Lecture by Dr. Raham Bacha PhD Scholar, M.Sc Ultrasound Gold Medalist Lecturer UIRSMIT UOL

1. قالو سُبحانك ل ا ع لام لنا
ال اما عا لمتنا انك انت العليمُ الحكيم
Surah Al Baqarahverse 32

2. By: Dr. RahamBacha
MD, MSc Sonology.
Lecturer of Ultrasound (UIRSMIT)
The university of
Lahore
Shoulder
Joint Ultrasound

3. Technical Guidelineswrist
Dr. RahamBacha
MD, MSc sonology

4. •The wrist US examination starts with evaluation of its dorsal aspect, followed by the palmar one. Depending on the specific clinical presentation, US images can be obtained in different position of the wrist (flexion and extension, radial and ulnar deviation, pronation and supination), with the patient seated in front of the examiner.
“ ULTRASOUND SEES THE FIRE –AS WELL AS THE SMOKE”
By; Dr. RahamBacha

5. By; Dr. RahamBacha

6. By; Dr. RahamBacha

8. •Linear probe 7-12 MHz
•power Doppler –color Doppler
•Scans approaches :Discussed one by one.
•Multiplannarscans
•two perpendicular planes
•Dynamic examination
•Extended view reconstructions
By; Dr. RahamBacha

9. Dorsal Hand: compartments of extensor tendon
•proper identification of the extensor tendons in transverse and following up them to the distal insertion is important.
•Long axis plane for the extensor tendons is only useful to evaluate the integrity of tendons and assess their dynamic motion in detail.
•Ultrasound of the dorsal of the wrist can be studded in six different compartments.
By; Dr. RahamBacha

13. First compartment.
•Keep the wrist in lateral place the transducer in short axis on the lateral aspect of the radial styloid. abductor pollicislongus(ventral) and extensor pollicisbrevis(dorsal), the retinaculum (note the possible occurrence of a vertical septum that splits the compartment in two distinct spaces) can be examined.
By; Dr. RahamBacha

14. By; Dr. RahamBacha

15. Radial artery and radial nerve in the first dorsal compartment.
The radial artery runs deep and the sensory branch of the radial nerve runs superficially to the first compartment. Scanning from proximal to distal,
Note the radial nerve and its branches snapping from ventral to dorsal over these tendons.
By; Dr. RahamBacha

18. Second compartment
•With the palm facing the examination table, shift the probe medially on transverse planes to depict the second compartment -extensor carpi radialislongusand extensor carpi radialisbrevistendons. Sweep the probe cranially over these tendons up to demonstrate the abductor pollicislongusand extensor pollicisbrevismuscles that encroach superficial to them at the distal forearm (intersection) to reach the first compartment.

21. Third compartment
•Find the lesser tubercle over the dorsal radius as the boney landmark to separate the second compartment (lateral) from the third compartment (medial).
•Once detected at the medial side of the lesser tubercle, the extensor pollicislongus tendon must be followed on short-axis scans down to its insertion. Care should be taken to demonstrate this tendon as it crosses the extensor carpi radialisbrevisand extensor carpi radialislongustendons.

22. Lesser Tubercle

26. Forth and fifth compartment
•Place the transducer on the transverse plane over the mid dorsal wrist to examine the fourth –extensor digitorumcommunisand extensor indicisproprius–and fifth – extensor digitiminimi–compartments. Dynamic examination during finger flexion and extension may aid to differentiate the individual tendons of the fourth compartment. Dynamic scanning is also useful to identify the extensor digitiminimi.

29. Scapho-lunate ligament
•Sweeping the probe distally from the level of the Lister tubercle on transverse planes, image the dorsal portion of the scapholunateligament. Ulnar deviation of the wrist may be useful to assess the integrity of this ligament.

31. •Place the wrist in slight radial deviation to examine the sixth compartment –extensor carpi ulnaris. Short-axis and long-axis planes should be obtained over this tendon.
•Look at the styloidprocess of the ulna and at the gap between the styloidand the radius filled with the triangular fibrocartilage complex: this structure can be evaluated partially by means of transverse and oblique coronal images.
SIXTH COMPARTMENT

34. •Examine the dorsal radio-ulnar joint by placing the probe on the transverse plane at a more proximal level than the joint line, where the capsule has a greater compliance to distension.
RADIO-ULNAR JOINT

37. Distal Radio-Ulnar joint
•Examinethedorsalradioulnarjointbyplacingtheprobeonthetransverseplaneatamoreproximallevelthanthejointline, wherethecapsulehasagreatercompliancetodistension.

40. Radiocarpaland medcarpaljoint
•Basedonthehyperechoicprofileofthecarpalbones,localizethesynovialrecessoftheradiocarpalandmidcarpaljointsusinglong-axisplanes.Lookforeffusionorsynovialthickening.

43. Ventral wristProximal carpal tunnel.
•Movingtothevolaraspectofthewrist, thepatientkeepsthedorsalwristfacingtheexaminationtable.Seekthebonylandmarksoftheproximalcarpaltunnel–thescaphoidtubercle(radialsided) andthepisiform(ulnarsided)–placingtheprobeoverthepalmarcreaseonaxialplane.

44. •Oncedetected,theprobeorientationshouldbeadjustedaccordingly(oneedgeoverthescaphoid,theotheroverthepisiform).Tiltingtheprobebackandforthmayhelptooptimizedepictionofthesoft-tissuescontainedwithinthetunnel.Checktheflexorretinaculumandeachoftheninelongflexortendons(fourfromtheflexordigitorumsuperficial,fourfromtheflexordigitorumprofundusandtheflexorpollicislongusradially)containedwithinthecarpaltunnel.

45. •Dynamicscanningduringpassiveflexionandextensionoftherespectivefingermayhelptoassesstheirintegrity. Checkthecontentofthecarpaltunneltorecognizepossibleabnormalfindings,includinganomalousmusclesandflexortenosynovitis.
•Attheradialsideofthecarpaltunnel,checktheflexorcarpiradialistendonthatoverliesthehyperechoiccortexofthescaphoid

48. Distal carpus tunnel
•shifttheprobemoredistallyformwristcreaseintransverseplanetoidentifythetwobonylandmarksofthedistalcarpaltunnel–thetrapeziumtubercle(radialsided)andthehamatehook(ulnarsided).Duetotheobliquecourseoftheflexortendonsandthemediannervetowardsdepth,mildchangesinprobeorientationorslightflexionofthewristshouldbeperformedtoimprovedepictionofthesestructures.

51. •sweepthetransducerupanddownoverthemediannerve.Themediannerveshouldbesystematicallyexaminedinitsshort-axisfromthedistalradius(cranialtotheproximaledgeoftheretinaculum)throughthepalm(beyondthedistaledgeoftheretinaculum).Careshouldbetakentoidentifyanatomicalvariants(bifidnerve,persistentmedianarteryoftheforearm)andchangesinthenervecross-sectionalareaoccurringatthecarpaltunnellevel.

52. GUYON TUNNEL Ulnar Nerve
•MovethetransducermediallyonthetransverseplanetoexaminetheGuyontunnel.Usethepisiformasalandmark.Checktheulnarartery(radial-sided)andtheulnarnerve(ulnar-sided).Followthenervedistallyonshort-axisplanestoexamineitstwodivisionalbranches–thesuperficialsensorybranchandthedeepmotorbranch(thelattercoursingalongsidethehamatehook).