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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5833_Библиотеки_им_академика_М_И_Перельмана.pdf
Fig. 7.24 Anatomical detail of the semimembranosus bur-
sa (*) and posterior-medial tendons. 1, sartorius (myotendi-
nous junction); 2, gracilis; 3, semitendinosus; 4, semi-
membranosus; GM, medial head of the gastrocnemius
muscle; mfc, medial femoral condyle
Fig. 7.25 Lower limb position to evaluate the posterior
compartment of the knee
don (medial) and the medial head of gastrocne-
mius (lateral) (Figs. 7.27a, b).
The semimembranosus muscle arises from
the ischiatic tuberosity medial to the biceps
femoris and semitendinosus. The distal ten-
don splits into three branches: the descend-
ing, inserting on the posterior side of tibial
medial condyle; the recurrent, inserting on
the lateral femoral condyle ending in the
popliteal ligament and the reflex, inserting
on the anterior part of medial tibial condyle.
The gastrocnemius is the most superficial
muscle of the posterior region of the leg. Its
medial head arises from the medial femoral
epicondyle and from the posterior side of the
knee joint capsule. The lateral head arises
from the lateral femoral epicondyle and from
the posterolateral side of knee joint capsule.
Their distal tendons blend with the soleus to
form the Achilles tendon that inserts on the
posterior aspect of the calcaneal tuberosity.
7 Knee
108
7.4 Posterior Compartment
Anatomical scheme of the posteromedial com-
partment of the knee is shown in Fig. 7.24. To
evaluate the posterior compartment of the knee,
the patient must lie prone with the knee extend-
ed (Fig. 7.25).
7.4.1 Medial Tendons
The posteromedial corner of the knee includes
tendons that distally become part of the medial
compartment. From medial to lateral, the sar-
torius, gracilis, semitendinosus, and semi-
membranosus tendons can be seen on axial
scans (Figs. 7.26a, b).
7.4.2 Semimembranosus Bursa
The semimembranosus bursa can be seen on
axial scans between the semimembranosus ten-
Posterior Compartment
109
Fig. 7.26a Probe position to eval-
uate the posteromedial
tendons on short axis
Fig. 7.26b Transverse scan of the posterior-medial tendons. 1, semi-
membranosus; 2, semitendinosus; 3, gracilis; 4, sartorius
Fig. 7.27a Probe position to evaluate
the semimembranosus bursa
Fig. 7.27b SM, semimembranosus; MHG, medial head of gastroc-
nemius; *, bursa
Fig. 7.28a Probe position to evaluate
the popliteal neurovascular bundle
Fig. 7.28b Axial scan on the popliteal neurovascular bundle.
A, popliteal artery; V, popliteal vein; arrowheads, tibial nerve
7.4.3 Popliteal Neurovascular Bundle
Move the probe on the popliteal hiatus to
detect the popliteal artery (deep and medial),
the popliteal vein (intermediate), and the tib-
ial nerve (superficial and lateral) (Figs. 7.28a, b).
Turn the probe by 90° to assess the neurovas-
cular bundle on the longitudinal axis
(Figs. 7.29a, b). Due to prone decubitus, the
popliteal vein usually collapses. To assess it
properly, patient’s calf could be gently
squeezed.
The tibial nerve is the prolongation of the
sciatic nerve. After its origin, it moves to the
popliteal hiatus, where it is located laterally
to popliteal vessels. Here some bundles form
the medial cutaneous nerve of the calf that
becomes superficial and joins a small branch
coming from the common peroneal nerve to
form the sural nerve. In the leg, the tibial
nerve runs under the arch of the soleus and
then it runs between the triceps surae and
deep muscles. Here it gives small branches
for all posterior muscles of the leg. Distally,
the nerve moves medially, passing posterior-
ly to the medial malleolus, where it gives
sensitive cutaneous branches. Finally, it
divides into the medial and the plantar
nerves that innervate the skin and the mus-
cles of the plantar side of the foot.
7 Knee
110
7.4.4 Posterolateral Corner and
Biceps Femoris Tendon
Anatomical scheme of the distal myotendinous
junction of the biceps femoris is shown in Fig.
7.30. By moving the transducer to the postero-
lateral side of the knee, the biceps femoris can
be seen. The tendon must be evaluated on both
the longitudinal and axial scan and must be fol-
lowed distally up to its insertion on the per-
oneal head (Figs. 7.31a-c).
The biceps femoris muscle is located in the
posterolateral compartent of the thigh and
consists of two heads. The long head, common
to the semitendinosus muscle, arises from the
upper tubercle of the ischiatic tuberosity. The
short head arises from the middle third of the
lateral lip of the linea aspera and from the
lateral intermuscular septum. The two heads
join into a common belly that inserts on the
fibular head with a few fibers also inserting on
the tibial lateral condyle.
Posterior Compartment
111
Fig. 7.29a Probe position to evaluate
the popliteal neurovascular bundle on
its longitudinal axis
Fig. 7.29b A, popliteal artery; star, inferior genicular artery; *, ante-
rior tibialis artery
Fig. 7.30 Anatomical scheme of the myotendinous junc-
tion (*) of biceps femoris muscle (lateral view). F, femur;
T, tibia; Fi, fibula
7 Knee
112
7.4.5 Peroneal Nerve
With the patient lying in the same position used
to evaluate the popliteal neurovascular bundle,
move the transducer proximally to find the sci-
atic nerve and its subdivision into the tibial
(central) and the common peroneal nerve (lat-
eral). Follow the nerve distally (Figs. 7.32a, b)
up to the fibular head and neck. The two
branches of the nerve (superficial and deep)
surround the fibula and pass deeply to the prox-
imal insertion of the peroneus longus.
Fig. 7.31a Probe position to evaluate
the posterolateral corner
Fig. 7.31b Scan of the posterior-lateral
corner. 1, popliteal tendon; 2, LCL; 3
biceps femoris tendon; hp, popliteal hia-
tus; Fe, femur
Fig. 7.31c Myotendinous junction
(arrowheads) and biceps femoris inser-
tion on the peroneal head. Fe, femoral
lateral condyle; Fi, f
ibula
The common peroneal nerve is one collat-
eral branch of the sciatic nerve. Arising
around the upper lateral corner of the
popliteal hiatus, it runs down and laterally
along the medial edge of the biceps femoris.
Then it leaves the popliteal hiatus, crossing
the biceps femoris tendon and the lateral
head of the gastrocnemius. Finally, it sur-
rounds the fibular neck and it splits into two
terminal branches (superficial peroneal and
deep peroneal nerves).
Posterior Compartment
113
Fig. 7.32b The US scan shows the superficial peroneal (white arrowhead)
and deep peroneal (void arrowhead) nerves on the short axis, at the level of
the fibular head (Fi)
Fig. 7.32a Probe position to evalu-
ate the common peroneal nerve
The standard US protocol includes the evalua-
tion of four compartments of the ankle: lateral,
medial, posterior, and anterior.
8.1 Lateral Compartment
The patient lies supine on the table with the
knee flexed at about 90°, with the foot slightly
intra-rotated (Fig. 8.1). The anatomical scheme
of the lateral compartment of the ankle is
shown in Fig. 8.2.
Ankle
8
Content s
8.1 Lateral Compartment
• Anterior Talo-Fibular Ligament
• Anterior Tibio-Fibular Ligament
• Calcaneo-Fibular Ligament
• Peroneal Tendons
8.2 Medial Compartment
• Deltoid Ligament
• Tarsal Tunnel
8.3 Posterior Compartment
• Achilles Tendon
• Posterior Tibio-Talar Recess
8.4 Anterior Compartment
• Anterior Tendons and Deep Peroneal Nerve
• Anterior Tibiotalar Recess
Fig. 8.1 Position of the ankle to evaluate the lateral com-
partment
Fig. 8.2 Anatomical scheme of the anterior talo-fibular
ligament (*). F, fibula; T, talus; Ti, tibia; C, calcaneus; S,
tarsal scaphoid; Cu, cuboid; II, III, IV, V, metatarsal bones
115
E. Silvestri, A. Muda, L. M. Sconfienza, Normal Ultrasound Anatomy of the Musculoskeletal System,
© Springer-Verlag Italia 2012
Fig. 8.3a Probe position to evaluate the anterior talo-fibu-
lar ligament
Fig. 8.3b Longitudinal scan of the anterior talo-fibular ligament (*). T, talus; F, fibula
8 Ankle
116
Anterior talo-fibular ligament functionality
can be tested using the ultrasonographic anteri-
or drawer test. This test consists of a forced
plantar flexion and internal rotation of the foot
and allows the assessment of the presence of a
ligament tear by separating its extremities
(Figs. 8.4a, b). Also, dynamic analysis can
detect a widening of the anterolateral recess in
the case of a full-thickness tear.
8.1.1 Anterior Talo-Fibular Ligament
The proximal edge of the probe must be placed
over the distal tip of the fibular malleolus and
the distal edge must be placed over the lateral
aspect of the talus (Fig. 8.3a, b).
The correct scanning plane can be easily
found placing the proximal edge of the probe
on the fibular tip with a semi-oblique scan and
slowly rotating the probe to reach an axial
plane.
Lateral Compartment
117
Fig. 8.4a Initial position of the ankle
Fig. 8.4b Stress position to test the anterior talo-
fibular ligament using the anterior drawer test
Fig. 8.6a Probe position to evaluate the
anterior tibio-fibular ligament
Fig. 8.6b Anterior tibio-
fibular ligament (*)
appears like a hyperechoic
fibrillar band connecting
the tibia (T) and the fibula
(F)
or edge of the probe on the lateral malleolus tip
and cranially rotate the distal edge until the
anterior tibio-fibular ligament can be seen
(Figs. 8.6a, b).
8 Ankle
118
8.1.2 Anterior Tibio-Fibular Ligament
Anatomic scheme of the anterior tibiofibular
ligament is shown in Fig. 8.5. Hold the posteri-
Fig. 8.5 Anatomical scheme of the anterior tibiofibular
ligament (*). F, fibula; Ti, tibia; T, talus; C, calcaneus;
S, scaphoid; Cu, cuboid; II, III, IV, V, metatarsal bones