Abstract

Objectives. Musculoskeletal ultrasound (MSUS) is increasingly being used by rheumatologists in routine clinical practice to aid with diagnosis and therapy monitoring in the rheumatic conditions. Undergraduate teaching in anatomy is often regarded as problematic and various approaches are in use in UK medical schools. To our knowledge no study to date describes the use of MSUS to facilitate understanding of pathology in the musculoskeletal system at undergraduate level. Accordingly, we wished to explore the usefulness of a short practical ultrasound course for medical undergraduates in learning basic and pathological features of the musculoskeletal system.

Methods. As part of the third-year undergraduate medical musculoskeletal attachment at Queens University Belfast, a 12-week student-selected component (SSC) entitled ‘Diagnostic Musculoskeletal Ultrasound in Rheumatology’ was offered. The course was a combination of lectures, hand-outs, practical demonstration and supervised hands-on scanning with three methods of summative assessment employed (MCQ paper, practical examination and general attitude).

Results. The course involved ∼30 h work for the two tutors. Seven students completed the course with an overall mean score of 85.3% attained in the assessment. The feedback on the course from the students was extremely positive.

Conclusion. Musculoskeletal ultrasound could be utilized to enhance the delivery of undergraduate teaching in rheumatology.

Introduction

Musculoskeletal ultrasound (MSUS) is increasingly being used by rheumatologists in routine clinical practice to aid with diagnosis and therapy monitoring in the rheumatic conditions [1]. MSUS is a safe, non-invasive technique, which allows rapid, real-time, repeatable, multi-planar dynamic examination of multiple joints and related soft-tissues in one examination. High-resolution MSUS (HRUS) has been shown to be superior to clinical examination in detecting evidence of joint and tendon inflammation and the addition of power Doppler (PD) allows assessment of the vascular component of inflammation [2].

Our local postgraduate training in diagnostic MSUS [3] highlighted the benefit of rapidly acquiring a greater knowledge and spatial understanding of joint anatomy through their ‘hands on’ experience. HRUS provides real-time 3D images of normal joint anatomy rewarding students with an increased practical knowledge of joint structure and function. Undergraduate teaching in anatomy is often regarded as problematic and various approaches are in use in UK medical schools. At Queen's University Belfast, a systems and case-based model utilizing tutorials, seminars and limited dissection room exposure is employed during Phase 2 of the 5-yr curriculum.

Recently, MSUS has been shown in undergraduate students to enhance knowledge and facilitate their learning of normal anatomy [4]. To our knowledge no study to date describes the use of HRUS to facilitate understanding of pathology in the MSK system at undergraduate level. Accordingly, we wished to explore the usefulness of a short practical ultrasound course for medical undergraduates in learning basic and pathological features of the musculoskeletal system.

We describe a teaching module that enabled undergraduate medical students to use HRUS to scan normal (and abnormal) joint structures. The aim of this module was to allow hands-on scanning of normal and abnormal joint structures to:

  • provide an understanding of the spatial and 3D structure of joints;

  • improve basic and surface MSK anatomy;

  • provide an insight into the pathological process of inflamed joints and tendons; and

  • allow appreciation of usefulness and limitations of HRUS as a diagnostic imaging modality.

Methods

In addition to the regular third-year undergraduate 3-week medical musculoskeletal attachment at Queens University Belfast (QUB), a 12-week student-selected component (SSC) entitled ‘Diagnostic Musculoskeletal Ultrasound in Rheumatology’ was offered. This was the first time such an SSC was offered at QUB and in order to allow for maximum exposure to practical hands-on MSUS, the group was limited to seven students out of a total of 180 students in third year (the other students were allocated to different SSCs). Table 1 outlines the module timetable and aims of each session. Each tutorial was conducted by one of the two tutors trained in MSUS [3], with a combination of lectures, hand-outs, practical demonstration and supervised hands-on scanning employed. In addition to these formal taught sessions, the students had access to the ultrasound machine if required. The same ultrasound machines (Esaote MyLab 70™) were used for all sessions. A high level of attendance was required (minimum 75%), as the major emphasis was on practical skills rather than theoretical aspects of MSUS.

Table 1.

Timetable and learning objectives of MSUS student study module

Session Activity 
The basics of MSUS
•    Explain the basic physical principles underlying the action of an ultrasound transducer. Define the frequency ranges useful in bone and joint imaging. Describe B-mode and Doppler-mode ultrasound usage.
•    List some medical and non-medical uses of ultrasound other than musculoskeletal imaging.
•    Describe normal ultrasound appearances of tendon, tendon sheath, fluid, fat, muscle, bone, ligaments, nerves, veins and arteries. Give examples of common visual artefacts that can occur in ultrasound scanning of joints and related structures. 
Introduction to the ultrasound machine and normal heel: Achilles tendon and insertion
•    Operate under supervision to demonstrate a MSUS machine (including power on/off, musculoskeletal presets, input of information by operator, selection of probe, frequency, gain, zoom, recording, freeze and measurement function).
•    (under supervision) Carry out a basic ultrasound scan of the normal heel; correctly position subject and be able to demonstrate dynamic and multidimensional capabilities of ultrasound.
•    Identify ultrasound appearances of structures at the heel including bone, tendon, bursa, fat, muscle and specific anatomical features: Achilles tendon, its insertion into the heel, plantar fascia and insertion.
•    Appreciate the ultrasound artefact of anisotropy as exemplified in the Achilles tendon. 
Introduction to standard musculoskeletal scans At the end of this session the successful student will be able to:
•    Demonstrate how to correctly position the ultrasound probe when scanning around a joint so as to produce standardized images on the ultrasound screen and explain why this is important.
•    Use the DVD of standardized scans to revise normal appearances.
•    Carry out a basic ultrasound scan under supervision of the normal extensor pollicis longus tendon including dynamic examination, the carpal tunnel and flexor aspect of the wrist. Be able to identify median nerve and long flexor tendons, radial and ulnar artery, palmaris longus tendon (when present). 
Hand and wrist––MCP joints, flexor tendons in hand
•    Carry out a basic ultrasound scan under supervision of the normal MCP joints and related flexor tendons.
•    Identify MCP cartilage, bone, normal joint outline, flexor tendons and attempt to distinguish deep and superficial flexor tendons by dynamic examination. 
Dorsum of wrist
•    List the six extensor tendon compartments of the dorsal wrist, their relationship to ulna, radius and radial styloid and Lister's tubercle; demonstrate their ultrasound appearances under supervision. 
Power Doppler ultrasound
•    Describe the physical principles underlying Doppler ultrasound, and the differences between colour Doppler and power Doppler.
•    Explain the usefulness of power Doppler in assessment of the inflamed joint. 
Patient demonstration
•    List possible ultrasound appearances in an inflamed synovial joint: synovial thickening, fluid effusion, bone erosion, cartilage loss and power Doppler signal.
•    Demonstrate relevant findings under supervision in patient with inflammatory arthritis. 
Patient demonstration
•    Another opportunity to scan a patient with arthritis: same learning outcomes as session 7. 
MCQ examination 
10, 11 Student revision for practical
•    An opportunity for student revision of heel, ankle, hand and wrist ultrasound scanning. 
12 Practical examination and student feedback. 
Session Activity 
The basics of MSUS
•    Explain the basic physical principles underlying the action of an ultrasound transducer. Define the frequency ranges useful in bone and joint imaging. Describe B-mode and Doppler-mode ultrasound usage.
•    List some medical and non-medical uses of ultrasound other than musculoskeletal imaging.
•    Describe normal ultrasound appearances of tendon, tendon sheath, fluid, fat, muscle, bone, ligaments, nerves, veins and arteries. Give examples of common visual artefacts that can occur in ultrasound scanning of joints and related structures. 
Introduction to the ultrasound machine and normal heel: Achilles tendon and insertion
•    Operate under supervision to demonstrate a MSUS machine (including power on/off, musculoskeletal presets, input of information by operator, selection of probe, frequency, gain, zoom, recording, freeze and measurement function).
•    (under supervision) Carry out a basic ultrasound scan of the normal heel; correctly position subject and be able to demonstrate dynamic and multidimensional capabilities of ultrasound.
•    Identify ultrasound appearances of structures at the heel including bone, tendon, bursa, fat, muscle and specific anatomical features: Achilles tendon, its insertion into the heel, plantar fascia and insertion.
•    Appreciate the ultrasound artefact of anisotropy as exemplified in the Achilles tendon. 
Introduction to standard musculoskeletal scans At the end of this session the successful student will be able to:
•    Demonstrate how to correctly position the ultrasound probe when scanning around a joint so as to produce standardized images on the ultrasound screen and explain why this is important.
•    Use the DVD of standardized scans to revise normal appearances.
•    Carry out a basic ultrasound scan under supervision of the normal extensor pollicis longus tendon including dynamic examination, the carpal tunnel and flexor aspect of the wrist. Be able to identify median nerve and long flexor tendons, radial and ulnar artery, palmaris longus tendon (when present). 
Hand and wrist––MCP joints, flexor tendons in hand
•    Carry out a basic ultrasound scan under supervision of the normal MCP joints and related flexor tendons.
•    Identify MCP cartilage, bone, normal joint outline, flexor tendons and attempt to distinguish deep and superficial flexor tendons by dynamic examination. 
Dorsum of wrist
•    List the six extensor tendon compartments of the dorsal wrist, their relationship to ulna, radius and radial styloid and Lister's tubercle; demonstrate their ultrasound appearances under supervision. 
Power Doppler ultrasound
•    Describe the physical principles underlying Doppler ultrasound, and the differences between colour Doppler and power Doppler.
•    Explain the usefulness of power Doppler in assessment of the inflamed joint. 
Patient demonstration
•    List possible ultrasound appearances in an inflamed synovial joint: synovial thickening, fluid effusion, bone erosion, cartilage loss and power Doppler signal.
•    Demonstrate relevant findings under supervision in patient with inflammatory arthritis. 
Patient demonstration
•    Another opportunity to scan a patient with arthritis: same learning outcomes as session 7. 
MCQ examination 
10, 11 Student revision for practical
•    An opportunity for student revision of heel, ankle, hand and wrist ultrasound scanning. 
12 Practical examination and student feedback. 

Resource materials

The students were provided with the following resource materials:

  • DVD: David Kane, Peter Balint, Roger Sturrock. Musculoskeletal ultrasound: a beginner's guide to normal peripheral joint anatomy. University of Glasgow, Arthritis Research Campaign 2005.

  • Backhaus et al. Guidelines for musculoskeletal ultrasound in rheumatology. Ann Rheum Dis 2001;60:641–9.

    This publication provides guidance on equipment, positioning of patient, positioning of probe and standard views for all the joint groups normally imaged. It includes scan pictures and lists of likely detectable pathologies at each joint site. Although too detailed for this module, it was a useful reference for the students to relate to the particular regions they were scanning.

  • http://www.sameint.it/eular/ultrasound

This is the website for the ‘Working Group for Musculoskeletal Ultrasound in Rheumatology’. It provides a wealth of useful images and illustrates standard scans.

Assessment

Three methods of summative assessment were undertaken:

  • MCQ examination: this consisted of 25 single, best answer format questions on basic aspects of MSUS, its practical use, normal appearances, basic technical artefacts and essentials of pathological changes in joints structures. Negative marking did not apply. The MCQ paper comprised 30% of the total assessment marks.

  • A practical examination that assessed only the joint regions covered in the module. This was in three parts:

    • students were asked to demonstrate and save to a hard drive the ultrasound images of specific normal anatomical structures using the ultrasound equipment and the human volunteer provided;

    • students were asked to demonstrate and save ultrasound and power Doppler images of specified areas of a patient with a rheumatic disease; and

    • students were asked to identify normal and pathological ultrasound appearances from previously saved images.

The practical examination comprised 60% of the total assessment marks.

  • (iii) A general impression mark given by each tutor on attendance, interest, group helpfulness, aptitude and application to tasks presented. This comprised of 10% of the total assessment marks.

Student evaluation and feedback

A standardized evaluation questionnaire of 20 questions, each requiring a 5-point Likert scale response and a free text section in standard use for SSCs within the medical school was completed by all students.

Results

Our experience of running the module, assessment and feedback is outlined as follows.

Attendance

Two students each missed one session of the course but all attended for assessment.

Amount of time devoted by tutors

There were ∼30 h of contact time with students, some of which involved both tutors (including revision supervision and assessment), and 10 h of preparation time. This gave a total time commitment over 12 weeks of about 25 h per tutor.

Assessment results

Overall marks (out of 100%) ranged from 84% to 87%, mean 85.3%

MCQ paper

This was marked out of 30% maximum. Student results ranged from 25.2 to 30 (one student), mean 27.4%.

Practical exam

Out of a possible maximum of 60%, marks ranged from 49.5% to 53%, mean 51%. Examples of images saved by students during assessment are shown (Figs 1 and 2).

Fig. 1.

Longitudinal dorsal scan of the heel showing plantar fascia and its insertion into the calcaneum. C, calcaneum; plantar fascia between two white arrows.

Fig. 1.

Longitudinal dorsal scan of the heel showing plantar fascia and its insertion into the calcaneum. C, calcaneum; plantar fascia between two white arrows.

Fig. 2.

Longitudinal dorsal scan of second MCP joint in a patient with RA showing a bone erosion and power Doppler signal. M, metacarpal; P, proximal phalanx; asterisk, joint space; white arrow, bone erosion.

Fig. 2.

Longitudinal dorsal scan of second MCP joint in a patient with RA showing a bone erosion and power Doppler signal. M, metacarpal; P, proximal phalanx; asterisk, joint space; white arrow, bone erosion.

Student feedback

A mean of 13 (range 10–19) of the 20 course assessment questions were rated as excellent by students, and a mean of 17 (16–19) as excellent or very good. No student rated any aspect of the course as poor or very poor. Free text comments were extremely positive. Examples include the following ‘Best SSC I have ever done’; ‘brilliant SSC and thoroughly enjoyed … very glad I picked a practical SSC which will hopefully stay with me through my course’; ‘unlike any SSC I have done before; varied, informative and very enjoyable’; ‘practical exam was challenging but made me realise how much we had learnt during the course’; ‘Excellent, I would recommend it to any student.’

Discussion

Our experience of running a MSUS module for undergraduates is extremely positive, enjoyed equally by tutors and students. Given the limited teaching time and scope available, the standard achieved by students in their end of course assessment was exceptional. This is well demonstrated by the examples of images (figures) saved by students under time-pressed examination conditions. In addition to the positive written feedback, several students commented during the course on the way in which performing ultrasound provides a clear 3D view of local anatomy improving previously vague spatial understanding. Thus, as third-year students first exposed to basic musculoskeletal anatomy in second year, the module literally provides a new dimension to previous understanding. In a similar way, student's grasp of rheumatic disease is also greatly enhanced by their visualization of specific pathological features, e.g. synovial swelling, effusion, erosion and ‘inflammation’ by power Doppler signal in joints of patients with RA.

We believe the strength of the module lies in well-prepared, enthusiastic tutors already experienced in using MSUS in clinical rheumatology; in limiting the scope to specific anatomical areas and pathologies; and in the focus on ‘hands on’ practical skills with a minimum of theoretical teaching or passive viewing of others performing ultrasound.

Our experience points to the potential value of a practical undergraduate MSUS course in assisting student's grasp of relevant anatomy and pathology. However, the course was chosen by participating students, possibly self-selecting those who would benefit most by this learning method. It relied on the availability of at least two high-quality ultrasound machines and a small group of students allowing one to one tuition. How far this approach could be adapted to become available to large numbers of undergraduate medical students is problematic, but not impossible—successful methods have already been applied in relation to anatomy learning in second-year undergraduates [4]. Following our successful pilot study, a further formal study with comparator group would be helpful, including before and after assessment of anatomical and pathological knowledge.

graphic

Disclosure statement: The authors have declared no conflicts of interest.

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