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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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190 Chapter 6
Common Fibular Nerve
1. Patient position: Prone or side-lying
2. Probe/transducer position: The probe is placed transversely across the common peroneal nerve
on the posterior aspect of the fibular head. After identifying the nerve, the LX view can be
obtained by rotating the probe (Figure 6-43).
AB
C
Figure 6-43. Common fibular nerve.
(A) Probe placement. Patient is sidelying. (B) SX view of the nerve (white
arrow) showing the biceps femoris
tendon (small red arrow). (C) SX view
of the nerve (white arrow) around the
fibula neck.
3. Relevant anatomy: The common fibular nerve behind the fibular head is covered with skin
and subcutaneous tissue. As it courses around the fibular neck to move anteriorly, it is covered
by the peroneus longus muscle (fibular tunnel). The nerve then divides into superficial and
deep branches.
9
4. Points to remember: The common fibular nerve appears as a hyperechoic flattened oval structure traveling between the fascial planes. The common fibular nerve view can be confirmed
by following it proximally at the level of the posterior knee where it joins the tibial counterpart
to form the sciatic nerve.
Knee 191
POSTERIOR KNEE
Joint Anatomy
1. Patient position: Prone
2. Probe/transducer position:
a. SX view/transverse view: The probe is placed transversely across the popliteal aspect to
examine the joint and other soft tissue structures overlying the joint, such as tendons,
muscles, nerves, and blood vessels (Figure 6-44).
A
Figure 6-44. SX view of the posterior knee. (A) Probe placement. (B) SX view of the posterior knee showing the tibial
nerve (yellow arrow) and popliteal artery (red A).
B
192 Chapter 6
b. LX view/longitudinal view: The probe is placed on the posterior aspect of the joint in the
LX. Sweeping the probe from medial to lateral examines the entire posterior aspect from
the medial femoral condyle to the lateral femoral condyle (Figures 6-45 and 6-46).
A
Figure 6-45. LX view of the
posterior knee. (A) Probe placement.
(B) Posterolateral LX view. (C)
Posteromedial LX view.
B
C
Knee 193
A
Figure 6-46. LX view of the posterior
knee at the midline. (A) Probe
placement. (B) LX view of the posterior
knee at the midline showing the PCL
(white arrow) and joint capsule (red
arrow).
B
3. Relevant anatomy: At the midline, the capsule and a small portion of the PCL are visualized.
As you go lateral or medial, femoral condyles and articulating tibial bony interfaces are visualized, with some visualization of the menisci.
4. Points to remember: MRI is the best choice for cruciate ligament imaging, and ultrasound does
not give much information about ACL or PCL pathology. Indirect signs of an ACL tear can be
seen as a femoral notch sign, PCL wave sign, or capsular protrusion.
10
194 Chapter 6
Semimembranosus Muscle-Tendon Complex
1. Patient position: Prone
2. Probe/transducer position: The probe is placed transversely across the posteromedial aspect of
the knee at the level of the medial femoral condyle (Figure 6-47). For the LX view, the probe is
rotated 90 degrees from the SX view to visualize the tendon at its direct insertion site on the
tibia (Figure 6-48).
AB
Figure 6-47. SX view of the
semimembranosus tendon. (A)
Probe placement. (B) SX view of
the semimembranosus tendon
(white arrow) also showing the
semitendinosus tendon (yellow arrow).
Figure 6-48. LX view of the semimembranosus tendon (white arrows) directly inserting on the tibia.
Knee 195
3. Relevant anatomy: The distal semimembranosus muscle-tendon unit reinforces the posterior
aspect of the knee via multiple tendinous expansions. These distal expansions include the
oblique popliteal expansion, anterior expansion, and inferior expansion (direct tendon). The
oblique popliteal expansion is the most proximal limb that blends with the posterior capsule
to form the oblique popliteal ligament. The anterior expansion sends off fibers to the medial
meniscus and the MCL. The inferior expansion sends off fibers to the fascia of the popliteus
muscle and inserts at the posteroinferior aspect of the medial tibial condyle (direct tendon;
Figures 6-49 through 6-51).
11
Figure 6-49. Relevant anatomy of the semimembranosus and its tendinous expansions.
196 Chapter 6
A B
Figure 6-50. Semimembranosus tendinous expansion to the popliteus muscle fascia. (A) Relevant anatomy and probe
placement. (B) Tendinous expansion (white arrows) to the popliteus muscle fascia.
A
Figure 6 -51. Oblique popliteal ligament
expansion of the semimembranosus.
(A) Relevant anatomy and probe
placement. (B) Oblique popliteal
ligament (white arrows) blending with
the posterior capsule.
B
4. Points to remember: The semimembranosus is an important structure providing stability to
the posteromedial aspect of the knee. When present, the neck/stalk of Baker’s cyst can be seen
between the tendon of the semimembranosus and the medial gastrocnemius. Baker’s cyst is
essentially a bursal effusion of the semimembranosus and medial gastrocnemius tendon.
Knee 197
Tibial Nerve and Blood Vessels
1. Patient position: Prone
2. Probe/transducer position: The probe is placed transversely at the posterior aspect of the knee
to scan the nerve in the SX view. The probe is moved in a proximal-to-distal direction to visualize the sciatic nerve splitting into the tibial and common peroneal counterparts. Once the
tibial nerve is confirmed, it can be scanned distally toward the leg (Figure 6-52).
A
Figure 6-52. Tibial nerve. (A) Probe
placement. (B) Tibial nerve (white
arrow), common fibular nerve (red
arrow), vein (V), and artery (white A).
B
198 Chapter 6
3. Relevant anatomy: After splitting from the main trunk of the sciatic nerve, the tibial nerve
courses straight down from the popliteal fossa and passes deep to the gastrocnemius muscle.
4. Points to remember: The branching pattern may differ; therefore, it is recommended to scan
the nerve in the SX view in a proximal-to-distal direction to visualize the sciatic nerve splitting into the tibial and common fibular nerves (Figure 6-53).
Figure 6-53. Relevant anatomy of the sciatic nerve and its branches.
Knee 199
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associated with anterior knee pain. Radiographics. 2018;38(7):2069-2101.
2. Liu F, Yue B, Gadikota HR, et al. Morphology of the medial collateral ligament of the knee. J Orthop Surg Res.
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3. Saigo T, Tajima G, Kikuchi S, et al. Morphology of the insertions of the superficial medial collateral ligament
and posterior oblique ligament using 3-dimensional computed tomography: a cadaveric study. Arthroscopy.
2017;33(2):400-407.
4. Jadhav SP, More SR, Riascos RF, Lemos DF, Swischuk LE. Comprehensive review of the anatomy, function, and
imaging of the popliteus and associated pathologic conditions. Radiographics. 2014;34(2):496-513.
5. Rosas HG. Unraveling the posterolateral corner of the knee. Radiographics. 2016;36(6):1776-1791.
6. Chahla J, Moatshe G, Dean CS, LaPrade RF. Posterolateral corner of the knee: current concepts. Arch Bone Jt
Surg. 2016;4(2):97-103.
7. Fairclough J, Hayashi K, Toumi H, et al. The functional anatomy of the iliotibial band during f lexion and extension of the knee: implications for understanding iliotibial band syndrome. J Anat. 2006;208(3):309-316.
8. Tubbs RS, Caycedo FJ, Oakes WJ, Salter EG. Descriptive anatomy of the insertion of the biceps femoris muscle.
Clin Anat. 2006;19(6):517-521.
9. Van den Bergh FR, Vanhoenacker FM, De Smet E, Huysse W, Verstraete KL. Peroneal ner ve: normal anatomy
and pathologic findings on routine MRI of the knee. Insights Imaging. 2013;4(3):287-299.
10. Mautner K, Sussman WI, Nanos K, Blazuk J, Brigham C, Sarros E. Validity of indirect ultrasound findings in
acute anterior cruciate ligament ruptures. J Ultrasound Med. 2019;38(7):1685-1692.
11. Benninger B, Delamarter T. Distal semimembranosus muscle-tendon-unit review: morphology, accurate terminology, and clinical relevance. Folia Morphologica. 2013;72(1):1-9.
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