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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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260 Chapter 8
MedianandAnteriorInterosseousNerves
1. Probe/patient position: The probe is placed on the anteromedial aspect of the elbow crease in
SX orientation. The median nerve is seen between the brachialis and pronator teres muscles,
medial to the brachial artery (Figure 8-33). The median nerve can be followed distally where
it travels between the humeral and ulnar heads of the pronator teres. The brachial artery at
this point divides into the radial and ulnar arteries, with the ulnar artery deep to the ulnar
head of the pronator teres muscles and the median nerve on the medial aspect of the ulnar
artery. In the mid-forearm, the median nerve leaves the ulnar artery and travels in the fascial
plane between the flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS)
muscles, where it is easy to locate (Figure 8-34).
9
A
B
Figure 8-33. Median nerve. (A) Probe placement on the anteromedial aspect
of the elbow crease in the SX orientation. (B) The median nerve (white arrow)
is visualized between the brachialis (BR) and pronator teres (PrTr) muscles,
medial to the brachial artery (white A).
Peripheral Nerves 261
Figure 8 -34. Median nerve (yellow
arrow) between the fascial planes
of the FDP and FDS muscles.
The anterior interosseous nerve (AIN) branching pattern is variable. The AIN can branch
off from the posterior aspect to the posteromedial aspect of the main median nerve at the level
proximal or distal to the pronator teres muscle.11
2. Landmarks: Brachial artery, brachialis muscle, and pronator teres muscle for median nerve
localization at the anterior elbow
3. Relevant anatomy: The median nerve innervates all the forearm flexors except the FCU
muscle and the ulnar aspect of the FDP muscle, with no sensory supply to the forearm. The
AIN emerges from the posterior aspect of the median nerve at the elbow level with a variable
branching pattern, which may be proximal or distal to the pronator teres level. Distally, the
AIN lies between the flexor pollicis longus (FPL) muscle laterally and FDP muscle medially,
sending motor innervation to these muscles. It follows along the anterior interosseous artery
and rests on the anterior surface of the interosseous membrane to give motor innervation to
the pronator quadratus distally and sensory innervation to the volar wrist joint capsule.
11
4. Points to remember: The AIN can be compressed by the fibrous arch of the pronator teres, the
fibrous arch of the FDS muscle, and Gantzer’s muscle when hypertrophied and anterior to the
AIN. The median nerve can be compressed by the ligament of Struthers.
9,11
262 Chapter 8
Wrist, Hand, and Digits
MedianNerve
1. Probe/patient position: The probe is placed in the SX view with the pisiform as the internal
landmark. The median nerve is visualized in the carpal tunnel with 9 tendon slips: 4 slips of
the FDP muscle, 4 slips of the FDS muscle, and 1 slip of the FPL muscle (Figure 8-35).
A
Figure 8-35. Median nerve at the wrist. (A) Probe placement. (B) SX view of the median nerve (white arrow), with the
pisiform (P) as an internal landmark.
2. Landmarks:
a. External: Pisiform
b. Internal: Pisiform, scaphoid bone, flexor retinaculum, and flexor tendons. Mean cross-
sectional area of the median nerve is 9 mm2 at the pisiform-scaphoid level.
3. Relevant anatomy: The median nerve enters the hand through the fibro-osseous tunnel or
carpal tunnel. The roof of the carpal tunnel is formed by the flexor retinaculum, and the floor
of the carpal tunnel is formed by the carpal bones.
4. Points to remember: Tilting the probe will make the tendons of the carpal tunnel appear
darker in one direction and brighter in other direction as tendons exhibit a greater degree
of anisotropy. This maneuver will help differentiate the nerve, which is hypoechoic and less
prone to anisotropy artifact, from the tendons.
B
12
Peripheral Nerves 263
PalmarCutaneousBranchoftheMedianNerve
1. Probe/patient position: The median nerve is localized at the carpal tunnel region and then
traced proximally to the distal forearm level (approximately 5 cm proximal to the wrist
crease). In the distal forearm, the palmar cutaneous nerve branches off from the median
nerve. It travels distally into the palm, passing superficial to the flexor retinaculum and just
medial to the flexor carpi radialis (FCR) tendon (Figure 8-36).
A
B
Figure 8-36. (A) Palmar cutaneous nerve (yellow arrow) splitting from the median nerve
(white triangle) in the distal forearm. (B) Palmar cutaneous branch of the median nerve
(yellow arrow) passing superficial to the flexor retinaculum (white arrows) and just medial to
the FCR tendon. (MN = median nerve.)
2. Landmarks: Median nerve in the carpal tunnel and FCR tendon
3. Relevant anatomy: The palmar cutaneous branch arises from the radial border of the median
nerve and provides sensory innervation to the skin of the radial aspect of the palm.
9
After
branching off, it travels with the median nerve for 2 to 3 cm and then runs along the ulnar
aspect of the FCR tendon.
264 Chapter 8
UlnarNerve
1. Probe/patient position: The probe is placed in the SX view at the level of the pisiform bone. The
ulnar nerve is visualized immediately radial to the pisiform bone. The ulnar artery is visualized radial to the ulnar nerve (Figure 8-37).
Figure 8-37. Ulnar nerve (white
arrow) at the wrist with the ulnar
artery (red arrow) radial to it and
the pisiform (P) as an internal
landmark.
2. Landmarks:
a. External: Pisiform
b. Internal: Ulnar artery
3. Relevant anatomy: The ulnar nerve enters the hand through Guyon’s canal with the ulnar
artery and vein. Guyon’s canal is formed by the pisiform medially and the hook of the hamate
laterally. The floor is formed by the f lexor retinaculum, and the root is formed by the palmar
carpal ligament and palmaris brevis muscle.
9
Peripheral Nerves 265
DorsalUlnarCutaneousNerve
1. Probe/patient position: The probe is placed transversely on the volar-ulnar aspect of the distal
third of the forearm to locate the ulnar nerve under the FCU muscle. Following the ulnar nerve
distally, the dorsal cutaneous nerve can be seen branching off from the medial aspect of the
ulnar nerve
AB
8
at about 6 cm proximal to the distal aspect of the head of the ulna (Figure 8-38).
Figure 8-38. Dorsal ulnar cutaneous nerve. (A) Probe placement transversely
on the volar-ulnar aspect of the distal third of the forearm to locate the ulnar
nerve under the FCU muscle. (B) The dorsal cutaneous nerve (yellow arrow)
can be seen branching off from the medial aspect of the ulnar nerve (white
arrow).
2. Landmarks: Ulnar nerve and FCU muscle at the distal third of the forearm
3. Relevant anatomy: The dorsal ulnar cutaneous nerve arises from the ulnar nerve and courses
distally, piercing the deep fascia to move dorsally to innervate the skin of the dorsoulnar
aspect of hand, dorsal aspect of the fifth digit, and dorsoulnar aspect of the fourth digit of
the hand.
266 Chapter 8
DigitalNerves
1. Probe/patient position: The probe is placed in SX orientation on the volar aspect of the digit.
The palmar digital nerve and blood vessel bundle can be seen on either side of the flexor tendons as the radial and ulnar digital nerves and blood vessel bundle (Figure 8-39).
AB
Figure 8-39. Digital nerves. (A) Probe placement. (B) The palmar digital nerve (white arrows) and blood vessel (red
areas) bundle can be seen on the either side of the flexor tendons (FT).
2. Landmark: Accompanying blood vessels with digital nerves on color Doppler
3. Points to remember: Digital nerves can be scanned from proximal to distal as they branch out
from median and ulnar nerves into smaller digital branches.
Peripheral Nerves 267
LOWER EXTREMITY NERVES
Hip and Pelvic Region
LateralFemoralCutaneousNerve
1. Probe/patient position: The probe is placed at the anterior superior iliac spine (ASIS) to visual-
ize the lateral femoral cutaneous nerve (LFCN; Figure 8-40). The nerve is then traced distally
as it passes beneath the inguinal ligament and courses anterolateral to the sartorius muscle,
where it divides into anterior and posterior branches (Figure 8-41).
AB
8
Figure 8-40. LFCN. (A) Probe
placement. (B) The LFCN (white arrow)
medial to the ASIS.
Figure 8-41. The LFCN (white
arrow) slightly distal to the
inguinal ligament, where it can
be seen overlying the sartorius
muscle.
268 Chapter 8
2. Landmarks:
a. Internal: Inguinal ligament and sartorius muscle
b. External: ASIS
3. Relevant anatomy: The LFCN originates from the lumbar plexus and L2 and L3 spinal nerves.
It courses inferiorly and laterally on the iliacus muscle before it reaches the medial aspect of
the ASIS. The LFCN runs under the inguinal ligament between 2 fascial planes: fascia iliaca
and fascia latae. It then runs in the fat compartment anterior and lateral to the sartorius
muscle.
8
It gives sensory innervation to the skin of the anterolateral aspect of the thigh.
4. Points to remember: The LFCN is a very small nerve and may require a higher frequency probe
in the range of 18 to 20 megahertz (MHz).
IlioinguinalandIliohypogastricNerves
1. Probe/patient position: The probe is placed at a level 5 cm proximal to the ASIS in an orientation perpendicular to the iliac crest, with the lateral end of the probe resting on the iliac crest.
Between the transverse abdominis and internal oblique muscles, the ilioinguinal nerve is seen
medial to the iliac crest and the iliohypogastric nerve is seen 1 cm medial to the ilioinguinal
nerve (Figure 8-42).
4,13
A
Figure 8-42. Ilioinguinal and iliohypogastric nerves. (A) Probe placement. (B) Ilioinguinal (white arrow) and
iliohypogastric (yellow arrow) nerves between the transverse abdominis (TA) and internal oblique (IO) muscles.
(EO = externa l ob lique muscle.)
B
2. Landmarks:
a. External: ASIS
b. Internal: External oblique, internal oblique, and transverse abdominis muscles
3. Relevant anatomy: The ilioinguinal and iliohypogastric nerves arise from the anterior ramus
of the L1 spinal root. The ilioinguinal nerve gives cutaneous innervation to the superior
medial thigh. In males, it gives innervation to the skin over the anterior third of the scrotum
and the root of the penis. In females, it innervates the anterior one-third of the labia majora
and the root of the clitoris. The ilioinguinal nerve gives motor branches to the internal oblique
and transverse abdominis muscles. The iliohypogastric nerve gives cutaneous innervation to
the posterolateral gluteal region and pubic region.
4. Points to remember: The ilioinguinal nerve may form a common trunk with the iliohypogastric nerve in 20% of cases.
14
Peripheral Nerves 269
PudendalNerve
1. Probe/patient position: The probe is placed in the SX at the level of the lesser sciatic notch of
the ischium. The pudendal nerve is seen overlying the curved course of the obturator internus
muscle, which overlies the ischium (Figure 8-43).
4
A
C
B
Figure 8-43. Pudendal nerve. (A and C) Probe placement and relevant
anatomy. (B) The probe is placed in the SX at the level of the lesser sciatic
notch of the ischium. The pudendal nerve (yellow arrow) overlies the curved
course of the obturator internus muscle, which overlies the ischium. Also
shown is the sciatic nerve (white arrow).
2. Landmarks: Ischial spine to locate the lesser sciatic notch level; curved course of the obturator
internus muscle over the ischium as an internal landmark
3. Relevant anatomy: The pudendal nerve arises from the S2, S3, and S4 nerve roots of the ante-
rior division of the sacral plexus and is the nerve of the perineum.
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