MUSCULOSKELETAL ULTRASOUND

Indeed, the initial scan showed nothing. However, being sent away to perform abdominal exercises and heavy lifting for 30 minutes, a small but definite spigelian hernia was seen to appear, extending supero-laterally from behind rectus abdominus.

MSKUS of other the hip joint and groin (including other abdominal and groin hernias, figure 6) is also a skill worth developing, but this takes time, a good tutor and lots of real-life cases to gain a decent level of mastery. Rheumatologists are increasingly expected to be competent in MSKUS of joint disease, and this can include the sacro-iliac joint. Brachial plexus lesions and other neural structures are also imminently accessible to MSKUS in skilled hands. For further areas of advanced scanning guidance, access to a comprehensive textbook is recommended (1-4).

SUMMARY POINTS ■ Most superficial non-bony structures in the peripheral muscu-

loskeletal system, especially tendon and ligament disease, can be successfully imaging with MSKUS. For those working in sports and exercise medicine, this can lead to enhanced diagnostic services, faster and more accurate diagnosis and “one-stop-shop” type clinics,

■ For clinicians setting out to gain introductory or intermediate level training and experience in MSKUS, the shoulder, knee, ankle and foot are the most suitable regions.

■ Most groin regions, muscle lesions, “lumps and bumps” and neural tissue will be best imaged via radiological referral or other modalities such as MRI.

■ To confidently achieve advanced-level MSKUS skills, the sports clinician-sonographer will probably require to combine a formal postgraduate qualification with an appropriate period of supervised/mentored scanning in a hospital MSKUS depart- ment.

■ Despite recent RCR guidelines on non-radiologist ultrasound, there remains scope for more clarity and specific professional guidance on the issues of long-term accreditation, governance and appraisal for such enhanced service skills.

With recent advances in technology, and reductions in the cost of equipment, the use of MSKUS, as an office procedure in primary care, continues to grow. The fact that both clinicians and patients seem to like it, serves only to enhance its prospects for the future.

FIGURE 6: DYNAMIC ULTRASOUND OF DIRECT INGUINAL HERNIA THE AUTHOR

Dr Robertson is a GPwSI and qualified MSK Sonographer, with a combined interest in sports & exercise medicine and musculoskele- tal ultrasound. He qualified MBChB in 1985 in Edinburgh University, gained the Diploma in SEM in 2001 and has been involved in MSKUS since 2003. Dr Robertson was privileged to gain tuition in the MSKUS out-patient clinics of several MSK Radiologists during his PGC in 2005 (at Lancaster University). He is a Founder Fellow of the UK Faculty of Sports & Exercise Medicine, and is a Senior Medical Officer in the British Army, currently posted to the Baird Military Medical Centre, Central London. docdunx@tiscali.co.uk

References 1. McNally, E. Practical Musculoskeletal Ultrasound. Churchill Livingstone 2004. ISBN: 978-0443073502 2. R. Cchem and E. Cardinal. Guidelines and Gamuts in Musculoskeletal Ultrasound. John Wiley & Sons Inc 1998. ISBN: 978-0471197553 3. Bianchi S, Martinoli C. Ultrasound of the Musculoskeletal System - Medical Radiology S. Springer-Verlag 2007. ISBN: 9783540422679 4. Van Holsbeeck MT and Intracaso JH. Musculoskeletal Ultrasound (2nd ed). Mosby 2001. ISBN 5. Mini-Symposium on Musculoskeletal Ultrasound. Imaging 2002;14(3). British Institute of Radiology. http://imaging.birjournals.org 6. BMUS Bulletin Nov 1998 (“Musculoskeletal Ultrasound”). British Medical Ultrasound Society. www.bmus.org 7. Dubbins P. Ultrasound in Primary Care; Optimising Management. National Association of Primary Care (Review January 2003) 79-81 8. http://www.aium.org/products/store/_productDetail.asp?id=05MUV &cat=&words=musculoskeletal&pg=1 9. Ferrari M, Weller R, Pfau T, Payne RC, Wilson AM. A comparison of three- dimensional ultrasound, two-dimensional ultrasound and dissections for determination of lesion volume in tendons. Ultrasound in Medicine and Biology 2006;32(6):797-804 10. Klauser A, Demharter J et al. The IACUS study group. Contrast enhanced gray-scale sonography in assessment of joint vascularity in rheumatoid arthritis: results from the IACUS study group. European Journal of Radiology 2005 Dec;15(12):2404-2410 11. Richter J, David A et al. Diagnosis of acute rupture of the anterior cruciate ligament. Value of ultrasonic in addition to clinical examination. Unfallchirurg 1996 Feb;99(2):124-129 12. Backhaus M, Burmester GR et al. Prospective two year follow up study comparing novel and conventional imaging procedures in patients with arthritic finger joints. Annals of Rheumatic Disease 2002 Oct;61(10):895-904 13. Brown AK, Roberts TE, et al. The development of an evidence-based educational framework to facilitate the training of competent rheumatol- ogist ultrasonographers. Rheumatology 2007;46(3):391-397 14. Royal Colleges of General Practitioners and Radiologist. Basic Ultrasound Training for General Practitioners: report of a joint work- ing party. January 1993

In figures 7a-c, the patient bears down to increase the intra-abdominal pressure. Sequential images from a video grab show that as the strain increases (green arrows) the widening inguinal hernial sac (orange outline) can be seen expanding as peritoneal con- tents slide medially. The inferior epigastric artery (yellow circle) is an important anatomical landmark.

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