Section Two‘Therese J. Craychee, D.V.M. hapter 15 Ultrasonographic Evaluation of Equine Musculoskeletal Injury fn recent years the use of ultrasonography in the eval of equine soft tissues has increased rapidly, greatly acing our ability o diagnose and monitor sof tissue loskeletal injury accurately and noninvasively. One #e most important clinical applications of sonography fen in the evaluation of tendon and ligament injury fhe performance horse. In addition, ultrasound is used tly in the evaluation of synovial sheaths, synovial joint capsule, muscle and bone.!- Physical palpation, survey and contrast radiography, tomography, endoscopy, and xeroradiography are ‘echniques that have been utilized to characterize soft injury-”-"° Unfortunately, these techniques are of- quite subjective or invasive, and most yield limited sii information regarding tendon and ligament injury. “The ability to perform and interpret an ultrasonographic ination requires a basic understanding of ullrasonog- yan accurate knowledge of the involved anatomy, the development of the practical ability o perform znostic examination. The physics of ultsasonography presented elsewhere in this ext. A basic understanding elevant regional anatomy is necessary as the anatomy ‘any given region is complex, and minute alterations ‘epresent pathologic changes. The technical ability 0 ‘an accurate and reproducible scan requires dex- land experience and is greatly enhanced and expe with training chapter addresses the basic techniques used in the fe of soft tissue examination, the normal eraphic appearance of specific soft tissue types and and the prineiples used in the interpretation of plogic changes. nly, a fairly accurate assessment of the site of jon and ligament injury is possible, depending on the ofthe equipment used. However, many limitations to ultrasonographic evaluation sill exist. Healing of ten don and ligament injury requires a very organized incor- poration of multiple extracellular proteins and glyeopro- teins into the scar tissue. The proportions and organization Of the various cellular and. extracellular components change significantly during scar maturation, with a pro found effect on the mechanical integrity of the stracture involved. A better understanding of the effect that these ultrastructural changes have on the sonographic image is needed Equipment and Technique ‘TRANSDUCER SELECTION Currently real-time ultrasound is used 10 evaluate soft tissues, allowing an accurate identification of the siruc- {ures to be examined, and in some instances an evaluation ofthe functional statis of those structures, ‘Transducer frequency selection invalves using the high estfrequeney transducer possible, while maintaining ade quate depth penetration, remembering that higher-fre quency transducers produce superior spatial and contrast, resolution, while lower-frequency transducers. improve tissue penetration. Generally, a 7.5-MHz transducer i used in evaluation of structures of up to 4 em in depth. Tendon and ligament ‘examinations usually fall within this range, Deeper exain- inations, such as deep muscle examinations, require a lower-frequency transducer for adequate penetration. A. 5.0-MHz transducer can penetrate adequately t0 a depth ‘of 10 to 15 cm in most cases. A 2.5- to 3.0-MHz trans- ducer can, depending on the equipment, be used for ‘examinations of up to 25 em in depth. Some practitioners, 265266 owing to economic constraints, use a single transducer for all examinations. This is usually a 5.0-MHz linear farmay transducer, used primarily for reproductive evalua Both sector and linear-array transducers|ma for tendon, ligament, and muscle studies. The vantages and disadvantages to each. Often preference is based on previous experience and transducer availabilty. Linear-array is often preferred for superficial tendon and ligament work as there i less near-field artifact, pro cing a clearer, broader, less distored image in the very pear field, ie, at depths of less than 2 em. In addition, the tendon ad ligament fiber pattern may be more com pletely visualized (Fig. 151A and B) Sector scanners produce a relatively unsharp near-field image and distor the ‘lirasound beam laterally when compared to linear-array. However, sector scanners pro: ‘duce an excellent cross-sectional image of tendon and lig fament in the focal zone, allowing, in many instances, a su petior evaluation ofthe cross-sectional area of a lesion. In {udition, the edge artifacts produced in sector scans cause s interference with the deeper tendon or ligament im- age. When using a sector transducer in a longitudinal Sean, only a very short segment of tendon or ligament fiber pattern is visualized at a time. However, with ade (quate scanhead repositioning, a thorough examination tay be performed, Sector scanners are often prefered for eeper scans as a wider tissue field is evaluated in the deeper fields PREPARATION Image quality is affected by the quantity of body hair present. Both the hair and the air trapped within the hai ittenate the ultrasound beam. The best image is achieved by shaving the site to be scanned. With close clipping of the hair a good scan may be obtained, especially ifthe clipped surface is soaked with water aftr clipping. Occa sionally it i necessary to perform a scan without remov- ing the hair. The image quality inthis case is improved by ‘thorough wetting ofthe hair coat, followed by a smooth- ing of the coat inthe direction of hair growth. ‘coupling gel is applied at the etamination site, The maintenance of an adequate amount of ge is essential for food image quality, and frequent reapplication may be necessary. Specific commercial preparations, as well as bother types of water soluble lubricants, may be used. Gen tally, the more viscous preparations yield more satisfac tory results, requiring less frequent reapplication. For tendon and ligament examinations, a soft cloth measuring tape can be fixed to a specific site on the limb, thus providing an accurate and simple means of lesion lo- alization Inthe front limb the accessory carpal bone pro: Vides a convenient, fixed, and reproducible landmark; in the rear limb the proximal aspects of the fourth metatarsal bone ean be used 2s "era measuring point. 'A “standoff” of some variety is often necessary for very superficial examinations, especially when a sector Scanner is to be used. Made of a nearly echolucent mate fia, I to 2 cm thick, a standoff pad, when placed between, the subject and transducer, places the skin and superficial structures more deeply within the image, preferably ‘within the optimal focal zone, and deep to the near-field farifact created by the plastic transducer housing. The Standoff pad improves contact between the transducer and, Skin. Standoff pads are usually made of a solid silicone fel inaterial, and ean be shaped in, or cut to a multitude of, onvenient sizes and thicknesses, Other types of relatively Sonolucent standoffs can be utilized.” Transducers equipped with a bait-in standoff are available, and can {really simplify the procedure. One artifact, which may ‘occur with any variety of standoff, is produced by the Figure 15-1. Tenn scan viens ineaaray 75-MH wansdvo AT tanec sans of ih sity. B. The longi scan demonsts te supe Visaliaton of te lic Sr venatecers Both imaper emote 3 small ype SSSGREGI Resor tondon (SDE) (orows Cite SDFT i beoeen te cuss mB) on wine petChapter 15—Unrasnographic Evaluation of Eguine Mosclosetlijry 267 standoff housing or standoff margins, and consists of are {erberation echo within the central regions of the image. ‘This artifact can interfere with image interpretation. Gen- erally, however, the subject of interest is supericial to the artifactual echo. SCAN DOCUMENTATION Several means are available for recording the ultra- sound examination, including directly photographing the tulirsound screen with a black-and-white instant came various printers, which use photosensitive paper; mutifor- ‘mat cameras, which ulilize a light-sensitive film; and Video recording devices. There are advantages and di vantages to each of these recording methods relating t0 cost per image, ease of image production, image quality, and image longevity. In the imaging of soft tissue injures advantages to both still images and videotaping exist. The photograph or hard copy provides a quick reference and enables direct comparison of separate scans. The video image is a more complete record of the examination, es- pecially with regard to tendon and ligament lesions, which ‘can vary markedly in severity through the length of i volved tissue. Without an image of some variety an accu- ‘ate comparison of follow-up examinations will be diffi- cult Soft Tissue Examination In this section the ultrasonographic appearances of spe- cific soft tissues related to the musculoskeletal system are reviewed. Included is a general review of the ultrastruc: {ural and gross anatomy, and ultrasonographic characteris ties of tendon, ligament, muscle, synovial structures, and joint capsule. The normal ultrasonographic appear- lance, and various pathologic conditions are discussed and illustrated. Table 15-1 isa lst of the sites most frequently scan- ned. The list is by no means all-inclusive. Any relatively Superficial soft tissue structure may be imaged. If the ‘region of interest is unfamiliar, a detailed comprehensive ‘ext in anatomy, and a comparison examination of the coresponding contralateral region, when normal, will be helpful. Figure 15-2 illustrates, in simple drawings, the sross-sectional and longitudinal anatomy of the equine ‘metacarpus/metatasus, fetlock, and distal extremity at several selected levels. Included with the drawings are approximate dorsopalmar and dorsoplantar measure iments for average sized horses. The images may be used 1 familiarize the examiner with the regional anatomy and ‘may serve as a visual guide during training and scan- sing. Once the general ultrasonographic characteristics of 4 given tissue type are known, examination of unfamiliar structures may be performed with a degree of confidence TTendons and ligaments are discussed separately, al- ‘hough they have many shared structural and ultrisono- graphic characteristics, Their differences are described for ‘the most part in their respective sections. ‘Table 15-1. EQUINE MUSCULOSKELETAL ULTRASONOGRAPHY: COMMON SCAN SITES, Superficial digital flexor tendon Deep digital flexor tendon Inferior check ligament Suspensory ligiment Common digital extensor tendon Extensor carpi radials tendon ‘Annular igaments| Palmar, plantar Digit Distal ligaments ofthe proximal sesamoid bones Staght(supericial) ‘Obtique (mide) Cruciate (deep) ‘Bicipital tendon Semimembranosus,semitendinosus muscles Synovial sheaths Navicular Joins Fellck Sille Bone ‘TENDON Ultrastructural Anatomy Normal ‘The ultrastructural composition of tendon is responsible for distinct ultrasonographic characteristics. Tendon is a highly organized tissue, roughly uniaxial, and composed almost exclusively of type I collagen fibrils embedded in a proteoglycan-water matrix.”- The collagen fibrils within tendon are not straight, but rather, follow a planar wavy, or zigzag, crimped course. The crimping morphol ‘ogy affects mechanical behavior, and is believed t0 con tribute to the absorption of potentially damaging. shock loads between musculature and skeleton, The fibrils are ‘almost parallel to the long axis of the tendon, and are {grouped into primary (fibers), secondary (fascicles), and ‘in some instances tertiary bundles. The collagen fibrils are roughly divided into closely packed bundles of collagen, fibers by parallel rows of spindle-shaped, longitudinally oriented tenocytes. Fascicles are bound together by sheaths of connective tissue, the epitenon, endotenon, and pparatenon, respectively. There is considerable variation between tendon structure in different anatomic situations Blood supply to tendon is generally considered to be poor, ‘with diffusion from synovial fluid constituting a signif: ‘ant nutrient pathway in the region of the tendon sheath, Blood supply in the zones between synovial sheaths is pr268 sein Hore Front Limb Oe losuPoal 02] 01Chapter 15—Utesonoprapic Evasion of Equine Muscle Injury 2699 Rear Limb 15-2 Cosco! anatomy of equine fot cs fon ‘mre ac pam un sthy Srnec {a cence and aed m8 ogy dooqaiaa een270 section Too Hone marily intratendinous. Generally, vasculature enters the tendon from sites of origin, insertion, and regions of ‘Sheath investment.” Tendons are enveloped in synovial Sheaths in specific areas of high mechanical stress Pouches of synovial fluid, synovial bursa, are also found. ‘areas of high stress where gliding motion is needed, generally at points of tendon attachment. Pathology In humans the majority of tendon ruptures have proved to he secondary 10 one ofthe folowing tendinopahis ypoxedegenerative,tendinopathy, caisiie. tendinitis, (Ootpomatoi and mucoid degeneration Ture, fr- ‘Sgn bodies, infectious dseasy, and other dsorders are ick frequen Tendinopaies inthe horse have not Yet been sms characterze TExtemal uma may. be dfereniated from stess- related tauma Lacerations, puncture wounds, and closed {Tet contusions are examples of external endon trauma, ST'in tae eases ltrasound often pays secondary role in diagnos. Stress tlated trauma usally occurs during 8 performance sport activity, and can resi from tension Placed on te endon during a movement of excessive In- {Ens or from a nocmal movement performed in & no prsilogie condiion, Repettive stretching ofthe tendon Inne weighibcaring phase of the sie with resultant mi Srodamage to eallagen fins and blood and iymphatic ‘tculature may be responsible for degenerative changes Tealing to ltr failure, Previously diseased tendons wil fatwa es stress than yl normal tendons. Factors hat predispose to tendon rupture inclade poor conditioning. ing. presence of clcfcation, genera or focal cortico- Sera heaps and certain underlying systemic diseases Stich specifically ater connective tissues" In spor Teutd njres the tendons and igaments involved ae Sarge depres a function ofthe breed of horse and the Spectc sport performed.