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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5782_Библиотеки_им_академика_М_И_Перельмана.pdf
CHAPTER 15 Musculoskeletal Scanning Protocol for Rotator Cuff, Carpal Tunnel 409
2. Turn the transducer to the longitudinal position to evaluate the
tendon in the transverse axis.
Carpal Tunnel Scanning Protocol Overview
Location
Carpal tunnel region is located along the midwrist proximal to the
crease toward the forearm and distal to the wrist crease toward the
fingers.
Anatomy
• The carpal tunnel houses bones, tendons, nerves, ligaments, mus-
cles and vessels, all providing the hand with the ability to function
properly.
• The carpal tunnel consists of a bundle of tendons coursing from
the flexor muscles in the forearm through the wrist and into the
hand. At the level of the midwrist the superficial border to the
tunnel is the transverse carpal tunnel ligament or flexor retinaculum. The tendons coursing through the tunnel are divided into
2 groups:
1. The more posteriorly situated tendons originate from the
flexor digitorum profundus muscle in the forearm and travel
through the tunnel to the fingers as the flexor profundus
tendons.
2. The anteriorly placed tendons originate from the flexor digi-
torum superficialis muscle in the forearm and travel through
the tunnel also to the fingers as the flexor superficialis tendons.
The muscle and tendon aiding the first digit, or the thumb,
originate from the flexor pollicis longus muscle on the radial
side of the forearm. The tendons are all covered by a synovial
sheath.
• The median nerve runs just anteriorly to the bundle of tendons
and slightly toward the radial edge. The transverse carpal tunnel
ligament or flexor retinaculum covers the tunnel transversely
just anterior to the median nerve. The nerve is naturally elliptical in shape and will flatten slightly as it courses distally into
the hand.
• The proximal carpal tunnel is located just before the crease in
the wrist on the side of the forearm. Here, with the hand supinated, at the proximal region the pisiform stands as the bony
landmark on the medial edge, scaphoid on the lateral edge, and
lunate posteriorly. The profundus and superficialis tendons
and median nerve are midline as described above. The flexor
pollicis tendon courses laterally along the border of the scaphoid. Also at this level, the ulnar nerve and artery course along
410 PART V Small Parts Scanning Protocols
the medial edge adjacent and slightly anterior to the pisiform
border. This anatomical area is known as Guyon’s canal.
The carpal tunnel anatomy is draped anteriorly by the flexor
retinaculum.
• The distal tunnel is located just past the crease in the wrist and
is distinguished by the bony landmarks of the hamate medially,
trapezium laterally and posteriorly by the capitate. The profundus
and superficialis tendons continue along the middle of the tunnel
with the flexor pollicis tendon far laterally along the border of the
trapezium. The median nerve continues its course anteriorly and
slightly laterally. All of these structures continue to be draped anteriorly by the flexor retinaculum.
Physiology
• The carpal tunnel houses the tendons that connect the muscles
in the forearm to each of the digits in the hand. These tendons
aid in movement of the fingers. Nerves coursing through the carpal tunnel, including the most prominent median nerve, provide
sensation and muscle function to the fingers. These structures are
surrounded by a tunnel of bones that provide stability, not only for
the structures inside the carpal tunnel but to the entire wrist and
hand.
Sonographic Appearance
• The tendons running midline through the carpal tunnel will
appear hypoechoic compared to adjacent structures and will move
with flexion of the fingers.
• The radial and ulnar arteries on the lateral and medial edges respec-
tively, will appear anechoic and can prove to be a valuable landmark when color is used for identification.
• The median nerve coursing anterior to the tendons will also be
hypoechoic relative to adjacent structures but the shape may be
slightly elliptical and a thin hyperechoic ring can be seen around
the periphery.
• Proximally, the echogenic curve of the bony surface of the pisi-
form on medial edge and scaphoid on the lateral edge is visualized. Moving distally, the bony surface of the hamate and
trapezium, medially and laterally, respectively, can be located.
CHAPTER 15 Musculoskeletal Scanning Protocol for Rotator Cuff, Carpal Tunnel 411
Preparation
Patient Prep
• No patient prep.
Transducer
• Linear 10 to 18 MHz.
Patient Position
• The patient should be sitting with the arm at 90 degrees and palm
facing up in a resting position on a stable surface.
• A towel rolled and placed under the wrist can add stability and aid
with neutral positioning of the anatomy.
Breathing Technique
• No breathing technique required.
Carpal Tunnel Survey
Transverse Plane
1. Toward the forearm side of the wrist place the transducer adjacent
to the wrist crease to visualize the proximal carpal tunnel.
2. Identify the flexor superficialis and flexor profundus tendons midline and the flexor pollicis along the radial edge by having the
patient flex the fingers. Identify the more hypoechoic median
nerve (MN) anterior to the group of tendons.
MN
FLEXOR
POLLICIS
LONGUS
A
PROX CARPAL TUNNEL TRV
B
PROX CARPAL TUNNEL TRV
A, Dashed arrow: Median nerve; dash-dotted arrow: flexor superficialis tendon; solid
arrow: flexor profundus tendon. B, Dashed arrow: Median nerve.
412 PART V Small Parts Scanning Protocols
3. This gray-scale version of color Doppler shows how it can be used
to identify Guyon’s canal with the ulnar artery and nerve along the
medial edge. (Dashed arrow: MN, Median nerve.)
PROX CARPAL TUNNEL TRV
4. Locate the midline posterior bony edge of the lunate. (Dashed
arrow: MN, Median nerve.)
MN
MN
ULNAR
VESSELS
ULNAR
VESSELS
LUNATE
PROX CARPAL TUNNEL TRV
5. Move the transducer distally toward the fingers, staying adjacent
to the crease of the wrist and angling slightly toward the proximal
region.
6. Identify the central bundle of tendons and the anteriorly placed
median nerve as described in the proximal carpal tunnel.
7. Locate the midline posterior boney edge of the capitate. (Dashed
arrow: Median nerve.)
CAPITATE
DISTALCARPALTUNNEL
CHAPTER 15 Musculoskeletal Scanning Protocol for Rotator Cuff, Carpal Tunnel 413
Sagittal Plane
1. Place the transducer along the midline wrist 90 degrees from transverse image of median nerve.
2. Move the transducer toward the forearm to image the proximal
carpal tunnel.
3. Identify the hypoechoic median nerve most anteriorly.
4. Identify the bundle of superficialis and profundus tendons just
posterior to median nerve (dashed arrow). With flexion of the fingers the tendons will move in a sliding motion. In the proximal
carpal tunnel the boney landmark seen posterior to the midline
will be the lunate. (Dashed arrow: Median nerve; dash-dotted arrow:
flexor superficialis tendon; solid arrow: flexor profundus tendon.)
PROX CARPAL TUNNEL LONG
5. Move the transducer toward the fingers into the distal carpal tunnel region, staying in the midline of the wrist. Identify the median
nerve and tendons in the same placement as the proximal carpal
tunnel.
Carpal Tunnel Required Images
Transverse Images
1. Transverse image of the proximal carpal tunnel. (Dashed arrow:
Median nerve; dash-dotted arrow: flexor superficialis tendon; solid
arrow: flexor profundus tendon.)
PROX CARPAL TUNNEL TRV
414 PART V Small Parts Scanning Protocols
2. Transverse image of the distal carpal tunnel. (MN, Median nerve.)
MN
ULNAR
VESSELS
Sagittal Images
3. Sagittal image of the proximal carpal tunnel. (Dashed arrow: Median
nerve; dash-dotted arrow: flexor superficialis tendon; solid arrow:
flexor profundus tendon.)
PROX CARPAL TUNNEL LONG
4. Sagittal image of the distal carpal tunnel. (Dashed arrow: Median
nerve; solid arrow: flexor superficialis tendon; dotted arrow: flexor
profundus tendon.)
CHAPTER 15 Musculoskeletal Scanning Protocol for Rotator Cuff, Carpal Tunnel 415
Achilles Tendon Scanning Protocol Overview
Location
• The insertion of the Achilles tendon is positioned along the poste-
rior calcaneus bone. The Achilles tendon continues to course along
the posterior lower leg until it forms with the gastrocnemius and
soleus calf muscles located in the mid to upper posterior lower leg.
Anatomy
• The Achilles tendon connects the lateral and medial gastrocne-
mius calf muscles and the soleus calf muscle to the calcaneus or
heel bone. The plantaris tendon, also originating from the gastrocnemius muscle will insert along the medial and posterior edge
of the calcaneus bone.
• 2 bursae are located just superior to or at the insertion of the Achil-
les tendon.
1. The subcutaneous calcaneus bursa sits along the posterior heel
superficial to the tendon and is sometimes referred to as the
retro-Achilles bursa and does not always contain fluid.
2. The retrocalcaneal bursa is located between the posterior and
superior aspect of the calcaneus bone and the Achilles. This
bursa should normally contain fluid which can make for easier
identification.
• Krager’s fat pad is an area of fatty tissue located just posterior to
the Achilles tendon. The posterior and superior edge of the calcaneus bone forms the inferior border, whereas the retrocalcaneal
bursa will be located along the most inferior and posterior edge.
Physiology
• The Achilles tendon is the strongest tendon in the body. The ten-
don aids in the movement of the foot downward and the ability to
put weight and balance on the toes, which are necessary for walking and running motion.
Sonographic Appearance
• In the longitudinal plane the Achilles tendon appears as a fibrillar
pattern of thin echogenic lines having uniform thickness throughout the midsection. Distally at the muscle interface and proximally
at the insertion the tendon will become narrower. A thin echogenic border surrounds the tendon.
• At the insertion point the echogenic border of the calcaneus bone
will be seen posteriorly.
• As the tendon continues superiorly up the leg and gets closer to the
muscle interface it will begin to appear less prominent and blend
in with the surrounding muscular structure.
416 PART V Small Parts Scanning Protocols
• With dorsiflexion and plantar flexion of the foot the tendon will
move in a sliding motion, which can be helpful for identification.
• At the midsection the tendon should measure between 5 and 6
mm in the anterior posterior dimension.
• Transversely the tendon will appear elliptical and possibly slightly
concave in shape with the same fibrillar pattern and thin echogenic rim.
• The retrocalcaneal bursa can be identified along the deep edge of
the calcaneus bone by the small pocket of hypoechoic fluid surrounding it. Krager’s fat pad adjacent to this bursa and just posterior to the Achilles tendon is more echogenic than the surrounding
tissue and has an irregular shape on ultrasound.
Preparation
Patient Prep
• None required.
Transducer
• 5 MHz to 12 MHz.
Breathing Technique
• None required.
Patient Position
• When possible the patient should be lying prone with feet hanging
off the end of the stretcher.
Achilles Tendon Survey
Longitudinal Survey
1. Begin scanning with transducer placed along the posterior calcaneus bone.
2. Identify the insertion point of the Achilles tendon with slight
movements of the transducer to avoid anisotropy
3. Slowly move the transducer superiorly following the tendon until
it blends into the muscles at the distal end, approximately at the
mid to upper calf.
Transverse Survey
1. Begin scanning with the transducer placed along the posterior
calcaneus bone.
2. Identify the insertion point of the Achilles tendon.
3. Slowly move the transducer superiorly following the tendon until
it blends into the muscles at the distal end approximately at the
mid to upper calf.
CHAPTER 15 Musculoskeletal Scanning Protocol for Rotator Cuff, Carpal Tunnel 417
Kager’s fat pad
Achilles tendon insertion
Achilles Tendon Required Images
Longitudinal Images
1. LONG AXIS of the Achilles tendon at the insertion point. (Arrow:
Achilles tendon)
Achilles
Calcaneous
Labeled: SAG AT INS PT
2. LONG AXIS of PROXIMAL Achilles tendon just superior to the
point of insertion.
ACHILLES
CALCANEOUS
Labeled: SAG AT PROX
3. LONG AXIS of the MID Achilles tendon.
ACHILLES
Labeled: SAG AT MID
4. LONG AXIS of the DISTAL Achilles tendon. (Arrow: Achilles tendon)
Labeled: SAG AT DIS
418 PART V Small Parts Scanning Protocols
5. PANORAMIC VIEW of entire length of Achilles tendon.
Labeled: SAG AT
Transverse Images
6. Achilles tendon at INSERTION POINT.
ACHILLES
ACHILLES
Labeled: TRV AT INS PT
7. PROXIMAL Achilles tendon proximally just superior to insertion
point.
ACHILLES
Labeled: TRV AT PROX
8. MID Achilles tendon.
ACHILLES
Labeled: TRV AT MID