Pearls and Pitfalls in Musculoskeletal Ultrasound - HD

Introduction

Hi, my name is Sandra Allison.

I am from Washington Radiology Associates in Washington, DC and today I'll be talking about pearls and pitfalls.

In musculoskeletal ultrasound, I have no disclosures.

And for today's talk I will list technical pointers to optimize your images, talk about potential pitfalls and performing musculoskeletal sonography, and also discuss various applications of di, the dynamic capabilities of ultrasound.

Keys to a Successful Examination

Here I have a list of keys to a successful examination.

And while some of them may seem intuitive, I thought to list them but also will be showing some examples during this talk.

Transducer Selection

First off, for musculoskeletal ultrasound, we prefer to use a linear transducer, and that is because normal tendons have linear a linear structure.

A normal tendon is hyper coic and composed of fine parallel echogenic fis, which make up the collagen fibrils.

And with a linear transducer you can see that these fibrils come into view quite nicely as the sound is bounced off them when they're at a 90 degree angle to the transducer.

With a curve transducer, first of all, you lose some of your resolution because of the higher or the lower frequency.

You can still see some of the fine parallel echogenic lines, right where the sound beam hits the tendon at a 90 degree angle.

But over here on the edges of the image, we have what is called anisotropy, where we have a loss of echogenicity in the tendon because it is not perpendicular to the sound beam because the structures we are evaluating are very superficial, it is preferable to use a high frequency transducer, which has better resolution,

see the achilles tendon in the same patient using three different transducers.

And as you can see, as we increase the frequency, we bring out the fine detail and the fine anatomy.

In this tendon we see more of the echogenic fis and it makes us easier for us to detect when there is a loss or change in the internal architecture.

Patient Positioning

Now patient positioning is very important.

Just like with any other examinations we perform with ultrasound, with musculoskeletal ultrasound, depending on the joint or the structure's imaged the position of the patient can be changed.

Usually it is to allow for the dynamic examination.

So here we have, evaluation of the hand, which I like to put on a, on a sort of a platform or a rolled up towel so that I can free up the fingers and flex or extend the fingers while looking with the ultrasound machine I can evaluate tendon motion for the ankle.

It's easier to follow the medial in the lateral tendons when the patient is prone and the foot is off the edge of the bed.

And we can also perform a dynamic maneuver or flex dorsi flex or plantar flex the foot if it is extending off the table.

Use of Gel and Avoiding Air

Now, because the structures we are looking at are superficial, many times it's important to use copious gel in order to bring that structure into better view, but also as to not obliterate the structure.

So for example, here we are looking at the dorsum of the left second or index finger at the level of the metacarpal phalangeal joint and we have the tendon extending across the top in an area of either focal thickening or a hypoechoic soft tissue in this area.

Now we could already describe that as an abnormality, but as you can see with the gel heaped up, which allows us to scan with a lighter hand, we can see that the structure is actually cystic rather than solid and it would otherwise have not been seen had it not been for the lighter hand when scanning this patient had a joint effusion.

In the same vein, air is the enemy of ultrasound and when we're trying to examine structures that are very superficial, we'd like to displace the air or remove the air by using copious amounts of gel.

For example, here we could have used a standoff pad, but because this lesion is on the side of the digit, filling in the gap, which would've contained air with gel can eliminate that artifact that's caused by the air and bring out the structure, very small structure that we're imaging.

And this is actually a, foreign body granuloma that was produced by a thorn in the patient's finger.

Example Case Illustrating Principles

Now this, these set of images is from a case that illustrates many of the principles that I thought to put in one case, this patient came with pain and cold sensitivity in the fingertip.

And here we are looked at the fingertip.

This is the distal phalanx, this is the nail.

We're looking at the nail bed here and perhaps you can see there's a hypoechoic structure at the base of the nail bed here.

But by optimizing the images using the MSK presets, you can see now that the hypoechoic structure is brought out in distinction to the more hyper coic surrounding tissues.

Now I wonder, is this the normal contour of the bone or is there scalloping or a pressure effect by this lesion?

So we can see it here, the comparison between left and right.

You'll see that I have some other examples showing comparison to be very useful.

And now I think you can better appreciate that there is pressure effect on the underlying bone in the affected digit compared with the unaffected digit.

And then power doppler or color doppler can be used to also show a difference or show an underlying lesion in this case.

And this was a case that was actually not demonstrated on MRI and yet the patient had significant symptoms and so the surgeon thought to order an ultrasound.

Knowledge of Anatomy

Now knowledge of anatomy is very important and the shoulder is one of the trickier joints to evaluate with ultrasound just because the tendons are not oriented in a linear fashion and the anatomy is a little bit more complex.

But here's a patient who presents with acute shoulder pain and I wanted to show you a normal rotator cuff.

And when I look at the rotor rotator cuff and when I talk to students, this is, this may be oversimplified, but I say that I do layer inventory.

There should be four layers that you see in a normal image.

We have the skin and subcutaneous fat, the overlying deltoid muscle.

We have the rotator cuff in this case, this is the supraspinatus tendon inserting on the greater tuberosity.

And here we have the humeral head with a greater tuberosity.

There is another layer which we don't usually see in normal situations, which is the subacromial subdeltoid bursa that sits in this location.

Abnormal Shoulder Findings

Now here we have the abnormal image in a patient presenting with acute shoulder pain.

And we see that we have the skin and subcutaneous fat, we have the deltoid, we're missing the normal rotator cuff that we expect to see.

And here we have the underlying humeral head that has an irregular contour.

And in this case we have fluid in the space that would've contained the rotator cuff because now it is completely torn and we don't see the cuff.

So we know we're looking at, at a acute rotator cuff tear.

This fluid may be in the gap of the cuff, but also may be descending a subacromial subdeltoid bursa, which happens in the setting of a rotator cuff tear.

So using those same principles, we have another patient who has shoulder pain and if we try to count the layers here, we have the skin and subcutaneous fat, we have the deltoid muscle, we have the humeral head, and then we have this, I'm not sure what this is, could this be, but we definitely don't have a normal rotator cuff.

Now the difference between this and the other case is that there's not much fluid descending this extra layer.

So this is a chronic rotator cuff tear.

And what we're looking at here is the bursal tissues over and probably a combination of that and the cartilage cap over the humeral head.

This is a chronic rotator cuff tear.

Post-Arthroplasty Shoulder

Now many times when you get to evaluate shoulders after shoulder replacement or arthroplasty, it gets a little confusing.

But if you use the same principles, so in this case, lemme start from the bottom, we're looking at the humeral head component of the arthroplasty, okay?

And then from the top we have this skin and subcutaneous fat and the deltoid.

So we see here that if we're looking for all four layers, we are missing the rotator cuff layer.

And this is a rotator cuff tear that has happened in the setting of a shoulder placement.

Thickened Bursa

And what about this case? This patient presents with pain clicking and decreased range of motion.

I show several pictures because sometimes one doesn't show all the detail, but let's do some layer inventory.

Let's look at this picture. These are the transverse and long axis views of the supraspinatus tendon.

We're looking at skin and subcutaneous fat.

We have the deltoid muscle, we have the Supraspinatus tendon part of the rotator cuff, and then we have the underlying, humeral head and greater tuberosity.

So we have all four layers.

We do not have a cuff tear or a defect in the layers, but if you look a little more closely at these two images just blowing up these images, you see that there is an extra layer here, which is this.

This should not be counted along with the supraspinatus tendon.

This is actually the subacromial subdeltoid bursa.

But in this case, it is not distended with fluid, it is just thickened.

So this is chronic thickening of the subacromial subdeltoid bursa, in a setting of possibly a chronic bursitis.

And the reason why this patient had decreased range of motion is because this thickening was, was a source of impingement.

And I'll talk a little bit more about dynamic studies and impingement later.

Finger Pulley

Now, knowledge of normal anatomy is also important because you don't want to mistake normal structures for pathology.

This case, the finger pulley, this is a flexor tendon in one of the digits.

There's a superficial and a deep flexor tendon.

And this is a pulley that holds the flexor tendon to the bone and is a focal thickening in the tendon sheath.

Now if you didn't know this or didn't expect this, this can be red as fluid, But just remember the pulley occurs at certain locations.

In this case the A one pulley, which occurs at the level of the metacarpal head, but also that the pulley is usually uniform in thickness as com as opposed to fluid, which can be irregular, can have areas of synovial thickening and can be seen in areas where you don't expect to see pulley.

So in this case, these images show a case of 10 synovitis of the flexor tendons.

And this image shows a comparison between a normal pulley and a thickened pulley or possibly fluid within the tendon sheath.

Groin Pain and Ilio Psoas Bursitis

Another example, where knowledge of anatomy can help, here's a patient who presents with groin pain and actually presented with a for a CAT scan or a CT scan.

And here is a structure that is fluid filled in the right groin.

That was actually, preliminarily dictated as A DVT.

So the patient came and had a DVT study.

Here we are looking at images of the right common femoral vein with without and with compression.

And you can see that the vein does compress.

So there is no DVT in this area, but we do see this same cystic collection that is seen here deep to the vessels.

And this is a case of ilio sous bursitis.

And this is fluid filling the bursa around the ilio sous tendon.

So the ilio sous tendon is right here in this image right here.

Using Bony Landmarks

Now, because we are looking at superficial structures when we are evaluating the musculoskeletal system, many times bony landmarks can be very helpful in determining or identifying tendons.

And early in my career, I started my career as a musculoskeletal ultrasound person.

I started training my technologists to perform some of these studies and she came out one day and she said, I have a prescription for evaluate for EPL tear.

And she said to me, what's the EPL?

And I said, well, nevermind about that at the moment we can talk about that, we can look it in atlas, but use this landmark.

The EPL is actually the tendon that extends across toward the thumb and can be seen when you, hyperextend or extend at the thumb.

So I showed it to her on myself and I said, look for this in this patient.

And if you can't find it compared with the other side, which is very important.

So here's an image of a normal extensor lysis longest tendon, which was correlative of this tendon right here you can see the fine fibrillary structure that is expected in a tendon.

And here's what she found in the abnormal side.

She did not see the normal tendon structure extending across the image.

There's an empty tendon sheath here.

This is probably the free edge of the ruptured tendon maybe here you can see with a greater, with a bigger feel of view.

You can see again the free edges of the ruptured tendon and the empty space where the tendon should belong.

So this is a ruptured extensor lysis longest tendon.

Anisotropy

Now I alluded to this earlier, but all tendons exhibit anti isotropy and knowledge of that will help you in distinguishing anisotropy from true pathology.

Here is an achilles tendon.

You can see the fine fibrillary structure, fine parallel echogenic lines that are the collagen fis and this drop in echogenicity as the tendon curves and is no longer perpendicular to the transducer.

This can typically be seen in tendons at the insertion, especially in the achilles tendon.

And how do you decide whether this is pathology or not?

Well, you can either reorient your transducer to bring this area more perpendicular to the sound or you can, reposition the patient either by flexing or extending at that joint.

And here we can see that there is now fine parallel lines extending all the way to the cortex and no anisotropy.

Same thing in the triceps tendon.

Here we are looking at the triceps tendon coming down towards its insertion and is this abnormal or not?

Well, we can reorient the tendon and see that we bring out the parallel echogenic lines and that there is no abnormality at the insertion.

Now how about here? Well, this is a normal rotator cuff with some an isotropy.

We already proved that by doing the same maneuvers as earlier, we reorient the transducer.

But what about here? Here we see some hypoechoic areas in the tendon that are perpendicular to the beam.

So this is not antrop in the tendon, this is abnormal loss of architecture.

We don't see the fine parallel lines and this is tendinosis in the tendon and this is what tendonosis looks like in the rotator cuff and this is what tendinosis looks like in other tendons.

And the same principles apply.

Now this patient was complaining of pain with overhead reaching and we're looking at the left supraspinatus tendon.

Here is the humeral head, greater tuberosity, the deltoid, the skin and subcutaneous fat.

And here is the supraspinatus tendon as part of the rotator cuff is this anisotropy.

So first you would reorient the transducer, make sure to see, but second, you can already see that air where we have the tendon at 90 degrees to the sound.

We do not have those parallel lines.

So this is a patient with tendonosis and this is included.

Part of this is part of the tendonosis, and is not an isotropy.

Cartilage vs. Fluid

Now the cartilage, which is part of covering the humeral head here, can be mistaken for fluid because cartilage can appear anti coic on the images.

And it's important to know that again, knowledge of the anatomy and the ultrasound appearance is important.

In this case, we can see that we have the skin and subcutaneous fat, the deltoid part of the rotator cuff we do not see.

And then we have the humeral head with a cartilage cap.

And you can see that where the fluid is overlying the cap, you can see this the surface of the cartilage.

And so you know that this is not part of the fluid, this is a normal structure.

And then we do have fluid here.

This is an a full thickness rotator cuff tear.

Hip Effusion and Capsule

Another thing important about knowledge of anatomy is that sometimes the examination may be counterintuitive.

Now in this patient we're looking for a HIPA effusion and the impetus would be, to look at the the acetabular acetabulum and the femoral head and looking at the joint here.

But if you knew that the capsule actually extends far down up to the femoral neck, then you would know that you would look in this area, but you would actually look more inferior to this at the level of the femoral neck to look to see for a fluid collection in this area.

Same thing when accessing the hip capsule or doing a hip injection.

You don't necessarily have to aim for this part of the hip joint.

You can aim for the capsule which extends this far down and have an easier access to the hip joint.

Another thing to know about the hip capsule is that you don't want to confuse that for fluid.

So here the hip capsule can be seen, you can see that it's this soft tissue structure that extends from the acetabulum, covers the femoral head and comes down as low as the femoral neck.

And you don't want to confuse this for hip effusion.

You wanna see that you're looking at fluid versus solid.

In this case, the hip capsule is actually distended with fluid.

So now you can appreciate again how far down the hip capsule extends and where it belongs and to not ex to not confuse it with fluid.

Comparison with the Asymptomatic Side

Now comparing with the asymptomatic side is very important and that's one of the big benefits of ultrasound when compared with other imaging modalities because a comparison is essentially free.

You don't have to order the other side as part of the study here we are looking at patient with heel pain.

We are looking at the right achilles tendon and this seems fairly normal.

You can see that there are fine parallel echogenic lines.

You see the tendon structure in here and it doesn't really look all that thickened at least at first glance.

But when you compare it with the asymptomatic side, you can see now that it is actually more hyper coic.

And there are areas where we don't see the normal architecture.

And you can also see that there is increased echogenicity in the deeper keggers fat pad because the transmission of sound is enhanced in the abnormal side.

So now you know that this is an abnormal right achilles tendon and in fact this is where the patient experience is experiencing tenderness.

This is tendinosis of the achilles tendon.

Rotator Cuff Comparison

I showed this case earlier, but again, it could be less obvious.

This doesn't look too thickened as a rotator cuff, we are looking at the subscapularis tendon.

This is the cricoid process.

We're looking at the tendon here.

This is a deltoid, an overlying subcutaneous fat.

And this tendon doesn't look too thickened, but when you compare it with the other side, you can see that there is asymmetry, asymmetry not only in the thickness but also in the architecture and the genicity.

And another point that I wanted to make is that measurements are very important because if you looked at this without measuring it, it wouldn't look too thickened and it still doesn't look too thick.

But when you compare it with the other side, even though we are looking at very small measurements here, percentage wise, this is significant thickening and asymmetric thickening.

But more importantly it corresponds with where the patient is feeling their symptoms.

And this is subscapularis tendon, tendinosis.

Muscle Comparison

We can compare muscles. Here we are looking at the left infraspinatus muscle muscle normally looks dark on ultrasound hypoechoic with bright echoes that represent the fascia and fibro septations that run through muscle.

And when compared with the right side, you can see that the muscle is not only decreased in volume but also increased in echogenicity.

So this is fatty atrophy of the right, infraspinatus muscle in the setting of a chronic rotator cuff tear.

Again, comparison is very important because it may not always be obvious.

Here is a patient, you can see the right infraspinatus muscle doesn't look so bad, especially when you compare it with the overlying muscle.

But when you look at it compared with the other side, now you can see that this is the normal infraspinatus muscle which is hypo to anti coic.

And now you can see that there's volume loss and some increased genicity on the right.

Pitfalls in Muscle Echogenicity

Now here's one pitfall.

Just because you see increased echogenicity in the muscle doesn't always mean that there is fatty atrophy.

And here is a patient with right shoulder pain.

We are looking at the supraspinatus muscle.

There is some normal appearance of the muscle here, but there is this one area of increased echogenicity as as bright as you would expect fat to be.

But be careful not to call this fatty atrophy.

Obviously you would still do the, the remaining study to look at the supraspinatus tendon.

But let's just look at the left side right here.

Here is the left supraspinatus muscle normal in appearance and here is the tendon.

So what's happening over here is that the tendon is actually retracted and that's why you see more of the tendon on this side.

And that's because there's been an acute rotator cuff tear and the tendon is retracted not to be confused with fatty atrophy of the muscle.

Of course you would've looked for the tendon tear at the level, of the insertion.

Adjacent Muscle Comparison

Now sometimes you can use adjacent muscles for comparison.

And here's another example, we're looking at the brachialis and the triceps.

In comparison, you can see that the brachialis is increased in echogenicity in this case it's not fatty atrophy, but there's been denervation because there is a nerve entrapment That is affecting the appearance of the brachialis.

So you can use the adjacent structures for comparison.

As I mentioned earlier, size matters because what looks like a normal size can be asymmetric when compared to the asymptomatic side.

And small measurements really do count for a lot.

In this case we're going from, you know, 3.9 millimeters to 5.3 millimeters.

So you know that this is greater than a 25% difference.

Doppler Use

I Doppler is very useful because it can sometimes help us in looking for active disease, recruitment of vessels but also distinguish fluid from solid.

Here, is important to use doppler because this patient had been repeatedly tapped with no help.

And you can see here that there is signal here, a power doppler signal in here because this is synovium and here is the fluid.

So you can use that to guide the needle in.

Also you wanna know are you looking at blood versus tissue.

So here in this distended joint that has, complex echoes within the capsule, we can say that we are looking at debris and thickened tissues at the same time and also guide the needle to the right location.

This is a patient who presented with acute calf pain.

We see this frequently, with DVT studies, but here we have a fluid collection in the expected location of the emran noses, gastroc anemia bursa.

So this is a baker cyst and is this blood within the cyst?

Did the, was there an acute hemorrhage in the cyst?

Is this debris within the cyst?

But in this case there is actually a lot of doppler flow within this tissue because this is synovial proliferation within the cyst in this patient with rheumatoid arthritis.

As I mentioned earlier, a light hand is very important because when you're evaluating very superficial structures, if you scan with a heavy hand, you may obliterate the doppler signal, by pressing out those small recruited vessels.

Here we are looking in the, at the region of the anterior talo fibular ligament.

And question was were acute versus, chronic, situation here or is the response to treatment.

And here we see that there is a thickened hypo co tissue in this area that we were scanning a little too hard when we eased up on the transducer.

We can see that there's a lot of doppler flow which is abnormal in this area and this is a patient with acute, symptoms and corresponding with a side of pain.

So we can say that this is a source of her lateral ankle pain.

Correlating with Patient Symptoms

So another thing that's a benefit of ultrasound when compared with MRI, let's say is that we get to talk to our patients and correlate not only the findings with their symptoms but also get more history from the patient.

And here's one such example.

Patient presents 40-year-old woman with ulnar sighted wrist pain is what was written on the prescription.

So we scanned that side of her wrist.

Here we are looking at the flexor carpi narrows on the ulnar side of the wrist and deep to this area is some extra tissue that doesn't belong there.

You're not sure compare with the other side.

So it looks like the FCU or the flexor carpi looks about the same but we don't have this extra tissue.

So now we're thinking could this perhaps be synovitis as a source of her pain?

But she actually said, you know, doctor, I, I actually felt pain at the time there but I don't feel it there now.

I actually feel it elsewhere.

Well we did a doppler and sure enough there's no increased vascularity in this area and as she said, this is not where her symptoms are at this time.

She did say however that the pain is on the radial side of the wrist.

So we evaluated that side.

Here we are looking at the flexor carpi radius.

We are looking at this tendon here we are seeing the parallel echogenic lines, which is the normal architecture of the tendon, which is lost as we are nearing the insertion.

So this doesn't look quite right. Are you not sure?

Well you can compare with the asymptomatic side.

Here's what the FCR looks like.

The other wrist you can see that that normal architecture and normal ultrasound appearance persists through the whole tendon that we are being imaged.

We don't see thickening like we do see here.

We can also use doppler and see if there's any increased flow.

We probably was scanning with a little bit of heavy hand here, but there was increased vascularity in this area and this is in insertional tendinosis or teno synovitis of the flexor carpi radi.

Heel Pain Example

Here is a 45-year-old woman who presents with heel pain and the radiograph that she had before the scan showed a large calcaneal spur.

So could this be the source of the heel pain?

Well there was an ultrasound that was obtained showing the achilles tendon coming down here.

There is a little bit of fluid in the retro achilles bursa.

So could this be rubbing against the spur and causing heel pain?

But the patient said, this is not where I'm feeling the pain.

I'm actually feeling it in a different location.

So you can see a little higher here is the achilles tendon and you can see focal thickening of the tendon, decreased echogenicity heterogeneity and loss of normal architecture.

With power doppler you see increased flow.

So this is what corresponded directly with our pain and you're able to make a diagnosis of achilles tendonosis as a source of pain rather than retro achilles bursitis.

Calf Tenderness Example

Here is a patient who presented with calf tenderness and the, and the history was to rule out DVT.

She does not have any dvt, but you do see where she points to tenderness is a fluid collection.

Now one of the nice things with ultrasound is that you can do a panoramic view and get a better idea of where you'll be in the structure.

So many times people will call this a hematoma in the calf, but now that we have a panoramic view, we know that this is the expected location of the plant terrace tendon.

It lies deep to the gastroc anemia and superficial to the sous classic location.

Knowledge of history is very important.

Talking to the patient is very important and again, this panoramic view is also very useful because you can see that there's plantar tendon rupture.

Not only that the muscle fibers of the anemia are disrupted.

So this patient not only had a plantars tendon rupture but also a gastroc muscle tear As a source of her pain.

Subtle Findings

Subtle findings may be significant.

So even though you see what looks like someone might think of as a drop of fluid or very minimal thickening comparison with the other side may tell you that these are significant findings.

But also of course an interaction with your patient.

This is a patient who presented with dorsal wrist pain, dorsal right wrist pain and right where she points to the pain.

We see the extensor tendons.

We're looking at extensor compartment three that not important right now.

It's important is to see that you see this extra structure projecting into this area.

This is a screw.

So this patient had a distal radial repair.

His history is very important and you can see that the screw next to it is a small amount of fluid.

Well is that important?

There's very little fluid there, but when you compare it with the asymptomatic side, you see that that fluid is does not belong there.

You also see that the synovial tissues or the reticulum over the tendons is thickened when compared to the other side.

And the most important thing again is because we are talking to our patient, she's saying this is exactly where the pain is.

So now you can say that this screw is causing impingement on these tendons and a source of her pain.

Dynamic Examination

Lastly, we wanna talk about the dynamic examination because this is definitely one of the biggest benefits of ultrasound that we can perform a dynamic examination in real time because as we know, pathology may not always be apparent at rest.

We can have the patient perform maneuvers to elicit or reveal pathology including tendon adhesions, subluxation of bones or tendons which can cause a snapping sensation.

We can look in a laxity in the joint to see if we're looking at a partial or complete ligamentous tear and we can look for impingement such as in the shoulder or in the ankle.

Ankle Subluxation

Dynamic exam can be performed with a patient eliciting what is causing let's say a lateral ankle snapping.

Here we have patient rotating their ankle while we are looking, looking at the lateral ankle tendons.

And here we have an example of what it looks like under ultrasound.

We are looking at the peroneus longest in brevis.

Here is the longest. Here is the brevis.

We expect to see two tendons in this location against the fibula.

Now as the patient is rotating their ankle, we now see three tendons.

We see a peroneous longus and two pieces of pers brevis.

So not only are we seeing subluxation or dislocation of the peroneous brevis, but we are also bringing out a longitudinal split tear in the brevis.

There's also fluid around the tendons, which is abnormal and the patient is indicating that is the side of her pain.

Calf Pain and Muscle Hernia

Here's a patient who presented with calf pain, came for a DVT study.

The DVT study was performed, it was negative, but the patient said, well, the pain is actually in front of my calf.

The pain is right here and it only occurs when I'm standing up and bending at my knee.

So benefit of ultrasound is we can have the patient stand up and we can scan her in that position.

We can have her bend at the knee and see what happens.

Here we are looking at the anterior tibialis muscle and as she performs a maneuver you can see that the muscle is herniating through a defect in the subcutaneous tissues.

So this is a muscle hernia found with dynamic ultrasound.

Trigger Finger

Here's a patient who presents with a clicking finger and the clinical concern was for, for trigger finger.

Here we are looking at the flexor tendons of the finger.

We are looking at the deep flexor tendon and the superficial flexor tendon and we see some thickening of the tendon sheath.

But to elicit the clicking, we have the patient do the maneuver and you can see that this tendon is not sliding normally through the tendon sheath.

And this is a case of trigger finger.

Comprehensive Case Example

So lastly, I just wanted to show one more example where you tell the story, you talk to the patient, take panoramic images and really put together all the elements of and and avoiding pitfalls that we discussed earlier.

So this patient presented with calf pain.

The question was rule out DVT.

The DVT study was normal and yet we find this fluid collection, complex fluid collection in the calf.

So it'd be easy to just call this a hematoma and call it a day and it is a hematoma, but where is it?

So it's nice 'cause we have a label here, but this is a hematoma in the medial head of the gastroc anemia.

And while this image may already answer your question, you can see that that we are in the muscle.

A panoramic view can really show what's going on.

Here we are looking at the medial head of the gastric anemia and you can see a tear going right through it with a hematoma that is tracking up behind the gastric anemia.

So using all those tools, you're able to, tell a better story rather than just say hematoma and provide service to your referring doctors.

Conclusion

And with that, I just want to end this talk and thank you for your attention.

I.