Chandra Bortolotto

Carpal tunnel: Normal anatomy, anatomical variants and ultrasound technique.

The carpal tunnel is an osteofibrous canal situated in the volar wrist. The boundaries are the carpal bones and the flexor retinaculum. In addition to the medial nerve, the carpal tunnel contains nine tendons: the flexor pollicis longus, the four flexor digitorum superficialis and the four flexor digitorum profundus. Ultrasound (US) study of the carpal tunnel generally involves short-axis imaging of the tendons, and in the presence of disease, long-axis imaging and dynamic maneuvers are added. There are numerous reports of anatomical variants of the wrist involving vessels, nerves, tendons and muscles, and they can all be studied by US. Some are particularly relevant from a clinical point of view and will therefore be accurately described. The anatomy is complex, and the US operator should therefore be thoroughly familiar with the normal anatomy as well as the anatomical variants that may have a role in the pathogenesis of carpal tunnel syndrome or influence treatment.

Hoffa’s fat pad abnormalities, knee pain and magnetic resonance imaging in daily practice

AbstractHoffa’s (infrapatellar) fat pad (HFP) is one of the knee fat pads interposed between the joint capsule and the synovium. Located posterior to patellar tendon and anterior to the capsule, the HFP is richly innervated and, therefore, one of the sources of anterior knee pain. Repetitive local microtraumas, impingement, and surgery causing local bleeding and inflammation are the most frequent causes of HFP pain and can lead to a variety of arthrofibrotic lesions. In addition, the HFP may be secondarily involved to menisci and ligaments disorders, injuries of the patellar tendon and synovial disorders. Patients with oedema or abnormalities of the HFP on magnetic resonance imaging (MRI) are often symptomatic; however, these changes can also be seen in asymptomatic patients. Radiologists should be cautious in emphasising abnormalities of HFP since they do not always cause pain and/or difficulty in walking and, therefore, do not require therapy. Teaching Points • Hoffa’s fat pad (HFP) is richly innervated and, therefore, a source of anterior knee pain. • HFP disorders are related to traumas, involvement from adjacent disorders and masses. • Patients with abnormalities of the HFP on MRI are often but not always symptomatic. • Radiologists should be cautious in emphasising abnormalities of HFP.

Imaging of plantar fascia disorders: findings on plain radiography, ultrasound and magnetic resonance imaging

AbstractPlantar fascia (PF) disorders commonly cause heel pain and disability in the general population. Imaging is often required to confirm diagnosis. This review article aims to provide simple and systematic guidelines for imaging assessment of PF disease, focussing on key findings detectable on plain radiography, ultrasound and magnetic resonance imaging (MRI). Sonographic characteristics of plantar fasciitis include PF thickening, loss of fibrillar structure, perifascial collections, calcifications and hyperaemia on Doppler imaging. Thickening and signal changes in the PF as well as oedema of adjacent soft tissues and bone marrow can be assessed on MRI. Radiographic findings of plantar fasciitis include PF thickening, cortical irregularities and abnormalities in the fat pad located deep below the PF. Plantar fibromatosis appears as well-demarcated, nodular thickenings that are iso-hypoechoic on ultrasound and show low-signal intensity on MRI. PF tears present with partial or complete fibre interruption on both ultrasound and MRI. Imaging description of further PF disorders, including xanthoma, diabetic fascial disease, foreign-body reactions and plantar infections, is detailed in the main text. Ultrasound and MRI should be considered as first- and second-line modalities for assessment of PF disorders, respectively. Indirect findings of PF disease can be ruled out on plain radiography. Teaching Points • PF disorders commonly cause heel pain and disability in the general population.• Imaging is often required to confirm diagnosis or reveal concomitant injuries.• Ultrasound and MRI respectively represent the first- and second-line modalities for diagnosis.• Indirect findings of PF disease can be ruled out on plain radiography.

Interventional musculoskeletal US: an update on materials and methods

Pain is one of the most common causes of reduced productivity. The annual cost of health-related reductions in productivity has been estimated at approximately 225 billion dollars in the United States alone. Ultrasound-guided locoregional infiltration procedures have frequently been shown to offer economical, effective, lasting relief of pain. In-depth familiarity with the equipment (probes and needles) and techniques used to perform these procedures are fundamental for safe, effective treatment. In fact, depending on the characteristics of the patient and the clinical problem, the approach and technique may have to be modified to simplify the procedure and ensure better results. Up-to-date knowledge of the drugs used for these infiltrations (indications, how they are used) is equally important. Our aim is to provide an update on the techniques and materials used in interventional musculoskeletal ultrasonography based on a review of the most recent literature as well as on our personal experience.RiassuntoIl dolore è una delle cause più frequenti di riduzione della produttività. Si stima che i costi della riduzione della produttività legata a problemi di salute siano di circa 225 miliardi di dollari per anno, nei soli Stati Uniti. Tra i trattamenti che hanno più frequentemente dimostrato di possedere caratteristiche di economicità, efficacia e durevolezza nella riduzione del dolore vi sono indubbiamente i trattamenti infiltrativi loco-regionali eco-guidati. E’ fondamentale avere una conoscenza approfondita delle apparecchiature (sonde e aghi) e delle diverse tecniche per raggiungere il sito di iniezione efficacemente ed in sicurezza. Infatti, in base alle caratteristiche del paziente e al problema clinico, può essere necessario cambiare approccio e tecnica al fine di raggiungere più semplicemente il miglior risultato. Non meno importante è un costante aggiornamento sulla corretta selezione e impiego delle sostanze da iniettare. Ci proponiamo pertanto di realizzare un update sulle tecniche e sui materiali utilizzati in ecografia interventistica muscoloscheletrica, alla luce sia della letteratura più recente che della nostra personale esperienza.

High-frame rate vector flow imaging of the carotid bifurcation

AbstractCarotid artery atherosclerotic disease is still a significant cause of cerebrovascular morbidity and mortality. A new angle-independent technique, measuring and visualizing blood flow velocities in all directions, called vector flow imaging (VFI) is becoming available from several vendors. VFI can provide more intuitive and quantitative imaging of vortex formation, which is not clearly distinguishable in the color Doppler image. VFI, as quantitative method assessing disturbed flow patterns of the carotid bifurcation, has the potential to allow better understanding of the diagnostic value of complex flow and to enhance risk stratification. This pictorial review article will show which new information VFI adds for the knowledge of hemodynamics in comparison to the conventional ultrasound techniques.Teaching points• VFI is an angle-independent technique measuring flow velocities in all directions. • This kind of VFI is based on a plane wave multidirectional excitation technique. • VFI allows quantitative assessment of carotid streamlines progression and visualizes vorticity. • VFI does not allow a precise comprehension of streamlines’ 3D shape. • VFI allows a better understanding of carotid artery complex flows.

Vector flow imaging techniques: An innovative ultrasonographic technique for the study of blood flow

Doppler ultrasonography is routinely used to identify abnormal blood flow. Nevertheless, conventional Doppler can be used to determine only the axial component of blood flow velocity and is angle dependent. A new method of multidimensional angle‐independent estimation of flow velocity, called Vector Flow Imaging (VFI), has been proposed. It quantitatively evaluates the true velocity vectors amplitude and direction at any location into a vessel and displays a more intuitive depiction of the flow movements. High frame rate VFI, based on plane wave imaging, allows a detailed dynamic visualization of complex flow by showing even transient events, otherwise undetectable.

Os peroneum imaging: normal appearance and pathological findings

AbstractThe os peroneum (OP) is a small sesamoid bone located inside the peroneus longus tendon (PLT), close to the cuboid. The OP can be the cause of pain and can be associated with lesions of the PLT. OP involvement in PLT disorders is frequently misdiagnosed by radiologists. Painful os peroneum syndrome (POPS) refers to a variety of conditions presenting with pain localized on the lateral aspect of the cuboid area. The syndrome can be observed as a consequence of local acute trauma such as ankle sprains or chronic overuse. Because of its intra-tendinous location, in tears of the peroneus longus tendon, the OP can show changes in its morphology or position, depending on the location of the tendon’s tear. Based on the level of the PLT tears, we propose a classification in three subtypes: tears localized proximal to the os peroneum (type I), at its level (type II) or distal to it (type III). These tears present with different changes on OP morphology or location. The aim of this article is to review the normal anatomy, imaging appearance and differential diagnosis of disorders of the OP as well as post-treatment imaging. Teaching points• PLT tears can be classified in three subtypes according to OP location.• POPS is characterized by pain on the lateral aspect of the cuboid.• OP involvement in PLT disorders is frequently misdiagnosed by radiologists.

Sonography of the Achilles Tendon After Complete Rupture Repair What the Radiologist Should Know

This review aims to provide the radiologist with simple and systematic guidelines for evaluation of the Achilles tendon after complete rupture repair. Currently, there is a plethora of nonsurgical and surgical treatments, but sonographic examination has shown no significant differences between them. A systematic analysis of several parameters (morphologic characteristics, structure, color Doppler vascularization, and mobility) should be undertaken. Morphologically, the repaired tendon is larger, wider, or both. The loss of the fibrillary structure, inhomogeneity, and the surgical material in the context of the tendon are “normal” aspects after a repaired rupture. The presence of fluid collections when affecting greater than 50% of the surface of the tendon and extensive calcifications should be considered pathologic aspects. In the immediate postoperative period, there is the absence of vascularization detectable by color Doppler imaging. During the first 3 months, there is an increase in intratendinous vascularization with hypervascularization. From 3 to 6 months, stabilization and regression of the vascularization occur. Beyond the first 6 months, the hypervascularization is pathologic. The pattern of motion is, generally, reduced considerably more often in surgically treated tendons than in non–surgically treated ones. Elastography generally shows a hard appearance, with only a relatively heterogeneous pattern. In conclusion, a treated tendon will never regain a normal sonographic appearance, and the operator must distinguish between normal posttreatment changes and real pathologic characteristics.

Musculoskeletal Sonography for Evaluation of Anatomic Variations of Extensor Tendon Synovial Sheaths in the Wrist

The purpose of this article is to show the anatomic variations of extensor tendon synovial sheaths in the wrist.

Elbow nerves: normal sonographic anatomy and identification of the structures potentially associated with nerve compression. A short pictorial-video article

PurposeTo demonstrate usefulness of ultrasonography evaluation of the nerves of the elbow and of the structures that more frequently might cause its compression.Materials and methodsAnatomic course of nerves, muscles, tendons, fibrous structures and bursae potentially associated with nerve compression syndromes were evaluated. Informed consent was obtained from each volunteer.ResultsUlnar, median and radial nerves are always evaluable with ultrasonography as well as muscles and tendons potentially associated with nerve compression. The bursae cannot be sonographically explored unless distended by fluid.ConclusionUltrasonography is a reliable method for the evaluation of the nerves of the elbow and of the structures that might cause its compression.RiassuntoScopo del lavoroDimostrare l’utilità dell’ecografia nella valutazione dei nervi del gomito e delle strutture che più frequentemente possono causarne la compressione.Materiali e MetodiSono stati valutati il decorso dei nervi del gomito e muscoli, tendini, strutture fibrose e borse sierose potenzialmente associati a sindromi da compressione. E’ stato ottenuto Il consenso informato da ciascun volontario.RisultatiI nervi ulnare, mediano e radiale sono sempre valutabili con l’ecografia come i muscoli e i tendini potenzialmente associati a compressione del nervo, le borse non possono essere valutate se non distese da liquido.ConclusioneL’ecografia è una metodica affidabile per la valutazione dei nervi del gomito e delle strutture che potrebbero causare la loro compressione.