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Boxall A. A pictorial guide for performing dynamic musculoskeletal ultrasound techniques of the Upper Limb. Radiography (Lond) 2024; 30:745-752. [PMID: 38428199 DOI: 10.1016/j.radi.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 01/13/2024] [Accepted: 02/14/2024] [Indexed: 03/03/2024]
Abstract
INTRODUCTION Dynamic techniques should be used to compliment static imaging in the field of Musculoskeletal ultrasound. Performing limb movements and imaging simultaneously, allows for diagnosing certain musculoskeletal conditions not otherwise confirmed by still images. This article aims to provide guidance on how to perform a selection of these dynamic musculoskeletal ultrasound techniques with a focus on the upper limb. METHODS This pictorial guide features techniques gathered from literature review and experience gained in the field. RESULTS Application of dynamic ultrasound techniques has been evidenced in the literature to diagnose conditions such as trigger finger, dislocating tendons and causes of peripheral neuropathy. CONCLUSION Musculoskeletal conditions only elicited during limb movement can be difficult to diagnose. Appropriate use of dynamic techniques increases likelihood of correct diagnosis of the described conditions. IMPLICATIONS FOR PRACTICE Ultrasound provides a unique opportunity to visualise these conditions thus ultrasound users should aim to familiarise themselves with dynamic ultrasound techniques to improve patient outcomes.
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Affiliation(s)
- A Boxall
- Royal Surrey NHS Foundation Trust, UK.
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2
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Fontes T, Saraiva F. Ultrasound exploration of the elbow: A user-friendly approach. Eur J Radiol 2023; 165:110896. [PMID: 37270897 DOI: 10.1016/j.ejrad.2023.110896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 05/25/2023] [Indexed: 06/06/2023]
Abstract
Ultrasound is a strong diagnostic and therapeutic tool for the elbow joint. Existing guidelines and protocols list relevant structures to be scanned but lack some logical connection and intermediate exploration manoeuvres to link each step, which we consider crucial from an operator's perspective that aims to be efficient in regular clinical practice. We present thirteen steps that are described in detail and accompanied by forty-seven ultrasound images, logically linked in what we believe is the best balance between detail and a real-world applicable protocol to perform an ultrasound of the elbow joint.
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Affiliation(s)
- Tomás Fontes
- Rheumatology Department, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa (CAML), Lisbon, Portugal; Rheumatology Department, Hospital Divino Espírito Santo, Ponta Delgada, Portugal.
| | - Fernando Saraiva
- Rheumatology Department, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa (CAML), Lisbon, Portugal
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Chianca V, Sutter R, Grande FD. Imaging of Anatomical Variants Around the Elbow. Semin Musculoskelet Radiol 2023; 27:163-168. [PMID: 37011617 DOI: 10.1055/s-0043-1761957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
The elbow is a synovial joint able to perform flexion, extension, supination, and pronation. Knowledge of anatomical variants is crucial to avoid misinterpretation during the evaluation of the elbow joint. We address those anatomical variants simulating pathologic conditions.
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Affiliation(s)
- Vito Chianca
- Clinica di Radiologia EOC IIMSI, Lugano, Switzerland
- Ospedale Evangelico Betania, Naples, Italy
| | - Reto Sutter
- Department of Radiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Aravind P, Tiongco RFP, McNichols CH, Williams EH. Ultrasound as a Useful Tool for a Peripheral Nerve Surgeon: Examples in Clinical Practice. J Reconstr Microsurg 2022. [PMID: 36584694 DOI: 10.1055/s-0042-1759526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Peripheral nerve surgeons often require additional imaging for examination, diagnostic testing, and preoperative planning. Point-of-care ultrasound (US) is a cost-effective, accessible, and well-established technique that can assist the surgeon in diagnosing and treating select peripheral nerve pathologies. With this knowledge, the properly trained surgeon may perform US-guided nerve blocks to help accurately diagnose and treat causes of neuropathic pain. We offer this paper, not as an exhaustive review, but as a selection of various peripheral nerve pathologies, which the senior author treats, and their associated US examination findings. Our goal is to encourage other peripheral nerve surgeons to incorporate US into their practices. METHODS We provide various cases from our outpatient peripheral nerve clinic demonstrating relevant US anatomy. We also review techniques for US guided nerve blocks with relevant anatomic landmarks. RESULTS US imaging successfully assisted in identification and injection techniques for various peripheral nerve pathologies in a surgeon's practice. Examples were presented from the neck, trunk, upper extremity, and lower extremity. CONCLUSION Our review highlights the use of US by a peripheral nerve surgeon in an outpatient private practice clinic to diagnose and treat select peripheral nerve pathologies. We encourage reconstructive surgeons to add US to their arsenal of diagnostic tools.
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Affiliation(s)
- Pathik Aravind
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rafael Felix P Tiongco
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Colton H McNichols
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Eric H Williams
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.,The Dellon Institutes for Peripheral Nerve Surgery, Towson, Maryland
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Belón-Pérez P, Calderón-Díez L, Sánchez-Sánchez JL, Robles-García M, Plaza-Manzano G, Fernández-de-las-Peñas C. Cadaveric and Ultrasound Validation of Percutaneous Electrolysis Approaches at the Arcade of Frohse: A Potential Treatment for Radial Tunnel Syndrome. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19042476. [PMID: 35206659 PMCID: PMC8872469 DOI: 10.3390/ijerph19042476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/15/2022] [Accepted: 02/18/2022] [Indexed: 02/01/2023]
Abstract
Entrapment of the radial nerve at the arcade of Frohse could contribute to symptoms in patients with lateral epicondylalgia or radial tunnel syndrome. Our aim was to determine the validity of applying percutaneous electrolysis, targeting the supinator muscle at the Frohse’s arcade with ultrasound imaging and in a Thiel-embalmed cadaver model (not ultrasound-guiding). Percutaneous electrolysis targeting the supinator muscle was conducted in five healthy volunteers (ultrasound study) and three Thiel-embalmed cadaver forearms. Two approaches, one with the forearm supinated and other with the forearm pronated were conducted. The needle was inserted until the tip reached the interphase of both bellies of the supinator muscle. Accurate needle penetration of the supinator muscle was observed in 100% in both US-imaging and cadaveric studies. No neurovascular bundle of the radial-nerve deep branch was pierced in any insertion. The distance from the tip of the needle to the neurovascular bundle was 15.3 ± 0.6 mm with the forearm supinated, and 11.2 ± 0.6 mm with the forearm pronated. The results of the current study support that percutaneous electrolysis can properly target the supinator muscle with either the forearm in supination or in pronation. In fact, penetration of the neurovascular bundle was not observed in any approach when percutaneous needling electrolysis was performed by an experienced clinician.
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Affiliation(s)
- Pedro Belón-Pérez
- Department of Physical Therapy, Real Madrid C.F., 28055 Madrid, Spain;
| | - Laura Calderón-Díez
- Department of Physical Therapy, Universidad de Salamanca, 37008 Salamanca, Spain; (L.C.-D.); (J.L.S.-S.)
| | - José Luis Sánchez-Sánchez
- Department of Physical Therapy, Universidad de Salamanca, 37008 Salamanca, Spain; (L.C.-D.); (J.L.S.-S.)
| | - Miguel Robles-García
- Department of Anatomy and Histology, Faculty of Medicine, Universidad de Salamanca, 37008 Salamanca, Spain;
| | - Gustavo Plaza-Manzano
- Department of Radiology, Rehabilitation and Physiotherapy, Universidad Complutense de Madrid, 28040 Madrid, Spain;
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos, 28040 Madrid, Spain
| | - César Fernández-de-las-Peñas
- Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos (URJC), 28922 Alcorcón, Spain
- Cátedra Institucional en Docencia, Clínica e Investigación en Fisioterapia: Terapia Manual, Punción Seca y Ejercicio Terapéutico, Universidad Rey Juan Carlos, 28922 Alcorcón, Spain
- Correspondence: ; Tel.: +34-91-488-88-84
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Becciolini M, Pivec C, Raspanti A, Riegler G. Ultrasound of the Radial Nerve: A Pictorial Review. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:2751-2771. [PMID: 33629784 DOI: 10.1002/jum.15664] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 02/03/2021] [Accepted: 02/07/2021] [Indexed: 06/12/2023]
Abstract
This pictorial review focuses on the ultrasound (US) appearance of the normal and pathological radial nerve (RN) and its branches and provides tips with which to locate them and avoid misinterpretation of normal findings. A wide range of our pathological cases are reviewed and presented to help in familiarizing the reader with common and uncommon clinical scenarios that affect the RN and its main branches.
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Affiliation(s)
- Marco Becciolini
- Misericordia di Pistoia, Pistoia, Italy
- Scuola Siumb di Ecografia Muscolo-Scheletrica, Pisa, Italy
| | | | - Andrea Raspanti
- SOC Ortopedia e Traumatologia, Ospedale Santa Maria Annunziata, Azienda USL Toscana Centro, Florence, Italy
| | - Georg Riegler
- PUC - Private Ultrasound Center Graz, Lassnitzhoehe, Austria
- Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Vienna, Austria
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Relationship between the Branching Patterns of the Radial Nerve and Supinator Muscle. BIOMED RESEARCH INTERNATIONAL 2021; 2021:8691114. [PMID: 34692843 PMCID: PMC8531769 DOI: 10.1155/2021/8691114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 07/19/2021] [Accepted: 10/04/2021] [Indexed: 12/14/2022]
Abstract
The posterior interosseous nerve (PIN) innervates the posterior compartment muscle of the forearm and is a continuation of the deep branch of the radial nerve. The anatomic descriptions of PIN vary among different authors. This study investigated the distribution patterns of PIN and its relationships to the supinator muscle. This study investigated which nerves innervate the posterior compartment muscles of the forearm, the radial nerve, and the PIN, using 28 nonembalmed limbs. Also, the points where the muscle attaches to the bone were investigated. The measured variables in this study were measured from the most prominent point of the lateral epicondyle of the humerus (LEH) to the most distal point of the radius styloid process. For each specimen, the distance between the above two points was assumed to be 100%. The measurement variables were the attachment area of the supinator and branching points from the radial nerve. The attachment points of the supinator to the radius and ulna were 47.9% ± 3.6% and 31.5% ± 5.2%, respectively, from the LEH. In 67.9% of the specimens, the brachioradialis and extensor carpi radialis longus (ECRL) were innervated by the radial nerve before superficial nerve branching, and the extensor carpi radialis brevis (ECRB) innervated the deep branch of the radial nerve. In 21.4% of the limbs, the nerve innervating the ECRB branched at the same point as the superficial branch of the radial nerve, whereas it branched from the radial nerve in 7.1% of the limbs. In 3.6% of the limbs, the deep branch of the radial nerve branched to innervate the ECRL. PIN was identified as a large branch without divisions in 10.7% and as a deep branch innervating the extensor digitorum in 14.3% of the limbs. The anatomic findings of this study would aid in the diagnosis of PIN syndromes.
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Benes M, Kachlik D, Kunc V, Kunc V. The arcade of Frohse: a systematic review and meta-analysis. Surg Radiol Anat 2021; 43:703-711. [PMID: 33677682 DOI: 10.1007/s00276-021-02718-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/16/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE The structure of the proximal margin of the superficial layer of the supinator muscle is of high interest to many researches. Its tendinous appearance, called the arcade of Frohse, may be clinically important because of its close relationship to the deep branch of the radial nerve passing beneath it and is considered to be the cause of several syndromes. Given the importance of this structure, we aimed to provide a comprehensive and evidence-based review with meta-analytic techniques. MATERIALS AND METHODS The meta-analysis was performed in adherence to the PRISMA guidelines. Three medical databases were searched in order to identify all potentially eligible articles. Included studies were assessed for quality and the extracted morphological and morphometric data from the relevant articles was analyzed with the use of random effects meta-analysis. RESULTS A total of 20 studies were included into this meta-analysis. The pooled prevalence of the arcade of Frohse was calculated to be 66% within the adult population and 0% in the fetuses. Other variations regarding the arcade of Frohse were identified as very rare. Analysis of the morphometric parameters revealed the average proportions to be 23.22 mm for the length, 11.05 mm for the width and the mean thickness is 0.67 mm. CONCLUSIONS The arcade of Frohse is a commonly found structure in adults and thoughtful knowledge of its texture and morphology is especially useful in neurology, neurosurgery, orthopedics, trauma surgery and hand surgery, because it is considered to be the most common source of compression for the deep branch of the radial nerve.
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Affiliation(s)
- Michal Benes
- Department of Anatomy, Second Faculty of Medicine, Charles University, Plzeňská 130/221, 150 06, Prague, Czech Republic
| | - David Kachlik
- Department of Anatomy, Second Faculty of Medicine, Charles University, Plzeňská 130/221, 150 06, Prague, Czech Republic. .,Department of Health Care Studies, College of Polytechnics, Jihlava, Czech Republic.
| | - Vladimir Kunc
- Department of Computer Science, Czech Technical University, Prague, Czech Republic
| | - Vojtech Kunc
- Department of Anatomy, Second Faculty of Medicine, Charles University, Plzeňská 130/221, 150 06, Prague, Czech Republic.,Clinic of Trauma Surgery, Masaryk Hospital, Usti nad Labem, Czech Republic
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Park D, Kim DY, Eom YS, Lee SE, Chae SB. Posterior interosseous nerve syndrome caused by a ganglion cyst and its surgical release with intraoperative neurophysiological monitoring: A case report. Medicine (Baltimore) 2021; 100:e24702. [PMID: 33663080 PMCID: PMC7909167 DOI: 10.1097/md.0000000000024702] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 01/21/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Intraoperative neurophysiological monitoring (IONM) has been utilized not only for the rapid detection of neural insults during surgeries, but also to verify the neurophysiological integrity of nerve lesions in the surgical field. PATIENT CONCERNS A 32-year-old woman presented with a wrist and finger drop that had lasted about 3 months. DIAGNOSES The result of the initial electrodiagnostic test was consistent with posterior interosseous nerve (PIN) syndrome. Ultrasonography and magnetic resonance imaging of the proximal forearm showed a cystic mass at the anterolateral aspect of the radial head, which was diagnosed as a ganglion cyst. INTERVENTIONS Surgical release of the ganglion cyst with IONM was performed. During the surgery, we induced nerve action potentials and compound motor action potentials across the ganglion cyst, which demonstrated neural continuity. OUTCOMES Three months after the surgery, the patient showed partial recovery of wrist and finger extensor muscle power. An electrodiagnostic test conducted 3 months after the surgery showed reinnervation potentials in PIN-innervated muscles. LESSONS IONM during peripheral nerve surgeries can support surgical decisions and confirm the location and degree of nerve damage.
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Affiliation(s)
| | - Dong Young Kim
- Department of Orthopedic Surgery, Spine and Joint Center, Pohang Stroke and Spine Hospital, Pohang
| | - Yoon Sik Eom
- Department of Orthopedic Surgery, Spine and Joint Center, Pohang Stroke and Spine Hospital, Pohang
| | | | - Seung Bum Chae
- Department of Orthopedic Surgery, Daegu Catholic University Hospital, Daegu, Republic of Korea
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Manoharan D, Sudhakaran D, Goyal A, Srivastava DN, Ansari MT. Clinico-radiological review of peripheral entrapment neuropathies - Part 1 upper limb. Eur J Radiol 2020; 131:109234. [PMID: 32949858 DOI: 10.1016/j.ejrad.2020.109234] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 06/21/2020] [Accepted: 08/08/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE This article aims to review the pertinent anatomy, etiopathogenesis, current clinical and radiological concepts and principles of management in case of upper limb entrapment neuropathies. METHODS The review is based on critical analysis of the existing literature as well as our experience in dealing with entrapment neuropathies. RESULTS Entrapment neuropathies of the upper limb peripheral nerves are common conditions that are often misdiagnosed because of their varying clinical presentations and lack of standardized diagnostic methods. Clinical assessment and electrodiagnostic studies have been the mainstay; however, imaging techniques have provided newer insights into the pathophysiology of these entities, leading to a paradigm shift in their diagnosis and management. The current best practice protocols for entrapment syndromes are constantly evolving with increasing emphasis on the role high-resolution ultrasound and magnetic resonance imaging. Many imaging criteria are described and we have tried to present the most validated measurements for diagnosing entrapment neuropathies. CONCLUSION It is imperative for a clinical radiologist to be familiar with the etiopathogenesis and clinical features of these conditions, in addition to being thorough with the anatomy and the latest imaging strategies.
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Affiliation(s)
- Dinesh Manoharan
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Dipin Sudhakaran
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Ankur Goyal
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India.
| | | | - Mohd Tahir Ansari
- Department of Orthopedics, All India Institute of Medical Sciences, New Delhi, India
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Evaluation of the supinator muscle and deep branch of the radial nerve: impact on nerve compression. Surg Radiol Anat 2020; 42:927-933. [PMID: 32367465 DOI: 10.1007/s00276-020-02480-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 04/23/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE The aim of this study was to investigate the superficial head of supinator muscle (SM) and deep branch of the radial nerve (DBRN) course in SM to see whether the texture characteristics of the superficial head of SM might have a potential compressive effect on the nerve. MATERIALS AND METHODS Elbow and proximal forearm region of 20 preserved cadavers (n 40, 12 M, 8 F) were dissected in order to measure total and part of DBRN lengths between some reference points. The texture characteristics of both the proximal (where DBRN enters SM) and distal arcade (where DBRN exits SM) of the superficial head of SM were evaluated based on its structure's being muscular, musculotendinous, tendinous, or membranous. RESULTS The total length of DBRN between sexes without taking side (L/R) into consideration (P = 0.030) and left radiocapitellar joint (RCJ)-arcade of Frohse (AF) length between sexes (P = 0.050) were statistically significant. There was a gradual increase in caliber getting more flattened in every consecutive level which was statistically significant when every two consecutive levels were compared. When compared according to the texture type, there were also significant differences. CONCLUSIONS Flattening of DBRN in the supinator canal suggests a chronic compression on the nerve. Differences in the texture of the superficial head of the supinator might facilitate this compression. An understanding of the anatomy and nerve topography is of utmost importance in the accurate diagnosis and effective management of peripheral nerve compression.
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