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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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270 Chapter 8
FemoralandSaphenousNerves
1. Probe/patient position: The probe is placed along the inguinal ligament, and the femoral artery
is identified as an anechoic pulsatile structure (Figure 8-44). Lateral to the femoral artery, the
femoral nerve appears as a hyperechoic triangular structure.
A
Figure 8-44. Femoral nerve. (A) Probe
placement and relevant anatomy.
(B) Femoral nerve (white arrow) and
femoral artery (white A).
B
For the saphenous nerve, the probe is placed in the SX in the femoral triangle region. The
saphenous nerve is seen accompanied by the femoral artery, deep to the sartorius muscle, medial
to the vastus medialis muscle, and superficial to the adductor longus muscle (Figure 8-45).
AB
15
Figure 8-45. Saphenous nerve in the femoral triangle area. (A) Probe placement. (B) Saphenous nerve (yellow arrow)
accompanied by the femoral artery (red A), deep to the sartorius muscle, medial to the vastus medialis muscle (VM),
and superficial to the adductor longus muscle (AL).
Peripheral Nerves 271
2. Landmarks: Femoral artery in the inguinal canal for femoral nerve localization; femoral
artery, sartorius muscle, vastus medialis muscle, and adductor longus muscle in the femoral
triangle for saphenous nerve localization
3. Relevant anatomy: The femoral nerve exits the pelvis into the anterior compartment of the
thigh after passing beneath the inguinal ligament. The femoral nerve divides into the motor
and sensory branches 2 to 3 cm distal to the inguinal ligament. The sensory branch of the
femoral nerve is the saphenous nerve, which innervates the skin of the anteromedial thigh,
anteromedial knee, and medial leg.
15
ObturatorNerve
1. Probe/patient position: The probe is placed along the inguinal ligament, medial to the femo-
ral artery, over the pectineus muscle with the probe oriented superiorly and dorsally (tilt the
probe). The obturator nerve is seen between the pectineus muscle superiorly and the obturator
externus muscle inferior to the nerve (Figure 8-46).
A
Figure 8-46. Obturator nerve. (A)
Probe placement along the inguinal
ligament, medial to the femoral artery,
and over the pec tineus muscle, with the
probe oriented superiorly and dorsally
(tilt the probe). (B) Obturator nerve
(white arrow) between the pectineus
muscle superiorly and the obturator
externus muscle inferior to the nerve.
B
272 Chapter 8
The probe is then moved distally to visualize the anterior and posterior divisions of the
nerves. The probe orientation is in the SX without any tilt because the nerve branches are anterior between the adductor group of muscles. Anterior division is seen in the SX between the
adductor longus and adductor brevis muscles. Posterior division is seen between the adductor
brevis and adductor magnus muscles (Figure 8-47).
Figure 8-47. Obturator nerve
anterior (white arrow) and
posterior (yellow arrow) divisions
between the adductor group
of muscles: adductor longus
(AL), adductor brevis (AB), and
adductor magnus (AM).
2. Landmarks:
a. External: Inguinal ligament and femoral artery
b. Internal: Pectineus muscle, obturator externus muscle, and superior and inferior pubic
rami; adductor longus, adductor brevis, and adductor magnus muscles for the anterior and
posterior divisions
3. Relevant anatomy: The obturator nerve arises from L2-L4. It enters the thigh through the
obturator canal. The anterior branch innervates the adductor longus, adductor brevis, and
gracilis muscles. The posterior branch innervates the adductor brevis, adductor magnus, and
obturator externus muscles.
Peripheral Nerves 273
SciaticNerve
1. Probe/patient position: The probe is placed along the piriformis muscle to visualize the sciatic
nerve as a hyperechoic structure under the piriformis muscle belly (Figure 8-48). The probe
is then moved distally to visualize the sciatic nerve overlying the quadratus femoris muscle
(Figure 8-49).
AB
Figure 8-48. Sciatic nerve. (A) Probe
placement. (B) Piriformis muscle (white
arrow), sciatic nerve (yellow arrow), and
greater trochanter (GT).
A B
Figure 8-49. Sciatic nerve overlying
the quadratus femoris muscle. (A)
Probe placement and relevant
anatomy. (B) The sciatic nerve (yellow
arrow) overlying the quadratus femoris
muscle (QF).
274 Chapter 8
2. Landmarks:
a. External: Greater trochanter to identify the distal part of the piriformis, which is then
traced medially to identify the sciatic nerve running under it.
b. Internal: LX view of the piriformis muscle. Moving the probe distally, the nerve is lateral to
the ischial tuberosity and superficial to the quadratus femoris muscle.
3. Relevant anatomy: The sciatic nerve is the largest nerve of the body, with root supply from
L4-S3. It supplies the posterior muscles of the thigh, lower leg, and foot. It provides sensory
innervation to the leg and foot, except the medial aspect.
Peripheral Nerves 275
Knee and Lower Leg Region
TibialandCommonFibularNervesandTheirBranches
1. Probe/patient position: The probe is placed in the SX on the posterior aspect of the knee to
visualize the hyperechoic sciatic nerve accompanied by the popliteal artery and vein. The
sciatic nerve is then followed distally to see the nerve dividing into the tibial and common
fibular branches (Figure 8-50).
A
Figure 8-50. Tibial and common
fibular nerves. (A) Probe placement.
(B) Hyperechoic sciatic nerve (white
arrow) on the posterior aspect of the
knee. (C) Sciatic nerve splitting into
the tibial (white arrow) and common
fibular (yellow arrow) nerves.
B
C
276 Chapter 8
The tibial nerve runs deep on the posterior aspect of the leg. The fibular nerve moves laterally and has a superficial course as it wraps around the fibular neck to divide into the deep and
superficial fibular nerves (Figure 8-51). The superficial fibular nerve passes deep between the
peroneal muscles to give motor supply to the peroneus longus and peroneus brevis muscles.
A
B
Figure 8-51. Common fibular nerve at the fibular neck. (A) Probe placement.
(B) Common fibular nerve (white arrow) at the fibular neck area.
2. Landmarks: Sciatic nerve, popliteal artery, and vein
3. Relevant anatomy: The sciatic nerve divides into the tibial and common peroneal nerves at the
apex of the popliteal fossa.
4. Points to remember: There is variation in the branching levels of the sciatic nerve. If the sciatic
nerve trunk is not found at the apex of the popliteal fossa, the probe can be moved proximally
to locate the common nerve trunk.
Peripheral Nerves 277
SuralNerve
1. Probe/patient position: The probe is positioned in the SX view in the posterior aspect of the
lower leg at the level of the musculotendinous junction of the Achilles tendon or 14 cm proximal from the lateral malleolus. The sural nerve is seen accompanied by the lesser saphenous
vein subcutaneously, overlying the tendinous portion of the Achilles (Figure 8-52). The sural
nerve can be traced distally as it branches into smaller sensory branches or proximally where
it is formed by the medial sural cutaneous nerve (MSCN) and lateral sural cutaneous nerve
(LSCN).
AB
Figure 8-52. Sural nerve. (A) Probe placement in the SX view in the posterior
aspect of the lower leg at the level of the musculotendinous junction of the
Achilles tendon or 14 cm proximal from the lateral malleolus. (B) The sural
nerve (white arrow) is seen accompanied by the lesser saphenous vein (LSV)
subcutaneously, overlying the tendinous portion (red arrow) of the Achilles.
278 Chapter 8
2. Landmark: Lesser saphenous vein
3. Relevant anatomy: The sural nerve is formed by the MSCN and LSCN. The MSCN originates
from the tibial nerve at the popliteal fossa, and the LSCN originates from the common fibular
nerve (Figure 8-53). The MSCN and LSCN merge together in the mid-calf to form the sural
8,16
nerve.
Figure 8-53. The MSCN (white
arrow) originates from the tibial
nerve (white triangle) at the
popliteal fossa, and the LSCN
(yellow arrow) originates from
the common fibular nerve (yellow
triangle). The MSCN and LSCN
merge together in the mid-calf to
form the sural nerve.
4. Points to remember: To locate the sural nerve at the distal level, very light pressure with the
probe is required because more pressure will obliterate the lesser saphenous vein, which is a
landmark for visualization of the sural nerve.
Peripheral Nerves 279
SaphenousNerve
1. Probe/patient position: The probe is placed in the SX view on the medial aspect of the thigh at
the adductor canal. The saphenous nerve is seen as a hyperechoic structure next to the femoral
artery and vein, with the sartorius muscle above it, the vastus medialis muscle lateral to it, and
the adductor longus muscle deep to it. As the saphenous nerve is followed distally, it gives an
infrapatellar branch at the medial and distal aspect of the patella and a sartorial branch that
descends along the medial tibia to the ankle and is accompanied by the greater saphenous vein
(Figure 8-54).
AB
8,16
Figure 8-54. Saphenous nerve at the distal leg. (A) Probe placement on the medial aspect of the tibia in the lower leg.
(B) Saphenous nerve (white arrow) along the medial tibia, accompanied by the greater saphenous vein (GSV).
2. Landmarks: Femoral artery and vein proximal to the knee level and greater saphenous vein
distal to the knee joint
3. Relevant anatomy: The saphenous nerve is the terminal sensory branch of the femoral nerve.
4. Points to remember: To locate the saphenous nerve distally, use very light pressure with the
probe because more pressure will obliterate the greater saphenous vein, which is a landmark
for visualization of the saphenous nerve.
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