applications of msk ultrasound in the upper extremity€¦ · malanga g, mautner k. atlas of...

APPLICATIONS OF MSK ULTRASOUND IN THE UPPER EXTREMITY

Todd P. Beery D.O.

OBJECTIVES

• Review fundamental nomenclature and principles of US.

• Accurately identify appearance of soft tissue structures under US.

• Review US guided injection techniques in common elbow and

wrist conditions.

• Understand coding for US guided injections and diagnostic scans.

ADVANTAGES OF MSK US

• Portable diagnostic tool

• Evolving technology

• Dynamic evaluation

• No contraindications

• Pacemakers/ Implants / Prosthesis

• Cost

• Patient satisfaction

• Improve patient care

ECHOGENICITY

• Hypoechoic: Appears DARK

• Waves absorbed, pass through or

scatter more easily

• Hyperechoic Appears BRIGHT

• Waves return to the reducer

https://commons.wikimedia.org/wiki/File:Ultrasound_lesions_echogenicity.svg

TISSUE APPEARANCE

• Tendon

• Muscle

• Ligament

• Bone

• Nerve

TENDON

• Longitudinal view:

• Hypoechoic with alternating

hyperechoic

• Fibrillar pattern

• Axial view:

• Speckled pattern

MUSCLE

• Hypoechoic with hyperechoic

pattern

• Variety shapes

• Axial view

• “Starry Night Pattern”

• Longitudinal view

• Pennate / Feather like

Boon AJ, Smith J, Harper CM. Ultrasound applications in electrodiagnosis. PM R 2012;4:37–49.

LIGAMENT

• Thin hypoechoic structure

BONE

• Hyperechoic surface with deeper

hypoechoic appearance

NERVE

• Axial view- honeycomb

appearance

• Hypoechoic fascicles

• Hyperechoic perineurium and

epineurium

• Longitudinal view-

striated/fascicular

https://openclipart.org/tags/honeycomb

VASCULAR STRUCTURES

• Power Doppler

• Low flow states

• Single color

• Not directional

• Color Doppler

• High flow states

• Two Color – Directional

CLINICAL APPLICATIONS

• Elbow

• Common extensor tendonitis

• Olecranon bursitis

• Hand

• 1st CMC joint arthropathy

• First dorsal compartment tenosynovitis

• Carpal tunnel syndrome

COMMON EXTENSOR TENDINOPATHY

• “Tennis Elbow”

• Anatomy

• ECRB, EDC, EDM, ECU

• Origin on the lateral epicondyle

• Microtrauma/ Overuse

https://orthoinfo.aaos.org/en/diseases--conditions/tennis-elbow-lateral-epicondylitis/

COMMON EXTENSOR TENDINOPATHY

• Depth 2-3 cm

• Cortical irregularities

• Hypoechogenic

• Thickening

COMMON EXTENSOR TENDON INJECTION

• Depth 2-3 cm

• Long axis to CET

• Needle approach distal to

proximal

• Target to the superficial to the CET

to the peritendinous region

Malanga G, Mautner K. Atlas of Ultrasound-Guided Musculoskeletal Injections. New York: McGraw-Hill Professional; 2014.

OLECRANON BURSITIS

• Anatomy

• Synovial pouch

• Only one in the elbow

• Between extensor surface of skin

and olecranon process

• No communication adjacent joint

• Trauma, Infection, Inflammatory

https://orthoinfo.aaos.org/en/diseases--conditions/elbow-olecranon-bursitis/

OLECRANON BURSITIS


• Calcifications/ Loose bodies

• Fluid hypoechoic to anechoic


OLECRANON BURSA ASPIRATION/INJECTION

• Supine with shoulder in IR and

flexion

• Variable approach

• Target middle of bursa

• Use transducer pressure to expel

fluid


CMC JOINT

• Anatomy

• Articulation with trapezium

• Radial artery branch to palmar

• Radial nerve

• Pain with gripping /holding

• Crepitus

• Joint “squaring “

https://www.mayoclinic.org/diseases-conditions/thumb-arthritis/symptoms-causes/syc-20378339

CMC JOINT

• Depth <1 cm

• “Seagull appearance”

• Enlarged triangular joint


• Erosions

• Effusion


CMC JOINT INJECTION

• Neutral position

• Long axis over joint

• In plane technique or stand off

• Avoid neurovascular bundle


FIRST EXTENSOR COMPARTMENT TENOSYNOVITIS

• Anatomy

• Lateral to radial styloid process

• EPB and APL

• Anatomical variation

• De Quervain syndrome

• Sheer injury/ repetitive

microtrauma

• Grasping with ulnar deviation

https://www.aafp.org/afp/2013/0415/hi-res/afp20130415p568-f5.gif

FIRST EXTENSOR COMPARTMENT TENOSYNOVITIS

• Depth < 3 cm

• Anechoic fluid surrounding tendon

• Tendon thickening

• Intrasubstance tears

• Multilamellar APL tendon not to be

confused with tears


FIRST EXTENSOR COMPARTMENT INJECTION

• Neutral position

• Axial view

• Lateral to medial approach

• Identify and avoid radial artery


CARPAL TUNNEL SYNDROME

• Anatomy

• 4 FDS, 4 FDP, FPL, Median nerve

• Most common mononeuropathy

• Hand weakness, paresthesia, pain

https://orthoinfo.aaos.org/en/diseases--conditions/carpal-tunnel-syndrome/


• Short axis view

• Proximal nerve swelling

• Cross sectional area >10 mm2

• Long axis view

• Proximal swelling

• “Notch sign” at compression site

• Anatomical variants

• Bifid median nerve



Anatomical

Variation:

Bifid median nerve

Boon AJ, Smith J, Harper CM. Ultrasound applications in electrodiagnosis. PM R 2012;4:37–49.

CARPAL TUNNEL INJECTION

• Wrist supinated in dorsiflexion

• Axial view at distal palmer crease

• Needle ulnar to radial

• Confirm ulnar and radial artery

location


BILLING MSK US – DIAGNOSTIC SCANS

• Diagnostic scans:

• Complete diagnostic US – 76881

• Scan of a joint that includes muscle, tendon, nerve , vascular and

other .

• Limited diagnostic US – 76882

• Focused study of a specific structure.

• Modifier 50 can be used for side to side comparison.

BILLING MSK US - GUIDED INJECTIONS

• US Guided Injections: – CPT 76942

• 20526 Injection to carpal tunnel

• 20550 Injection to tendon sheath, ligament

• 20551 Injection to tendon origin/insertion

• 64450 Injection to other peripheral nerve

BILLING MSK US - GUIDED INJECTIONS

• US Guided joint injection:

• In 2016, Payment for US was bundled into new CPT codes

• 20604 small joint/bursa

• 20606 medium joint/bursa

• 20611 large joint /bursa

SUMMARY

• US is an evolving diagnostic

tool for musculoskeletal and neurologic conditions in the

upper extremity.

• Allows for accurate imaging

guidance for soft tissue and

joint injections.

• Use allows for reimbursable

services.

THANK YOU

REFERENCES

• Boon AJ, Smith J, Harper CM. Ultrasound applications in electrodiagnosis. PM R 2012;4:37–49.

• Malanga G, Mautner K. Atlas of Ultrasound-Guided Musculoskeletal Injections. New York: McGraw-Hill Professional; 2014.

• Ozackar L, Tok F, Kesikburun s, Palamar D, Erden G, Ulasli A, et al. Musculoskeletal sonography in physical and rehabilitation and medicine: results of the first worldwide survey study. Arch Phys Med Rehabil 2010; 91: 326-331.

• Louis LJ. Musculoskeletal ultrasound intervention: principles and advances. Radiol Clin North Am 2008; 46: 515-533.

• Davidson J, Jayaraman S. Guided interventions in musculoskeletal ultrasound: what’s the evidence? Clin Radiol. 2011;66(2):140–52.

• Sivan M, et al. A one-stop approach to the management of soft tissue and degenerative musculoskeletal conditions using clinic based ultrasonography. Musculoskeletal Care. 2011;9(2):63–8.

applications of msk ultrasound in the upper extremity€¦ · malanga g, mautner k. atlas of...

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