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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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250 Chapter 8
b. Spinoglenoid notch: The probe is placed over the posterior glenohumeral joint and then
moved medially and rotated slightly in the SX to the spinoglenoid notch area. The suprascapular nerve is visualized with the suprascapular artery in the notch (Figure 8-20).
A B
Figure 8-20. Suprascapular nerve
from the spinoglenoid notch. (A)
Probe placement over the posterior
glenohumeral joint, then moved
medial and rotated slightly to the SX
view of the spinoglenoid notch area. (B)
Suprascapular nerve (yellow arrow) and
artery (red area).
7
2. Landmarks: Suprascapular notch and coracoid process (for probe orientation); spinoglenoid
notch and posterior glenohumeral joint
3. Relevant anatomy: The supraspcapular nerve arises from the superior trunk of the brachial
plexus and has fibers derived from the C5 and C6 nerve roots. It gives motor supply to the
supraspinatus and infraspinatus muscles and sensory innervation to the acromioclavicular
joint, subacromial bursa, and glenohumeral joint.
4. Points to remember: It is important to turn on color Doppler mode to identify the artery, which
helps in visualization of suprascapular nerve. The artery is superficial to the superior transverse ligament in the suprascapular notch. The artery accompanies the suprascapular nerve
in the spinoglenoid notch.
Peripheral Nerves 251
AxillaryNerve
1. Probe/patient position: The posterior cord from the subpectoralis minor space is followed
laterally to visualize the axillary nerve between the subscapularis and coracobrachialis/short
head of the biceps muscle (Figure 8-21). The probe is placed in the LX on the posterior aspect
of the shoulder at the level of the teres minor muscle. The axillary nerve (posterior branch) is
seen between the teres minor and the lateral head of the triceps, overlying the humeral bony
interface and accompanied by the posterior circumflex humeral artery (Figure 8-22).
1
A
Figure 8-21. Axillary nerve anteriorly.
(A) Probe placement. The posterior
cord of the subpectoralis minor space
is followed laterally to visualize the axillary nerve between the subscapularis and coracobrachialis/short head of the
biceps muscle. (B) The axillary nerve (yellow arrow) is seen between the subscapularis (SubS) and coracobrachialis/
short head of the biceps muscle (small white B).
B
A B
Figure 8-22. Axillary nerve posteriorly.
(A) Probe placement in the LX on the
posterior aspect of the shoulder at the
level of the teres minor muscle. (B) The
axillary nerve posterior branch (yellow
arrow) is seen between the teres minor
(TM) and lateral head of the triceps,
overlying the humeral bony interface and accompanied by the posterior circumflex humeral artery (red arrow).
2. Landmarks: The teres minor muscle, lateral head of the triceps, and posterior circumflex
artery are internal landmarks.
3. Relevant anatomy: The axillary nerve arises from the posterior cord of the brachial plexus and
derives fibers from the C5 and C6 roots.
252 Chapter 8
Ulnar,Median,Radial,andMusculocutaneousNerves
1. Probe/patient position: The probe is placed in the oblique LX along the anterior axillary fold, and
the axillary artery is identified. With respect to the axillary artery, the median nerve is lateral,
the ulnar nerve is medial, and the radial nerve is posterior (Figure 8-23). Laterally, the musculocutaneous nerve is seen between the biceps brachii and coracobrachialis muscles (Figure 8-24).
3
A
Figure 8-23. Median, ulnar, and radial
nerves at the anterior axillary fold. (A)
Probe placement. (B) Median (yellow
arrow), ulnar (white arrow), and radial
(red arrow) nerves around the axillary
artery (white A).
Figure 8 -24. The musculocutaneous
nerve (white arrow) is seen between
the biceps brachii (SHbr) and
coracobrachialis (Cbr) muscles.
B
2. Landmarks:
a. External: Anterior axillary fold
b. Internal: Axillary artery as an internal landmark for the median, ulnar, and radial nerves;
biceps brachii and coracobrachialis muscles as internal landmarks for the musculocutaneous
nerve
Peripheral Nerves 253
Elbow and Forearm Region
LateralAntebrachialCutaneousNerve
1. Probe/patient position: The probe is placed transversely at the elbow crease to visualize the
lateral antebrachial cutaneous (LABC) nerve in the SX view. The LABC nerve is visualized
lateral to the distal biceps tendon, just below or next to the cephalic vein (Figure 8-25). Tracing
the nerve proximally, it can be seen joining the musculocutaneous nerve.
8
A
B
Figure 8-25. LABC nerve. (A) Probe placement transversely at the elbow
crease. (B) The LABC nerve (white arrow) is visualized lateral to the distal
biceps tendon (BT), just below or next to the cephalic vein (CV).
2. Landmarks:
a. Internal: Cephalic vein and distal biceps tendon. The nerve is lateral to the distal biceps
tendon.
3. Relevant anatomy: The LABC nerve is the terminal sensory branch of the musculocutaneous
nerve. It branches out from the musculocutaneous nerve, piercing the deep fascia at the level
proximal to the elbow joint to lie lateral to the distal biceps tendon. It runs along the cephalic
vein and divides distally into the ventral and dorsal branches that supply the lateral and posterior aspects of the forearm up to the wrist.
4. Points to remember: The LABC nerve can be injured due to injury to the cephalic vein (eg, dur-
ing venipuncture) or due to distal biceps tendon tears due to its close proximity to the cephalic
vein and distal biceps tendon.
8
254 Chapter 8
MedialAntebrachialCutaneousNerve
1. Probe/patient position: The probe is placed in the sagittal oblique axis on the axillary fossa. The
medial antebrachial cutaneous (MABC) nerve is seen above the axillary artery and vein, close
to the ulnar and median nerves (Figure 8-26). The MABC nerve can be followed distally as it
travels with the basilic vein between the brachialis and triceps brachii muscles (Figure 8-27).
AB
8
Figure 8-26. MABC nerve. (A) Probe placement in the sagittal oblique axis on the axillary fossa. (B) The MABC nerve
(white arrow) is seen above the axillary artery (red A) and vein (blue V).
A
Figure 8-27. The MABC nerve with the basilic vein distally at the mid-arm level. (A) Probe placement. (B) The MABC
nerve (yellow arrow) with the basilic vein (BV) and ulnar nerve (white arrow).
B
2. Landmarks: Axillary artery in the axillary fossa; basilic vein in the arm
3. Relevant anatomy: The MABC nerve is derived from the medial cord of the brachial plexus.
It pierces the brachial fascia and courses at the ulnar aspect of the brachial artery and along
the basilic vein.
Peripheral Nerves 255
PosteriorAntebrachialCutaneousNerve
1. Probe/patient position: The probe is placed on the posterior aspect of the mid-arm in SX ori-
entation. The radial nerve is seen under the lateral head of the triceps muscle. Following the
radial nerve distally, the posterior antebrachial cutaneous (PABC) nerve is seen leaving the
radial nerve and is seen subcutaneously (Figure 8-28).
8
A
Figure 8-28. PABC nerve. (A) Probe
placement on the posterior aspect
of the mid-arm in the SX orientation
to visualize the radial nerve. The
radial nerve is followed distally to
visualize the PABC nerve leaving the
radial nerve and travelling lateral and
superficial. (B) The radial nerve (white
arrow) is seen under the lateral head of
the triceps muscle. (C) The PABC nerve
(white arrow) is in close proximity to
the lateral epicondyle. Accompanying
blood vessel can be seen (red area).
B
C
2. Landmarks: Radial nerve and lateral head of the triceps
3. Relevant anatomy: The PABC nerve is a branch of the radial nerve. It branches from the main
trunk of the radial nerve at the outlet of the spiral groove. It travels between the lateral head
of the triceps and the brachialis muscle and then emerges subcutaneously, giving anterior and
posterior branches to supply the posterolateral aspect of the forearm.
4. Points to remember: The PABC nerve is in close proximity to the lateral epicondyle and should
be examined in cases of chronic lateral epicondylitis or recalcitrant lateral epicondylitis.8
256 Chapter 8
UlnarNerve
1. Probe/patient position: The probe is placed in the SX over the ulnar nerve at the medial elbow,
bridging the medial epicondyle and the olecranon process (Figure 8-29). The ulnar nerve is
closer to the medial epicondyle bony landmark. The ulnar nerve can be followed proximally
where it lies just above the medial triceps muscle. It can be followed distally in the true cubital
tunnel as it travels between the 2 heads of the flexor carpi ulnaris (FCU) muscle (see Figures
3-19 and 3-20).
A
Figure 8-29. Ulnar nerve. (A) Probe
placement in the SX over the ulnar nerve
at th e medi al elbow, bridging the me dial
epicondyle and olecranon process. (B)
SX view of the ulnar nerve (white arrow)
showing the medial epicondyle (ME)
and olecranon (OL).
B
2. Landmarks: The medial epicondyle and olecranon are bony landmarks. The 2 heads of the
FCU muscle are internal landmarks for scanning the nerve distal to the medial epicondyle in
the true cubital tunnel.
3. Relevant anatomy: The ulnar nerve travels along the medial aspect of the arm and overlies the
medial triceps as it approaches posterior to the medial epicondyle. The fascia of the medial
triceps brachii and the intermuscular septum form Osborne’s fascia, which covers the ulnar
nerve at the level proximal to the medial epicondyle. Just distal to the medial epicondyle, the
ulnar nerve is covered by the arcuate ligament, which forms the roof of the cubital tunnel
between the humeral and ulnar heads of the FCU muscle.
9
4. Points to remember: The ulnar nerve should be scanned with the elbow in about 60 to
70 degrees of flexion. Scanning the nerve in 90 degrees or more of elbow flexion is not recommended because it has been reported that 20% of the asymptomatic population may have
ulnar nerve dislocation, and at 90 degrees of flexion the ulnar nerve may be at the apex of the
medial epicondyle or anterior to the medial epicondyle.
10
Peripheral Nerves 257
RadialNerveandItsBranches
1. Probe/patient position: The probe is positioned on the radial aspect of the anterior elbow
crease in SX orientation. The radial nerve is located between the brachialis and brachioradialis
muscles. The radial nerve is followed distally where it divides into the superficial and deep
branches of the radial nerve (Figure 8-30).
A
B
Figure 8-30. Radial nerve. (A) Probe placement on the radial aspect of the
anterior elbow crease in SX orientation. (B) The radial nerve is visualized
between the brachialis (BR) and brachioradialis (BrD) muscles. Also shown are
the superficial branch (yellow arrow) and deep branch (white arrow).
258 Chapter 8
The superficial branch of the radial nerve is seen branching out from the medial aspect of
the radial nerve and descending underneath the brachioradialis muscle.8 Distally, the superficial branch pierces the antebrachial fascia between the extensor carpi radialis longus and
brachioradialis tendons, approximately 10 cm proximal to the anatomical snuff box, and then
runs the dorsal-radial aspect of hand to give sensory innervation of the dorsal-radial aspect of
the hand up to the radial aspect of the fourth digit (Figure 8-31).
AB
Figure 8-31. Superficial branch of the radial nerve. (A) Probe placement.
(B) Superficial branch of the radial nerve (yellow arrow) and overlying
brachioradialis muscle (BrD).
Peripheral Nerves 259
The deep branch passes through the arcade of Frohse between the 2 heads of the supinator
muscle to pass dorsally, where it becomes the posterior interosseous nerve supplying other
extrinsic wrist extensor muscles (Figure 8-32).
A
Figure 8-32. Deep branch of the radial
nerve. (A) Probe placement. (B) Deep
branch of the radial nerve (yellow
arrow) between the superficial head
(SS) and the deep head (DS) of the
supinator muscle. (R = radius.)
B
2. Landmarks: Brachialis and brachioradialis muscles to locate the main trunk of the radial
nerve at the anterior elbow crease; 2 heads of the supinator muscle to locate the deep branch
3. Relevant anatomy: The main trunk of the radial nerve at the elbow divides into 2 branches:
the superficial branch, which branches out from the medial aspect of the main trunk, and the
deep branch, which enters the arcade of Frohse to pass between the 2 heads of the supinator
muscle to become the posterior interosseous nerve. The deep branch gives motor innervation to the supinator and extensor carpi radialis brevis muscles before entering the arcade
of Frohse. The posterior interosseous nerve supplies all the extrinsic wrist extensor muscles
except the extensor carpi radialis longus. Distally, the posterior interosseous nerve gives sensory supply to the dorsal wrist capsule.
4. Points to remember: In suspected cases of radial tunnel syndrome, the radial nerve should
be checked in SX and LX view as it enters the arcade of Frohse. Focal compression may be
evident as an hour-glass deformity or a focal constriction of the nerve as it enters the arcade
of Frohse. Other causes of focal neuropathy include ganglion cyst, soft tissue masses, or other
space occupying lesions.
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