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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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280 Chapter 8
Ankle and Foot Region
DeepPeronealNerve
1. Probe/patient position: The probe is placed in the SX view on the anterior aspect of the ankle.
The deep peroneal nerve is seen deep to the tendons and just above the talus. It is accompanied
by the dorsalis pedis artery (Figure 8-55).
A
Figure 8-55. Deep peroneal nerve. (A) Probe placement. (B) The deep peroneal nerve (white arrow) is seen deep to
the anterior tendons of the ankle and just above the talus. It is accompanied by the dorsalis pedis artery (white A).
(EHL = extensor hallucis longus muscle; TA = tibialis anterior.)
2. Landmarks: Dorsalis pedis artery and talar bony surface under it
3. Relevant anatomy: After branching off from the common peroneal nerve, the deep peroneal
nerve passes deep to the extensor digitorum longus (EDL) muscle and courses distally on the
anterior aspect of the interosseous membrane. At the ankle, it passes through the anterior
tarsal tunnel. Due to the sharper turn of the deep peroneal nerve around the fibular neck to
enter the anterior aspect, it is tethered more to the fibula than the superficial peroneal nerve,
and therefore more susceptible to compression.
B
Peripheral Nerves 281
SuperficialPeronealSensoryNerve
1. Probe/patient position: The probe is placed on the anterolateral aspect of the leg about 10 to
12 cm proximal to the lateral malleolus. The superficial peroneal nerve lies between the EDL
and peroneus longus muscles (Figure 8-56).
AB
16
Figure 8-56. Superficial peroneal sensory nerve. (A) Probe placement. (B)
The superficial peroneal nerve (white arrow) lies between the EDL and
peroneus longus (PL) muscles.
2. Landmarks: Peroneus longus and EDL muscles
282 Chapter 8
TibialNerveattheTarsalTunnelandItsBranches
1. Probe/patient position: The probe is placed on the medial aspect of the ankle with the medial mal-
leolus as a bony landmark to visualize the tarsal tunnel structures in the SX view. The posterior
tibial nerve at the medial ankle is a hyperechoic structure accompanied by the artery and vein
(Figure 8-57).
A
Figure 8-57. Tibial nerve at the
tarsal tunnel/medial ankle. (A) Probe
placement. (B) The posterior tibial
nerve (white arrow) is visualized as a
hyperechoic structure accompanied by
the artery (white A) and vein (V). Also shown are the tibialis posterior (TP), flexor digitorum longus (FDL), and flexor
hallucis longus (FHL) muscles and the medial malleolus (MM) as an internal landmark.
B
2. Landmarks: Medial malleolus as an internal landmark. The tibial nerve divides into the medi-
al plantar, lateral plantar, and medial calcaneal branches (Figure 8-58). The medial calcaneal
branch has a variable branching pattern and may branch out from the tibial nerve at the level
proximal to the tarsal tunnel.
Figure 8-58. The tibial nerve divides
into the medial plantar (white arrow),
lateral plantar (yellow arrow), and
medial calcaneal branches (red
arrow).
16
3. Relevant anatomy: From anterior to posterior, structures in the tarsal tunnel are arranged
as the tibialis posterior, flexor digitorum longus (FDL) muscle, posterior tibial artery, nerve,
vein, and flexor hallucis longus (FHL) muscle. Distally, the tibial nerve branches into the
medial plantar, lateral plantar, and medial calcaneal branches.
4. Points to remember: There is great variability in the branching pattern of the posterior tibial
17
nerve.
Peripheral Nerves 283
MedialPlantarNerve
1. Probe/patient position: The probe is positioned over the medial ankle to localize the tibial
nerve, which is then followed distally to locate the medial plantar nerve. On the medial aspect
of the foot, the medial plantar nerve is visualized between the abductor hallucis muscle and
knot of Henry (FDL and FHL intersection; Figure 8-59). On the plantar aspect of the foot,
the medial plantar nerve accompanied by the medial plantar artery is visualized between the
flexor hallucis brevis and quadratus plantae muscles.
15,16
A
Figure 8-59. Medial plantar nerve.
(A) Probe placement. (B) The medial
plantar nerve (small white arrow),
accompanied by the medial plantar
artery (red arrow), is visualized between
the abductor hallucis muscle and knot
of Henry (FDL and FHL intersection;
large white arrow).
B
2. Landmark: Medial plantar artery
3. Relevant anatomy: The medial plantar nerve provides motor innervation to the flexor digi-
torum brevis, flexor hallucis brevis, abductor hallucis longus, and medial lumbrical muscles.
It provides sensory cutaneous innervation to the medial aspect of the plantar foot and toes.
284 Chapter 8
LateralPlantarNerve
1. Probe/patient position: The probe is positioned over the medial ankle to localize the tibial
nerve, which is then followed distally to locate the lateral plantar nerve. The lateral plantar nerve and first branch of the lateral plantar nerve, or Baxter’s nerve, are best visualized
through the acoustic window of the abductor hallucis muscle (Figures 8-60 and 8-61).
AB
Figure 8-60. Lateral plantar nerve. (A) Probe placement. (B) Lateral plantar nerve (white arrow), lateral plantar artery
(red arrow), and quadratus plantae (QP) muscle.
A B
Figure 8-61. First branch of the lateral
plantar nerve, or Baxter’s nerve. (A)
Probe placement. (B) Baxter’s nerve
(white arrow) between the abductor
hallucis (AH) and quadratus plantae
(QP) muscles. (C = calcaneus.)
Peripheral Nerves 285
2. Landmark: Lateral plantar artery
3. Relevant anatomy: The lateral plantar nerve provides motor innervation to all the intrinsic foot
muscles except for the muscles supplied by the medial plantar nerve. The lateral plantar nerve
travels with the lateral plantar artery as it courses medial to lateral. On the plantar aspect of
the foot, it is seen between the flexor digitorum brevis and quadratus plantae muscles. After
emerging from the lateral plantar nerve, the first branch of the lateral plantar nerve, or inferior
calcaneal nerve or Baxter’s nerve, passes between the abductor hallucis and quadratus plantae
muscles. As it travels laterally, it passes between the anterior aspect of the medial tubercle of
the calcaneus and flexor digitorum brevis muscle–aponeurosis complex.
16,18
4. Points to remember: Visualization of the first branch of the lateral plantar nerve is challenging
due to its size, which is in the range of 1 to 2 mm,
15,18
and due to the thicker skin of the plantar
aspect of the heel. The abductor hallucis muscle serves as a good acoustic window to visualize
the lateral plantar nerve and the first branch of the lateral plantar nerve.
286 Chapter 8
DigitalNerves
1. Probe/patient position: The probe is positioned in the SX at the intermetatarsal space. The digital nerves are visualized as hyperechoic structures accompanied by artery and vein bundles on
either side of the metatarsal (Figure 8-62).
A
B
C
D
Figure 8-62. Digital nerves (white arrows) on the dorsal and plantar aspects of the foot. (A) Probe placement
for dorsal digital nerve. (B) Dorsal digital nerve (white arrow). (C) Probe placement for plantar digital ner ve. (D)
Plantar digital nerves (white arrows). (red areas = blood vessels.)
2. Landmarks: Digital artery and vein
3. Relevant anatomy: The digital nerves originate from the medial or lateral plantar nerves.
Peripheral Nerves 287
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Financial Disclosures
Dr. Gina A. Ciavarra has no financial or proprietary interest in the materials presented herein.
Dr. Dimitrios Kostopoulos has no financial or proprietary interest in the materials presented herein.
Dr. Kornelia Kulig has no financial or proprietary interest in the materials presented herein.
Dr. Mukund Patel has no financial or proprietary interest in the materials presented herein.
Dr. Mohini Rawat has no financial or proprietary interest in the materials presented herein.
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