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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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30 Chapter 2
DISTAL RADIOULNAR JOINT
1. Patient position: Sitting or in supine with wrist in full pronation and resting on the table
2. Probe/transducer position:
a. SX view/transverse view: Place the transducer over the dorsum of the distal end of radius
and ulna to bridging both bones.
b. LX view/longitudinal view: Once you have located the joint in the SX view, turn the probe
90 degrees to evaluate the joint in the LX view (Figure 2-18).
AB
C
Figure 2-18. Distal radioulnar joint.
(A) Probe placement. (B) Ultrasound
image of the distal radioulnar joint
(white arrow); note that the extensor
digiti minimi (white triangle) overlies it.
Extensor digiti minimi appears dark in this image due to anisotropy. (C) Relevant anatomy and transducer position for
imaging the distal radioulnar joint.
3. Relevant anatomy: The triangular fibrocartilage complex (TFCC) is the major stabilizer of
the distal radioulnar joint. The fifth dorsal compartment tendon, the extensor digiti minimi,
directly overlies the distal radioulnar joint. On the volar aspect, the pronator quadratus
muscle fibers are oriented transversely.
11
4. Points to remember: The distal radioulnar joint is commonly involved in rheumatoid arthritis and can cause secondary pathological changes in the extensor digiti minimi tendon that
overlies it.
SCAPHOLUNATE LIGAMENT
Anatomy of the region is shown in Figure 2-19.
Wrist and Hand 31
Figure 2-19. Relevant anatomy of the scapholunate ligament.
1. Patient position: Sitting with wrist in full pronation, slight flexion for dorsal band, and supina-
tion with slight extension for volar band
12
32 Chapter 2
2. Probe/transducer position:
a. SX view/transverse view: Locate Lister’s tubercle in the SX view and then move the probe
distally to get the scapholunate joint view to visualize the interval. The dorsal band of the
scapholunate ligament appears as a hyperechoic triangular structure with an average thickness of 1.1 mm and average length of 4.2 mm.
this region (Figure 2-20) .
12
13
The SX view is the best view to evaluate
A
Figure 2-20. Dorsal band of the scapholunate ligament. (A) Probe placement. Wrist in full pronation and slight
flexion. Locate Lister’s tubercle in the SX view and then move the probe distally to get the scapholunate joint view to
visualize the dorsal band. (B) Ultrasound image of the dorsal band of the scapholunate ligament, which appears as a
hyperechoic fibrillar structure (white arrow).
B
Volar band of the scapholunate ligament: Bridge the scapholunate interval on the volar
aspect to visualize the anterior band as a hyperechoic fibrillar structure (Figure 2-21).
12
AB
Figure 2-21. Volar band of the scapholunate ligament. (A) Probe placement. Wrist in supination with slight extension.
Bridge the scapholunate interval on the volar aspect to visualize the volar band as a hyperechoic fibrillar structure. (B)
Ultrasound image of the volar band of the scapholunate ligament, which appears as a hyperechoic fibrillar structure
(white arrow).
b. LX view/longitudinal view: Once the scapholunate joint is located in the SX view, rotate the
probe to evaluate the joint in the LX view if needed.
Wrist and Hand 33
3. Relevant anatomy: Lister’s tubercle is an important bony landmark to navigate to the scaph-
olunate interval dorsally.
4. Points to remember: The scapholunate interval can be compared with the contralateral wrist to
measure the separation distance in cases of ligament tear. A scapholunate distance larger than
4.2 mm is an indication of a tear in the dorsal band of the scapholunate. Dynamic assessment
can be performed with radial/ulnar deviation or clenching of the fist.
13
TRIANGULAR FIBROCARTILAGE COMPLEX
Anatomy of the region is shown in Figure 2-22.
Figure 2-22. TFCC anatomy.
34 Chapter 2
1. Patient and probe/transducer position:
a. Dorsal view: Patient seated with the hand in full pronation and resting on the table. Ask
the patient to radially deviate the wrist to open up the ulnar aspect of the wrist. Place the
transducer in the LX view over the dorso-ulnar aspect of wrist joint, keeping the distal end
of the ulna and triquetrum bone in view. The TFCC is seen as a triangular region between
the ulnar and triquetrum through the acoustic window of the ECU tendon (Figure 2-23).
A
to open up the ulnar aspect of the wrist. Place the transducer in the LX view over the dorso -ulnar aspect of the wrist joint,
keeping the distal end of the ulna and triquetrum bone in view. (B) Ultrasound image of the dorsal view of the TFCC,
which is seen as a triangular region between the ulnar and triquetrum through the acoustic window of the ECU tendon.
B
Figure 2-23. Dorsal view of the TFCC. (A) Probe placement. Wrist in full
pronation and resting on the table. Ask the patient to deviate the wrist radially
b. Volar view: Hand resting on the table with full supination. Place the probe on the ulnar
aspect of the wrist in the LX to visualize the TFCC region from the anterior aspect
(Figure 2-24).
AB
Figure 2-24. Volar view of the TFCC. (A) Probe placement. Hand resting on the
table with full supination. Place the probe on the ulnar aspect of the wrist in the
of the volar view of the TFCC (white arrow), which is seen as the triangular region between the ulna and triquetrum.
LX to visualize the TFCC region from the anterior aspect. (B) Ultrasound image
Wrist and Hand 35
c. Dorsal radioulnar ligament: Hand resting on the table in pronation. The probe is placed on
the dorsal aspect bridging the radius and ulna to visualize the hyperechoic dorsal radioulnar ligament (Figure 2-25).
AB
Figure 2-25. Dorsal radioulnar ligament. (A) Probe placement. Hand resting
on the table in pronation. The probe is placed on the dorsal aspect bridging
the radius and ulna. (B) Ultrasound image of the dorsal radioulnar ligament
(white arrow) as a hyperechoic fibrillar structure.
d. Volar radioulnar ligament and limited disk view: Wrist in supination and slight extension.
The probe is placed on the volar aspect bridging the radius and ulna to visualize the volar
radioulnar ligament as a hyperechoic structure (Figure 2-26).
A
B
Figure 2-26. Volar radioulna r ligament. (A) Probe placement. Wrist in su pination
and slight ex tension. The probe is placed on the vo lar aspect bridging the ra dius
and ulna. (B) Ultrasound image of the volar radioulnar ligament (white arrow)
as a hyperechoic fibrillar structure. Deep to the volar radioulnar ligament, a
limited view of the disk as a triangular structure can be seen.
12
36 Chapter 2
2. Relevant anatomy: The TFCC comprises the dorsal and volar radioulnar ligaments, central
articular disk, meniscus homologue, ulnar collateral ligament (UCL), subsheath of the fifth
and sixth dorsal compartments, proximal portion of the ulnolunate, and ulnotriquetral liga-
14
ments.
It cannot be evaluated in full detail with the ultrasound imaging and requires magnetic resonance imaging or arthroscopic assessment. Only the periphery of the TFCC can be
visualized with ultrasound.
3. Points to remember: Patients with a TFCC tear present with ulnar-sided pain, instability, clicking, and difficulty with activities like turning a doorknob. Radial and ulnar deviation of the
wrist are often painful.
HAND AND DIGITS
Volar Aspect
Anatomy of the region is shown in Figures 2-27 and 2-28.
Figure 2-27. Flexor tendons of the digit and the flexor tendon sheath. On the volar aspect of the digit, the flexor
tendons (flexor digitorum profundus [FDP] and FDS) are surrounded by a synovial layer (blue) and contained within
the flexor tendon sheath (purple), which is further divided into areas of annular (A1-A5) and cruciate (C1-C3) pulleys.
The metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal joints on the volar aspect
are covered by volar plates (orange), which also provide insertion to the flexor tendon sheath on either side. The flexor
tendon sheath provides stability to the flexor tendons by holding it close to the bone and joint as the finger moves into
flexion and extension. (DP = distal phalanx; MC = metacarpal; MP = middle phalanx; PP = proximal phalanx.)
Wrist and Hand 37
Figure 2-28. Volar aspect of the digit in a transverse section at the level of proximal phalanx showing 2 tendon slips of
the FDS and 1 tendon slip of the FDP surrounded by the synovial layer (pink) and contained within the flexor tendon
sheath (blue). On either side of the tendon are digital nerves and blood vessel bundles.
1. Patient position: Sitting with wrist in full supination and resting on the table
2. Probe/transducer position:
a. LX view/longitudinal view: The transducer is placed in LX alignment with respect to the
digit of interest. The digit is scanned proximal to distal to evaluate the structures in continuity (Figure 2-29).
A
B
Figure 2-29. (A) Ultrasound image of the LX view of the digit. (B) Labelled image of the LX view of the digit showing
the flexor tendons (FDS and FDP), annular (A1-A5) and cruciate (C1-C3) pulleys, and interphalangeal joints (distal
interphalangeal [DIP] joint, MCP joint, and PIP joint).
38 Chapter 2
b. SX view/transverse view: The transducer is placed in SX alignment with respect to the
digit of interest. The digit is scanned from proximal to distal to evaluate the structures in
continuity (Figure 2-30).
A B
Figure 2-30. (A) Ultrasound image of the SX view of the digit at the level of the proximal phalanx. (B) Labelled image of
the SX view of the digit showing the FDS tendons overlying a single FDP tendon contained within the pulley or flexor
tendon sheath (blue), with the digital artery (white A) and digital nerve (N) on either side.
3. Relevant anatomy: It is important to understand the anatomy of the digits. Figure 2-27 shows
the FDP and FDS of the digit covered by the synovial layer, which helps in the gliding of the
tendon. The flexor tendon sheath is a tunnel-like structure attaching on the margins of the
phalangeal bones and palmar ligaments, starting from the head of the metacarpal to the distal
phalangeal joint level. The flexor tendon sheath is divided into regions of annular and cruciate
pulleys depending on the fiber orientation of the sheath. It is important to note that the flexor
tendon sheath forms a tunnel with denser areas at the annular pulley, oblique fiber arrangement at the cruciate part of the pulley, and in between the loose, thin part of the sheath where
synovial outpouching may be seen.
15,16
4. Points to remember: At the level of the metacarpal head, the FDP is deep to the FDS. At the
level of the proximal phalanx, the FDS splits and is seen as 2 superficial slips on either side of
the FDP. The FDS then attaches to the middle phalanx, and the FDP emerges superficial to
travel distally to attach to the distal phalanx.
Dorsal Aspect
Anatomy of the region is shown in Figure 2-31.
Wrist and Hand 39
Figure 2-31. Anatomy of the dorsal aspect of the digit. (MCPJ = metacarpophalangeal joint.)
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