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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5779_Библиотеки_им_академика_М_И_Перельмана
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100 Chapter 4
Suprascapular Nerve at the Spinoglenoid Notch
1. Patient position: Sitting
2. Probe/transducer position: The probe is placed on the posterior glenohumeral joint, and then
attention is focused on the spinoglenoid notch, which is just medial to the posterior glenohumeral joint (Figure 4-23).
5
A
Figure 4-23. Suprascapular nerve at the spinoglenoid notch. (A) Probe placement. (B) The suprascapular nerve (red
arrow) with vessels (red area) sits deep in the spinoglenoid notch.
B
3. Relevant anatomy: The suprascapular nerve with vessels sits deep in the spinoglenoid notch,
where its terminal branches enter the infraspinatus muscle.
10
4. Points to remember: Color Doppler is helpful in differentiating nerve from artery in the
spinoglenoid notch because the nerve and vascular bundle are very small structures and may
be difficult to distinguish with B-mode imaging.
Shoulder 101
ACROMIOCLAVICULAR JOINT
1. Patient position: Sitting with shoulder in neutral position
2. Probe/transducer position: The probe is placed over the acromioclavicular (AC) joint in trans-
verse orientation to bridge the articulating ends of the acromion and clavicle (Figure 4-24).
A
B
C
Figure 4-24. AC joint. (A) Probe placement: top view of the shoulder. (B)
Probe placement: front view of the shoulder. (C) AC joint. (ACR = acromion;
CL = clavicle.)
102 Chapter 4
3. Relevant anatomy: The AC joint is a diarthrodial joint between the medial facet of the acromion and the lateral end of the clavicle. Articulating surfaces are lined with fibrocartilage.
There may be an intra-articular disk between the articulating surfaces. The AC joint is surrounded by a fibrous capsule that extends 2.8 mm lateral to the medial facet of the acromion
and 3.5 mm medial to the lateral clavicle articulating surface, with a mean capsule width
ranging from 1.6 to 2.9 mm.
11
The capsule is reinforced by the superoposterior AC ligament,
which is well defined and well developed, and the anteroinferior AC ligament, which is less
developed. Superoposterior fibers run obliquely across the joint between the anterosuperior
aspect of the acromion to the posterior part of the distal end of the clavicle, at an angle about
30 degrees to the joint surface (Figure 4-25).
12
Figure 4-25. Relevant anatomy of the AC joint showing the superoposterior AC ligament (green) and AC joint capsule
(yellow). (ACR = acromion; CL = clavicle.)
4. Points to remember: Standing behind the patient for an AC joint scan helps with proper probe
placement over the AC joint in the direction of the superoposterior band of the AC ligament,
thereby visualizing the joint, capsule, and ligament in one view.
Shoulder 103
STERNOCLAVICULAR JOINT
1. Patient position: Sitting
2. Probe/transducer position: The probe is placed on the sternoclavicular (SC) joint bridging
the clavicle and manubrium. The orientation of the probe is oblique, with the medial end
of the probe rotated downward to align the probe along the LX of the articulating surface
(Figure 4-26).
AB
Figure 4-26. SC joint. (A) Probe placement. (B) SC joint.
3. Relevant anatomy: The SC joint is a double arthrodial synovial joint. There is an articular disk
interposed between articulating surfaces of the clavicle and manubrium. The articular disk
attaches to the posterosuperior aspect of the medial articulating surface of the clavicle and
the anterosuperior aspect of the first costal cartilage, with remaining disk covered by capsule.
The disk is thicker in the periphery and at the attachment sites.
joint area include the anterior SC ligament, posterior SC ligament, costoclavicular ligament,
14
and interclavicular ligament.
joint (Figure 4-27).
15
The posterior SC ligament is the primary stabilizer of the SC
13
The ligaments around the
Figure 4-27. Relevant anatomy of the SC joint.
4. Points to remember: Movement occurs in the anteroposterior and vertical axis. In elevation
and depression, movement occurs between the articular disk and clavicle. In protraction and
retraction, movement occurs between the articular disk and sternum.13
104 Chapter 4
LIGAMENTS
Coracohumeral Ligament
1. Patient position: Sitting with shoulder in external rotation
2. Probe/transducer position: The probe is placed over the long head of the biceps in the SX and
then moved medially to visualize the coracoid process. Then the medial end of the probe is
fixed at the coracoid process, and the lateral end of the probe is rotated toward the humerus
to scan the coracohumeral ligament (Figure 4-28).
A
Figure 4-28. Coracohumeral ligament.
(A) Probe placeme nt. (B) Coracohumeral
lig ament (wh ite ar row) att achin g on th e
lateral aspect of the coracoid process
(CP). (Subsca p = subscapularis.)
B
Shoulder 105
3. Relevant anatomy: The coracohumeral ligament originates from the lateral aspect of the base of
the coracoid process. Its lateral insertion varies greatly. The coracohumeral ligament inserts into
the rotator interval and into the supraspinatus tendon. It also envelops the subscapularis tendon
and is an important structure responsible for the stability of the glenohumeral joint. Based on
the histologic features, the coracohumeral ligament is more capsular than ligamentous. The coracohumeral ligament is composed of irregular and sparse fibers and interstitial vascularity and
contains type III collagen, which gives flexibility to the ligament (Figures 4-29 and 4-30).
16,17
Figure 4-29. Coracohumeral ligament (CHL) attachments. The coracohumeral ligament originates from the lateral
aspect of the base of the coracoid process (CP). Its lateral insertion varies greatly. It inserts into the rotator interval and
into the supraspinatus tendon (SUP). It also envelops the subscapularis tendon (SUB). (INF = infraspinatus; LHB = long
head of the biceps.)
106 Chapter 4
Figure 4-30. Relevant ligament anatomy of the anterior shoulder. (LHB = long head of the biceps.)
4. Points to remember: The coracohumeral ligament is best visualized close to its origin at the
coracoid process. The ligament then fans laterally and sends its fibers in different directions
to different structures; therefore, it is difficult to visualize laterally.
Shoulder 107
Coracoacromial Ligament
1. Patient position: Sitting
2. Probe/transducer position: The probe is placed over the long head of the biceps in the SX and
then moved medially to visualize the coracoid process. Then the medial end of the probe is
fixed at the coracoid process, and the lateral end of the probe is rotated superiorly to bring the
acromion in the view. The coracoacromial ligament is visualized between the coracoid process
and acromion (Figure 4-31).
AB
Figure 4-31. Coracoacromial
ligament. (A) Probe placement. (B)
Coracoacromial ligament (white arrow)
between the acromion (ACR) laterally
and the coracoid process (CP) medially.
108 Chapter 4
3. Relevant anatomy: The coracoacromial ligament has 2 bundles: the anterior bundle, which is
more prominent, and the posterior bundle, which attaches medial to the anterior bundle on the
coracoid process. The 2 bundles have a common attachment site at the acromion (Figure 4-32).
18
Figure 4-32. Relevant anatomy of the coracoacromial ligament (CAL) and subacromial space. (CHL = coracohumeral
ligament; LHB = long head of the biceps; SUBSCAP = subscapularis.)
4. Points to remember: A forward head and rounded shoulder posture makes it difficult to scan
the ligament. An upright posture is recommended for better visualization of the ligament.
Shoulder 109
ROTATOR INTERVAL
1. Patient position: Sitting in modified Crass position
2. Probe/transducer position: The probe is placed in the oblique SX view over the anterosuperior
aspect of the shoulder (Figure 4-33).
AB
Figure 4-33. Rotator interval. (A) Probe
placement. (B) The rotator interval
is the anterosuperior aspect of the
capsule, which is reinforced externally
by the coracohumeral ligament (yellow
arrow) and reinforced internally by the
superior glenohumeral ligament (red
arrow). Contents of the rotator inter val include the coracohumeral ligament, superior glenohumeral ligament,
glenohumeral capsule, and long head of the biceps (white star). The subscapularis (white triangle) and supraspinatus
(white arrow) are also seen.
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