Practice exam

Question 1

Name the origins and insertions of the shoulder girdle muscles

Answer 1

Lhb - glenoid tubercle to the radial tuberosity
Shb - corocoid process
Subscap - subscap fossa to lesser tubercle
Supra - supra fosaa to greater greater tubercle
Infra - infra foss to greater tubercle
Teres min - lat border scap to greater tubercle
Teres major- inferior angle and lower part of the lateral border of scapula to the crest of the lesser tubercle
Deltoid - lateral third clav, acromion, spine of scap to deltoid tubercle

Question 2

You are performing a dynamic assessment involving abduction of the shoulder. What features would you be looking for

Answer 2

• Pain on abduction
• Bunching of the bursa under the acromion or CA ligament
• Look for upward movement of the humeral head causing supraspinatus tendon bunching
• If bunching occurs in the absence of pain, check the contralateral shoulder
• Lack of movement of the supraspinatus tendon under the C-A lig (that is, blocking) is a sign of capsulitis.

Question 3

The inserting fibres of the distal biceps tendon may appear hypoechoic. Name and describe the artefact that interferes with visualization in this region

Answer 3

• Anisotropy
• When the fibres of the tendon are not perpendicular to the beam they will appear more hypoechoic than they are in reality giving the false appearance of pathology in a normal tendon or muscle
• To minimise this artifact, the structure to be scanned should be perpendicular to the ultrasound beam (parallel to the transducer face)
  In this case use heel toeing

Question 4

List the important structures to be imaged in the ultrasound examination to assess the lateral elbow

Answer 4

CEO
RCL
Lateral epicondyle bony surface
Lateral synovial fringe
Radial nerve and its branches

Question 5

Define and list the sonographic appearances of: (a) de Quervain’s

Answer 5

• A type of tenosynovitis
• involves the abductor pollicis longus and the extensor pollicis brevis tendons in compartment 1.
• The patient complains of pain specifically over the radial styloid, worse with thumb movements, sometimes with swelling localised to the styloid.
• due to a repetitive overuse injury.
• The tendon itself is usually normal in echotexture.
• It is seen as
o fusiform tendon swelling and thickening of the tendon sheath at the level of the radial styloid
o increased synovium, usually around APL, +/- swelling of tendon.
o In the chronic stage, there is thickening of the tendon and synovial sheaths, with formation of cysts and nodules

Question 6

Define and list the sonographic appearances of: (b) trigger finger

Answer 6

• Locking of a digit in a flexed position.
• usually caused by a stenosing tenosynovitis at the level of the A1 pulley
• Usually a tendon thickening(nodule) that eventually passes through an annular pulley in flexion or extension.
• Can also be a normal tendon doing the same through a narrowed pulley.
• Can be a combination of both of the above. tendon thickening.
• synovial sheath fluid and thickening.
• small peritendinous cysts.
• The tendon proximal to the restricting lesion may appear to buckle slightly, with flexion.

Question 7

Define and list the sonographic appearances of: (c) stener lesion

Answer 7

• UCL rupture at the MCPJ of the Thumb. (gamekeepers thumb)
• Distal rupture of the UCL can remain permanently separated by the adductor aponeurosis
• This prevents healing and is an indication for surgical repair.
• Appears as retraction of the ligament fibres which looks like a small mass displaced superficial to the adductor aponeurosis;
• this gives the yo-yo on a string appearance
• passive flexion of the interphalangeal joint of the thumb during dynamic ultrasound imaging of the ulnar collateral ligament (UCL) allows for identification of a non-displaced UCL tear from a Stener lesion

Question 8

Define and list the sonographic appearances of: (d) cubital tunnel syndrome

Answer 8

• the clinical symptoms that manifest due to ulnar neuropathy.
• this may appear as neural thickening, fascicular oedema of the nerve, there may be perineural echogenic cuffing, increased vascularity.
• On dynamic assessment, the ulnar nerve may be seen to sublux over the medial epicondyle with gentle flexion, or it may only enlocate after flexion.
• At the distal end of the groove the ulnar nerve can become entrapped by the heads of the flexor carpi ulnaris muscle, each head on the ulnar, and the humeral aspect.
• It is important to assess the cubital tunnel for masses that may cause this appearance such as a ganglion or accessory muscle anconeus epitrochlearis

Question 9

Define and list the sonographic appearances of 3 hernias relating to the anterior abdominal wall.

Answer 9

Umbilical - defect at the umbilicus
Spigelian -This occurs between the layers of internal abdominal oblique and transverse abdominus.
Epigastric - defect in the linea alba between the rectus abdominis muscles

Question 10

List the anatomical structures of the medial ankle.

Answer 10

Deltoid ligament
Spring ligament
FDL
FHL
Posterior tibial tendon
Posterior tibial nerve
Posterior tibial artery

Question 11

Briefly describe the normal sonographic appearances of the following conditions: (a) hip joint effusion

Answer 11

• Capsule distension may result from synovitis and/or effusion
• The capsule and iliofemoral ligament will bulge convexly over the neck with an underlying effusion.
• You need to demonstrate a difference of joint distension of greater than or equal to 2 mm between the symptomatic and asymptomatic hips to be considered significant.
• The effusion may be anechoic, hypoechoic, or complex
• You may also see loose bodies or intra-articular osteochondromas.

Question 12

Briefly describe the normal sonographic appearances of the following conditions: (b) Iliopsoas bursa

Answer 12

• This bursa is not seen well when normal.
• a bursal collection will lie just between the iliopsoas tendon and the joint capsule
• is hourglass or heart shaped when viewed in transverse at the hip joint due to compression by the overlying iliopsoas tendon

Question 13

Briefly describe the normal sonographic appearances of the following conditions: (c) trochanteric bursa

Answer 13

• large structure located deep to the gluteus maximus muscle as it inserts into the ITB.
• It covers the posterior facet of the greater trochanter as well as the gluteus medius tendinous insertion onto the lateral facet.
• The normal bursa appears a thin, anechoic line anterior to the greater trochanter with echogenic fat on either side.
  Bursitis
• Well circumscribed fluid collection superficial to the greater trochanter
• Caused by trauma, infection or inflammation due to abnormal gait
• Normally collects just posterior to the trochanter between the muscles deep to the ITB

Question 14

Describe the sonographic appearance of patellar tendinopathy.

Answer 14

Hypoechoic
Heterogeneous
Delamination tearing
Neovascularity 
Diffuse or focal thickening
usual site for tendinopathy to occur is at the inferior pole of the patella involving the deep fibres of the proximal mid tendon.

Question 15

Define and list the sonographic appearances of: (a) paratenonopathy

Answer 15

• the paratenon is a fibrous sheath of connective tissue which covers the Achilles tendon.
• It can undergo acute injury during repetitive stress
  Appears as
• a focal hypoechoic swelling around the Achilles
  usually involving the lateral surface.
• In the transverse plane a cresenteric thickening will appear at the margin of the Achilles, extending into the deeper fat pad.
• It is painful with compression.

Question 16

Define and list the sonographic appearances of: (b) plantar fasciitis

Answer 16

• mildly hypoechoic linear band of tissue originating from the undersurface of the calcaneus
• It should generally not exceed 3mm in thickness
• Often associated with a spur that develops on the under surface of the medial calcaneal tubercle
• the fascia can become swollen
• its normally flat superficial surface will become convex.
• Some fasciitis can be focal andmore distal than the calcaneal origin.
• These nodules of fasciitis are usually oval shaped hypoechoic swellings within the fibres of the fascia, known as plantar fibromatosis.

Question 17

Define and list the sonographic appearances of: (c) haglund’s

Answer 17

• occurs at the tendon-bone interface where the Achilles inserts onto the calcaneus.
• Bony protrusions and spurs develop at the posterosuperior surface of the calcaneus with an associated thickening of the overlying dermis and soft tissues.
• continual dorsi and plantar flexion of the foot during walking will cause a retrocalcaneal bursitis to develop.
• The patient usually presents with symptoms similar to tendinopathy.

Question 18

What are the anatomical structures of the lateral knee?

Answer 18

LCL
Biceps femoris
Lateral meniscus
ITB
Popliteus tendon

Question 19

Whilst scanning a tendon you are looking for neovascularization. List 4 factors you would consider changing to improve its detection.

Answer 19

Low flow
High gain
Decrease scale
Light transducer pressure

Question 20

You are scanning a foreign body. Describe all the information required to report its location.

Answer 20

Size
Depth from skin surface at both ends of the foreign body
Location - mark the midpoints of your transducer and draw and x that will be in the middle of the foreign body

Question 21

With reference to the supraspinatus tendon describe the types of tears possible.

Answer 21

Delamination
Rim rent
Partial thickness - articular, bursal, insubstance
Full thickness
Complete

Question 22

Chronic overuse injuries attribute to the majority of tendon disease. Explain the process of tendinosis.

Answer 22

• fatigued and loses reparative ability
• Repetitive microtrauma results in damage to collagen fibres
• swells due to development of mucoid ground substance
• Focal or diffuse
• Hypoechoic change in echotexture
• Avascular tendon is compromised by micro and macrovasculature resulting in tissue hypoxia
• Leads to linear defects –> intrasubstance degenerative PT tears or splits
• Mucoid degeneration appears as fluid filled cystic mass
• Chronic tendinosis can result in partial or complete rupture when activity is applied

Question 23

Describe the appearances of a grade 1 muscle tear?

Answer 23

3 grades of partial tears:
Grade I
• May appear normal or focal fibre discontinuity.
• Small hematoma (<1cm)

Question 24

Describe the appearances of a grade 2 muscle tear?

Answer 24

Grade II
• partial disruption or tear of muscle fibres with discontinuity.
• Involves less than 1/3 of the muscle (in transverse)
• Moderate hematoma (<3cm)
• Small interfascial hematoma

Question 25

Describe the appearances of a grade 3 muscle tear?

Answer 25

Grade III • Firbres rupture involving >1/3 of the muscle (in transverse) • Large hematoma (>3cm) • Large interfascial hematoma.

Question 26

Describe the appearances of a complete muscle tear?

Answer 26

Complete tear • A retracted and hyperechoic muscle due to fatty atrophy • Surrounded by a large hematoma ("bell clapper" appearance) • Fascial tear may be demonstrated Bull-nosed appearance of the muscle ends

Question 27

List your primary and secondary criteria for the diagnosis of Infantile Hypertrophic Pyloric Stenosis

Answer 27

Primary o canal length > 16 mm o muscle wall thickness > 3 mm/transverse Secondary - delayed gastric emptying with little or no passage of fluid through the pylorus or even hyperperistalsis of the stomach. - Active gastric peristalsis that ends abruptly at the margin of the hypertrophied muscle - absence of a normal opening of the pylorus

Question 28

Describe the sonographic findings of an obstructed duplex renal collecting system.

Answer 28

In the acute stage - the upper moiety displays parenchymal thinning and has a variable degree of hydroureteronephrosis - can contain echogenic, fine grained debris, which is pus, known as pyoureteronephrosis. - If the ureter is severely dilated, it can follow a tortuous path to the bladder. - The distal ureter of this upper moiety can be stenotic or insert into a ureterocele. - The ureterocele appears as a rounded, thin walled, anechoic cyst-like structure at the bladder base. In the chronic, longstanding stage - the upper moiety can display homogenous, dysplastic renal tissue with a loss of corticomedullary differentiation and small cysts with a small ureter which may or may not be dilated.

Question 29

Discuss any further imaging that may be required of an obstructed duplex renal collecting system and why?

Answer 29

- A nuclear medicine DTPA or a Mag 3 scan will ascertain if obstruction of the upper moiety is occurring at the ureterocoele in the acute stage in the chronic stage, will assess whether there is any function in the upper moiety. - In the lower moiety, due to its ectopic insertion in the bladder base, it predisposes it to reflux. - An MCU can determine the presence of reflux and a nuclear medicine DMSA scan can assess the cortex for scarring - a DTPA or Mag 3 can assess function.

Question 30

What is a tethered cord?

Answer 30

- A tethered cord is a pathologic fixation of the spinal cord in an abnormal caudal location, so that the cord suffers mechanical stretching, distortion and ischemia with growth and development.

Question 31

What are the sonographic features of paediatric spinal cord tethering, when seen associated with spinal dysraphism

Answer 31

- low lying position of the conus medullaris below the level of L2 - the spinal cord adhered to the posterior wall or dorsal aspect of the spinal canal which therefore, demonstrates a reduced or absent nerve root oscillation with patient respiration or movement in real‐time scanning.

Question 32

What does the normal spinal cord look like on ultrasound?

Answer 32

The cord should be central in the dependent portion of the canal, and cord and roots should move normally in both the anterior-posterior direction with normal respiration and craniocaudally with neck flexion. In tethered cord this is not the case.

Question 33

Describe the sonographic appearances you would expect to encounter in a cranial ultrasound on a premature infant (32 weeks) with known haemorrhage. How would you classify the intra cranial haemorrhage?

Answer 33

Grade 1 Subependymal haemorrhage Grade 2 Intraventricular extension without hydrocephalus Grade 3 Intraventricular extension with dilatation of ventricle Grade 4 Haemorrhage infarction of the periventricular parenchyma

Question 34

Discuss the sonographic appearances of MCDK

Answer 34

- anechoic cysts of varying sizes which show no communication. - The cysts are held together by dysplastic renal tissue that is usually homogeneous. - The largest cyst is not usually in the location of the renal pelvis. - Sometimes only one large cyst and a smaller daughter cyst are seen. - Sometimes a hydronephrotic form is seen as small cysts surrounding a larger one. Nuclear medicine DTPA or a Mag 3 scan can make the definitive diagnosis because they assess function. A true MCDK will show no uptake of radionuclide.

Question 35

Describe the appearance of the normal posterior tibial tendon

Answer 35

- At the attachment of the tendon to the navicular there is a fanning of the fibres and hence it is normal to get a hypoechoic appearance not to be confused with tendonitis - Applying pressure with the transducer to elicit symptoms at the site of a suspected abnormality can aid in distinguishing normal asymptomatic heterogeneity from true symptomatic disease or injury, such as a tendon tear.

Question 36

How do tears of the posterior tibial tendon appear?

Answer 36

- Most commonly tears longitudinally - longitudinal tears are seen most often with degenerative changes. - Above the medial mallolous degenerative splits while below the malleolus, as a transverse rupture. - The former is by far the more common presentation and usually occurs after a history of chronic tendinosis in this area.

Question 37

What are the structures examined in the posterior elbow?

Answer 37

olecranon triceps insertion olecranon bursa posterior joint recess

Question 38

Describe students elbow

Answer 38

olecranon bursitis when the patient has been leaning on the posterior aspect of their elbow for frequent and extended periods of time. The underlying bursa becomes inflamed and thickened, and can be very painful to touch.

Question 39

Describe cubital tunnel syndrome

Answer 39

- entrapment of the ulnar nerve just at the distal end of the ulnar groove. - The nerve gets tethered or entrapped between the two heads of the flexor carpi ulnaris muscle. - Flexing and extending the forearm and scanning over the posterior elbow will show limited movement of the ulnar nerve in the affected elbow - as opposed to the gentle rotational and lifting movements of the ulnar nerve seen in the normal elbow.

Question 40

Describe patella tendinopathy

Answer 40

- usual site for tendinopathy to occur is at the inferior pole of the patella involving the deep fibres of the proximal mid tendon. - Focal hypoechoic changes to the tendon texture and size occur, with a gradual loss of fibrillar texture and even cystic degenerative changes leading to the formation of a mucoid cyst.

Question 41

What is jumpers knee?

Answer 41

- clinical syndrome affecting adults, usually athletes, who are involved in sports that require repetitive violent contraction of the quadriceps muscle. - characterized by chronic recurrent anterior knee pain and tenderness of the patellar tendon near its insertion to the patella. - Initially the pain is present only after activity. - Later, it may become persistent until finally the tendon ruptures

Question 42

How does jumpers knee appear on ultrasound?

Answer 42

- the proximal patellar tendon is thickened. - central area of low echogenicity is visible posteriorly in the tendon close to the patellar apex - suggests a primary abnormality of the osteotendinous junction. - More discrete focal hypoechoic areas may represent small partial tears. - Calcification or dystrophic ossification can occur within an area of chronically inflamed or damaged tendon. - In addition, rarefaction and fragmentation of the inferior pole of the patella can occur in long-standing disease, most likely as a result of chronic avulsion injury

Question 43

What is Sindig-larsen Johansson disease and what does it look like?

Answer 43

- syndrome that occur in adolescence and are thought to be related to traction trauma at the immature osteotendinous junction. - Sinding-Larsen-Johansson disease affects the proximal tendon at its insertion to the patella - consists of point tenderness and soft-tissue swelling at the inferior pole of the patella, - There is bony irregularity and fragmentation of the inferior pole of the patella at the site of insertion of the patellar tendon. - The proximal tendon is enlarged and hypoechoic and may contain bony ossicles - there is overlying soft-tissue swelling.

Question 44

What is osgood schlatters disease?

Answer 44

- Osgood-Schlatter disease affects the distal tendon at its insertion into the tibial tuberosity - The condition is bilateral in 25% of patients cause is thought to be traumatic in origin, resulting in avulsion of fragments of cartilage and bone from the tibial tuberosity - Clinically, there is pain, tenderness, and soft-tissue swelling over the tibial tuberosity at the site of insertion of the patelar tendon

Question 45

How does osgood schlatters disease appear on ultrasound?

Answer 45

- swelling of the unossified cartilage and overlying soft tissues - fragmentation, and irregularity of the ossification center with reduced internal echogenicity, - thickening of the tendon - infrapatellar bursitis.

Question 46

How does a patella tendon tear/rupture appear?

Answer 46

recurrent partial tears one of the major factors causing jumper’s knee typically presents as chronic pain. An acute tendon tear usually presents with sudden pain, typically after a sports injury, and can be partial or complete. A discrete hypoechoic focus is visible within the tendon, representing intratendinous hematoma and edema Although rare, complete tenndon rupture appears as a full-thickness discontinuity of the tendon.

Question 47

What are the structures examined in the lateral kne?

Answer 47

ITB LCL Biceps femoris Popliteal tendon

Question 48

How does the ITB and pathology appear?

Answer 48

At the knee it crosses the lateral condyle and inserts into the anterior surface of the tibia at Gerdy's Tubercle. There is a bursa deep to it. Comparison with the other side is important to identify minor degrees of enlargement. Correlate the point of pain with the anatomy. ITB Syndrome occurs when the tendon is inflamed by 'snapping' over the femoral condyle. This is usually a clinical diagnosis. On ultrasound the ITB appears enlarged and hypoechoic. Look for fluid in or thickening of the bursa

Question 49

How does the LCL and pathology appear?

Answer 49

It is separate to the capsule and lateral meniscus. There is a bursa deep to it at the femoral and tibial attachment sites. Tears result from varus stress. o Partial tears – the ligament becomes enlarged and hypoechoic with the loss of one or both of the echoic margins. o Complete tears – fluid filled gap. o Chronic tears – increased size, mucoid degeneration, and calcification.

Question 50

How does the biceps femoris and pathology appear?

Answer 50

Originating from the ischial tuberosity it inserts onto the head of fibula, splaying out to form a cowl around the outside of the lateral ligament. There is a bursa deep to it. Look for fluid in the bursa and correlate pathology with pain. Tears commonly occur at the musculotendinous junction.

Question 51

How does the popliteus tendon appear?

Answer 51

- The popliteus is a short muscle originating from the lateral surface of the lateral femoral condyle, in a groove just proximal to the joint. - Popliteal tendinitis and/or associated bursitis can be quite difficult to diagnose on a clinical basis alone, and need to be distinguished from other pathologies involving the lateral joint.

Question 52

How do wood foreign bodies appear on ultrasound?

Answer 52

- initially appear echogenic - become progressively less echogenic as the surrounding inflammatory reaction evolves. - Eventually the fragment will decompose over a few weeks, but a residual post-inflammatory granuloma may persist. - Posterior shadowing present acutely, but as the organic material disappears, so too does the shadowing.

Question 53

How do plastic foreign bodies appear on ultrasound?

Answer 53

- slightly less echogenic than wood - demonstrate posterior shadowing. - This material will not decompose in the surrounding inflammatory reaction.

Question 54

How do glass foreign bodies appear on ultrasound?

Answer 54

echogenic, with comet-tail artifact produced by reverberation.

Question 55

How do metal foreign bodies appear on ultrasound?

Answer 55

- Metal foreign bodies also appear brightly echogenic and are associated with a significant comet-tail artifact. - Metal fragments may migrate through the soft tissues.

Question 56

How can wood foreign bodies appear after a few days?

Answer 56

Hypoechoic granulomatous change is seen around the foreign body. marked cellulitic change in the soft tissue seen as diffuse hyperechoic change. At times this can become attenuative and appear as a snow storm.