June 14, 2022

Aaron Fleming is a Senior Sonographer at Qscan Radiology’s Red Hill Clinic in Brisbane, Australia – a leading diagnostic medical imaging and interventional practice that provides the imaging for numerous professional sporting teams and organizations as well as the general public. Aaron has a particular interest in MSK ultrasound that has evolved from an unparalleled passion for sport – a product of his upbringing in country NSW. One of the first specialists to scan with the new Aplio i-series / Prism Edition ultrasound system from Canon Medical, Aaron explained to VISIONS how the advanced new features and improved ergonomics enhance the scanning experience and facilitate greater accuracy in ultrasound diagnoses.

‘From an MSK point of view, I think this system can help challenge and even overturn the notion that MRI is the gold standard for MSK imaging,’ Aaron says. Ultrasound offers many benefits over MRI such as availability, cost and superior spatial resolution to name but a few. Tendon and especially nerve assessment with ultrasound can trump MRI. Furthermore, ultrasound can be used for screening checks and in the rehab and progress of various injuries providing invaluable prognostic information and up-to-date return to play estimates for the team that oversees the care and treatment of professional and amateur athletes.

“The Prism Edition’s transducers are very versatile. The matrix probes all produced fantastic images and you could have quite easily performed the same scan with a number of different probes with no loss in scanning confidence.”

For Clinical Case 1 – Aaron used a High Frequency 24 MHz (i24LX8) linear matrix transducer, to demonstrate an intact Flexor Digitorum Profundus (FDP) and Flexor Digitorum Superficialis (FDS) tendons of the second finger. However, there were changes to the echogenicity of the adjacent lumbrical muscle. The muscle appeared enlarged and heterogenous with anechoic areas consistent with fluid. Increased vascularity was detected with SMI using Doppler luminance. These findings are consistent with a partial tear of the first lumbrical muscle of the hand – an unusual occurrence.

In another case, Clinical Case 3, the Aplio i800 / Prism Edition's 22 MHz High Frequency Hockey Stick transducer (i22LH8) was used to scan the thumb of an elite AFLW player – whose thumb was injured in a contest. A full thick- ness tear of the RCL and an avulsion fracture of the first metacarpal joint were visualized. Ultrasound findings also suggested a partial thickness tear of the UCL with no Stener lesion.

Canon Medical provides two high-frequency hockey sticks from 17 to 22 MHz with the Aplio i800 / Prism Edition. Both hockey sticks have a very fine footprint that allows easy access for imaging superficial areas in hard- to-reach anatomical places. ‘The interventional radiologists were also big fans of the hockey stick transducers.’

Ergonomics are an important aspect of scanning for any sonographer.

Aaron found that the electric lift button as a sit/stand sonographer improved this aspect tremendously.

He also found the Aplio i800 / Prism Edition was very customizable which added benefits not just to ergonomics but in flattening the learning curve inherent in adjusting to a new machine.

“Similar to previous models, you have control over the setup of the control panel and interface. Therefore, there is next to no lag time in adjusting to a new machine,” he said. “Furthermore, the additions to previous models are all very intuitive, so it was very easy-to- use, and the learning curve was very smooth.”

This case features a 49-year-old female patient who sustained an injury at yoga, and was referred for an ultrasound of her right hand. The patient presented with a small lump on the palmar aspect of her right hand, over the second metacarpal. She also had pain associated with flexion and extension of the index finger. Differential diagnosis at the time of referral was Dupuytren’s contracture, a collagen disorder where the fascia in the hands becomes thickened and fibrotic. The abnormal collogen proliferation of this disorder means the condition will often first present as a thickening or nodule in the palm.

The Flexor Digitorum Profundus (FDP) and Flexor Digitorum Superficialis (FDS) tendons of the second finger were seen intact however there were changes to echogenicity of the adjacent lumbrical muscle. The muscle appeared enlarged and heterogenous with anechoic areas consistent with fluid. Increased vascularity was seen with Superb Microvascular Imaging (SMI) using Doppler luminance. These findings are consistent with a partial tear of the first lumbrical muscle of the hand.

An interesting case study of an uncommonly seen lumbrical injury.

This case study follows a 52-year-old firefighter who pre- sented to his doctor with pain in his left elbow upon pronation and supination. There was no acute injury reported by the patient. Possible distal biceps tendinosis was thought to be the cause of his symptoms.

The scan revealed a high-grade partial tear of the distal biceps at its insertion, predominantly involving the long head of biceps. Some vascularity in the distal biceps was also demonstrated with Superb Microvascular Imaging (SMI). Post diagnosis, it was recommended that the patient return for a Platelet Rich Plasma (PRP) injection into the area to help with tendon repair and alleviate symptoms.

Partial tear findings of the long head of biceps are an import- ant diagnosis to help prevent the possibility of further full thickness tearing. The deep section of the distal insertion of biceps can be difficult to image.

A 29-year-old female AFL player presented with pain in the first metacarpophalangeal joint (MCP) following a hyper-extension injury.

A full thickness tear of the radial collateral ligament (RCL) and an avulsion fracture of the first metacarpal joint were visualised. Ultrasound findings also suggested a partial thickness tear of the ulnar collateral ligament (UCL) without a Stener Lesion.

The ulnar and radial collateral ligaments are the two main supporting structures that traverse the metacarpophalangeal (MCP) joint of the thumb. Forced adduction is the most common cause of injury to the RCL, while forced abduction movements are the cause of most acute injuries to the UCL. The damage sustained to both ligaments were clearly demonstrated in this hyperflexion case.