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Musculoskeletal Ultrasound Imaging

Dr. Anupama Verma
Clinical Marketing & Research Collaboration
Siemens Healthcare

www.siemens.co.in
Musculoskeletal Ultrasound Imaging

Musculoskeletal Ultrasound Imaging

Musculoskeletal ultrasound (MSUS) utilizes high frequency sound waves to assess pathologies in soft tissues and bones to
assist diagnosis as well as management. Superb spatial resolution & real time capabilities of ultrasound imaging making it
a powerful tool to not only visualize structural anatomy, but derive unparalleled functional & dynamic information of the
musculoskeletal tissue, not otherwise available on CT or MR.

Advantages Applications

 Non-invasive Diagnostic
 Portable  Tendon (tendinopathy, tears)
 Widely accessible  Muscle (strains, contusions)
 Low cost  Nerve (entrapment)
 Lack of radiation  Ligament (sprains)
 Real time dynamic imaging  Joint (effusions) pain, swelling or mechanical
 Interactive imaging (sonographic palpation) symptoms at certain joints that clinical examination
fails to diagnose
 Very high axial & lateral resolution than most
modalities  Dynamic studies
 Repeatable, useful in monitoring treatment  Evaluation of inflammation, ganglions and foreign
bodies
 Safe in patients with metal implants, pacemaker
Interventional
 Injections
 Tenotomy
 Articular & Peri-articular Aspirations
 Biopsy

Musculoskeletal sonography has been a highly specialized stream of radiology, demanding special set of requirements in
the ultrasound system as well as the operator skill.
Development of dedicated solutions that are apt to the anatomy & function of musculoskeletal system, as well as easy to
use & maneuver is thus crucial to advance the prospects of ultrasound in this field.

Siemens Answers Special Clinical Needs of MSUS

 Excellent image quality  18 L6 High definition probe

&  Hockey stick probes
 Doppler sensitivity to demonstrate  Multi-D Matrix probes
microvasculature & inflammatory  Advanced SieClear compounding
arthropathies
 DTCE speckle reduction --> provides superior contrast and detail resolution
needed to distinguish the subtle changes and fine tissue texture in tendons,
nerves and ligaments
 Robust System architecture

 Advanced Applications for  Cadence contrast applications for contrast enhanced ultrasound: Cadence
specialized studies and research CPS, Contrast harmonic imaging & Contrast Dynamics for quantification
 Complete suite of elastography applications: eSie Touch, ARFI - Virtual
Touch imaging & quantification, Virtual Touch IQ

 Enhanced needle visualization  Wireless ultrasound technology in ACUSON Freestyle system, ACUSON
for procedures, Portability, P300 portable system
Intervention workflow needs  Multi-modality review with Ct, Mr for side to side comparison
 One click eSie Fusion: Real time Ultrasound Fusion with CT, MR; auto-
registeration in a single click

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Transducer innovations • ElastoGrip coating for non slip usage

• Extra long cable ~2.1m for ease of use
1. High Definition Transducer Technology - 18L6HD:
 Available on Acuson S family ultrasound systems (S3000
more clinical information in every single image HELX, S2000 HELX, S1000 HELX)

2. Hockey Stick Transducers- 14L5 SP & VF13-5 SP:

These are specialized high frequency linear array
transducers developed for MSUS, with a small footprint
(typically 25–30 mm), small field-of-view, & easy
maneuverability.

{ 14L5 SP → available for Acuson S class of ultrasound systems

VF13-5 SP → Acuson X300 PE ultrasound system

High density of elements, matched with system channels,

maximizes information density acquired by HD transducers.

 Widest bandwidth of 6 - 18 MHz

 Widest linear field of view of 58 mm; Industry’s Best
• It covers more anatomy in a single image, reducing
the need for additional image acquisition.
They are especially useful at sites where it is difficult to
 Highest number of array elements: 576 elements maneuver probe and obtain adequate skin contact with
 Fine Pitch Allows Beam Steering at Greater Angles → routine larger transducers (i.e., soft tissues adjacent to bony
prominences like clavicle, malleoli).
• Increased detail resolution
• Improved speckle presentation That makes them ideal for imaging the ankle, foot, hand
and elbow.
• Increased contrast resolution
• Clearer border definition and continuity 3. Multi-D Matrix Transducer- 14L5 probe & 9L4 probe:
 Improved color sensitivity  Uniform image from near field to far field
 Enhanced ergonomics –  Virtual format supported on 14L5
• Palmer grip for improved stress distribution  9L4 supports ARFI elastography

Figure: 18L6HD imaging with Advanced SieClear spatial compounding & DTCE

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Musculoskeletal Ultrasound Imaging

Figure: ACUSON Freestyle system with three wireless transducers

4. MultiHertz™ multiple frequency imaging:

Improve the penetration on larger shoulders and legs with
just a touch of a button on the premium ACUSON S class
of systems, as well as ACUSON X700 and ACUSON X300 PE
systems.

5. Hanafy Lens Technology

6. Micro-Pinless Connectors

Figure: Median nerve using L13-5 on ACUSON Freestyle

7. Wireless Transducer, L 13-5 & L8-5 on ACUSON

Freestyle platform:
 The ACUSON Freestyle™ ultrasound system is the world’s
first ultrasound system with wireless transducers.
 Using proprietary ultra-wideband radio technology,
the transducers are able to send images at a high Figure: Botulinum injection in leg for exertional compartment
syndrome; NeedleV feature to enhance needle visualization
sustainable data rate back to the system, all while
maintaining excellent image quality and high frame
rates. Image quality improvements

}
 Integrated controls on the transducers allow operation
of all imaging parameters on the system from up to 1. Advanced Sieclear Spatial
Compounding: Helps to
3 meters/10 feet away from the system
Industry-leading 13 lines of sight pick subtle
 Transducers are powered by a removable battery which provides unrivaled detail and contrast changes
offers up to 90 minutes of continuous scan time resolution and fine
between charges tissue
2. Dynamic Tissue Contrast
texture in
 For proper and complete disinfection, the probe and Enhancement (DTCE)
tendons,
battery should be immersed separately. Achieves speckle reduction, contrast
nerves and
enhancement
 NeedleV: Enhanced needle visualization during ligaments
procedures both In-plane and Out of Plane 3. Tissue Harmonic Imaging

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 Musculoskeletal Ultrasound Imaging

Figure: Tendon fibrotic site showing high shear wave velocity on

Figure: Quadriceps on ACUSON X700 ultrasound system with VF12-4 VTQ image → stiff
probe
3. Multi-modality Review:
4. Virtual field & Trapezoid imaging for extended field of
The multi-modality review provides a comparison with MR/
view in the near field
CT images side-by-side with the ultrasound image. This
capability can provide better precision of anatomy from MR
Advanced applications available with real time sonography. It is available on the
ACUSON S Family systems.
1. Contrast enhanced ultrasound applications- Cadence
CPS, Contrast Harmonic Imaging, Contrast Dynamics
Cadence CPS application for CEUS offers an extremely
sensitive tool for detecting microvascularity and can aid
in assessing inflammatory diseases, rheumatoid arthritis,
focal lesions & malignancies. Contrast Dynamics application
provides quantification capability which can potentially
help in therapeutic monitoring of the disease activity, e.g.
antiTNF treatment.

2. Ultrasound Elastography applications

ARFI - Virtual Touch imaging (VTI)
Virtual Touch quantification (VTQ)
Virtual Touch IQ (VTIQ)
eSie Touch elastography Figure: MMR of US with MR of shoulder

Elastography is an emerging new tool for evaluating various

4. Ultrasound Fusion / One click eSie Fusion:
MSK conditions like muscle fibrosis, muscular dystrophy,
spasticity in upper motor neuron disease, tumors; as the CT guidance is time expensive, requiring periodic scanning
pathology often brings a change in tissue mechanical to keep updating the position of the needle to guide
properties. Preliminary studies show potential use of through the procedure. Ultrasound Fusion with previously
elastography to differentiate inflammatory from infectious acquired CT dataset can provide an efficient & cost effective
synovitis; to differentiate malignant from benign synovial tool with real-time advantage. Similarly Ultrasound fusion
masses, monitoring the process of healing. with MR can be potentially invaluable in musculoskeletal
malignancies and guided tumor biopsies.

5. syngo Velocity Vector Imaging:

It is an investigational tool in MSUS that can help track
muscle motion in neuromuscular disorders, identify muscle
deformations.

Figure: Tendon fibrosis depicted as dark on VTI image → stiff

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Musculoskeletal Ultrasound Imaging

Case studies

1. Tarsal Tunnel Syndrome

 22y old female dancer of initially successful  Test: HFUS
tenosynovectomy.  Challenge: DD of Pain & Swelling
 10 months history of postero-medial ankle pain radiating  Tarsal Tunnel syndrome may has varied etiology and
distally to foot. presentation individual to individual

Figure: Fusiform swelling of the right lateral plantar nerve (arrows) when compared with the normal left lateral plantar nerve (arrowheads)

Figure: Thickened & scarred flexor retinaculum (arrowheads), most pronounced laterally toward the calcaneal attachment

Comments:  Trapezoid format enhances the visualization of small,

subtle structures in relation to associated anatomical
Virtual Field and Trapezoid view
landmarks. The vascular, nerve, ligament, and tendon
 Trapezoid format imaging provides a large FOV without anatomy of the ankle is very complex and can be difficult
any limitation or deterioration in the near field imaging to interpret with a limited FOV. Trapezoid format
area. provides a “global” appreciation of anatomy and the
“extent” of pathological changes, both during dynamic
maneuvers and on hard copy for referring physicians.

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2. Ganglion Comments:

 Patient presented with complaint of painful Rt. wrist hard  Hockey stick probe 14L5SP provides exquisite soft tissue
swelling, along radial & volar aspect for 15 days. detail & ease of manoeuvrability.

 Adv: HFUS  High frequency High definition 18L6 probe provides

stellar visualization of pathology.
 Findings : A well defined anechoic cystic lesion in the
subcutaneous tissue plane superficial to FCR tendon
and the radial artery. A branch of radial is seen alon the 3. Tenosynovitis
lateral aspect of the lesion. No communication with
 Patient presented with complaint of swelling along left
the joint observed. Color Doppler does not show any
ankle for 2 months.
intralesional vascularity.
 RA tests were negative
 Adv: HFUS
 Findings: Extensive hypoechoic synovial tissue seen in
left ankle joint with bony erosions. Color Doppler shows
increased vascularity in the synovial tissue. There is
associated Tibialis posterior tenosynovitis seen.
 Diagnosis: Extensive left ankle joint synovitis with Tibialis
posterior tenosynovitis.

(Courtesy: Dr. Ashwin Lawande, Consultant Radiologist, Mumbai)

(Courtesy: Dr. Ashwin Lawande, Consultant Radiologist, Mumbai)

(Courtesy: Dr. Ashwin Lawande, Consultant Radiologist, Mumbai)

(Courtesy: Dr. Ashwin Lawande, Consultant Radiologist, Mumbai)

(Courtesy: Dr. Ashwin Lawande, Consultant Radiologist, Mumbai)

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Musculoskeletal Ultrasound Imaging

Figure: Normal

(Courtesy: Dr. Ashwin Lawande, Consultant Radiologist, Mumbai)

(Courtesy: Dr. Ashwin Lawande, Consultant Radiologist, Mumbai)

Figure: Abnormal

(Courtesy: Dr. Ashwin Lawande, Consultant Radiologist, Mumbai)

4. Plantar Fasciitis (Courtesy: Dr. Ashwin Lawande, Consultant Radiologist, Mumbai)

 Patient presented with left heel pain

Comments:
 Adv: HFUS
High frequency High Definition imaging with 18L6HD
 Findings: Left Plantar fascia is hypoechoic with loss of transducer with Advanced SieClear & DTCE
fibrillar echopattern, blurring of borders . Thickness
 Stellar depiction of complex anatomy
5mm. Probe tenderness ++
 Clear delineation & differentiation of the fibrillar anatomy
 Right plantar fascia is normal 3mm thickness
and the borders
 Diagnosis – Left plantar fasciitis

We would like to convey our thanks to Dr. Ashwin Lawande from Imaging Clinic in Mumbai for his valuable
inputs & clinical images.

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Quiz: MSK US

1. What is highest available frequency on an ultrasound 4. Which of the following is true about Siemens ACUSON
transducer for musculoskeletal imaging: Freestyle system:
a. 10MHz a. World’s first wireless ultrasound system
b. 18MHz b. Probe can be easily sterilized for intervention
c. 17MHz environment
d. 16MHz c. NeedleV features allow both in-plane and out-of plane
needle visualization
e. 20MHz
d. Probes can perform up to 90 minutes continuous
scanning
2. Which of the following transducers can support
ultrasound elastography applications: e. All of the above
a. 18L6HD
5. Siemens offers the following technologies for MSK
b. 9L4
ultrasound imaging:
c. 14L5
a. High frequency High definition transducer 18L6HD
d. 6C1HD &Hockey stick probes 14L5 SP & VF13-5 SP
e. All of the abov b. Ultrasound Cadence contrast & ARFI elastography
applications
3. Which of the following probes feature Palmar grip, c. Virtual format/Trapezoid view for extended field of
designed to decrease the “pinch” grip which causes view
repetitive stress injury:
d. syngo Velocity Vector imaging
a. 18L6HD
e. All of the above
b. 14L5SP
c. 9L4
Please send your answers along with your contact
d. 14L5
details and the lucky five will receive a special prize.
e. All of the above
E-mail to hc_contact.india@siemens.com
Read further on Siemens Ultrasound:
http://www.healthcare.siemens.com/ultrasound#