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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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60 Chapter 3
Pronator Teres
Relevant anatomy of the region is shown in Figure 3-13.
Figure 3-13. Relevant anatomy of the pronator teres, which has 2 heads: the humeral head and ulnar head. The 2 heads
fuse to form a muscle belly, which inserts through a short tendon on the lateral aspect of the middle third of the radius.
The median nerve runs between the ulnar and humeral heads of the pronator teres. The ulnar artery runs deep to the
ulnar head of the pronator teres.
Elbow 61
1. Patient position: Sitting with elbow extension and forearm full supination
2. Probe/transducer position: The probe is placed transversely over the pronator teres at the level
of distal humerus and then moved distally along the muscle belly to scan the humeral and
ulnar heads as they course distally toward the lateral aspect of the radius. The probe is then
rotated 90 degrees to scan the pronator teres in the LX view and as it inserts over the lateral
aspect of the radius (Figures 3-14 through 3-16).
A
Figure 3-14. SX view of the pronator
teres at the level of the humeral head.
(A) Probe placement. (B) SX view of
the humeral head of the pronator teres
(white star) medial to the brachialis
muscle.
A
B
B
Figure 3-15. SX view of the pronator
teres at the level of the ulnar head. (A)
Probe placement. (B) SX view of the
pronator teres at the ulnar head level.
Shown are the pronator teres humeral
head (white star), pronator teres ulnar
head (white arrow), and median nerve
(white triangle), which is between the
humeral head and ulnar head of the
pronator teres.
62 Chapter 3
AB
C
Figure 3-16. LX view of the pronator teres at the distal insertion. (A) Probe
placement. (B) LX view of the distal insertion of the pronator teres tendon
(white arrows) on the lateral aspect of the middle third of the radius. (C)
Relevant anatomy and probe placement.
3. Relevant anatomy: The pronator teres has 2 heads: humeral and ulnar. The humeral head
originates from the proximal and anterior aspect of the medial epicondyle, medial intermuscular septum of the arm, medial common flexor tendon, and antebrachial fascia. The ulnar
head originates from the medial border of the coronoid process and the medial aspect of the
brachialis tendon. The 2 heads fuse to form a muscle belly, which inserts through a short tendon on the lateral aspect of the middle third of the radius.
7
4. Points to remember: A dynamic maneuver where the elbow is flexed and the patient is asked
to pronate against resistance and then the examiner extends the forearm while the patient
maintains resisted pronation can facilitate detection of focal median nerve compression.
7
Elbow 63
MEDIAL ELBOW
Common Flexor Tendon
1. Patient position: Sitting with elbow slightly flexed and externally rotated
2. Probe/transducer position: The probe is placed on the medial epicondyle as a bony landmark
and oriented along the common flexor tendon. The tendon is shorter than the common extensor tendon. The SX view is obtained by rotating the probe 90 degrees from the LX orientation
(Figures 3-17 and 3-18).
A
8
B
C
Figure 3-17. LX view of the common flexor origin. (A) Probe placement showing the location of the medial epicondyle
(blue star). (B) LX view of the pronator teres humeral head (white arrow), which originates from the proximal and anterior
aspect of the medial epicondyle. (C) LX view of the common flexor origin (white arrow) at the medial epicondyle.
64 Chapter 3
BA
Figure 3-18. SX view of the common
flexor tendon. (A) Probe placement. (B)
SX view of the common flexor tendon
(white arrow) at the medial epicondyle.
3. Relevant anatomy: Common flexor-pronator muscles originate from the medial epicondyle.
4. Points to remember: Deep to the common flexor-pronator origin, the anterior band of the
ulnar collateral ligament (UCL) can be visualized.
Elbow 65
Ulnar Nerve
1. Patient position: Supine with elbow flexed and arm externally rotated
2. Probe/transducer position: The probe is placed over the medial elbow bridging the medial epi-
condyle and olecranon process to visualize the ulnar nerve in the SX view. The probe is then
rotated 90 degrees to visualize the nerve in the LX view (Figures 3-19 and 3-20).
BA
C
D
Figure 3-19. SX view of the ulnar nerve. (A) Probe placement showing the location of the medial epicondyle (blue star).
(B) Ulnar nerve at the level proximal to the medial epicondyle. The ulnar nerve (white arrow) is seen above the triceps
muscle. (C) Ulnar nerve (white arrow) at the level of the medial epicondyle (ME) between the medial epicondyle and
the olecranon (OL). (D) Ulnar nerve (white arrow) between the 2 heads of the flexor carpi ulnaris (FCU).
66 Chapter 3
A B
C
D
Figure 3-20. LX view of the ulnar nerve. (A) Probe placement. (B) Ulnar nerve (small white arrow) proximal to the
medial epicondyle. (C) Ulnar nerve (white arrow) at the medial epicondyle. (D) Ulnar nerve (white arrow) distal to the
medial epicondyle between the 2 heads of the flexor carpi ulnaris muscle.
3. Relevant anatomy: The ulnar nerve is retroepicondylar before it enters the cubital tunnel and
then emerges anteriorly after passing through the 2 heads of the flexor carpi ulnaris. The cubital tunnel is a fibro-osseous tunnel, the roof of which is formed by Osborne’s fascia connecting
the medial epicondyle and olecranon process.
8
4. Points to remember: Scanning the ulnar nerve around the elbow requires knowledge of the
course of the nerve around the epicondyle, which necessitates slight rotation of the probe as
the nerve is followed from distal to proximal or vice versa.
Ulnar Collateral Ligament
Relevant anatomy of the region is shown in Figure 3-21.
Elbow 67
Figure 3-21. Anatomy of the UCL of the elbow. There are 3 bands: anterior, posterior, and transverse or oblique bundle.
68 Chapter 3
1. Patient position: Sitting with elbow slightly flexed and externally rotated
2. Probe/transducer position: The probe is placed on the medial epicondyle as the bony landmark
and oriented along the common flexor tendon. Deep to the common flexor tendon anterior
band, the UCL is visualized as a hyperechoic fibrillary structure inserting on the sublime
tubercle of the ulna. The posterior band of the UCL is visualized in the SX view of the ulnar
nerve between the medial epicondyle and olecranon process. The posterior band is visualized
as a sling under the ulnar nerve. The transverse or oblique band bridges the medial olecranon
and inferomedial aspect of the coronoid process (Figures 3-22 through 3-24).
AB
Figure 3-22. Anterior band of the UCL.
(A) Probe placement. (B) Anterior band of
the UCL (white arrows), which originates
from the anteroinferior aspect of the
medial epicondyle (ME) and inserts on
the sublime tubercle of the coronoid
process.
A
Figure 3-23. Posterior band of the UCL. (A) Probe placement. (B) Posterior band of the UCL (white arrows), which
originates from the posterior and inferior aspect of the medial epicondyle (ME) and inserts on the medial aspect of the
olecranon process (OL). It appears as a sling under the ulnar nerve (white triangle).
B
Elbow 69
AB
Figure 3-24. Transverse band of the UCL. (A) Probe placement. (B) Transverse band of the UCL (white arrows) between the
medial aspect of the tip of olecranon process (OL) and the inferomedial aspect of the coronoid process (CP).
3. Relevant anatomy: The UCL is the main stabilizer against valgus stress when the elbow is
flexed more than 20 degrees. There are 3 bands: anterior, posterior, and transverse or oblique.
The anterior band is the most important and provides the greatest degree of stabilization. The
anterior band of the UCL originates from the anteroinferior aspect of the medial epicondyle
2,8
and inserts on the sublime tubercle of the coronoid process of the ulna.
The anterior band
of the UCL has a mean length of 27 mm and an average thickness of 5 mm.8 The posterior
band is a fan-shaped ligament that is best defined at 90 degrees of elbow flexion. The posterior
band originates from the posterior and inferior aspect of the medial epicondyle and inserts
on the medial aspect of the olecranon process. Average thickness of the posterior band ranges
from 5 to 8 mm.8 The posterior band of the UCL forms the floor for the ulnar nerve as it
wraps around the medial epicondyle. The oblique or transverse band of the UCL has limited
contribution to the stability of the elbow as it originates from the medial aspect of the tip of
the olecranon and inserts on the inferomedial aspect of the coronoid process of the ulna, spanning the insertion of the anterior and posterior bands.
8
4. Points to remember: Dynamic evaluation of the ligament can be performed if ligament integrity is in question. With the elbow flexed 30 degrees, valgus stress can be applied to visualize
signs of abnormal gapping of the medial joint space or to check for tears of the anterior band
of the UCL.
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