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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5833_Библиотеки_им_академика_М_И_Перельмана.pdf
5 Hand
66
Fig. 5.3b US axial scan of the hand palm. FDS, flexor digitorum superficialis tendon; FDP, flexor digitorum profun-
dus tendon; M, metacarpal bone; L, lumbrical muscle; white arrowheads, common digital nerve; void arrowheads,
common digital arteries (Doppler signal in red); *, interosseous muscles
Fig. 5.3a Probe position to evaluate the flexor digitorum
tendons on the short axis
Ventral Side
67
Fig. 5.4a Probe position to evaluate the flexor digitorum
tendons on the long axis
Fig. 5.4b US longitudinal scan of the third flexor digitorum tendon. FDS, flexor digitorum superficialis tendon;
FDP, flexor digitorum profundus tendon; M, metacarpal bone
5.1.3 Metacarpophalangeal and
Interphalangeal Joints
The metacarpophalangeal and interphalangeal
joints must be assessed using longitudinal scans
(Figs. 5.5a, b, 5.6a, b). Collateral ligaments can
be seen by placing the probe on a longitudinal
plane on both the radial and ulnar side of the
joints (Figs. 5.7a, b). The most common liga-
ment injury affects the ulnar collateral ligament
of the thumb. Note that small avulsion frag-
ments can easily be detected using US.
5 Hand
68
Fig. 5.5a Probe position to evaluate the metacarpopha-
langeal joints on the long axis
Fig. 5.5b Longitudinal scan of the metacarpophalangeal joint, palmar side. M, metacarpal head; P1, proximal pha-
lanx; T, flexor tendons; *, palmar plate; circle, proximal synovial recess; arrowheads, A1 pulley
Ventral Side
69
Fig. 5.6a Probe position to evaluate the
interphalangeal joint on the long axis
Fig. 5.6b Proximal interphalangeal joint longitudinal scan, palmar side. P1, proximal phalanx; P2, middle phalanx;
T, flexor tendons; *, palmar plate
Fig. 5.6c Distal interphalangeal joint longitudinal scan, palmar side. P2, middle phalanx; P3, distal phalanx; T, flex-
or digitorum profundus tendon
5 Hand
70
Fig. 5.7a Probe position to evaluate the ulnar collat-
eral ligament of the thumb
Fig. 5.7b Ulnar collateral ligament of the thumb. M, metacarpal head; P1, proximal phalanx; arrowheads, ulnar col-
lateral ligament of the thumb
5.2 Dorsal Side
Dorsal compartment can be assessed with the
hand lying on the table, with the palm facing
down (Fig. 5.8). Anatomical scheme of dorsal
compartment of fingers is shown in Fig. 5.9.
5.2.1 Extensor Digitorum Tendons
Extensor digitorum tendons can be assessed
using axial scans, moving the transducer from
the carpus distally to the fingertips. Tendons
become very thin distally, then transform into
lamina extensoria (Figs. 5.10a-c, Figs. 5.11a-c).
Dorsal Side
71
Fig. 5.8 Probe position to evaluate the dorsal compart-
ment of the hand
Fig. 5.9 Anatomical
scheme of the dorsal com-
partment of the hand. Void
arrowheads, e
xtensor digi-
torum communis tendon;
white arrowheads, extensor
digitorum superficialis ten-
don; *, extensor digitorum
rpofundus tendon; M,
metacarpal bone;
P1, proximal phalanx;
P2, middle phalanx
5 Hand
72
Fig. 5.10a Probe position to evaluate the metacarpopha-
langeal joint and extensor digitorum tendon
Fig. 5.10b Metacarpophalangeal joint longitudinal scan, dorsal side. M, metacarpal head; P1, proximal phalanx;
arrowheads, extensor tendon
Fig. 5.10c Longitudinal scan, dorsal side. Arrowheads indicate the course of the extensor tendon. P2, middle phalanx
Dorsal Side
73
Fig. 5.11a Probe position to evaluate the proximal
and distal interphalangeal joints
Fig. 5.11b Proximal interphalangeal joint longitudinal scan, dorsal side. P1, proximal phalanx; P2, middle phalanx;
arrowheads, extensor tendon
Fig. 5.11c Distal interphalangeal joint longitudinal scan, dorsal side. P2, middle phalanx; P3, distal phalanx; arrow-
heads, estensor digitorum profundus tendon
The hip is divided into four compartments:
anterior, medial, lateral and posterior.
6.1 Anterior Hip
The patient lies supine, with the lower limb in
a neutral position (Fig. 6.1).
Hip
6
Content s
6.1 Anterior Hip
• Sartorius and Tensor Fasciae Latae Muscles
• Rectus Femoris Muscle
• Iliopsoas Muscle
• Femoral Neurovascular Bundle
• Coxo-Femoral Joint
6.2 Medial Hip
6.3 Lateral Hip
6.4 Posterior Hip
• Ischiocrural Tendons (Hamstrings)
• Sciatic Nerve
75
E. Silvestri, A. Muda, L. M. Sconfienza, Normal Ultrasound Anatomy of the Musculoskeletal System,
© Springer-Verlag Italia 2012
Fig. 6.1 Lower limb position to evaluate the anterior hip
6.1.1 Sartorius and Tensor Fasciae
Latae
With the patient supine, find the anterior-supe-
rior iliac spine (ASIS) with palpation and place
the probe on it in an axial position (Fig. 6.2a).
See the typical “pseudo-thyroid” aspect (Fig.
6.2b) with the hyperechoic ASIS at the centre,
next to the short tendinous insertions of the sar-
torius (medial) and the tensor fasciae latae
(lateral) muscles. The tensor fasciae latae muscle
courses distally on the lateral side of the thigh,
whereas the sartorius muscle can be seen with
medial orientation, superficially to the rectus
femoris muscle (Fig. 6.2c). Examine the muscle
bellies using both axial and longitudinal scans.
6.1.2 Rectus Femoris
Starting from the position previously described
at ASIS level shift the transducer caudally to
reach the anterior-inferior iliac spine (AIIS)
(Fig. 6.3a). There, the direct tendon of the rec-
tus femoris muscle inserts on the lateral side,
deeper than the iliopsoas muscle (Fig. 6.3b).
6 Hip
76
From this position, translate the transducer
caudally to reach the muscle belly of the rectus
femoris (Fig. 6.3c).
Rotate the transducer by 90° to evaluate, by
longitudinal scans, the myotendinous junctions
of the rectus up to the insertion onto the AIIS
(Figs. 6.4a, b).
Evaluate the direct and indirect tendon of
the rectus femoris (Fig. 6.5), using longitudinal
(Figs. 6.6a, b) and axial scans (Figs. 6.7a-d).
The rectus femoris muscle is characterized
by a complex organization of proximal
insertions, consisting of a direct tendon
inserting on the AIIS and an indirect ten-
don running distally as an aponeurosis into
the muscle belly. Proximally it runs under
the direct tendon then proceeds more exter-
nally, with an oblique trend compared to the
overhanging direct tendon that inserts into
the acetabular tubercle. The third small ten-
don anchors the insertional complex of rec-
tus reflecting distally in the proximity of the
greater tuberosity (reflected tendon).