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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5833_Библиотеки_им_академика_М_И_Перельмана.pdf
2 Shoulder
24
Fig. 2.22a Probe position to evaluate the teres
minor on its long axis
Fig. 2.22b Teres minor tendon
insertional area (arrowheads).
H, humerus
Fig. 2.22c Teres minor tendon
course (arrowheads). TM, teres
minor muscle belly; G, glenoid;
L, posterior glenoid labrum; *,
posterior joint recess;
H, humerus
Acromion-Calvicular Joint
25
Fig. 2.23 Glenohumeral joint posterior
recess. H, humerus; G, glenoid; *,
posterior joint recess; arro
wheads,
posterior glenoid labrum
Fig. 2.24a Probe position to evaluate the
acromion-clavicular joint
Fig. 2.24b Coronal scan of the acromion-
clavicular joint. Arrowheads, joint capsule;
Ac, acromion; Cl, clavicle
US evaluation of the elbow is divided into
four compartments: anterior, lateral, medial
and posterior.
3.1 Anterior Compartment
Anatomical scheme of the compartment is
presented in Figs. 3.1 and 3.2. The patient sits
opposite the examiner, with the elbow on the
table and the arm extended (Fig. 3.3).
3.1.1 Distal Tendon of Biceps Brachii
To maximally expose the tendon, patient fore-
arm should be as supinated as possible. The
tendon should first be evaluated on its long
axis up to the insertion on the radial tuberosi-
ty (Figs. 3.4a, b). The tendon has a very
oblique course, being deeper distally when it
inserts on the radial tuberosity. For this rea-
son, the distal edge of the probe should be
slightly pressed on the patient’s skin to have
the US beam as perpendicular as possible to
the tendon fibers. The distal biceps tendon is
surrounded by the bicipitoradial bursa, which
is visible only when distended by fluid.
Elbow
3
Content s
3.1 Anterior Compartment
• Distal Tendon of Biceps Brachii
• Anterior Joint Recess
• Median Nerve
• Radial and Posterior Interosseous Nerves
3.2 Lateral Compartment
• Common Extensor Tendon
• Humeral-Radial Joint
3.3 Medial Compartment
• Common Flexor Tendon
• Medial Collateral Ligament
3.4 Posterior Compartment
• Triceps Brachii Muscle and Tendon
• Olecranon Fossa and Posterior Olecranon Recess
• Cubital Tunnel and Ulnar Nerve
27
E. Silvestri, A. Muda, L. M. Sconfienza, Normal Ultrasound Anatomy of the Musculoskeletal System,
© Springer-Verlag Italia 2012
3 Elbow
28
Fig. 3.1 Anatomical scheme of the anterior compartment.
1, biceps brachii muscle belly; 2, distal tendon of the
biceps brachii; *, lacertus f
ibrosus; 3, radial nerve; 3a,
posterior interosseous nerve; 3b, subcutaneous sensory
branch of the radial nerve; 4, median nerve
Fig. 3.3 Position of the elbow to evaluate the anterior compartment
Fig. 3.2 Anatomical scheme of the biceps brachii distal
tendon (2). 1, biceps brachii muscle; *, lacertus fibrosus;
R, radius; U, ulna; H, humerus
The median nerve arises from the brachial
plexus, runs within the axillary cavity to
the medial region of the anterior compart-
ment of the arm, firstly next to the coraco-
brachialis muscle and then on the medial
side of the biceps brachii muscle. It cross-
es the crease of the elbow and reaches the
forearm, where it passes between the ulnar
and the humeral head of the pronator teres
muscle, and distally deeper to the flexor
digitorum superficialis muscle. In the fore-
arm, the nerve runs between the flexor dig-
itorum superficialis and flexor digitorum
profundus muscles.
Anterior Compartment
29
Fig. 3.4a Probe position to evaluate biceps brachii along its longitudinal axis
Fig. 3.4b Longitudi-
nal scan of biceps
brachii distal tendon
(arrowheads). R, radi-
al tuberosity
3.1.2 Anterior Joint Recess
On longitudinal scans, the coronoid fossa
appears like a concavity containing a fat pad.
Articular cartilage can be seen covering the
underlying bone (Figs. 3.5a and 3.5c).
On axial scans, the distal humeral epiphysis
appears like a curved hyperechoic line, with a
thin hypoechoic line above it, representing the
cartilage. The lateral side of the humerus (capit-
ulum humeri) articulates with the radial head,
while the medial side (trochlea) articulates with
the ulna (Figs. 3.5a, b).
3.1.3 Median Nerve
The median nerve arises from the brachial
plexus, runs within the axillary cavity to the
medial region of the anterior compartment of
the arm, firstly next to the coracobrachialis
muscle and then on the medial side of the
biceps brachii muscle. It crosses the crease of
the elbow and reaches the forearm, where it
passes between the ulnar and the humeral
head of the pronator teres muscle, and distally
deeper to the flexor digitorum superficialis
muscle. In the forearm, the nerve runs
between the flexor digitorum superficialis and
flexor digitorum profundus muscles.
The probe must be placed on a transverse
plane on the anterior face of the elbow.
The median nerve runs in the anterior
compartment of the elbow, medial to the
brachial artery. Medially to the brachial artery,
the biceps brachii tendon can be seen (Figs.
3.6a, b).
The median nerve must be evaluated along
its whole course, sliding the probe upwards
and downwards. Then the probe must be rotat-
ed by 90° to evaluate it on its longitudinal
axis. Nerve visualization can be improved
slightly by pressing the distal edge of the
probe, due to its curvilinear course.
3.1.4 Radial and Posterior
Interosseous Nerves
The radial nerve arises from the secondary
rear trunk of the brachial plexus, running in
the axillary cavity, and then obliquely along
the humeral artery. It courses within the long
and medial head of the triceps brachii muscle,
then distally through the brachialis and bra-
chioradialis muscles. It then reaches the ante-
rior compartment where it splits into a deep
radial branch (mainly motor) and a superficial
radial branch (mainly sensitive).
The probe must be placed a few inches
proximally of the elbow crease. The radial
nerve must be followed distally in the antero-
lateral direction (Fig. 3.7). Follow the nerve
between the brachioradialis and brachialis
muscle up to its split into the sensitive super-
ficial branch and interosseous posterior nerve
(Figs. 3.8, 3.9a, b). The posterior interosseous
nerve can be seen until it pierces the supinator
muscle and passes through the Fröhse arcade
(Figs. 3.9a and 3.9c). The posterior
interosseous nerve is more easily assessed
with the probe fixed on the supinator muscle
while the patient pronates and supinates the
forearm.
3 Elbow
30
Anterior Compartment
31
Fig. 3.5a Probe position to evaluate the anterior joint recess
Fig. 3.5b Transverse
scan of the anterior
recess. Br, brachialis
muscle; Ch, capitu-
lum humeri;
Tr, trochlea;
*, cartilage
Fig. 3.5c Longitudi-
nal scan of the
anterior recess.
Br, brachialis muscle;
Ch, capitulum
humeri; R, radius
3 Elbow
32
Fig. 3.6b Anterior compart-
ment on an axial scan.
Arrowheads outline the median
nerv
e; T, biceps brachii tendon;
A, brachial artery
Fig. 3.6c Longitudinal scan of
the median nerve (arrowheads)
Fig. 3.6a Probe position to evaluate the median nerve along its short axis
Anterior Compartment
33
Fig.3.7 Anatomical scheme of the radial nerve
(RN) in longitudinal axis. BB, biceps brachialis
muscle; R, radius; SS, supinator muscle superf
i-
cial head; DS, supinator muscle deep head;
U, ulna; *, posterior interosseous nerve; circle,
cutaneous branch of radial nerve; H, humerus
Fig. 3.8 Axial scheme of the
posterior interosseous nerve
(*). Br, brachialis muscle;
R, radius; SS, supinator
muscle superficial head;
DS, supinator muscle
deep head
3 Elbow
34
Fig. 3.9b Scan of the radial nerve splitting in-
to the posterior interosseous nerve (empty ar-
rowhead) and sensitive superficial branch
(white arrowhead). R, radius
Fig. 3.9c Scan of the Fröhse arcade.
Arrowhead, posterior interosseous nerve;
S, supinator muscle; R, radius
Fig. 3.9a Probe positions to evaluate the radial and the posterior interosseous nerves