motion of the knee. There was some localized tenderness medial to the tibial tuberosity, directly where the ACL scar was. the patellar tendon and tibial tuberosity insert were intact. There was no evidence of deep infrapatellar bursitis. There was an anechoic, noncompressible lesion medial to the tibial tuberosity that appeared to communicate with the calf cortex in the area of the ACL scar. No vascularity was visible. It was not compressible and there seemed to be a clear relationship between cortical irregularities. The lesion was painful under pressure from the probe, reproducing the patient's symptoms. When viewing the images, a collection of fluid was visible on the front tibia. opinion about the pretibial ganglion. Conclusion: Pretibial hygroma.
Tags: lectures joints ultrasound