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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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20 Chapter 2
Structures Outside the Carpal Tunnel
1. Patient position: Sitting or in supine with wrist in full supination and resting on the table
2. Probe/transducer position:
a. SX view/transverse view: Use the pisiform as a bony landmark for the SX/transverse view
of the carpal tunnel. Sweep the transducer proximal and distal to scan the structures as
they enter the wrist.
b. LX view/longitudinal view: Once you locate a structure of interest in the SX view, keeping
the structure in focus, rotate the probe 90 degrees to see the LX view of the structure of
interest (Figure 2-6).
A
B
C
Figure 2-6. Structures outside the
carpal tunnel. (A) Probe placement. (B)
SX view showing the FCR outside the
carpal tunnel in its own sheath, the
ulnar artery (white A) and ulnar nerve
outside the carpal tunnel, the median
nerve (MN) inside the carpal tunnel and
the palmaris longus (PL) outside the carpal tunnel as the most superficial structure. (C) LX view showing the palmaris
longus tendon (white arrows) as the most superficial thin band and the median nerve (MN) as a hypoechoic band. The
flexor tendons are a thicker hyperechoic band deeper to the median nerve.
3. Relevant anatomy: The FCR is on the radial side of the carpal tunnel in its own sheath and
runs distally through the groove on the medial side of the trapezium.
8
The ulnar nerve and
artery are on the ulnar side next to the pisiform bone. The palmaris longus tendon continues
as the palmar aponeurosis in the palm and appears as a hyperechoic structure in the middle
just superficial to the f lexor retinaculum in the volar aspect of wrist.
4. Points to remember: The palmaris longus may be absent in a small percentage of the population. There is an anomaly, reverse palmaris longus, that may be present in a very small percentage of the population where the muscle part of the palmaris longus is present at the level
of the volar wrist and the tendon is located proximally.
6
Wrist and Hand 21
Volar-Radial Aspect of the Wrist
1. Patient position: Sitting or in supine with wrist in full supination and resting on the table
2. Probe/transducer position:
a. SX view/transverse view: Use the pisiform as a bony landmark for the SX/transverse view
of the carpal tunnel and then slide the probe on the radial aspect to view the FCR, which
lies outside the carpal tunnel in its own sheath.
b. LX view/longitudinal view: Once you locate the FCR in the SX view, keeping the FCR in
focus, rotate the probe 90 degrees to get the LX view of the FCR. In the same view, the
scaphotrapezial joint can be visualized (Figure 2-7).
A
Figure 2-7. FCR tendon. (A) Probe placement. (B) SX view of the FCR tendon on the radial side outside the carpal tunnel.
The median nerve is visible as a hypoechoic structure ulnar to the FCR. (C) LX view of the FCR tendon (white arrows),
which crosses the scaphotrapezial joint to insert on the anterior aspect of the base of the second metacarpal (MC).
B
C
22 Chapter 2
3. Relevant anatomy: The FCR inserts on the anterior aspect of the base of the second metacarpal
and gives small slips to the trapezial tuberosity and third metacarpal base (Figure 2-8).
8
Figure 2-8. Relevant anatomy: The FCR inserts at the base of the second metacarpal and gives off tendinous slips to
the base of the third metacarpal and tuberosity of trapezium.
4. Points to remember: Severe cortical irregularities at the scaphotrapeziotrapezoid joint are suggestive of arthritic changes and are frequently associated with FCR tenosynovitis or rupture.
8
Wrist and Hand 23
Volar-Ulnar Aspect of the Wrist
1. Patient position: Sitting or in supine with wrist in full supination and resting on the table
2. Probe/transducer position:
a. SX view/transverse view: Use the pisiform as a bony landmark for the SX/transverse view.
Move the probe slightly proximal to visualize the flexor carpi ulnaris (FCU) tendon.
b. LX view/longitudinal view: Using the pisiform as a bony landmark, keep the probe along
the FCU tendon, with the distal end of the probe on the pisiform (Figure 2-9).
A
B
C
Figure 2-9. FCU tendon. (A) Probe
placement. (B) SX view of the FCU
tendon (between the white arrows) and
median nerve (MN) radial to the FCU.
(C) LX view of the FCU tendon (white
arrows) attaching to the pisiform and its
distal tendinous slips to the hamate and
fifth metacarpal base (not shown).
For ulnar nerve imaging, locate the ulnar nerve in SX view and, keeping the nerve in focus,
rotate the probe 90 degrees to get the LX view of the ulnar nerve. The ulnar nerve is just radial
to the pisiform bone, followed by the ulnar artery, which is radial to the ulnar nerve (see
Figures 2-2 and 2-4).
24 Chapter 2
3. Relevant anatomy: The FCU is the ulnar-most tendon in the volar wrist and inserts into the
pisiform bone and via ligaments to the hamate and fifth metacarpal base (Figure 2-10).
Figure 2-10. Relevant anatomy: The FCU inserts into the pisiform and via ligaments to the hamate and fifth metacarpal
base.
4. Points to remember: FCU tenosynovitis may be considered as a differential diagnosis in ulnarsided wrist pain. For patients presenting with ulnar nerve symptoms, evaluate this area for any
space-occupying lesions like ganglion cysts, synovial masses, or soft tissue growths.
DORSAL WRIST
Six Dorsal Compartments
(Tendons From Radial to Ulnar Aspect)
Anatomy of the region is shown in Figure 2-11.
Wrist and Hand 25
Figure 2-11. The 6 dorsal compartments starting from the radial aspect: (1) abductor pollicis longus (APL) and extensor
pollicis brevis (EPB); (2) extensor carpi radialis longus (ECRL) and extensor carpi radialis brevis (ECRB); (3) extensor
pollicis longus (EPL); (4) extensor digitorum communis (EDC) and extensor indicis proprius (EIP); (5) extensor digiti
minimi (EDM); (6) extensor carpi ulnaris (ECU).
1. Patient position: Sitting or in supine with wrist in full pronation and resting on the table
2. Probe/transducer position: The wrist has 6 dorsal compartments of tendons (see Figure 2-11).
The first dorsal compartment tendons are the most radial tendons of the wrist. Starting from
radial to ulnar, the 6 dorsal compartment tendons can be scanned. The SX view is the best
view to locate the tendon of interest, and then the transducer can be rotated 90 degrees to get
the longitudinal view of each tendon.
a. SX view/transverse view: All the tendons of the 6 dorsal compartments can be scanned in
the SX view. It is important to align the transducer in the SX to the tendon and not to the
wrist to get the best view of the tendon. Remember that each tendon has a slightly oblique
course, and it is important to align the transducer perpendicular to the tendon to get the
best visualization.
b. LX view/longitudinal view: Once the tendon is located in the SX view, the transducer can
be rotated 90 degrees to get the LX view of each tendon.
26 Chapter 2
3. Relevant anatomy: The wrist has 6 dorsal compartments:
a. The first dorsal compartment consists of the abductor pollicis longus and extensor pol-
licis brevis. In a small part of the population, both tendons are separated by a septum.
Knowledge of the presence and absence of a septum is important if local steroid injection is
indicated in De Quervain’s tenosynovitis. In the presence of a septum, the involved tendon
can be selectively injected to maximize the benefit of the injection (Figure 2-12).
9
A
B
C
Figure 2-12. First dorsal compartment. (A) Probe placement. Note that the transducer is in the SX to the tendons of the
first dorsal compartment, which is not a true SX view of the wrist. (B) Ultrasound image of the first dorsal compartment
ten dons. The extensor po llicis brevis (wh ite arrow) is dors al to th e abdu ctor p ollicis long us (white triangl e). (C) Rele vant
anatomy of the first dorsal compartment, which is the radial-most compartment of the 6 dorsal compartments of the
wrist, with the transducer position.
Wrist and Hand 27
b. The second dorsal compartment consists of the extensor carpi radialis longus and extensor
carpi radialis brevis. This compartment has the fewest anatomical anomalies (Figure 2-13).
AB
C
Figure 2-13. Second dorsal
compartment. (A) Probe placement.
(B) Ultrasound image of the second
dorsal compartment tendons: extensor
carpi radialis brevis (white triangle) and
extensor carpi radialis longus (white
arrow). (C) Relevant anatomy of the
second dorsal compartment, with
transducer position.
c. The third dorsal compartment has a single tendon: the extensor pollicis longus. Lister’s
tubercle is an important bony landmark to differentiate the third dorsal compartment from
the second. The appearance of Lister’s tubercle can vary. It may appear as a sharp protuberance or a flatter protuberance (Figure 2-14).
AB
C
Figure 2-14. Third dorsal co mpartment.
(A) Probe placement. (B) Ultrasound
image of the third dorsal compartment
tendons: extensor pollicis longus (big
white arrow); Lister’s tubercle (small
white arrow), an important bony
landmark that helps in differentiating the third dorsal compartment from the second dorsal compartment; and the
extensor carpi radialis brevis (ECRB) and extensor carpi radialis longus (ECRL). (C) Relevant anatomy of the third dorsal
compartment, with the transducer position.
28 Chapter 2
d. The fourth dorsal compartment has 5 tendon slips, including 4 slips of the extensor digito-
rum communis and 1 slip of the extensor indicis proprius. The fourth dorsal compartment
is located in the center of the wrist dorsum and is the only compartment with 5 tendons
(Figure 2-15).
AB
C
Figure 2-15. Fourth dorsal compartment.
(A) Probe placement. (B) Ultrasound
image of the four th dorsal compartme nt
(big white arrow) showing the extensor
pollicis longus tendon (small white
arrow) radial to the fourth dorsal
compartment. (C) Relevant anatomy of
the fourth dorsal compartment, with
the transducer position.
e. The fifth dorsal compartment has a single tendon: the extensor digiti minimi. The extensor
digiti minimi overlies the distal radioulnar joint (Figure 2-16).
AB
C
Figure 2-16. Fifth dorsal compartment.
(A) Probe placement. (B) Ultrasound
image of the fifth dorsal compartment
(DC) showing the extensor digiti
minimi tendon (white arrow). Note that
the extensor digiti minimi overlies the
distal radioulnar joint. (C) Relevant anatomy of the fifth dorsal compartment, with the transducer position.
Wrist and Hand 29
f. The sixth dorsal compartment has a single tendon, the extensor carpi ulnaris (ECU), which
can be seen sitting in the bony groove of the distal ulna (Figure 2-17).
A
B
10
C
Figure 2-17. Sixth dorsal compartment.
(A) Probe placement. (B) Ultrasound
image of the sixth dorsal compartment
showing the ECU (white arrow) sitting
in the groove of the distal end of the
ulna. (C) Relevant anatomy of the
sixth dorsal compartment, with the
transducer position.
4. Points to remember: Dorsal compartment tendons are best visualized at the level of the dis-
tal radius and ulna. In Figure 2-2A, notice the radius and ulna underneath the tendons. If
scanned distally at the level of the carpal bones or metacarpals, the aforementioned arrangement of tendons is not present, as they cross over to travel in different directions to their
respective attachment sites distally.
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