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
• Cortical irregularities
• Calcifications/ Loose bodies
• Fluid hypoechoic to anechoic
Malanga G, Mautner K. Atlas of Ultrasound-Guided Musculoskeletal Injections. New York: McGraw-Hill Professional; 2014.
OLECRANON BURSA ASPIRATION/INJECTION
• Supine with shoulder in IR and
flexion
• Variable approach
• Target middle of bursa
• Use transducer pressure to expel
fluid
Malanga G, Mautner K. Atlas of Ultrasound-Guided Musculoskeletal Injections. New York: McGraw-Hill Professional; 2014.
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
• Cortical irregularities
• Erosions
• Effusion
Malanga G, Mautner K. Atlas of Ultrasound-Guided Musculoskeletal Injections. New York: McGraw-Hill Professional; 2014.
CMC JOINT INJECTION
• Neutral position
• Long axis over joint
• In plane technique or stand off
• Avoid neurovascular bundle
Malanga G, Mautner K. Atlas of Ultrasound-Guided Musculoskeletal Injections. New York: McGraw-Hill Professional; 2014.
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
Malanga G, Mautner K. Atlas of Ultrasound-Guided Musculoskeletal Injections. New York: McGraw-Hill Professional; 2014.
FIRST EXTENSOR COMPARTMENT INJECTION
• Neutral position
• Axial view
• Lateral to medial approach
• Identify and avoid radial artery
Malanga G, Mautner K. Atlas of Ultrasound-Guided Musculoskeletal Injections. New York: McGraw-Hill Professional; 2014.
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/
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
Malanga G, Mautner K. Atlas of Ultrasound-Guided Musculoskeletal Injections. New York: McGraw-Hill Professional; 2014.
CARPAL TUNNEL SYNDROME
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
Malanga G, Mautner K. Atlas of Ultrasound-Guided Musculoskeletal Injections. New York: McGraw-Hill Professional; 2014.
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.