Question

can you write 3 to 5 pages on the following topic please:

MSK (musculoskeletal) ultrasound.

This paper should include at least two types of MSK exams that would be performed with ultrasound.

Include proper exam indications, patient preparation, the role the sonographer plays in the exam, and discuss the RMSKS registry the American Registry of Diagnostic Medical Sonograhy offers.

You will use a minimum of 5 references for your paper.

Answer 1

Ultrasound - Musculoskeletal

Ultrasound imaging uses sound waves to produce pictures of muscles, tendons, ligaments, nerves and joints throughout the body. It is used to help diagnose sprains, strains, tears, trapped nerves, arthritis and other musculoskeletal conditions. Ultrasound is safe, noninvasive, and does not use ionizing radiation.

This procedure requires little to no special preparation. Leave jewelry at home and wear loose, comfortable clothing. You may be asked to wear a gown.

What is Ultrasound Imaging of the Musculoskeletal System?

Ultrasound is safe and painless. It produces pictures of the inside of the body using sound waves. Ultrasound imaging is also called ultrasound scanning or sonography. It uses a small probe called a transducer and gel placed directly on the skin. High-frequency sound waves travel from the probe through the gel into the body. The probe collects the sounds that bounce back. A computer uses those sound waves to create an image. Ultrasound exams do not use radiation (as used in x-rays). Because images are captured in real-time, they can show the structure and movement of the body's internal organs. They can also show blood flowing through blood vessels.

Ultrasound imaging is a noninvasive medical test that helps physicians diagnose and treat medical conditions.

Ultrasound images of the musculoskeletal system provide pictures of muscles, tendons, ligaments, joints, nerves and soft tissues throughout the body.

What are some common uses of the procedure?

Ultrasound images are typically used to help diagnose:

• tendon tears or tendinitis of the rotator cuff in the shoulder, Achilles tendon in the ankle and many other tendons throughout the body.
• muscle tears, masses or fluid collections.
• ligament sprains or tears.
• inflammation or fluid (effusions) within the bursae and joints.
• early changes of rheumatoid arthritis.
• nerve entrapments such as carpal tunnel syndrome.
• benign and malignant soft tissue tumors.
• ganglion cysts.
• hernias.
• foreign bodies in the soft tissues (such as splinters or glass).
• dislocations of the hip in infants.
• fluid in a painful hip joint in children.
• neck muscle abnormalities in infants with torticollis (neck twisting).
• soft tissue masses (lumps/bumps) in children.

How should I prepare?

Wear comfortable, loose-fitting clothing. You may need to remove all clothing and jewelry in the area to be examined.

You may be asked to wear a gown during the procedure.

Ultrasound examinations are very sensitive to motion, and an active or crying child can prolong the examination process. To ensure a smooth experience, it often helps to explain the procedure to the child prior to the exam. Bringing books, small toys, music or games can help to distract the child and make the time pass quickly. The ultrasound exam room may have a television. Feel free to ask for your child's favorite channel.

What does the equipment look like?

Ultrasound scanners consist of a computer console, video display screen and an attached transducer. The transducer is a small hand-held device that resembles a microphone. Some exams may use different transducers (with different capabilities) during a single exam. The transducer sends out inaudible, high-frequency sound waves into the body and then listens for the returning echoes. The principles are similar to sonar used by boats and submarines.

The technologist applies a small amount of gel to the area under examination and places the transducer there. The gel allows sound waves to travel back and forth between the transducer and the area under examination. The ultrasound image is immediately visible on a video display screen that looks like a computer monitor. The computer creates the image based on the loudness (amplitude), pitch (frequency) and time it takes for the ultrasound signal to return to the transducer. It also takes into account what type of body structure and/or tissue the sound is traveling through.

How does the procedure work?

Ultrasound imaging is based on the same principles involved in the sonar used by bats, ships and fishermen. When a sound wave strikes an object, it bounces back, or echoes. By measuring these echo waves, it is possible to determine how far away the object is as well as the object's size, shape and consistency. This includes whether the object is solid or filled with fluid.

In medicine, ultrasound is used to detect changes in the appearance of organs, tissues, and vessels and to detect abnormal masses, such as tumors.

In an ultrasound exam, a transducer both sends the sound waves and records the echoing waves. When the transducer is pressed against the skin, it sends small pulses of inaudible, high-frequency sound waves into the body. As the sound waves bounce off internal organs, fluids and tissues, the sensitive receiver in the transducer records tiny changes in the sound's pitch and direction. These signature waves are instantly measured and displayed by a computer, which in turn creates a real-time picture on the monitor. One or more frames of the moving pictures are typically captured as still images. Short video loops of the images may also be saved.

How is the procedure performed?

For certain ultrasound examinations of the musculoskeletal system, the patient may be seated on an examination table or a swivel chair. For other ultrasound exams, the patient is positioned lying face-up or face-down on an examination table. The radiologist or sonographer may ask you to move the extremity being examined or may move it for you to evaluate the anatomy and function of the joint, muscle, ligament or tendon.

Most ultrasound studies of infants and children are performed with the child lying on his or her back on the examination table, but other positions may be required.

After you are positioned on the examination table, the radiologist (a physician specifically trained to supervise and interpret radiology examinations) or sonographer will apply a warm water-based gel to the area of the body being studied. The gel will help the transducer make secure contact with the body and eliminate air pockets between the transducer and the skin that can block the sound waves from passing into your body. The transducer is placed on the body and moved back and forth over the area of interest until the desired images are captured.

There is usually no discomfort from pressure as the transducer is pressed against the area being examined. However, if scanning is performed over an area of tenderness, you may feel pressure or minor pain from the transducer.

Once the imaging is complete, the clear ultrasound gel will be wiped off your skin. Any portions that are not wiped off will dry quickly. The ultrasound gel does not usually stain or discolor clothing.

What will I experience during and after the procedure?

Most ultrasound exams are painless, fast and easily tolerated.

Musculoskeletal ultrasound examination is usually completed within 15 to 30 minutes but may occasionally take longer.

When the exam is complete, you may be asked to dress and wait while the ultrasound images are reviewed.

After an ultrasound examination, you should be able to resume your normal activities immediately.

Who interprets the results and how do I get them?

A radiologist, a doctor trained to supervise and interpret radiology exams, will analyze the images. The radiologist will send a signed report to the doctor who requested the exam. Your doctor will then share the results with you. In some cases, the radiologist may discuss results with you after the exam.

Follow-up exams may be needed. If so, your doctor will explain why. Sometimes a follow-up exam is done because a potential abnormality needs further evaluation with additional views or a special imaging technique. A follow-up exam may also be done to see if there has been any change in an abnormality over time. Follow-up exams are sometimes the best way to see if treatment is working or if an abnormality is stable or has changed.

What are the benefits vs. risks?

Benefits

• Most ultrasound scanning is noninvasive (no needles or injections).
• Occasionally, an ultrasound exam may be temporarily uncomfortable, but it should not be painful.
• Ultrasound is widely available, easy-to-use and less expensive than most other imaging methods.
• Ultrasound imaging is extremely safe and does not use radiation.
• Ultrasound scanning gives a clear picture of soft tissues that do not show up well on x-ray images.
• Ultrasound provides real-time imaging, making it a good tool for guiding minimally invasive procedures such as needle biopsies and fluid aspiration.
• Patients with cardiac pacemakers and certain types of metallic implants or fragments in the body cannot be safely exposed to the strong magnetic field required for magnetic resonance imaging (MRI); however, patients can safely receive ultrasound imaging.
• Ultrasound is also an excellent alternative to MRI for claustrophobic patients.
• Compared to MRI, ultrasound may provide greater internal detail when assessing soft tissue structures such as tendons and nerves.
• Because ultrasound images are captured in real time, they can show the movement of a soft tissue structure such as a tendon, joint or an extremity.

• Ultrasound imaging is faster than MRI and does not require the patient to remain completely still, allowing infants to be imaged without sedation.
• The hip joints of infants, unlike those of adults, are largely made of cartilage. Ultrasound is able to clearly see cartilage.

Skeletal Muscle

On longitudinal views, the muscle septae appear as bright/echogenic structures, and are seen as thin, bright, linear bands (i.e., “feather” or “veins on a leaf”). On tranverse views, the muscle bundles appears as speckled echoes with short, curvilinear, bright lines dispersed throughout the darker/hypoechoic background (i.e., “starry night”).

Fascia

Fascia is a collagenous structure that usually surrounds the musculotendinous areas of the extremities. Fascia is encompassed by subcutaneous tissue. The fascia is often seen inserting onto bone and blending with the periosteum. Normal fascia appears as a fibrous, bright hyperechoic structure (see Figure 1).

Subcutaneous Tissue

Subcutaneous tissue is isoechoic (equal brightness) to that of skeletal muscle. The difference between subcutaneous tissue and skeletal muscle visualized on ultrasound is that the septae do not lay in lines or layers. A thick, continuous hyperechoic band usually separates subcutaneous fat from muscle.

Cortical Bone

Normal cortical bone appears as a well-defined, linear, smooth, continuous echogenic line with posterior acoustic shadowing (image beyond the interface appears black). The hyperechogenicity of bone is caused by the high reflectivity of the acoustic interface.

Periosteum

Occasionally visualized as a thin, echogenic line running parallel with the cortical bone on ultrasound. Injuries to the bone—especially to the cortex, periosseous soft tissues, and periosteum—will produce a periosteal reaction which may be visualized.

Tendons

A normal tendon on ultrasound examination is a bright/echogenic linear band that can vary in thickness according to its location. The internal echoes are described as having a fibrillar echotexture on longitudinal views. On ultrasound, the parallel series of collagen fibers are hyperechoic and separated by darker/hypoechoic surrounding connective tissue. Normally, the collagen fibers are continuous and intact. When interruptions in tendon fibers exist, they are visualized as anechoic/black areas within the tendon. As solid structures, they are noncompressible and do not normally exhibit blood flow.

Ligaments

On ultrasound examination, a normal ligament is a bright, echogenic, linear structure. However, for ligaments having a more, compact, fibrillar echotexture, the individual strands/fibers of the ligaments are more closely aligned. Ligaments are composed of dense connective tissue, similar to tendons, but with much more variability in the amounts of collagen, elastin, and fibrocartilage. This makes imaging a ligament more variable than a tendon. Ligaments can easily be distinguished from tendons by tracing the ligament to the bony structures to which it attaches with a characteristic “broom-end” appearance in transverse views.

Peripheral Nerves

High-frequency transducers allow the visualization of peripheral nerves that pass close to the skin surface. Peripheral nerves appear as parallel hyperechoic lines with hypoechoic separations between them. On longitudinal views, their appearance is similar to tendons, but less bright/echogenic. On transverse views, peripheral nerves, individual fibers, and fibrous matrix present with multiple, punctuate echogenicities (bright dots) within an ovoid, well-defined nerve sheath. Nerves are differentiated from tendons by their echotexture, relative lack of anisotropy, location and proximity to the vessels.

Bursae

In a normal joint, the bursa is a thin, black/anechoic line which is less than 2mm thick. The bursa fills with fluid when irritated or infected. Depending on the extent of effusion, the bursa will distend and enlarge, with inflammatory debris expressed as internal brightness echoes (see Figure 2).

Vessels

Veins and arteries appear as hypo- or anechoic tubular structures that can be compressed and exhibit blood flow on Doppler examination. Arteries will remain pulsatile during compression, whereas veins do not. Usually, localizing vessels may facilitate in localizing nerves which lie beside them.

Diagnostic ultrasound imaging is instrumental in detecting injuries in the above structures.1,11

Figure 2. Hip ilio psoas bursa. Longitudinal view of the hip. Cortical outline of femoral head and neck is as landmark to determine capsule contour. Anechoic/black fluid is seen in interface between capsule (between double-end arrows) and the ilio psoas muscle.

Longitudinal of the Car e of head and necklas ondankto determine contour. Anechoic black fuldis seen in interfaca bahan (bandon dhe me

Tendon Injuries

Tendonosis manifests as tendon enlargement, hypo-echogenicity and increase in interfibrillar distance—primarily due to intratendinous edema. Partial-thickness tears present as additional findings of focal regions of anechogenicity accompanied by loss of the normal fibrillar pattern but tendon continuity is maintained. High-grade, partial thickness tearing is imaged as tendon thinning due to tendon substance loss. Full-thickness tearing is seen as tendon gaps occurring in conjunction with tendonosis-related changes. Tenosynovitis may appear as either simple anechoic with easily displaceable fluid surrounding the tendon or complex fluid with mixed echogenicity. Complex fluid seen on imaging within the tendon sheath should be diagnostically aspirated if infection is suspected.

Ligament Injuries

Low-grade injuries are imaged as enlarged, hypoechoic ligaments with normal echotexture, while partial- and full-thickness tears reveal fibrous disruption. Stress testing may be able to differentiate between partial vs. complete tears and assess joint stability as in the case of tendon pathology.

Nerve Injuries

Similar to tendons and ligaments, affected nerves reveal regional swelling, diffuse hypo-echogenicity and loss of fascicular pattern. A “notch sign” is a reflection of entrapment sites which are localized by evaluating swelling proximal to the entrapment site and a focal narrowing at that site.

Muscle Injuries

Low-grade muscle strains exhibit subtle regions of hypoechogenicity accompanied by reduction in the normal pennate echotexture, making the affected area look “washed out.” High-grade contusions and injuries reveal variability in frank fiber disruption and hetergenous fluid as seen in hematomas.

Bone and Joint Disorders

Periostitis or stress fracture is seen with irregularities in the smoth, superficial surface of bone. Ultrasound is very sensitive in the detection of joint effusions. Joint effusions are anechoic, compressible, and devoid of Doppler flow. Complex, heterogenous-appearing fluid may be indicative of infection for which aspiration is recommended. Synovitis appears as noncompressible, echogenic tissue within a joint and hyperemia on Doppler. Periarticular erosions, crystal-related deposits and gouty tophi may also be seen in the joint evaluation. Enlarged bursae contain simple anechoic fluid but, similar to joint effusions, may contain complex fluid. Periarticular and peritendinous ganglia may be present as multilobulated, anechoic noncompressible structures devoid of blood flow.

Therapeutic Applications in Musculoskeletal Ultrasound

The use of ultrasonography in interventional musculoskeletal radiology is well established and is used primarily to guide needle placement for injections, aspirations and biopsies.12 The choice of ultrasound transducer is critical, with high-frequency (7-12 MHz) linear array transducers used most frequently. For deeper structures, such as hips and larger patients, lower frequency curvilinear probes may be required, although they may be prone to anisotropic artifact. Regardless of the probe selected, a complete sonographic examination (including Doppler exam) of the proposed area should be conducted to determine critical structures such as nerve and vessels. This allows the determination of needle trajectory and avoidance of areas of potential infection.

Figure 3. Suprapatellar aspiration. A. longitudinal views of the suprapatellar pouch/bursa demonstrate a large anechoic fluid collection; B. needle insertion for aspiration; C. post aspiration view. Ultrasound image prior to aspiration allowed determination of no internal debris in the often recurring site of fluid accumulation. Figure 4. Supraspinatus injection. A. longitudinal probe placement on the anterior/lateral shoulder reveals a nearly full thickness tear of the supraspinatus tendon. B. ultrasound guided injection.

Most musculoskeletal US procedures are performed with a “free-hand technique” which allows direct, dynamic visualization of the needle tip. After planning the safest route of needle access, a line parallel to the long axis of the probe face can be drawn on the skin and the patient’s skin and transducer is sterilized and draped. The needle is directed toward the intended target under vigilant observation with the long axis of the needle and in line with the long axis of the transducer face.

Strategies to discriminate the needle tip under US involve keeping the tranducer face as perpendicular to the needle as possible by heel-toe angling and probe rocking. By doing so, reverberation artifact posterior to the needle is seen and aids in highlighting the needle. Other approaches include sweeping the transducer from side to side while moving the needle in and out; injecting a small amount of local anesthetic to localize the needle tip; and rotating the probe ninety degrees to examine the needle in short axis and determine the needle’s pathway.

Intra-articular interventional injections using US may be used for joint aspirations (e.g., detection of crystal arthropathy or septic arthritis; see Figure 3) or therapeutic intra-articular injections with corticosteroids or viscosupplementation (e.g., treatment of joint arthritis; see Figure 4). Diagnostic injections with use of short- and long-acting anesthetics can determine the patient’s symptom improvements with long-acting agents. Most hip and shoulder joints may accept up to 10 mL but small joints of the hands and feet may only accept 1-2 mL.

How to Prepare for a Musculoskeletal Ultrasound:

Fortunately, this will be a quick, simple and painless process. No preparation is required but you will have to change into a gown for the procedure. The tips below will help keep your appointment and your day on track.

• Wear loose fitting and easily removable clothing.
• Leave jewelry at home if possible.
• Plan to be there for about an hour. While the ultrasound procedure is fairly quick you may be asked to stay while your images are reviewed.
• Find someone to watch any children you may be caring for, as this appointment is focused on you and your health. Any distractions can prolong the process.
• If your child is the one being examined, bring items from home to help the procedure to go as smoothly as possible. Ultrasound examinations are sensitive to motion so a moving or stressed child can add extra time to your visit. Items that comfort the child, such as books, music or small toys will help pass time and make your child feel secure and relaxed.

At Carolina Arthritis, our goal is to ensure you feel comfortable and informed about how we handle a musculoskeletal ultrasound procedure and the results. If you have any questions or concerns about this or any other procedures, please give us a call or fill out our contact form for more information.

Role the sonographer plays in the exam

The wide availability and recent improvement in technology coupled with portability, low cost and safety makes ultrasound the first choice imaging investigation for the evaluation of musculoskeletal diseases. Diagnostic use of ultrasound findings is greatly enhanced by knowledge of the clinical presentation. Conversely, ultrasound skills with its prerequisite anatomical knowledge make the clinical diagnosis more precise and reduce uncertainty in the choice of therapy. Therefore, it is essential for rheumatologists to acquire ultrasonography skills in order to improve patient care. Ultrasound examination provides an excellent opportunity for patient education and to explain the rationale for therapy. This review summarizes the indications for musculoskeletal ultrasound and describes its role in diagnosis, monitoring and prognosis.

RMSKS registry the American Registry of Diagnostic Medical Sonograhy offers:

The American Registry for Diagnostic Medical Sonography® (ARDMS®), incorporated in June 1975, is an independent nonprofit organization that administers examinations and awards credentials in the areas of diagnostic medical sonography, diagnostic cardiac sonography, vascular technology, physicians’ vascular interpretation, musculoskeletal sonography and midwifery ultrasound. ARDMS has over 90,000 certified individuals in the U.S., Canada and throughout the world. ARDMS provides certifications, resources, and career information to healthcare practitioners and students practicing medical sonography.

Organizational Structure

The ARDMS is part of the non-profit Inteleos™ family of Councils, which includes the Alliance for Physician Certification & Advancement™ (APCA™). To better meet the needs of diverse healthcare professionals around the world, Inteleos and APCA join the ARDMS in furthering its long-standing mission of raising the global standards of excellence in healthcare and patient safety.

ARDMS Awards the Following Sonography Credentials:

RDMS® Registered Diagnostic Medical Sonographer®

RDCS® Registered Diagnostic Cardiac Sonographer®

RVT® Registered Vascular Technologist®

RMSKS™ Registered Musculoskeletal Sonographer™