Ultrasonography of Peripheral Nerve -upper extremity

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1 Ultrasonography of Peripheral Nerve -upper extremity Department of Physical Medicine and Rehabilitation Korea University Guro Hospital Korea University College of Medicine Yoon Joon Shik

2 Normal median nerve Normal nerve Flattened ovoid structure on top of superficial and deep flexor tendons

3

4 Normal nerve Bright linear interface in tendon than in nerve

5 General course of median nerve Entire course in upp.ext. Course in forearm, wrist

6 Normal median nerve(transverse)-wrist Medial nerve, carpal tunnel Bony structure Tendon Radial carpal ligament Radial artery median nerve (N) may be confused with the adjacent palmaris longus and flexor carpi radialis. The median nerve lies superficial to tendons of the flexor digitorum. The radiocarpal ligament lies deep to flexor digitorum tendons and superficial to the ulna and radius.

7 Sonography of median nerve Carpal and Guyon tunnels. (a, b) Drawing (a) and corresponding transverse 5 12-MHz US scan (b) show the proximal level of the carpal tunnel delimited by the pisiform (P) and the scaphoid (S). (c, d) Drawing (c) and corresponding transverse 5 12-MHz US scan (d) show the distal level of the carpal tunnel delimited by the hook of the hamate (H) and the tubercle of the trapezium (T). The flexor retinaculum (medium gray region in a and c; open arrowheads in b and d) forms the roof of the carpal tunnel and the floor of the Guyon tunnel. The palmar carpal ligament (dark gray region in a) forms the volar boundary of the Guyon tunnel. The flexor tendons and median nerve (MN) extend through the carpal tunnel, with the nerve lying palmar and radial. At the level of the pisiform, the ulnar nerve (U) courses medial to the ulnar artery (solid arrowhead) within the Guyon tunnel. At the level of the hamate, the ulnar nerve divides into two terminal branches, a deep motor branch (curved arrow) and a superficial sensory branch (straight arrow). = flexor pollicis longus tendon, = flexor carpi radialis tendon. RadioGraphics 2000; 20:S199 S217

8 Normal median nerve(transverse) Normal median nerve -wrist Flattened ovoid structure on top of superficial and deep flexor tendons

9 Sonography of median nerve(transverse) Median nerve foream level -distal forearm Corresponding to the middle level (B) in Figure, the median nerve (N) courses around the radial aspect of the flexor digitorum superficialis (S) lying between the flexor digitorum superficialis and the flexor digitorum profundus (p). The pronator quadratus (Q) lies deep to flexor muscles. J Ultrasound Med 20: , 2001 Med Nerve, ant interosseous nerve

10 Sonography of median nerve(transverse)-mid forearm Corresponding to the proximal level (C) in Figure, the median nerve (N) now appears relatively hyperechoic, contrasting with adjacent hypoechoic muscle, and lies between the flexor digitorum superficialis (S) and the flexor digitorum profundus (P). J Ultrasound Med 20: , 2001

11 Sonography of median nerve( transverse)-upper forearm Upper 1/3 D s D s Median nerve, Muscle (superficial and deep) Ulnar artery, radius, ulnar bone

12 Median nerve 에서다른구조물과구분하는 point - differentiating the nerve from the nearby tendons, palmaris longus * superficial to flexor tendon, tendons are hyperechoic with fined packed echoes - nerve has oval or slightly dumbbell shaped in axial view * circular shape of tendon - much less movement of nerve * finger wiggling cause prominent to and fro movement of tendon

13 Dynamics of normal median nerve

14 Carpal tunnel syndrome

15 Carpal tunnel syndrome( cut off)

16 Swelling ratio of median nerve (A) normal median nerve cross-section at the distal wrist crease 11 mm 2. (B) normal median nerve in the forearm measuring 9 mm 2. This control had a WFR of 1.2. (C) CTS at the distal wrist crease measuring 17 mm 2 (D) median nerve in the forearm 7 mm 2 The WFR was 2.4.

17 The WFR in patients with CTS is elevated as compared to asymptomatic controls. A WFR of P1.4 gave 100% sensitivity for detecting patients with CTS while using only median nerve area at the wrist resulted in a sensitivity of 45 93%, depending on the cutoff value used.

18 Ulnar nerve: Humero ulnar joint

19 Ulnar nerve Med to brachial artery Ant to triceps med

20 Guyon s canal Ulnar nerve is visible(arrow, Rt.)

21 Lower 1/3 of forearm Ulnar nerve is visualized by arrow

22 Mid portion of forearm Ulnar nerve is about to split from artery(arrow)

23 Prox. 1/3 of forearm

24 Cubital tunnel Hemeroulnar arcade lies about 1 cm distal to epicondyle olecranone line Roof aponeurotic arch and muscle fiber of FCU Floor med. ligament of elbow

25 Cubital tunnel(ulnar nerve) Transverse sections of US images show normal anatomy of proximal inlet level (,B) and distal outlet level (D) of cubital tunnel. (ME: medial epicondyle, O: olecranon, arrows: arcuate ligament of Osborne, : 2 heads of flexor carpi ulnaris muscle) M E O B D

26 Dynamics of normal ulnar nerve

27

28 Characteristics of Pathologic Ulnar Nerve

29 A) Anconeous epitrochlearis muscle (arrows) is replacing the arcuate ligament ( : ulnar nerve). B) Ulnar nerve shows fusiform swelling(arrows) with decreased echogenecity in longitudinal scan. A B

30 A B

31 Neuroma

32 Subluxation of ulnar nerve

33 Radial nerve Hypoechoic nerve fasciculi, surrounded hyperechoic sheath Diameter: 2 mm Rounded at prox, 1/3 of humerus, oval at middle third Rounded again at distal third thickening ( 3 mm) of the radial nerve hourglass-shaped appearance: we noted first a thickening of the nerve ( 3 mm), then a stricture abnormal hypoechogenicity and loss of neuronal fascicle distinction. J Ultrasound Med 2004; 23:

34 Normal radial- contralateral side

35 Traumatic injury of radial nerve

36 Traumatic injury-radial nerve

37 Suprascapular Nerve 10 ml 0.5% bupivacaine 40 mg methylprednisolone needle was directed over the spine in the plane of the scapula

38 subcutaneous tissue(sct) trapezius (trm) supraspinatus muscles (ssm) suprascapular notch (n) superior transverse scapular ligament (arrows) - echogenic linear corocoid process (cp) shadow is just lateral to the suprascapular notch

39 Suprascapular nerve - round hyperechoic structure at 4 cm depth

40 Brachial plexus

41 Brachial plexus

42 Brachial plexus : C6 root

43 Brachial plexus : trunk level Scale ne Scale ne

44 Cervical root injection

45 NERVE LOCALIZATION Musculo cutaneous nerve

46

47 Thank you for your attention

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