Sonographic Peripheral Nerve Topography: A Landmark-based Algorithm [1st ed.] 978-3-030-11032-1;978-3-030-11033-8

Table of contents :
Front Matter ....Pages i-xiii
How to Use This Book Effectively: A User’s Guide! (Bernhard Moriggl, Alexander Loizides, Hannes Gruber)....Pages 1-5
Neck (Alexander Loizides, Sebastian Schuhmayer, Bernhard Moriggl)....Pages 7-54
Upper Arm, Forearm and Hand (Alexander Loizides, Sebastian Schuhmayer, Bernhard Moriggl)....Pages 55-109
Trunk (Alexander Loizides, Hannes Gruber, Philipp Koch, Sebastian Schuhmayer, Bernhard Moriggl)....Pages 111-143
Gluteal Region (Hannes Gruber, Philipp Koch, Bernhard Moriggl)....Pages 145-155
Thigh, Lower Leg, and Foot (Hannes Gruber, Philipp Koch, Bernhard Moriggl)....Pages 157-223
Back Matter ....Pages 225-228

Citation preview

Hannes Gruber Alexander Loizides Bernhard Moriggl Editors

Sonographic Peripheral Nerve Topography A Landmark-based Algorithm

123

Sonographic Peripheral Nerve Topography

Hannes Gruber  •  Alexander Loizides Bernhard Moriggl Editors

Sonographic Peripheral Nerve Topography A Landmark-based Algorithm

Editors Hannes Gruber Department Radiologie Medizinische Universität Innsbruck Innsbruck Austria

Alexander Loizides Department Radiologie Medizinische Universität Innsbruck Innsbruck Austria

Bernhard Moriggl Clinical & Functional Anatomy Medical University of Innsbruck Innsbruck Austria

Translation from the German language edition: Nervensonographie kompakt - Anatomie der peripheren Nerven mit Landmarks edited by Gruber, Loizides, Moriggl. Copyright © Springer-Verlag GmbH Deutschland 2018 Springer is part of Springer Nature All Rights Reserved. ISBN 978-3-030-11032-1    ISBN 978-3-030-11033-8 (eBook) https://doi.org/10.1007/978-3-030-11033-8 © Springer Nature Switzerland AG 2019 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Foreword

If we wish to be consistently successful in finding peripheral nerves, whether it is for regional anesthesia, pain management, or other clinical applications, we must have in-depth knowledge of clinically relevant anatomy. Recognizing vascular, muscular, bony, and other nearby nonneural structures helps us identify the target nerve we seek to find. For beginners of nerve sonography, learning to identify relevant sonoanatomy can be quite challenging at the outset and often time consuming if it is self-taught. It is akin to traveling in a foreign land for the first time without a map or navigation aid of any kind. It would be most helpful to be prepared before embarking on a new journey by gathering useful information and directions. This is especially true for ultrasound-guided regional anesthesia as well as many other interventional pain management or diagnostic procedures. This nerve sonography handbook authored by Professors Hannes Gruber, Alexander Loizides, and Bernhard Moriggl, all experts in nerve sonography, is precisely such a helpful aid. One may consider this handbook the Google Maps for nerve sonographers to navigate the world of peripheral nerve sonography. It is a simple, easy-to-follow, reference book with some very cool features – simplicity, landmark-based illustrations, practical tips on scanning, and standardized algorithm for nerve localization. In this handbook, a search of the nerve not only includes a basic nerve compass, it also highlights alternate routes to find the nerve realizing that variation is the rule of human anatomy as Professor Moriggl, the best anatomy and ultrasound professor I have ever known, so often reminds us. This is a great feature to overcome navigational difficulties by showing sonographic views and screenshots of unfamiliar anatomical terrains. I am confident you will find this one-of-a-kind handbook an invaluable asset to sonographers of musculoskeletal and peripheral nerve anatomy. You will benefit from the authors’ wealth of knowledge, practical scanning advice, and step-by-step nerve localization algorithm. This handbook is easy to understand, concise, and enlightening. Studying this book is a great way to plan and get ready before embarking on a journey of peripheral nerve sonography. As the popular slogan says, “Don’t Leave Home Without It.” 

Vincent W. S. Chan, MD, FRCPC, FRCA Department of Anesthesia University of Toronto Toronto, ON, Canada

v

Preface

“For whom, and why?” Our target audience and the purpose of this book. This atlas is meant to be a useful “vade mecum” for all colleagues interested and involved in nerve sonography in order to locate nerves as quickly and easily as possible in daily clinical practice. You could put it this way, too: “Never search again for a nerve” – for in this book, you have already found it. Thus, the “Why?” has already been nearly answered since nothing comparable exists until now. With this book, you will save valuable time, time that most certainly can be better used for a subsequent diagnosis, intervention, and/or therapy. Quite deliberately, this atlas does not contain any information on these latter aspects! Due to the clear descriptions of visible and/or palpable “external” landmarks by illustrations and short (!) texts, the ultrasound probe can be placed optimally from the beginning: initial probe positioning. In the ultrasound images, a few but characteristic “internal” landmarks are shown, which help in finding the location and topographic allocation of the “target structure” nerve. As a valuable support for practical application, we, in particular, documented those areas where specific nerves can be delimited best: the respective “point of optimal visibility” (POV). Such a point does exist for (nearly) any peripheral nerve! Not without reason, the “POV” does take central position in the overview tables for each single nerve! We are convinced that, especially in cases of unfavorable sonographic conditions, the exact knowledge of these POVs can be of decisive help. All this shows that the authors paid very special attention to the practical aspects of nerve sonography. As a result, relevant variations were mentioned, and – if feasible and reasonable – alternative plans were addressed. Additionally, some comments (concerning, e.g., positioning or pitfalls) were enclosed. References to the innumerable studies concerning nerve sonography, however, were intentionally left out since including them would have conflicted with the intention of this compact manual. We do hope very much that you will be pleased by this atlas and that, above all, it will be used frequently! We should close our introduction with a “quotation” inspired by the famous German author Wilhelm Busch (1832–1908): “You’ll miss a nerve quite easily, if searched for it where it can’t be.”

May our book help you to avoid that calamity! Innsbruck, Austria  

Bernhard Moriggl Alexander Loizides Hannes Gruber

vii

Contents

1 How to Use This Book Effectively: A User’s Guide! �����������������������������������������������   1 Bernhard Moriggl, Alexander Loizides, and Hannes Gruber 2 Neck�����������������������������������������������������������������������������������������������������������������������������   7 Alexander Loizides, Sebastian Schuhmayer, and Bernhard Moriggl 3 Upper Arm, Forearm and Hand�������������������������������������������������������������������������������  55 Alexander Loizides, Sebastian Schuhmayer, and Bernhard Moriggl 4 Trunk��������������������������������������������������������������������������������������������������������������������������� 111 Alexander Loizides, Hannes Gruber, Philipp Koch, Sebastian Schuhmayer, and Bernhard Moriggl 5 Gluteal Region ����������������������������������������������������������������������������������������������������������� 145 Hannes Gruber, Philipp Koch, and Bernhard Moriggl 6 Thigh, Lower Leg, and Foot ������������������������������������������������������������������������������������� 157 Hannes Gruber, Philipp Koch, and Bernhard Moriggl Appendix ����������������������������������������������������������������������������������������������������������������������������� 225 Index������������������������������������������������������������������������������������������������������������������������������������� 227

ix

Contributors

Hannes Gruber  Department of Radiology, Medical University Innsbruck, Innsbruck, Austria Philipp Koch  Department of Radiology, Medical University Innsbruck, Innsbruck, Austria Alexander  Loizides Department of Radiology, Medical University Innsbruck, Innsbruck, Austria Bernhard  Moriggl Division of Clinical and Functional Anatomy, Medical University Innsbruck, Innsbruck, Austria Sebastian Schuhmayer  Department of Radiology, Medical University Innsbruck, Innsbruck, Austria

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Abbreviations

A. Arteria Aa. Arteriae AP Alternative plan ELM External landmarks ILM Internal landmarks IPOS Initial positioning of the probe K Comments M. Musculus Mm. Musculi N. Nervus Nn. Nervi POV Point of optimal visibility R. Ramus Rr. Rami V. Vena VAR Variations Vv. Venae

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How to Use This Book Effectively: A User’s Guide! Bernhard Moriggl, Alexander Loizides, and Hannes Gruber

Contents The simple structure

 2

The example: Ramus palmaris of Nervus medianus

 2

General remarks

 5

B. Moriggl (*) Division of Clinical and Functional Anatomy, Medical University Innsbruck, Innsbruck, Austria e-mail: [email protected] A. Loizides · H. Gruber Department of Radiology, Medical University Innsbruck, Innsbruck, Austria e-mail: [email protected]; [email protected] © Springer Nature Switzerland AG 2019 H. Gruber et al. (eds.), Sonographic Peripheral Nerve Topography, https://doi.org/10.1007/978-3-030-11033-8_1

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As a consequence of what we said above, we want to illustrate here how this book may be used most effectively with an example, having first presented a short overview (valuable time can also be lost by consulting an “unknown” manual!). Finally we present a short list of generally valid statements. The simple structure The book contains just five major regions: –– –– –– –– ––

The neck The upper extremity (upper arm, forearm/hand) The trunk The gluteal region The lower extremity (thigh, lower leg/foot)

In these regions the nerves are listed alphabetically (with page numbers) in LATIN following the Terminologia Anatomica (International Anatomical Terminology) by FCAT (Federative Committee on Anatomical Terminology; 1998 IFFA; FACT; Georg Thieme Verlag, Stuttgart, Germany) and treated in exactly that order on a double page each: –– Important branches (ramus/rami) are to be found under the name of the respective nerve of origin! –– If a nerve is mentioned more than once, it is numbered consecutively, and the region is named! The example: Ramus palmaris of Nervus medianus Necessary steps in order to locate the respective branch: 1 . Choose the body region – search under “forearm/hand.” 2. Consult the list – “nervus medianus.” 3. You will find “nervus medianus and ramus palmaris” (with page numbers). 4. Open the book on that side and read.

1  How to Use This Book Effectively: A User’s Guide!

On the left side on the upper half page, there is the following (standardized) table. ELM IPOP ILM POV VAR

AP C

1. Palpable groove between tendo musculi flexoris carpi radialis and tendo musculi palmaris longi* Transverse, at the transition between the middle and distal forearm** 1. Tendon of the M. flexor carpi radialis 2. Tendon of the M. palmaris longus*** A few millimeters distal to the origin from the N. medianus ** Origin far proximal or distal *** No tendon of the musculus palmaris longus (in 15–20% of cases!) No ramus palmaris nervi mediani (rare!) NONE Use the highest possible frequency (minimum 15 MHz) *Thumb and small finger in opposition

Meaning of abbreviations ELM IPOP ILM POV VAR AP C

External landmark(s) Initial positioning of probe Internal landmark(s) Point of optimal visibility Relevant (exclusively such!) variations Alternative plan (if worth mentioning!) Comment(s) – if helpful/of interest

… in the lower half of that page two photographs …

Fig. 1.1  Legend ELM [here as an example: palpable groove between the tendon of the musculus flexor carpi radialis and musculus palmaris longus (the latter clearly seen here; but see VAR)]

Fig. 1.2  Legend IPOP [here as an example: transverse probe positioning – initial placement far proximal! (see VAR in the table)]

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… in the upper half of the page on the right side …

Fig. 1.3  Legend ILM [here as an example: depiction of the musculus flexor digitorum superficialis (MFDS) and musculus flexor digitorum profundus (MFDP). Superficially the tendon of the musculus flexor carpi radialis (T-MFCR) is depicted. Arteria radialis (AR). Musculus pronator quadratus (MPrQ)]

… in the lower half of that page …

Fig. 1.4  Legend POV [here as an example: the ramus palmaris nervi mediani (large arrow) is best depicted at its origin radial to the nervus medianus (small arrows) between the superficial and deep flexor muscles and deep to the tendon of the musculus flexor carpi radialis]

1  How to Use This Book Effectively: A User’s Guide!

General remarks –– For a faster and better comparison, we chose identical images for the ILM and POV! –– The illustration of the ILM is labelled. –– The illustration of the POV contains in nearly all cases only the marking of the nerve(s) (ARROWS!).

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Neck Alexander Loizides, Sebastian Schuhmayer, and Bernhard Moriggl

Contents Ganglion cervicale medium

 8

Nervus accessorius

 10

Nervus auricularis magnus

 12

Nervus dorsalis scapulae

 14

Nervus facialis: R. colli

 16

Nervus hypoglossus 1 (diaphragma oris)

 18

Nervus hypoglossus 2 (trigonum caroticum)

 20

Nervus laryngeus inferior

 22

Nervus laryngeus recurrens

 24

Nervus laryngeus superior: R. externus

 26

Nervus laryngeus superior: R. internus

 28

Nervus laryngeus superior

 30

Nervus occipitalis major

 32

Nervus occipitalis minor

 34

Nervus occipitalis tertius

 36

Nervus phrenicus

 38

Nervus subclavius

 40

Nervi supraclaviculares

 42

Nervus suprascapularis

 44

Nervus thoracicus longus 1 (fossa supraclavicularis major)

 46

Nervus transversus colli

 48

Nervus vagus (X)

 50

Plexus cervicalis: R. trapezius

 52

A. Loizides (*) · S. Schuhmayer Department of Radiology, Medical University Innsbruck, Innsbruck, Austria e-mail: [email protected]; [email protected]

B. Moriggl Division of Clinical and Functional Anatomy, Medical University Innsbruck, Innsbruck, Austria e-mail: [email protected]

© Springer Nature Switzerland AG 2019 H. Gruber et al. (eds.), Sonographic Peripheral Nerve Topography, https://doi.org/10.1007/978-3-030-11033-8_2

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Ganglion cervicale medium ELM IPOP ILM

POV VAR AP C

1. Pulsation of the arteria carotis communis 2. Palpable tuberculum anterius of the processus transversus C6 (=tuberculum caroticum or “Tubercule de Chassaignac”) Transverse, middle of the probe over the tuberculum anterius C6 1. Tuberculum anterius C6 2. Musculus longus colli 3. Musculus longus capitis At the level of the tuberculum anterius C6, on the ventral aspect of the M. longus colli (mostly medial to the M. longus capitis) Missing ganglion cervicale medium Ganglion cervicale medium further cranial (C5/C4); in that case on the ventral aspect of the M. longus capitis! NONE NONE

Fig. 2.1  Feel the pulsation of the arteria carotis communis at the anterior border of the musculus sternocleidomastoideus, and palpate the tuberculum anterius of the processus transversus C6

Fig. 2.2  The middle of the probe is placed over the tuberculum anterius of the processus transversus C6

2 Neck

9

Fig. 2.3  Characteristic dorsal shadowing of the mighty tuberculum anterius (TA) of the processus transversus C6. The glandula thyroidea (GT) is depicted medial to the vena jugularis interna (VJI) and the arteria carotis communis (ACC). Deep to the fascia cervicalis profunda: musculus longus colli (MLCo) and musculus longus capitis (MLCa)

Fig. 2.4  Depiction of the ganglion cervicale medium (arrow) at the POV between the vessels and the praevertebral muscles. Nervus vagus (small arrow)

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Nervus accessorius ELM

IPOP ILM POV VAR AP C

The PUNCTUM NERVOSUM can be palpated during contraction of the  1. Platysma  2. M. sternocleidomastoideus Oblique (transverse to assumed course of the nerve) to the posterior border of the M. sternocleidomastoideus; probe position one fingerbreadth cranial to the punctum nervosum 1. M. sternocleidomastoideus 2. Nervus auricularis magnus Within the M. sternocleidomastoideus Course medial to the M. sternocleidomastoideus In case of the mentioned VAR, the nerve can be found more easily latero-posterior, deep to the M. trapezius at its anterior border (probe parallel), and can be followed cranially towards the M. sternocleidomastoideus NONE

Fig. 2.5  Locate the punctum nervosum: at the cross point of the posterior platysma border (“grimace“) with that of the musculus sternocleidomastoideus

Fig. 2.6  Placement of the probe one finger’s breadth cranial to the punctum nervosum perpendicular to the course of the nerve

2 Neck

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Fig. 2.7  The musculus sternocleidomastoideus (MSCM) with the superficially located, nearly anechoic  – and here oval  – appearing nervus auricularis magnus (see Fig. 2.8)

Fig. 2.8  POV of the nervus accessorius (arrow) within the musculus sternocleidomastoideus. Nervus auricularis magnus (small arrow)

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Nervus auricularis magnus ELM

IPOP ILM POV VAR AP C

The PUNCTUM NERVOSUM can be palpated during contraction of the  1. Platysma  2. M. sternocleidomastoideus Transverse, one fingerbreadth cranial to the punctum nervosum, middle of probe central over the M. sternocleidomastoideus 1. M. sternocleidomastoideus enveloped by the fascia cervicalis superficialis See IPOP: at the outer surface of the M. sternocleidomastoideus* Early division of the nerve (before penetrating the fascia cervicalis superficialis) >> Two smaller nerves at the POV NONE *The N. auricularis magnus is simultaneously seen also deep to the muscle (looping around the posterior border!); differentiation to other nerves of the plexus cervicalis by up and down movement of the probe!

Fig. 2.9  Locate the punctum nervosum: at the cross point of the posterior platysma border (“grimace“) with that of the musculus sternocleidomastoideus

Fig. 2.10  Placement of the probe central over the musculus sternocleidomastoideus one fingerbreadth cranial to the punctum nervosum

2 Neck

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Fig. 2.11  The musculus sternocleidomastoideus (MSCM) slightly cranial to the punctum nervosum; clearly delimited by the fascia cervicalis superficialis

Fig. 2.12  The nervus auricularis magnus at the POV slightly cranial to the punctum nervosum (arrows). Cave: in contrary to the superficial part, the deep part can be confused with other hypoechogenic, round to oval structures!

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Nervus dorsalis scapulae ELM IPOP ILM POV VAR

AP C

1. Posterior border of the M. sternocleidomastoideus 2. Palpable hiatus scalenorum* Oblique, approximately transverse to the course of the musculus scalenus medius** 1. M. scalenus medius 2. Root C5 Within the M. scalenus medius Common trunk of the N. dorsalis scapulae and N. thoracicus longus Course superficial to the M. scalenus medius Two nervi dorsales scapulae (one within the M. scalenus medius, the other superficial to it) NONE *Inspiration! **Neck of the patient in a stretched position, head turned to the contralateral side

Fig. 2.13  By turning the head to the contralateral side, the hiatus scalenorum can be best palpated at the posterior border of the musculus sternocleidomastoideus

Fig. 2.14  The probe is placed at the dorsal border of the musculus sternocleidomastoideus and nearly transverse to the course of the musculus scalenus medius

2 Neck

Fig. 2.15  Root C5 within the hiatus scalenorum between musculus scalenus anterior (MSA) and musculus scalenus medius (MSM)

Fig. 2.16  Depiction of the nervus dorsalis scapulae at the POV (arrow) within the musculus scalenus medius

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Nervus facialis: R. colli ELM IPOP ILM

POV VAR AP C

1. Angulus mandibulae 2. Palpable tractus angularis fasciae cervicalis* Parallel to the inferior border of the mandibula, midpoint of probe one fingerbreadth dorsal to the angulus mandibulae** 1. Glandula parotis 2. Vena retromandibularis 3. Glandula submandibularis [4. Septum interglandulare (between glandula parotis and glandula submandibularis): appears often as an artefact!] Superficial to the V. retromandibularis, at the most caudal part of the glandula parotis Position of the nerve medial to the V. retromandibularis NONE *Stretched position as depicted in ELM and IPOP! **No compression! (ILM: V. retromandibularis!)

Fig. 2.17  Palpate the tractus angularis fasciae cervicalis immediately caudal to the angulus mandibulae

Fig. 2.18  Place the centre of the probe one fingerbreadth dorsal to the angulus mandibulae

2 Neck

17

Fig. 2.19  The vena retromandibularis (VRM) lies within the glandula parotis (GP) and is the decisive internal landmark for finding the ramus colli; glandula submandibularis (GSM)

Fig. 2.20  POV of the ramus colli nervi facialis (Pfeil) superficial/anterior to the vena retromandibularis

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Nervus hypoglossus 1 (diaphragma oris) ELM IPOP* ILM

POV VAR AP C

1. Corpus mandibulae 2. Palpable os hyoideum Slightly oblique, parallel to the posterior border of the musculus mylohyoideus** 1. M. mylohyoideus 2. M. hyoglossus 3. Glandula submandibularis 1. Near the posterior border of the M. mylohyoideus NONE See N. hypoglossus 2! *Use a probe with a smaller footprint: e.g. “hockey stick!” heel-in-manoeuvre! **Two to three fingerbreadths anterior to the angulus mandibulae

Fig. 2.21  Palpate the corpus mandibulae and os hyoideum (cornu majus) simultaneously

Fig. 2.22  The probe is placed in a slightly oblique orientation two to three fingerbreadths anterior to the angulus mandibulae

2 Neck

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Fig. 2.23  Depiction of the musculus mylohyoideus (MMH) and the musculus hyoglossus (MHG) with the vena comitans nervi hypoglossi (Vc) in between them. Glandula submandibularis (GSM)

Fig. 2.24  The nervus hypoglossus (arrow) at the POV between musculus mylohyoideus and musculus hyoglossus

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Nervus hypoglossus 2 (trigonum caroticum) ELM

IPOP* ILM POV VAR AP C

1. Pulsation of the A. carotis externa 2. Palpable os hyoideum 3. Corpus mandibulae Longitudinal, dorsal to the os hyoideum, cranial border of the probe at the lower jaw** A. carotis externa Directly lateral to (“on top of”) the A. carotis externa In case of a very lateral course of the A. carotis interna in the trigonum caroticum, the N. hypoglossus is better/also seen on that artery! NONE *Probe with a smaller width preferable: e.g. “Hockey Stick!” **Heel-in-manoeuvre!

Fig. 2.25  Feel the pulsation of the arteria carotis externa (dorsal to the os hyoideum)

Fig. 2.26  Placement of the probe along the course of the arteria carotis externa

2 Neck

Fig. 2.27  The arteria carotis externa (ACE) as the most important internal landmark

Fig. 2.28  The nervus hypoglossus (arrow) runs directly lateral to the arteria carotis externa: POV

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Nervus laryngeus inferior* ELM

IPOP ILM

POV VAR AP C

1. Fossa suprasternalis 2. M. sternocleidomastoideus 3. Palpable trachea Transverse, three to four fingerbreadths cranial to the fossa suprasternalis**, middle of probe over the medial border of the M. sternocleidomastoideus 1. Trachea 2. Oesophagus 3. Glandula thyroidea At the most cranial part of the sulcus oesophago-trachealis, dorsal to the glandula thyroidea NONE Look for the nerve further caudal; there, however, the nerve shows a deeper course and is therefore more difficult to depict (use lower frequencies!) *The N. laryngeus inferior can be depicted at the right side only after maximal tilting of the head to the contralateral side. **Considerable variance! (length of the neck, constitution, age, etc.)

Fig. 2.29  Starting point of the (deep) palpation: upper border of the fossa suprasternalis, medial to the musculus sternocleidomastoideus; the trachea is thereby clearly palpable

Fig. 2.30  Transverse probe positioning distinctly cranial to the fossa suprasternalis (in this subject, four fingerbreadths) at the medial border of the musculus sternocleidomastoideus

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Fig. 2.31  Oesophagus (OE) and trachea (T) (and the groove between them) are the main internal landmarks. Note: only after turning the head to the contralateral side, the OE appears on the right side of the neck! Glandula thyroidea (GT), arteria carotis communis (ACC), musculus sternocleidomastoideus (MSCM)

Fig. 2.32  The right nervus laryngeus inferior (arrow) in the terminal segment of the sulcus oesophago-trachealis: point of optimal visibility (POV)

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Nervus laryngeus recurrens ELM IPOP ILM POV VAR AP C

1. Clavicula 2. Pulsation (often deep palpation necessary!) of the arteria subclavia within the fossa supraclavicularis major Directly above and parallel to the clavicula lateral to the M. sternocleidomastoideus 1. A. subclavia 2. Truncus brachiocephalicus* Posterior to the A. subclavia (or the truncus brachiocephalicus*) Nerve not traceable at the POV: N. laryngeus non-recurrens** **In that case, follow the N. vagus (starting cranial to the bifurcation of the A. carotis communis) until the nerve branches off *Not always visible!

Fig. 2.33  Feel the pulsation of the arteria subclavia in the fossa supraclavicularis major

Fig. 2.34  Place the probe parallel to and directly above the clavicula

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Fig. 2.35  Unmistakable internal landmarks are the arteria subclavia (AS) and truncus brachiocephalicus (TBC), respectively

Fig. 2.36  The nervus laryngeus recurrens (arrow) is depicted (here) dorsal to the primary segment of the arteria subclavia (cave: hyperechogenic due to a “dorsal acoustic enhancement”!)

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Nervus laryngeus superior: R. externus ELM IPOP ILM

POV VAR AP C

1. Pulsation of the A. carotis communis 2. Palpable cartilago thyroidea: cornu inferius Oblique to nearly transverse between the ELMs 1. A. thyroidea superior 2. Glandula thyroidea (polus superior) 3. Musculus cricothyroideus Near the A. thyroidea superior (or a branch), medial of the polus superior of the glandula thyroidea (in a normal-­appearing thyroid!) NONE NONE Minimum required frequency: 18 MHz!

Fig. 2.37  Palpate the external landmarks: the arteria carotis communis and medio-caudal to it the cartilago thyroidea with its cornu inferius

Fig. 2.38  Oblique probe orientation, with centre of probe at the medial border of the musculus sternocleidomastoideus at the level of the upper thyroid pole

2 Neck

27

Fig. 2.39  Internal landmarks: polus superior of the glandula thyroidea (GT), branch of the arteria thyroidea superior (arrowhead), here at the medial border of the GT and anterior to the (hypoechogenic) musculus cricothyroideus (MCT); arteria carotis communis (ACC), cartilago thyroidea (CT), cartilago cricoidea (CC)

Fig. 2.40  Depiction of the ramus externus of the nervus laryngeus superior (arrow) at the POV lying on the musculus cricothyroideus

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Nervus laryngeus superior: R. internus ELM IPOP ILM

POV VAR AP C

1. Posterior end of the cornu majus ossis hyoidei 2. Cartilago thyroidea: cornu superius Oblique, cranial end over the os hyoideum, caudal end over the cartilago thyroidea 1. Os hyoideum 2. Membrana thyreohyoidea 3. A. laryngea superior 4. Glandula submandibularis 5. M. thyrohyoideus Superficial to the membrana thyreohyoidea, between os hyoideum and cartilago thyroidea (cornu superius) NONE NONE Minimum required frequency: 18 MHz

Fig. 2.41  Localisation of the two external landmarks by palpation: os hyoideum (posterior end of the cornu majus) and the cartilago thyroidea (cornu superius)

Fig. 2.42  Oblique probe positioning between the two external landmarks

2 Neck

29

Fig. 2.43  Depiction of important internal landmarks: os hyoideum (OH), musculus thyrohyoideus (MTH), A. laryngea superior (arrowhead), glandula submandibularis (GSM)

Fig. 2.44  The nervus laryngeus superior – ramus internus (arrow) is depicted at the POV between the musculus thyrohyoideus and the membrana thyreohyoidea (white line)

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Nervus laryngeus superior ELM IPOP ILM POV VAR+ AP C

1. Anterior border of the M. sternocleidomastoideus 2. Pulsation of the A. carotis communis at the trigonum caroticum Longitudinal, over the A. carotis externa; probe position cranial to the palpation point! (The acoustic window is more from lateral and differs therefore slightly from that of the N. hypoglossus 2!) 1. A. carotis externa Medial to the A. carotis externa When the A. carotis interna is medial to the externa: Nerve can run* between the two arteries! Bifurcation of the A. carotis communis very cranial (outside the trigonum caroticum!): Nerve lies then medial to the communis* NONE + Generally speaking, all VAR of the arteries in the trigonum caroticum complicate the reliable depiction of the N. laryngeus superior!

Fig. 2.45  Feel the pulsation of the arteria carotis communis at the trigonum caroticum

Fig. 2.46 Longitudinal positioning of the probe over the arteria carotis externa

2 Neck

Fig. 2.47  The arteria carotis externa (ACE) is the internal landmark (consider VAR! in the table)

Fig. 2.48  The nervus laryngeus superior (arrow) lies (mostly, see VAR!) medial to the arteria carotis externa

31

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Nervus occipitalis major ELM IPOP ILM POV VAR AP C

1. Processus mastoideus 2. Processus spinosus axis Oblique, medial end of the probe over the processus spinosus axis; lateral end targets a point one fingerbreadth caudal to the tip of the processus mastoideus 1. M. obliquus capitis inferior 2. Processus spinosus and lamina arcus vertebrae axis At the dorsal surface of the M. obliquus capitis inferior, 2.5 to max. 3 cm lateral to the processus spinosus axis NONE NONE In cases of a burly neck, consider using a convex probe!

Fig. 2.49  Die bony landmarks are palpated with the thumb and the index finger: processus mastoideus lateral and processus spinosus axis medial

Fig. 2.50  The medial end of the probe lies over the processus spinosus axis, the lateral end approximately two fingerbreadths more cranial

2 Neck

33

Fig. 2.51  The internal landmark is the hyperechogenic-appearing musculus obliquus capitis inferior (MOCI). Processus spinosus and lamina of the axis with typical dorsal shadowing! Musculus semispinalis capitis (MSspC)

Fig. 2.52  The nervus occipitalis major (arrow) lies on the dorsal surface of the musculus obliquus capitis inferior, covered by the  – clearly brighter-appearing – musculus semispinalis capitis (“sandwiched”)

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Nervus occipitalis minor* ELM

IPOP ILM

POV VAR

AP C

The PUNCTUM NERVOSUM can be palpated during contraction of the  1. Platysma  2. M. sternocleidomastoideus Transducer oblique, which means perpendicular to the long axis of the M. sternocleidomastoideus; midpoint of probe on the posterior border of the muscle, three(!) fingerbreadths cranial to the punctum nervosum 1. Posterior border of the M. sternocleidomastoideus 2. Fascia cervicalis profunda on the M. levator scapulae; more cranial 3. Fascia covering the M. splenius cervicis (fascia thoracolumbalis) Superficial to the fascia cervicalis profunda, on or near to the dorsal border of the M. sternocleidomastoideus (but noteworthy: see VAR!) Course and size of the N. occipitalis minor are extremely variable!  Almost transverse initial course towards the M. trapezius possible!**; then, after piercing of that muscle, the nerve ascends to the regio occipitalis **In case you cannot find the nerve right away, consider VAR and orientate probe more longitudinal! (with consecutive parallel shift towards the anterior border of the M. trapezius) *Mandatory are probes with highest resolution (minimum 18 MHz)

Fig. 2.53  Locate the punctum nervosum: at the cross point of the posterior platysma border (“grimace“) with that of the musculus sternocleidomastoideus

Fig. 2.54  Probe positioning three fingerwidths cranial to the punctum nervosum (probe at the posterior border of the musculus sternocleidomastoideus)

2 Neck

35

Fig. 2.55  The fascia cervicalis profunda (small arrows) covers the musculus levator scapulae (MLS). Musculus sternocleidomastoideus (MSCM): posterior border

Fig. 2.56  The nervus occipitalis minor (arrow) is best seen (POV) near the posterior border of the musculus sternocleidomastoideus and superficial to the fascia cervicalis profunda

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Nervus occipitalis tertius ELM IPOP ILM POV VAR AP C

1. Processus mastoideus 2. Processus spinosus axis Oblique, medial end of the probe over the processus spinosus axis; lateral end targets a point one fingerbreadth caudal to the tip of the processus mastoideus 1. M. obliquus capitis inferior 2. Processus spinosus and lamina arcus vertebrae axis At the dorsal surface of the M. obliquus capitis inferior, approximately one fingerbreadth lateral to the processus spinosus axis N. occipitalis tertius runs within the M. semispinalis capitis* Visualisation of the nervus occipitalis tertius also at the level of the facet-joint C2/3 possible (Eichenberger et al. 2006) *In that case difficult to find!

Fig. 2.57  Die bony landmarks are palpated with the thumb and the index finger: processus mastoideus lateral and processus spinosus axis medial

Fig. 2.58  The medial end of the probe lies over the processus spinosus axis, the lateral end approximately two fingerbreadths further cranial

2 Neck

37

Fig. 2.59  The internal landmark is the hyperechogenic-appearing musculus obliquus capitis inferior (MOCI). Processus spinosus and lamina of the axis with typical dorsal shadowing! Musculus semispinalis capitis (MSspC)

Fig. 2.60  The nervus occipitalis tertius (arrow) is depicted posterior to the musculus obliquus capitis inferior, medial to the nervus occipitalis major (small arrow)

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Nervus phrenicus ELM IPOP ILM POV VAR AP C

1. Posterior border of the M. sternocleidomastoideus 2. Palpable hiatus scalenorum* Transverse probe positioning on the M. sternocleidomastoideus (near its posterior border) at the transition between the middle and caudal third of the muscle 1. M. scalenus anterior 2. Fascia cervicalis profunda (covering the muscle) Anterior surface of the M. scalenus anterior, deep to a branch of the truncus thyreocervicalis (often the A. cervicalis superficialis) Two Nn. phrenici (can be merged more caudally) N(n). phrenicus(i) accessorius(ii) arising from C3 and/or C5! If difficult to find, depict C4 and C5 nerve roots and look for the origin of the N. phrenicus (accessorius), and then follow caudally on the M. scalenus anterior *In inspiration!

Fig. 2.61  Palpate the hiatus scalenorum at the posterior border of the musculus sternocleidomastoideus

Fig. 2.62  Transverse probe positioning at the posterior border of the musculus sternocleidomastoideus at the border between the middle and caudal third of the muscle

2 Neck

39

Fig. 2.63  In its cross section mostly oval-appearing musculus scalenus anterior (MSA) with its fascial covering. TTC: a branch of the truncus thyreocervicalis deep to the musculus sternocleidomastoideus (MSCM)

Fig. 2.64  The POV of the nervus phrenicus (arrow): deep to a branch of the truncus thyreocervicalis (here the A. cervicalis superficialis)

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Nervus subclavius ELM IPOP ILM POV VAR AP C

1. Clavicula 2. Feel the pulsation (often deep palpation necessary!) of the A. subclavia within the fossa supraclavicularis major Immediately above and parallel to the clavicula lateral to the M. sternocleidomastoideus 1. A. subclavia 2. Plexus brachialis on the first rib (“bunch of grapes”) On the A. subclavia, immediately after branching from the plexus brachialis Missing nerve (if M. subclavius is missing) NONE NONE

Fig. 2.65  Feel the pulsation of the arteria subclavia in the fossa supraclavicularis major

Fig. 2.66  Probe positioning parallel to and immediately above the clavicula

2 Neck

41

Fig. 2.67  The arteria subclavia (AS) on the first rib (dorsal shadowing!); the plexus brachialis (“bunch of grapes”) lies lateral to the artery

Fig. 2.68  Ventral to the arteria subclavia, you can find the POV of the nervus subclavius (arrow) (the dashed line depicts the plexus brachialis)

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Nervi supraclaviculares ELM

IPOP ILM

POV VAR AP C

The PUNCTUM NERVOSUM can be palpated during contraction of the  1. Platysma  2. M. sternocleidomastoideus Oblique (medial end more caudal), centre of the probe over the M. sternocleidomastoideus near its posterior border, one fingerbreadth cranial to the punctum nervosum; lateral end at the posterior border of the platysma 1. N. auricularis magnus (the first part medial to the M. sternocleidomastoideus) 2. Fascia cervicalis superficialis 3. Fascia cervicalis profunda Of the trunk (trunks*) found medial to the M. sternocleidomastoideus (after exiting the plexus cervicalis)** *Number of nerve trunks varies at the POV (one to three) (Separate visualisation of the Nn. supraclaviculares mediales et intermedii is possible (POV: ventral to the M. omohyoideus) **For exact differentiation of the Nn. supraclaviculares from the central part of the N. auricularis magnus (and other nerves of the plexus cervicalis), the probe should be moved a few centimetres cranial and caudal!

Fig. 2.69  Locate the punctum nervosum: at the cross point of the posterior platysma border (“grimace”) with that of the musculus sternocleidomastoideus

Fig. 2.70  Oblique placement of the probe, approximately one finger’s breadth cranial to the punctum nervosum with its latero-posterior end at the posterior border of the platysma (“grimace”)

2 Neck

43

Fig. 2.71  The fascia cervicalis superficialis (small arrows) and the fascia cervicalis profunda (arrowheads) are the main landmarks. Musculus sternocleidomastoideus (MSCM)

Fig. 2.72  The nervi supraclaviculares (arrows) are best visible medial to the musculus sternocleidomastoideus immediately after leaving the plexus cervicalis (POV). Nervus accessorius (small arrow), ramus trapezius of the plexus cervicalis (arrowhead)

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Nervus suprascapularis ELM

IPOP ILM POV VAR AP C

1. Fossa supraclavicularis major (trigonum omoclaviculare: clavicula, posterior border of the M. sternocleidomastoideus and M. omohyoideus venter inferior*) 2. Palpable plexus brachialis within the hiatus scalenorum** Nearly sagittal, at the lateral edge of the trigonum omoclaviculare; caudal end of the probe touches the clavicula; shoulder should be lowered (!) for widening of the trigonum cervicale posterius (and so for the trigonum omoclaviculare) 1. M. omohyoideus 2. Plexus brachialis Dorsal to the M. omohyoideus (venter inferior), at or immediately after branching from the truncus superior of the plexus brachialis*** Branching level from the truncus superior varies considerably! NONE *The venter inferior of the M. omohyoideus can be palpated, when the patient swallows with a stretched neck and slightly elevated shoulder **Deep inspiration helpful! ***The N. suprascapularis appears often as the thickest, “darkest” and most lateral lying “ball” (“bubble”, “grape” of the bunch of grapes) of the plexus brachialis

Fig. 2.73  Palpate the hiatus scalenorum and the plexus brachialis, and then move to the caudal part of the trigonum cervicale posterius

Fig. 2.74 Nearly sagittal orientation of the probe in the trigonum cervicale posterius. In cases of very obese patients, the caudal end of the probe can lie on the clavicula (with a respective dorsal shadowing in the image)

2 Neck

45

Fig. 2.75  The relation of the nervus suprascapularis to the musculus omohyoideus (venter inferior) (MOH) is constant; therefore the muscle is the internal landmark. Arteria subclavia (AS)

Fig. 2.76  The musculus omohyoideus serves as an ideal acoustic window! This is why the POV of the nervus suprascapularis (arrow) is dorsal to the muscle

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Nervus thoracicus longus 1 (fossa supraclavicularis major) ELM IPOP ILM

POV VAR AP C

1. Dorsal border of the M. sternocleidomastoideus 2. Palpable hiatus scalenorum*, beginning at (1) Probe oblique (=transverse to the course of the M. scalenus medius); antero-caudal end approx. one fingerbreadth from the (lowered!) clavicula 1. M. scalenus medius 2. M. scalenus anterior 3. C5 and C6 roots of the plexus brachialis Within the M. scalenus medius** NONE **The ligamentous structure of this muscle often hampers the clear (fast) depiction of the nerve! In that case it is recommended to start from the C5/6 roots at the cranial part of the hiatus scalenorum *Deep inspiration helpful

Fig. 2.77  Palpate the hiatus scalenorum in the trigonum cervicale posterius (near the posterior border of the M. sternocleidomastoideus)

Fig. 2.78  By placing the probe as shown here, the musculus scalenus medius becomes visible in a transverse cross section. Consider the distance to the clavicula!

2 Neck

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Fig. 2.79  Apart from the musculus scalenus medius (MSM) and musculus scalenus anterior (MSA), the in-between lying C5 and C6 nerve roots have to be considered (see also alternative plan in the table)

Fig. 2.80  POV (see also alternative plan in the table!) of the nervus thoracicus longus (arrow) inside the musculus scalenus medius

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Nervus transversus colli* ELM

IPOP ILM POV VAR

AP C

The PUNCTUM NERVOSUM can be palpated during contraction of the  1. Platysma  2. M. sternocleidomastoideus  3. V. jugularis externa** Oblique, according to the course of the V. jugularis externa**; middle of the probe exactly at the dorsal border of the M. sternocleidomastoideus 1. V. jugularis externa 2. M. sternocleidomastoideus On the M. sternocleidomastoideus, at the crossing point with the V. jugularis externa Course lateral to the V. jugularis externa The N. transversus colli forms a “loop” around the V. jugularis externa Two nerves (each one accordingly small!)* Missing of the V. jugularis externa (>> no vascular ILM!) NONE *Frequencies best >> 18 MHz **Visible in slim patients, often palpable in obese patients (Valsalva manoeuvre). **No pressure!! (a stand-off gel pad may be helpful)

Fig. 2.81  Locate the punctum nervosum: at the cross point of the posterior platysma border (“grimace“) with that of the musculus sternocleidomastoideus

Fig. 2.82  Probe positioning along the vena jugularis externa (excellently visible in this example; consider Valsalva manoeuvre!)

2 Neck

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Fig. 2.83  Depiction of the vascular landmark vena jugularis externa (VJE) with the help of a stand-off gel pad; course over the musculus sternocleidomastoideus (MSCM)

Fig. 2.84  Depiction of the nervus transversus colli (arrow) at the POV: medial to the vena jugularis externa

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Nervus vagus (X) ELM

IPOP ILM

POV VAR AP C

1. Pulsation of the A. carotis communis in the trigonum caroticum 2. Anterior border of the M. sternocleidomastoideus 3. Palpable tuberculum anterius C6 Transverse with midpoint of probe over the A. carotis communis 1. A. carotis communis 2. V. jugularis interna 3. Tuberculum anterius C6 At the level of the tuberculum anterius C6 dorsal to the large vessels N. vagus runs ventral to the large vessels (approx. 4% of the population!) NONE NONE

Fig. 2.85  Feel the pulsation of the arteria carotis communis at the anterior border of the musculus sternocleidomastoideus

Fig. 2.86  Transverse probe positioning, centred over the arteria carotis communis

2 Neck

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Fig. 2.87  Internal landmarks are the large vessels: vena jugularis interna (VJI) and arteria carotis communis (ACC) at the level of the tuberculum anterius of the C6 transverse process (TA C6). Musculus sternocleidomastoideus (MSCM), glandula thyroidea (GT)

Fig. 2.88  The nervus vagus (arrow) at the POV within the vagina carotica: deep to and between the vena jugularis interna and the arteria carotis communis

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Plexus cervicalis: R. trapezius ELM

IPOP ILM POV VAR AP C

The PUNCTUM NERVOSUM can be palpated during contraction of the  1. Platysma  2. M. sternocleidomastoideus Oblique (transverse to the assumed course of the nerve) to the posterior border of the M. sternocleidomastoideus, centre of the probe directly on the punctum nervosum 1. N. accessorius (see there) 2. Nn. supraclaviculares (see there) “NONE!”*, also because of VAR. If present as a separate nerve, then lying somewhere between ILM (1) and (2) Missing of the nerve (or direct connection to the N. accessorius!) Common origin and initial course with the Nn. supraclaviculares laterales NONE *The R. trapezius of the plexus cervicalis can only be identified per exclusionem: “not N. accessorius, not Nn. supraclaviculares >> the remaining nerve is the R. trapezius of the plexus cervicalis”

Fig. 2.89  Locate the punctum nervosum: at the cross point of the posterior platysma border (“grimace”) with that of the musculus sternocleidomastoideus

Fig. 2.90  Placement of the probe’s midpoint over the punctum nervosum at the posterior border of the musculus sternocleidomastoideus

2 Neck

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Fig. 2.91  The nervus accessorius and the Nn. supraclaviculares are often helpful internal landmarks for finding the R. trapezius. Posterior border of the musculus sternocleidomastoideus (MSCM)

Fig. 2.92  Ramus trapezius of the plexus cervicalis (arrow) caudal to the nervus accessorius (small arrow); here a bit further away from the nervi supraclaviculares (arrowheads)

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Reference Eichenberger U, Greher M, Kapral S, Marhofer P, Wiest R, Remonda L, Bogduk N, Curatolo M.  Sonographic visualization and ultrasound-guided block of the third occipital nerve: prospective for a new method to diagnose C2-C3 zygapophysial joint pain. Anesthesiology. 2006 Feb;104(2):303–8.

A. Loizides et al.

3

Upper Arm, Forearm and Hand Alexander Loizides, Sebastian Schuhmayer, and Bernhard Moriggl

Contents 3.1  Upper Arm

 56

Median nerve loop

 56

Nervus axillaris (anterior approach)

 58

Nervus axillaris (posterior approach)

 60

Nervus cutaneus antebrachii lateralis

 62

Nervus cutaneus antebrachii medialis 1

 64

Nervus cutaneus antebrachii medialis 2

 66

Nervus cutaneus antebrachii posterior

 68

Nervus cutaneus brachii lateralis superior

 70

Nervus cutaneus brachii medialis

 72

Nervus cutaneus brachii posterior

 74

Nervus medianus

 76

Nervus musculocutaneous

 78

Nervus radialis

 80

Nervus ulnaris

 82

3.2  Forearm and Hand

 84

Nervi digitales palmares communes

 84

Nervi digitales palmares proprii

 86

Nervus medianus: R. muscularis thenaris

 88

Nervus medianus: R. palmaris

 90

Nervus radialis: N. interosseus antebrachii posterior

 92

Nervus radialis: R. (proximal)

 94

Nervus radialis: R. superficialis (proximal)

 96

Nervus radialis: R. superficialis (distal)

 98

Nervus ulnaris: R. dorsalis manus

 100

Nervus ulnaris: R. palmaris 

 102

Nervus ulnaris: R. profundus 1 (Hypothenar: ulnar-proximal)

 104

Nervus ulnaris: R. profundus 2 (Hypothenar: palmar-distal)

 106

Nervus ulnaris: R. superficialis

 108

A. Loizides (*) · S. Schuhmayer Department of Radiology, Medical University Innsbruck, Innsbruck, Austria e-mail: [email protected]; [email protected]

B. Moriggl Division of Clinical and Functional Anatomy, Medical University Innsbruck, Innsbruck, Austria e-mail: [email protected]

© Springer Nature Switzerland AG 2019 H. Gruber et al. (eds.), Sonographic Peripheral Nerve Topography, https://doi.org/10.1007/978-3-030-11033-8_3

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3.1

Upper Arm

Median nerve loop ELM

IPOP ILM

POV VAR

AP

C

1. Palpable anterior axillary fold 2. Trigonum clavipectorale with processus coracoideus 3. Sulcus bicipitalis medialis 4. Reference line processus coracoideus–anterior axillary fold Nearly sagittal at the border trigonum clavipectorale–axilla; cranial end of the probe touches the clavicula; subsequently parallel movement of the probe towards the axilla Proximal approach  1. A. subclavia/axillaris  2. Fasciculi of the plexus brachialis* None (see VAR!) Multiple “forks” or missing Level of the fork unpredictable Two instead of three fasciculi, etc. Distal approach  1. A. brachialis/axillaris  2. N. medianus at the beginning of the sulcus bicipitalis medialis** *POV of the fasciculi in the spatium costo-claviculare **Retrograde “tracing” until the fasciculi of the plexus brachialis come into sight

Fig. 3.1  Palpation of the border of the anterior axillary fold and the processus coracoideus (in the trigonum clavipectorale) for definition of marked dotted line

Fig. 3.2  Sagittal probe orientation directly inferior to the clavicula. Arrow, direction of the parallel shift

3  Upper Arm, Forearm and Hand

57

Fig. 3.3  Musculus pectoralis major (MPma) and proximal border of the musculus pectoralis minor (MPmi) ventral to the arteria (AS) and vena (VS) subclavia/axillaris. The fasciculi of the plexus brachialis are found next to the artery in a 6–10 o’clock position

Fig. 3.4  Depiction of an extremely far proximal median nerve loop (arrow). Fasciculus lateralis (FL), fasciculus posterior (FP) and fasciculus medialis (FM)

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Nervus axillaris (anterior approach) *ELM IPOP ILM ***POV VAR AP C

1. Posterior axillary fold (tendons of the Mm. latissimus dorsi and teres major) 2. Pulsation of the A. axillaris On the posterior axillary fold** 1. A. circumflexa humeri posterior 2. M. subscapularis On the lateral border of the M. subscapularis None None *Arm in slight elevation and external rotation **Inclination of the probe inwards and upwards ***Use lower frequencies in case of obese patients

Fig. 3.5  The upper part of the posterior axillary fold can be palpated (tendons) just as good as the pulsation of the arteria axillaris in elevation and external rotation

Fig. 3.6  Probe positioning at the upper part of the posterior axillary fold

3  Upper Arm, Forearm and Hand

59

Fig. 3.7  Depiction of the arteria circumflexa humeri posterior (arrowhead) as a vascular internal landmark on the lateral border of the musculus subscapularis (MSuS). Note: The artery is not always immediately next to the nerve

Fig. 3.8  The nervus axillaris (arrow) at the POV in near proximity to the arteria circumflexa humeri posterior

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Nervus axillaris (posterior approach) ELM* IPOP ILM POV VAR AP C

1. Palpable groove between the M. deltoideus and the Caput longum musculi tricipitis brachii Nearly sagittal, at the reference line between Angulus acromialis and the axilla 1. A. circumflexa humeri posterior 2. M. teres minor Distal to the inferior border of the M. teres minor, on the humerus shaft, next to the A. circumflexa humeri posterior None None *Arm in a slight abduction and inner rotation (tension of the M. teres minor). On further abduction a part of the humerus shaft (shadowing!) disappears from the US image; however the visualisation of the nerve is further improved (nerve is stretched!)

Fig. 3.9  Palpate the groove between the musculus deltoideus and the caput longum musculi tricipitis brachii for a rough orientation

Fig. 3.10  Nearly sagittal probe positioning between the axilla and angulus acromialis

3  Upper Arm, Forearm and Hand

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Fig. 3.11  Clear depiction of the internal landmarks: musculus teres minor (MTmi) and arteria circumflexa humeri posterior (arrowhead). Musculus deltoideus (MD)

Fig. 3.12  Depiction of the nervus axillaris (arrow) in near proximity to the arteria circumflexa humeri posterior: POV

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Nervus cutaneus antebrachii lateralis ELM IPOP ILM

POV VAR AP C

1. Palpable groove between the tendon of the M. biceps brachii and the M. brachioradialis Transverse, middle of probe on the lateral border of the biceps tendon, on the cubital crease 1. Fascia brachii/antebrachii 2. Tendon of the M. biceps brachii [3. Often: clearly visible Vv. subfasciales near/on/deep to the nerve]* Subfascial! Within the fatty tissue of the fossa cubitalis** None None *Compression of the veins proximal to the POV **The N. cutaneus antebrachii lateralis lies within a “fat-filled flat tunnel” (FFFT) before he gradually reaches the subcutis

Fig. 3.13  Palpate the groove between the tendon of the musculus biceps brachii and musculus brachioradialis

Fig. 3.14  Transverse placement of the probe on the cubital crease with its centre at the lateral border of the biceps tendon

3  Upper Arm, Forearm and Hand

63

Fig. 3.15  Internal landmarks: tendon of the musculus biceps brachii (MBB-T; dark by anisotropy!) and the fascia brachii/antebrachii (arrowheads)

Fig. 3.16  Within a “fat-filled flat tunnel”, the nervus cutaneus antebrachii lateralis (arrow) is depicted lateral to the musculus biceps brachii. Consider a subfascial vein directly near the nerve (at 9 o’clock position!)

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Nervus cutaneus antebrachii medialis 1 ELM IPOP ILM

POV VAR AP C

1. Anterior and posterior axillary fold 2. Pulsation of the A. axillaris Transverse to the long axis of the arm, middle of the probe on the A. axillaris (touches the anterior axillary fold) 1. A. axillaris 2. N. medianus 3. N. ulnaris At the transition between the axilla and upper arm (crossing point with the tendon of the M. latissimus dorsi), course between the N. medianus and N. ulnaris* None None *The further proximal, the nearer the nerve to the N. ulnaris

Fig. 3.17  Palpable pulsation of the arteria axillaris when crossing the posterior axillary fold (runs over the tendon of the musculus latissimus dorsi)

Fig. 3.18  Transverse probe positioning relative to the long axis of the arm

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Fig. 3.19  The most important internal landmark is the arteria axillaris (AAX)

Fig. 3.20  Depiction of the nervus cutaneus antebrachii medialis (arrow) at the POV: superficial to the arteria axillaris and between the nervus medianus (NM; lesser intraneural tissue) and the nervus ulnaris (NU; lesser intraneural tissue)

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Nervus cutaneus antebrachii medialis 2 ELM

IPOP ILM POV VAR AP C

1. Palpable M. biceps brachii 2. Palpable M. triceps brachii 3. Palpable sulcus bicipitalis medialis Transverse, ulnar-sided in the middle of the upper arm*; arm in external rotation 1. V. basilica On the V. basilica before she exits the hiatus basilicus** within a “fat-filled flat tunnel” More than two nerves at the hiatus basilicus None *No pressure **N. cutaneus antebrachii medialis already divided in most cases

Fig. 3.21 Palpable Sulcus bicipitalis medialis between musculus biceps brachii and musculus triceps brachii

Fig. 3.22  Transverse probe positioning at the mid-third of the upper arm with its centre on the sulcus bicipitalis medialis

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Fig. 3.23  The vena basilica (VBas) between the musculus biceps brachii (MBB) and the musculus triceps brachii (MTB)

Fig. 3.24  The nervus cutaneus antebrachii medialis (arrow) is depicted on/beside the vena basilica in a “fat-filled flat tunnel”. Nervus medianus (small arrow)

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Nervus cutaneus antebrachii posterior ELM

IPOP ILM

POV VAR AP C

1. Palpable M. brachioradialis 2. Palpable caput laterale musculi tricipitis brachii 3. Epicondylus radialis humeri Transverse, four fingerbreadths proximal to the epicondylus lateralis humeri* 1. M. brachioradialis 2. M. triceps (caput laterale) 3. N. radialis On the M. brachioradialis (often accompanied by a branch of the A. collateralis radialis** None None *Further posterior as the IPOP of the N. radialis **Change to highest frequency available for POV (after simultaneous depiction of the N. cutaneus antebrachii posterior and N. radialis)

Fig. 3.25  Palpable groove between musculus brachioradialis and caput laterale musculi tricipitis brachii

Fig. 3.26  Transverse probe positioning at the distal third of the upper arm approximately four fingerbreadths cranial to the epicondylus radialis humeri

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Fig. 3.27  Depiction of the musculus triceps brachii–caput laterale (MTB-cl) and musculus brachioradialis (MBrR) as internal landmarks. Musculus brachialis (MBr)

Fig. 3.28  Depiction (POV) of the nervus cutaneus antebrachii posterior (arrow) superficial between caput longum musculi triceps brachii and musculus brachioradialis. Nervus radialis (small arrow)

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Nervus cutaneus brachii lateralis superior ELM IPOP ILM POV VAR AP C

1. Palpable groove between the M. deltoideus and caput laterale musculi tricipitis brachii* Perpendicular to the posterior border of the M. deltoideus 1. M. deltoideus 2. M. triceps brachii (caput laterale) Subfascial in the mentioned groove/furrow (ELM) None None *In extension

Fig. 3.29  Palpate the groove between the dorsal border of the musculus deltoideus and the caput laterale of the musculus tricipitis brachii

Fig. 3.30  Probe positioning perpendicular to the dorsal border of the musculus deltoideus

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Fig. 3.31  Depiction of the groove between the caput laterale of the musculus triceps brachii (MTB) and the dorsal border of the musculus deltoideus (MD). Immediately subfascial small branch of the arteria circumflexa humeri posterior (arrowhead)

Fig. 3.32  Depiction of the nervus cutaneus brachii lateralis superior (arrow) in near proximity to the ramus cutaneus arteriae circumflexae humeri posterioris

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Nervus cutaneus brachii medialis ELM IPOP ILM

POV VAR AP C

1. Pulsation of the A. axillaris/A. brachialis at the posterior axillary fold In line with the posterior axillary fold; centre of the probe over the A. axillaris/A. brachialis 1. N. ulnaris 2. A. axillaris/A. brachialis and respective V(v) 3. M. latissimus dorsi 4. M. teres major Either at the IPOP or not existing* Communication between the N. cutaneus brachii medialis and N. cutaneus antebrachii medialis Missing (replaced by a branch of the nervus cutaneus antebrachii medialis) None *Continuous tracing/following from proximal to distal is essential for identification; in some cases identification of the nerve is only possible by exclusion (“what remains is…”)

Fig. 3.33  Palpate the pulsation of the arteria axillaris/arteria brachialis at the posterior axillary fold

Fig. 3.34  Probe positioning parallel to the posterior axillary fold with its centre over the arteria axillaris/ arteria brachialis

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Fig. 3.35  Internal landmarks: arteria axillaris (AAX) and vena(e) axillaris(es) (VAX). Musculus biceps brachii (MBB), musculus coracobrachialis (MCBr), musculus latissimus dorsi/teres major (MLaD)

Fig. 3.36  Depiction of the nervus cutaneus brachii medialis (arrow) adjacent to the vena axillaris

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Nervus cutaneus brachii posterior ELM IPOP ILM POV VAR AP C

1. Palpable groove between the M. deltoideus and caput laterale musculi tricipitis brachii* Transverse over the caput laterale of the M. triceps, one to two fingerbreadths proximal to the insertion of the M. deltoideus 1. Caput laterale musculi tricipitis brachii Dorsal upper arm, middle third; within the caput laterale musculi tricipitis brachii In some cases missing None *In extension

Fig. 3.37  Palpate the groove between musculus deltoideus and caput laterale musculi tricipitis brachii

Fig. 3.38  Transverse probe positioning, centred over the caput laterale musculi tricipitis brachii

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Fig. 3.39  The internal landmark is the caput laterale musculi tricipitis brachii (MTB-cla) – the nerve is found within the muscle. Caput longum (MTB-clo) and caput mediale (MTB-cm) musculi tricipitis brachii

Fig. 3.40  The POV of the nervus cutaneus brachii posterior (arrow) in this example is found at the border of the caput laterale musculi triceps brachii (can also be found more centred)

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Nervus medianus ELM

IPOP

ILM

POV

*VAR

AP C

Proximal approach  1. Pulsation of the A. brachialis  2. Palpable epicondylus medialis humeri  3. Palpable medial border of the M. biceps brachii Distal approach  1. Middle of the forearm Proximal  Oblique, centre of the probe between epicondylus medialis humeri and M. biceps brachii Distal  Transverse, on the middle of the forearm Proximal  1. A. brachialis  [2. M. pronator teres] Distal  1. M. flexor digitorum superficialis  2. M. flexor digitorum profundus Proximal  1. Ulnar to the A. brachialis  2. Slightly distal as soon as the nerve “disappears” between the two heads of the M. pronator teres (orientation corresponding to the course of the nerve is a must!) Distal  1. Between M. flexor digitorum superficialis and M. flexor digitorum profundus at the mid forearm Radial to the A. brachialis Dorsal to the A. brachialis A. radialis superficialis Clear distance of the nerve from the artery (more often ulnar-sided) None * All apply for proximal

Fig. 3.41  Palpate the epicondylus medialis humeri, the medial border of the musculus biceps brachii and the arteria brachialis

Fig. 3.42  Probe positioning in an oblique orientation between musculus biceps brachii and epicondylus medialis humeri

3  Upper Arm, Forearm and Hand

Fig. 3.43  The internal landmark is the arteria brachialis (ABr)

Fig. 3.44  As shown here, the nervus medianus (arrow) is mostly found ulnar to the arteria brachialis (regular position)

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Nervus musculocutaneous ELM

IPOP ILM POV **VAR AP C

1. Posterior axillary fold and lateral border of the M. pectoralis major 2. A. axillaris within the sulcus bicipitalis medialis 3. Palpable: M. coracobrachialis and caput breve musculi bicipitis brachii* Abduction, probe transverse to the proximal upper arm touching the anterior axillary fold 1. M. coracobrachialis 2. Caput breve musculi bicipitis brachii At the IPOP, within the M. coracobrachialis or between the M. coracobrachialis and caput breve musculi bicipitis brachii** Course between the M. coracobrachialis and caput breve musculi bicipitis brachii Arising from the N. medianus (instead of the fasciculus lateralis), “No nerve at the POV” See VAR *Isometric contraction helpful

Fig. 3.45  “Grab” the posterior axillary fold and simultaneously palpate the pulse of the arteria brachialis and the muscles: musculus biceps brachii – caput breve, musculus coracobrachialis and the edge of the musculus pectoralis major

Fig. 3.46  Probe positioning transverse to the longitudinal axis of the arm directly at the lateral border of the Musculus pectoralis major

3  Upper Arm, Forearm and Hand

Fig. 3.47  Internal landmarks: musculus coracobrachialis (MCoBr) and caput breve musculi biceps brachii (MBB-cb)

Fig. 3.48  The nervus musculocutaneus (arrow) lies here between the musculus coracobrachialis and the caput breve musculi bicipitis brachii

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Nervus radialis ELM IPOP ILM POV VAR AP C

1. Palpable groove between the M. biceps brachii and M. brachioradialis Three to four fingerbreadths proximal to the cubital crease 1. M. brachialis 2. M. brachioradialis Shortly before entering the fossa cubitalis None None None

Fig. 3.49  Palpate the groove between the musculus biceps brachii and the musculus brachioradialis

Fig. 3.50  Transverse probe positioning radial-sided at the distal upper arm, approximately four finger breaths proximal to the middle of the fossa cubitalis

3  Upper Arm, Forearm and Hand

Fig. 3.51  The internal landmarks are the musculus brachioradialis (MBrR) and the musculus brachialis (MBr)

Fig. 3.52  The nervus radialis (arrow) has its POV between the musculus brachioradialis and musculus brachialis. Note: Although one entity at this level, the two parts (Rr. superficialis et profundus) are already perceptible

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Nervus ulnaris ELM

IPOP

ILM

POV

VAR AP C

Proximal approach  1. Epicondylus medialis humeri Distal approach  1. Middle of the forearm, palpable M. flexor carpi ulnaris Proximal  Transverse, two to three fingerbreadths proximal to the epicondylus medialis humeri Distal  Transverse, at the ulnar side of the middle forearm Proximal  1. Caput laterale of the M. triceps brachii  2. Fascia brachialis Distal  1. A. ulnaris Proximal  Two to three fingerbreadths proximal to the epicondylus medialis humeri Distal  At the middle lower arm, ulnar to the A. ulnaris No accompanying vessels at the distal POV (A. ulnaris with unusual origin and course!) None None

Fig. 3.53  Palpation of the crista supracondylaris medialis (ELM Epicondylus ulnaris humeri visible) for rough distance estimation of IPOS

Fig. 3.54  Positioning of the probe in a transverse orientation two to three fingerbreadths proximal to the epicondylus ulnaris humeri

3  Upper Arm, Forearm and Hand

Fig. 3.55  Depiction of the crista supracondylaris medialis humeri (H) and the caput laterale musculi tricipitis brachii (MTB-cl)

Fig. 3.56  The nervus ulnaris (arrow) lies subfascial (POV!) and adjacent to the caput laterale musculi tricipitis brachii

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Forearm and Hand

Nervi digitales palmares communes ELM IPOP ILM POV VAR AP C

1. Visible linea cephalica 2. Palpable groove(s) between the metacarpal bones and flexor tendons Transverse probe positioning at the level of the linea cephalica 1. Flexor tendons 2. Aa. digitales palmares communes In 9 o’clock and 11 o’clock position to the flexor tendons (IPOP) None None Cave: anastomosis of the N. medianus/ulnaris at the level of the fourth finger

Fig. 3.57  The linea cephalica serves as an external landmark

Fig. 3.58  Transverse probe positioning on the linea cephalica

3  Upper Arm, Forearm and Hand

Fig. 3.59  Depiction of the internal landmarks: flexor tendons (T-MFD) and one arteria digitalis palmaris communis (arrowhead)

Fig. 3.60  At the POV, the nervus digitalis palmaris communis (arrow) runs adjacent to the arteria digitalis palmaris communis

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Nervi digitales palmares proprii ELM IPOP ILM POV VAR AP C

1. Phalanx proximalis 2. Interarticular finger segments (proximal approach) Transverse probe positioning over the palmar side of the respective finger* 1. Aa. digitales palmares propriae 2. Tendons of Mm. flexor digitorum superficialis et profundus At the level of the phalanx proximalis palmar and medial to the respective artery None At the level of the finger pad (central metacarpal heads) in 9 o’clock and 3 o’clock position to the not yet divided Aa. digitales palmares communes Trace from distal to proximal *The use of a standoff gel pad is helpful

Fig. 3.61  Palpate the edges of the phalanx proximalis of the respective finger

Fig. 3.62  Transverse probe positioning over the phalanx proximalis

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Fig. 3.63  The internal landmarks are the tendons of the musculus flexor digitorum superficialis (T-MFDS) and profundus (T-MFDP) as well as the arteriae digitales palmares propriae (arrowheads)

Fig. 3.64  The nervi digitales palmares proprii (arrows) in close proximity to the arteriae digitales palmares propriae

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Nervus medianus: R. muscularis thenaris ELM IPOP ILM POV VAR AP C

1. Thenar 2. Palpable transition of the thenar to the palma manus Probe placement slightly proximal to the linea vitalis, tilted towards the thenar* Distal border of the thenar muscles: M. flexor pollicis brevis At the entry into the M. flexor pollicis brevis Early division of the R. muscularis thenaris from the N. medianus and penetration of the retinaculum flexorum Position the probe central over the thenar and follow the intramuscular branches towards the linea vitalis until the “main trunk” is found *Thumb in a slight extension, hand flattened

Fig. 3.65  Palpable transition of the thenar to the palma manus

Fig. 3.66  Probe positioning along the distal thenar border

3  Upper Arm, Forearm and Hand

Fig. 3.67  The most important internal landmark is the musculus flexor pollicis brevis (MFPB)

Fig. 3.68  Depiction of the ramus muscularis thenaris (arrow) at the POV: at its entry into the musculus flexor pollicis brevis

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Nervus medianus: R. palmaris ELM IPOP ILM POV VAR

AP C

1. Palpable groove between tendo musculi flexoris carpi radialis and tendo musculi palmaris longi* Transverse, at the transition between the middle and distal forearm** 1. Tendon of the M. flexor carpi radialis 2. Tendon of the M. palmaris longus*** A few millimetres distal to the origin from the N. medianus **Origin far proximal or distal ***No tendon of the musculus palmaris longus (in 15–20% of cases!) No ramus palmaris nervi mediani (rare!) None Use the highest possible frequency (minimum 15 MHz) *Thumb and small finger in opposition

Fig. 3.69  Palpable groove between the tendon of the musculus flexor carpi radialis and musculus palmaris longus (the latter clearly seen here; but see VAR)

Fig. 3.70  Transverse probe positioning: initial placement far proximal! (see VAR in the table)

3  Upper Arm, Forearm and Hand

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Fig. 3.71  Depiction of the musculus flexor digitorum superficialis (MFDS) and musculus flexor digitorum profundus (MFDP). Superficially the tendon of the musculus flexor carpi radialis (T-MFCR) is depicted. Arteria radialis (AR). Musculus pronator quadratus (MPrQ)

Fig. 3.72  The ramus palmaris nervi mediani (large arrow) is best depicted at its origin radial to the nervus medianus (small arrows) between the superficial and deep flexor muscles and deep to the tendon of the musculus flexor carpi radialis

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Nervus radialis: N. interosseus antebrachii posterior ELM IPOP ILM POV VAR AP C

1. Tuberculum dorsale radii (Listeri) Transverse, with the middle of the probe over the tuberculum dorsale* 1. Tuberculum dorsale radii (Listeri) 2. Finger extensor tendons (fourth tendon compartment) In the fourth tendon compartment directly adjacent to the bone Different forms of the tuberculum dorsale (e.g. two humps) None *The use of a standoff gel pad is very helpful

Fig. 3.73  Palpate the tuberculum dorsale radii (Listeri)

Fig. 3.74  Transverse probe positioning central over the tuberculum dorsale radii

3  Upper Arm, Forearm and Hand

93

Fig. 3.75  The most important internal landmarks are the tuberculum dorsale radii (TDR; here with depiction of two “humps” as a variant) and the tendon of the musculus extensor indicis (T-MEI) and those of the musculus extensor digitorum (T-MED), respectively. Tendon of the musculus extensor pollicis longus (T-MEPL) and of the musculus extensor carpi radialis brevis (T-MECRB)

Fig. 3.76  Lying directly on bone, the nervus interosseus antebrachii posterior (arrow) is depicted immediately ulnar to the tuberculum dorsale radii and covered by the finger extensor tendons

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Nervus radialis: R. (proximal) ELM IPOP ILM

POV VAR AP C

1. Palpable groove between M. biceps brachii and M. brachioradialis* Centred over the M. brachioradialis, almost at the level of the mid-cubital fossa 1. M. brachioradialis 2. M. brachialis (at the IPOP level) 3. M. supinator (more distal) Starting from the beginning of the bifurcation of the N. radialis until the entry into the M. supinator None None *The R. profundus nervi radialis is always covered by the M. brachioradialis

Fig. 3.77  Palpate the groove between the musculus biceps brachii and musculus brachioradialis

Fig. 3.78  Transverse probe positioning, slightly tilted cranially, over the musculus brachioradialis

3  Upper Arm, Forearm and Hand

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Fig. 3.79  Internal landmarks are the musculus brachioradialis (MBrR) and musculus supinator (MSUP)

Fig. 3.80  The ramus profundus nervi radialis (large arrow) is best depicted immediately before entering the Arcade of Frohse (POV). Ramus superficialis nervi radialis (small arrow)

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Nervus radialis: R. superficialis (proximal) ELM IPOP ILM POV VAR AP C

Palpable groove between the M. biceps brachii and M. brachioradialis Centred over the M. brachioradialis, two fingerbreadths proximal to the mid-cubital fossa 1. M. brachioradialis 2. M. brachialis Immediately at/shortly after the division of the N. radialis None None None

Fig. 3.81  Palpate the groove between the musculus biceps brachii and musculus brachioradialis

Fig. 3.82  Transverse probe positioning, radial-sided and slightly tilted over the proximal M. brachioradialis

3  Upper Arm, Forearm and Hand

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Fig. 3.83  At the IPOP the nerve runs between the musculus brachioradialis (MBrR) and musculus brachialis (MBr)

Fig. 3.84  Depiction of the ramus superficialis nervi radialis (large arrow) at the POV immediately at the bifurcation of the nervus radialis. Ramus profundus nervi radialis (small arrow)

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Nervus radialis: R. superficialis (distal) ELM IPOP ILM POV VAR AP C

1. M. brachioradialis 2. M. flexor carpi radialis Transverse radial-sided in the middle of the forearm 1. A. radialis and Vv. comitantes* 2. M. brachioradialis In the middle of the forearm* Variants of the A. radialis None *Contrary to a widespread opinion, the nerve does not run directly adjacent to the vessels in the majority of cases

Fig. 3.85  Palpable groove between the facing borders of musculus flexor carpi radialis and musculus brachioradialis at the middle of the forearm

Fig. 3.86  Transverse probe positioning radial-sided in the middle of the forearm, centre of the probe at the ulnar border of the musculus brachioradialis

3  Upper Arm, Forearm and Hand

99

Fig. 3.87  Depiction of the internal landmarks: arteria radialis (A) and venae comitantes (arrowheads) posterior to the musculus brachioradialis (MBrR). Musculus flexor digitorum (MFD)

Fig. 3.88  Depiction of the ramus superficialis nervi radialis (arrow) radial to the vessels, adjacent to the M. brachioradialis. Notice the distance of the nerve to the vascular landmarks

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Nervus ulnaris: R. dorsalis manus ELM IPOP ILM POV VAR AP C

Easily palpable M. flexor carpi ulnaris* Transverse, at the ulnar side of the forearm (between middle to distal third) 1. N. ulnaris 2. M. flexor carpi ulnaris Immediately after its origin from the N. ulnaris None None *Hand in ulnar adduction

Fig. 3.89  In an ulnar duction, the musculus flexor carpi ulnaris is excellently palpable

Fig. 3.90  Ulnar-sided transverse probe positioning at the transition from the middle to distal forearm

3  Upper Arm, Forearm and Hand

101

Fig. 3.91  The musculus flexor carpi ulnaris (MFCU) and its tendon (T-MFCU) cover the nerve immediately after origin. Arteria ulnaris (AU)

Fig. 3.92  The POV of the ramus dorsalis manus nervi ulnaris (large arrow) is found immediately after its origin from the nervus ulnaris (small arrows)

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Nervus ulnaris: R. palmaris ELM IPOP ILM

POV VAR AP C

Palpable M. flexor carpi ulnaris* Transverse, at the ulnar side of the forearm, proximal third** 1. N. ulnaris 2. M. flexor carpi ulnaris/tendo musculi flexoris carpi ulnaris 3. A. ulnaris Immediately after branching from the N. ulnaris*** **Level of origin varies None *Hand in ulnar duction ***Slow trancing of the N. ulnaris towards distal

Fig. 3.93  Palpate the entire musculus flexor carpi ulnaris in an ulnar duction of the hand

Fig. 3.94 Transverse probe positioning at the proximal forearm, ulnar-sided

3  Upper Arm, Forearm and Hand

103

Fig. 3.95  Depiction of the neurovascular bundle between the musculus flexor carpi ulnaris (MFCU) and the flexor muscles – musculus flexor digitorum superficialis (MFDS) and musculus flexor digitorum profundus (MFDP). Arteria ulnaris (AU; duplex mode)

Fig. 3.96  POV of the ramus palmaris nervi ulnaris (large arrow) immediately after branching from the nervus ulnaris (small arrows)

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Nervus ulnaris: R. profundus 1 (Hypothenar: ulnar-proximal) ELM IPOP ILM POV VAR AP C

Palpable os pisiforme Ulnar at the distal border of the os pisiforme 1. A. ulnaris–R. profundus 2. Border of the hypothenar The nerve runs radial to the R. profundus arteriae ulnaris (at the point of IPOS) None None None

Fig. 3.97  Palpate the os pisiforme

Fig. 3.98  Probe positioning in a nearly transverse orientation ulnar at the distal border of the os pisiforme

3  Upper Arm, Forearm and Hand

105

Fig. 3.99  The neurovascular bundle is covered by hypothenar muscles (HYP). Ramus profundus arteriae ulnaris (A). Musculus opponens digiti minimi (MODM)

Fig. 3.100  The ramus profundus nervi ulnaris (arrow) is depicted radial to the ramus profundus arteriae ulnaris

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Nervus ulnaris: R. profundus 2 (Hypothenar: palmar-distal) ELM IPOP ILM

POV VAR AP C

1. Os pisiforme 2. Hypothenar Longitudinal along the course of the os metacarpale V 1. Os metacarpale V 2. Hamulus ossis hamati 3. Mm. hypothenares 4. Arcus palmaris profundus Between hamulus ossis hamati and arcus palmaris profundus deep to the Mm. hypothenares None None By coursing radial, the R. profundus nervi ulnaris crosses the arcus palmaris profundus

Fig. 3.101  Palpation of the os pisiforme

Fig. 3.102  Probe positioning along the course of the os metacarpale V, beginning at the distal border of the Os pisiforme

3  Upper Arm, Forearm and Hand

107

Fig. 3.103  Depiction of the hypothenar muscles (HYP) and the hamulus ossis hamati (HOH) as the internal landmarks. Superficial and deep to the muscles, the arcus palmaris superficialis et profundus can be found (arrowheads). Os metacarpale V (MC V)

Fig. 3.104  The ramus profundus nervi ulnaris (arrow) is best depicted in near proximity to the Arcus palmaris profundus (POV)

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Nervus ulnaris: R. superficialis ELM IPOP ILM POV VAR AP C

Lateral Hypothenar, M. palmaris brevis* Transverse probe positioning centred over the musculus palmaris brevis 1. M. palmaris brevis 2. Hypothenar muscles Between the musculus palmaris brevis and the hypothenar within the hypothenar fascia None None *Palpate the M. palmaris brevis after spreading of the little finger with a flat hand

Fig. 3.105  After spreading the small finger, the M. palmaris brevis is comfortably palpable (external landmark)

Fig. 3.106  Probe positioning in a transverse orientation centred over the musculus palmaris brevis

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Fig. 3.107  Important internal landmarks are the musculus palmaris brevis (MPB) and the deeper-lying hypothenar muscles (HYP)

Fig. 3.108  The ramus superficialis nervi ulnaris (arrow) is excellently delineated between the two muscles; it courses within the hypothenar fascia (POV)

4

Trunk Alexander Loizides, Hannes Gruber, Philipp Koch, Sebastian Schuhmayer, and Bernhard Moriggl

Contents Nervi clunium medii

 112

Nervi clunium superiores

 114

Nervus coccygeus

 116

Nervus genitofemoralis: R. femoralis

 118

Nervus genitofemoralis: R. genitalis

 120

Nervus Iliohypogastricus and Nervus ilioinguinalis

 122

Nervus iliohypogastricus: R. cutaneus anterior

 124

Nervus iliohypogastricus: R. cutaneus lateralis

 126

Nervi intercostobrachiales

 128

Nervus intercostobrachialis II

 130

Nervus(i) pectoralis(es) lateralis(es) et medialis(es): cranial approach

 132

Nervus(i) pectoralis(es) lateralis(es) et medialis(es): caudal approach

 134

Nervus(i) subscapularis(es)

 136

Nervus thoracicus longus 2 (Fossa infraclavicularis)

 138

Nervus thoracicus longus 3 (Regio thoracica lateralis)

 140

Nervus thoracodorsalis

 142

A. Loizides (*) · H. Gruber · P. Koch · S. Schuhmayer Department of Radiology, Medical University Innsbruck, Innsbruck, Austria e-mail: [email protected]; [email protected]; [email protected]; [email protected] B. Moriggl Division of Clinical and Functional Anatomy, Medical University Innsbruck, Innsbruck, Austria e-mail: [email protected] © Springer Nature Switzerland AG 2019 H. Gruber et al. (eds.), Sonographic Peripheral Nerve Topography, https://doi.org/10.1007/978-3-030-11033-8_4

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Nervi clunium medii ELM

IPOP ILM POV VAR AP C

1. Spina iliaca posterior superior 2. Os coccygis [3. Crista sacralis lateralis] Shift probe from the reference line between the ELM parallel about two fingerbreadths laterally 1. M. gluteus maximus 2. Connective tissue septa of the subcutis Directly on the M. gluteus maximus in the deep layer of the subcutis None None None

Fig. 4.1  Palpation of the external landmarks spina iliaca posterior superior and the tip of the os coccygis (cranial end of the rima ani) for definition of the reference line

Fig. 4.2  The probe is positioned (slightly tilted) at the abovementioned line and then shifted about two fingerbreadths laterally

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Fig. 4.3  Thick echoic band (arrowheads): delineation of the deepest lobe of the subcutis by prominent connective tissue. Musculus gluteus maximus (GM) with filmy fascia

Fig. 4.4  The nerves (arrows) lie in the deepest lobe of the subcutis underneath dense connective tissue septa and superficially to the fascia glutealis of the musculus gluteus maximus

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Nervi clunium superiores ELM IPOP ILM POV VAR AP C

1. Lateral border of the M. latissimus dorsi 2. Crista iliaca Medial to the lateral border of the M. latissimus dorsi, about two fingerbreadths cranial to the crista iliaca* 1. Fascia thoracolumbalis (superficial lamina) 2. M. iliocostalis lumborum Within the M. iliocostalis lumborum None None *From IPOP move probe repeatedly up and down to find POV

Fig. 4.5  Palpation of the trigonum lumbale (middle finger of the left hand) for definition of the lateral border of the musculus latissimus dorsi and simultaneous indication of the crista iliaca (thumb of the right hand)

Fig. 4.6  The probe is placed slightly oblique (perpendicular to the assumed course of the nerves!) about two fingerbreadths cranial to the crista iliaca and centered on the musculus iliocostalis lumborum. Index finger at the crista iliaca

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Fig. 4.7  The musculus iliocostalis lumborum (ILCL) is covered by the superficial lamina of the fascia thoracolumbalis (FTLB, arrowheads)

Fig. 4.8  The nervi clunium superiores (Pfeile) are defined best within the (most superficial part of) musculus iliocostalis lumborum (POV)

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Nervus coccygeus ELM IPOP ILM

POV VAR AP C

Cornua sacralia Transverse over the cornua sacralia 1. Cornua sacralia 2. Ligamentum sacrococcygeum posterius (superficiale)–(membrana tectoria) [3. Dorsal surface of the os sacrum] Superficial to the ligamentum sacrococcygeum* Variable point of passage through the “membrana tectoria” (no POV)* None *Clear definition not always possible (even with highest frequencies)

Fig. 4.9  Palpation of the cornua sacralia (one to three* fingerbreadths cranial to the rima ani; *variable!)

Fig. 4.10  Transverse probe position; center of probe between the cornua sacralia

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Fig. 4.11  The shadowing bones of the cornua sacralia (CS; keep the variable height in mind!); in between the hiatus sacralis (HS; arrowheads) being occluded by a mass of ligaments (membrana tectoria = ligamentum sacrococcygeum posterius)

Fig. 4.12  The nervi coccygei (arrows) at the surface of the ligamentum sacrococcygeum posterius. In this example the POV is dorsal to the cornua sacralia (variable!)

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Nervus genitofemoralis: R. femoralis ELM IPOP ILM POV VAR AP C

1. Palpation of the A. femoralis 2. Ligamentum inguinale (or baseline between spina iliaca anterior superior and tuberculum pubicum) Directly cranial and parallel to the ligamentum inguinale 1. A. iliaca externa 2. A. circumflexa ilium profunda* Ventral or the A. circumflexa ilium profunda** Course dorsal to the A. circumflexa ilium profunda (rare) None *The artery must be depicted longitudinally **R. femoralis nervi genitofemoralis already divided into at least two branches in most cases

Fig. 4.13  Palpation of the arteria femoralis (rough orientation to find the internal landmarks arteria iliaca externa and arteria circumflexa ilium profunda more easily)

Fig. 4.14  Positioning of the probe cranial to the ligamentum inguinale (or the abovementioned baseline) for assessing the internal landmarks

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Fig. 4.15  The arteria circumflexa ilium profunda (ACIP) leaves the arteria iliaca externa (AIE) lateral. Musculus psoas major (PSM)

Fig. 4.16  The ramus femoralis nervi genitofemoralis has already spread into several branches (arrows); all of them are found ventral to the arteria circumflexa ilium profunda

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Nervus genitofemoralis: R. genitalis ELM IPOP ILM

POV VAR AP C

1. Palpable pulsation of the A. femoralis 2. Ligamentum inguinale (i.e., line between the spina iliaca anterior superior and the tuberculum pubicum) Transverse, about two fingerbreadths cranial to the ligamentum inguinale 1. A. and V. iliaca externa 2. A. epigastrica inferior* [3. Ductus deferens or ligamentum teres uteri] 2–3 cm cranial to the origin of the A. epigastrica inferior on the ventral “surface” of the A. (usually) oder V. (rarely) iliaca externa None None *If you cannot find the A. epigastrica inferior at its origin, it may easily be found within the vagina musculi recti abdominis dorsal to the muscle and then followed caudally

Fig. 4.17  Palpation of the arteria femoralis (rough orientation to find the internal landmarks arteria iliaca externa and arteria epigastrica inferior more easily)

Fig. 4.18  Positioning of the probe strictly transversely about two fingerbreadths cranial to the ligamentum inguinale

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Fig. 4.19  The essential internal landmarks are of vascular nature: arteria iliaca externa (AIE; with the medially neighboring vein) and the arteria epigastrica inferior (AEI); musculus psoas major (PSM). musculus rectus abdominis (RA)

Fig. 4.20  A reliable identification of the ramus genitalis (arrows) is only possible on the ventral “surface” of the arteria (or rarely Vena) iliaca externa (POV)

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Nervus Iliohypogastricus and Nervus ilioinguinalis ELM IPOP ILM

POV VAR AP C

1. Spina iliaca anterior superior 2. Crista iliaca About three to four fingerbreadths cranio-posterior to the spina iliaca anterior superior; the probe is coupled almost perpendicularly to the crista iliaca 1. Crista iliaca 2. M. obliquus externus abdominis 3. M. obliquus internus abdominis 4. M. transversus abdominis Between M. transversus abdominis and M. obliquus internus abdominis* Common trunk of both nerves None *The shadow of the crista iliaca must be depicted in the ultrasound image; directly next to the crista iliaca is N. ilioinguinalis, and about 1 cm medial to that is N. Iliohypogastricus

Fig. 4.21  Simultaneous palpation of the spina iliaca anterior superior and the crista iliaca; the middle finger indicates the optimal IPOP

Fig. 4.22  The lateral end of the probe is directly over the crista iliaca; the medial end is pushed into the abdominal wall (heel-in maneuver)

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Fig. 4.23  Crista iliaca (CI) and “triple of the abdominal wall” (1. Musculus obliquus externus [OE], 2. Musculus obliquus internus [OI], 3. Musculus transversus abdominis [TV])

Fig. 4.24  Both nerves (arrows) are clearly depicted (POV) interposed between musculus obliquus internus and musculus transversus abdominis: nervus ilioinguinalis (II) next to the shadowing by the crista iliaca and the nervus iliohypogastricus (IH) immediately medial to that; remarkably more medial is the nervus subcostalis (SUBC)

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Nervus iliohypogastricus: R. cutaneus anterior ELM IPOP ILM POV VAR AP C

1. Anulus inguinalis superficialis (palpable in men*) 2. Ligamentum inguinale (or line between spina iliaca anterior superior and tuberculum pubicum) Oblique and ascending medially, center of the probe about two fingerbreadths cranial and lateral (!) to the anulus inguinalis superficialis 1. M. rectus abdominis 2. M. obliquus internus abdominis (and its aponeurosis) Within the M. obliquus internus abdominis, directly before the nerve appears at the ventral surface of the muscle Early bifurcation (hampers definition severely) Lacking (replaced by a branch of the N. subcostalis and/or the N. ilioinguinalis) None *Coughing is necessary, in order to clearly palpate the anulus inguinalis superficialis in male subjects

Fig. 4.25  Localization of the anulus inguinalis superficialis (easier in men) directly above the ligamentum inguinale by palpation with the small finger (let the subject cough!)

Fig. 4.26  The oblique probe position correlates with the assumed course of the nerve (always scan perpendicularly to the course!)

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Fig. 4.27  The musculus obliquus internus abdominis (OI) must be depicted at the transition of muscle to aponeurosis. An additional muscular landmark is the musculus rectus abdominis (RA)

Fig. 4.28  The region where the fleshy part of the musculus obliquus internus turns into its aponeurosis: POV of the nerve (arrows) before it (its branches) leaves (leave) the muscle toward the subcutis

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Nervus iliohypogastricus: R. cutaneus lateralis ELM

IPOP ILM

**POV VAR AP C

1. Spina iliaca anterior superior 2. Crista iliaca [2a. Tuberculum iliacum (if palpable!)] Almost transverse about a hand’s breadth cranio-posterior to the spina iliaca anterior superior; dorsal end on the crista iliaca* 1. Crista iliaca 2. M. obliquus externus abdominis 3. M. obliquus internus abdominis Cranial to the crista iliaca at its exit through the M. obliquus externus abdominis One branch of the N. subcostalis may replace the R. cutaneous lateralis nervi iliohypogastrici None *Do not apply much pressure on the probe **Although the nerve has a direct relation to the crista iliaca, it is almost impossible to find it there! After passing the crista iliaca, the nerve enters the subcutis, and its delineation is difficult

Fig. 4.29  Palpation of the spina iliaca anterior superior and of the crista iliaca (maybe you can even feel the tuberculum iliacum)

Fig. 4.30  The placement of the probe is approximately one hand’s breadth away (cranio-posterior) from the spina iliaca anterior superior

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Fig. 4.31  Please note: Just cranial to the crista iliaca (CI), the musculi obliquus externus (OE) and internus (OI) abdominis may not be differentiated that well. Moreover, even parts of the subcutis (SC) might be mixed up with parts of these muscles

Fig. 4.32  Only the intramuscular course of the nerve (arrows) can be depicted reliably! Due to the individual transmuscular path of the nerve, the probe must me moved up and down in that region

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Nervi intercostobrachiales ELM IPOP ILM POV VAR AP C

1. Palpable posterior axillary fold* Perpendicular to the posterior axillary fold at its cranial end 1. M. latissimus dorsi (and M. teres major) 2. Fascia axillaris On the posterior axillary fold, within a duplication of the fascia axillaris, superficial to the tendo musculi latissimi dorsi One to three Nn. intercostobrachiales (of different caliber!) None *Arm in elevation

Fig. 4.33  Palpation of the posterior axillary fold until the tendon of the musculus latissimus dorsi (arm elevated)

Fig. 4.34  Probe transverse to the posterior axillary fold with the medial end touching the anterior axillary fold (slightly pressed inward)

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Fig. 4.35  Internal landmark is the fascia axillaris (arrowheads) over the musculus latissimus dorsi (MLaD)

Fig. 4.36  At the POV the nervi intercostobrachiales (arrows) lie directly on the tendon of the musculus latissimus dorsi

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Nervus intercostobrachialis II ELM IPOP ILM

POV VAR AP C

1. Anterior axillary fold* 2. Palpable chest wall (ribs and M. serratus anterior)* Nearly sagittal; compression 1. A. thoracica lateralis** 2. M. serratus anterior 3. M. pectoralis minor At the crossing point with the A. thoracica lateralis (nerve mostly dorsal to the artery) None None *Arm maximal abducted (90°) **The use of Power Doppler is helpful

Fig. 4.37  Palpate the chest wall deep to the anterior axillary fold

Fig. 4.38  Push the anterior axillary fold toward cranial and press the probe to the chest wall; probe slightly tilted

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Fig. 4.39  The arteria thoracica lateralis (arrowhead) lies deep to the musculus pectoralis minor (MPmi) directly on the musculus serratus anterior (MSeA). Musculus pectoralis major (MPma)

Fig. 4.40  The nervus intercostobrachialis II (arrow) is found most easily at its crossing point with the arteria thoracica lateralis (POV)

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Nervus(i) pectoralis(es) lateralis(es) et medialis(es): cranial approach ELM

IPOP ILM

POV VAR

AP C

1. Trigonum clavipectorale 2. Palpable processus coracoideus 3. Palpable M. pectoralis major/M. pectoralis minor Within the trigonum clavipectorale directly caudal to the clavicula and parallel to it 1. V. cephalica 2. V. subclavia 3. A. subclavia Ventral to the A. subclavia (N. pectoralis lateralis) and respectively dorsal to the confluence of the V. cephalica and the V. subclavia (N. pectoralis medialis) Common trunk for the N. pectoralis medialis and N. pectoralis lateralis Plexiform arrangement around the A. thoracoacromialis Atypical course and thus confluence of the V. cephalica (no clear ILM!) Use probe with low frequencies (even convex probes) in obese patients* * >>Depiction of the nerves under these circumstances often doubtful Note: The cranial approach differs by just a few millimeters from the caudal one (see there), by the different main ILM as well as by the POV

Fig. 4.41  Localize the trigonum clavipectorale and palpate the processus coracoideus below the clavicula in an abducted arm

Fig. 4.42  Probe positioning parallel to the clavicula; middle of the probe over the center of the trigonum clavipectorale

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Fig. 4.43  The arteria (AS) and vena (VS) subclavia with confluence of the Vena cephalica (VC) are the vascular internal landmarks

Fig. 4.44  The nervi pectorales mediales et* laterales (arrows) are seen particularly well (POV) due to the dorsal sound enhancement by the vena cephalica. *Note here: common trunk (VAR)

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Nervus(i) pectoralis(es) lateralis(es) et medialis(es): caudal approach ELM

IPOP ILM

POV VAR AP C

1. Trigonum clavipectorale 2. Palpable processus coracoideus 3. Palpable M. pectoralis major/M. pectoralis minor Within the trigonum clavipectorale directly caudal to the clavicula and parallel to it 1. A. thoracoacromialis 2. V. axillaris 3. A. axillaris Dorsal to the M. pectoralis minor (near its cranial border) in vicinity to the A. thoracoacromialis and the A. axillaris, respectively Common trunk for the N. pectoralis medialis and N. pectoralis lateralis Plexiform arrangement around the A. thoracoacromialis Use probe with low frequencies (even convex probes) in extremely obese patients* *>> Depiction of the nerves under these circumstances often doubtful Note: The caudal approach differs by just a few millimeters from the cranial one (see there), by the different main ILM as well as by the POV

Fig. 4.45  Localize the trigonum clavipectorale and palpate the processus coracoideus below the clavicula in an abducted arm

Fig. 4.46  Probe positioning parallel to the clavicula; middle of the probe over the center of the trigonum clavipectorale

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Fig. 4.47  Depiction of the arteria (AAX) and vena axillaris (VAX) as well as the arteria thoracoacromialis (arrowhead) as internal landmarks dorsal to the musculus pectoralis minor (MPmi; cranial border). Musculus pectoralis major (MPma)

Fig. 4.48  The nervi pectorales mediales (large arrows) beside the arteria thoracoacromialis. One nervus pectoralis lateralis (small arrow)

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Nervus(i) subscapularis(es) ELM IPOP ILM **POV VAR AP C

1. Palpable M. subscapularis* 2. Palpable lateral border of the scapula Nearly parallel to the anterior axillary fold and pressed deep into the axilla 1. M. subscapularis On the ventral surface of the M. subscapularis None Use low frequencies (even convex probes; in that case however transpectoral insonation is necessary!) *Abduction/elevation of the arm with simultaneous external rotation **Sometimes no POV

Fig. 4.49  Palpate the musculus subscapularis deep inside the axilla; start from the posterior axillary fold

Fig. 4.50  With the probe pressed deep into the axilla, direct the sound plane cranially toward the clavicula

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Fig. 4.51  The most important internal muscular landmark is the musculus subscapularis (MSSc). Scapula (S)

Fig. 4.52  Depiction of the (in this case) two nervi subscapulares (arrows) directly on the musculus subscapularis before entering the muscle

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Nervus thoracicus longus 2 (Fossa infraclavicularis) *ELM IPOP ILM POV VAR AP C

1. Clavicula 2. Fossa infraclavicularis Probe positioning in contact with the anterior border of the clavicula 1. M. serratus anterior on the first rib (longitudinal orientation) 2. M. subclavius On the first spike of the M. serratus (covered by the M. subclavius) None None *Shoulder elevated (M. subclavius! See ILM)

Fig. 4.53  The finger lies on the clavicula (transition from middle to medial third) and points to the fossa infraclavicularis

Fig. 4.54  Probe positioning parallel and below the clavicula. Midpoint of transducer as indicated in Figure on the left. Note: beam orientation toward cranial (underneath the clavicula)

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Fig. 4.55  The muscular landmarks are the musculus subclavius (MSCl) and the uppermost spike of the musculus serratus anterior (MSerA); both muscles as well as the first rib (C1) are only visible when the shoulder is elevated(!). Musculus pectoralis major (MPma)

Fig. 4.56  Depiction of the nervus thoracicus longus (Pfeil) at the POV: lying on the first spike of the musculus serratus anterior, dorsal to the musculus subclavius

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Nervus thoracicus longus 3 (Regio thoracica lateralis) *ELM IPOP ILM

POV VAR AP C

1. Anterior axillary fold 2. Palpable fourth/fifth ribs Nearly transverse at the level of the fourth intercostal space 1. Lateral border of the M. pectoralis major 2. M. serratus anterior 3. Branch of the A. thoracoacromialis On the M. serratus anterior beside a branch of the A. thoracoacromialis (or the A. thoracica lateralis) None None *Arm in a 90-degree abduction

Fig. 4.57  Palpation of the fourth and fifth rib when arm is fully abducted

Fig. 4.58  Nearly transverse transducer orientation at the level of the fourth intercostal space

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Fig. 4.59  Besides the musculus serratus anterior (MSeA), a branch of the arteria thoracodorsalis (or arteria thoracica lateralis; arrowhead) serves as an internal landmark. Musculus pectoralis major (MPma)

Fig. 4.60  The nervus thoracicus longus (arrow) within the fascia of the musculus serratus anterior. Detection is often facilitated by a branch of the arteria thoracoacromialis (here in 3 o’clock position to the nerve)

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Nervus thoracodorsalis ELM IPOP ILM POV VAR AP C

1. Posterior axillary fold (M. latissimus dorsi and M. teres major)* 2. Palpable groove between the posterior axillary fold and the M. subscapularis Transverse, probe central on the posterior axillary fold, press the medial end into the body: “Heel-in maneuver” 1. A. thoracodorsalis On the inner surface of the M. latissimus dorsi, often posterior or medial to the A. thoracodorsalis None None *Arm in abduction and external rotation for better placement of the probe (see IPOP)

Fig. 4.61  Palpation of the groove between the muscles of the posterior axillary fold and the Musculus subscapularis in an abducted and external rotated arm

Fig. 4.62  Probe positioning perpendicular to the posterior axillary fold; press in the medial end of the probe

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Fig. 4.63  Depiction of the musculus latissimus dorsi (MLaD), the arteria thoracodorsalis (A), and venae thoracodorsales (arrowheads) as the internal landmarks

Fig. 4.64  The nervus thoracodorsalis (and its branches, respectively; arrows) is (are) visible best at the inner surface of the musculus latissimus dorsi (POV)

5

Gluteal Region Hannes Gruber, Philipp Koch, and Bernhard Moriggl

Contents Nervi clunium inferiores

 146

Nervus gluteus inferior

 148

Nervus gluteus superior

 150

Nervus ischiadicus 1: subgluteal segment

 152

Nervus pudendus

 154

H. Gruber (*) · P. Koch Department of Radiology, Medical University Innsbruck, Innsbruck, Austria e-mail: [email protected]; [email protected] B. Moriggl Division of Clinical and Functional Anatomy, Medical University Innsbruck, Innsbruck, Austria e-mail: [email protected] © Springer Nature Switzerland AG 2019 H. Gruber et al. (eds.), Sonographic Peripheral Nerve Topography, https://doi.org/10.1007/978-3-030-11033-8_5

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Nervi clunium inferiores ELM IPOP ILM

POV VAR AP C

1. Sulcus glutealis Transverse, about two to three fingerbreadths cranial to the sulcus glutealis 1. M. gluteus maximus 2. Mm. ischiocrurales (“hamstrings”) 3. Spatium subgluteale fibro-adiposum Within the spatium subgluteale as well as on the dorsal surface of the M. gluteus maximus None None The Nn. clunium inferiores loop around the inferior border of the M. gluteus maximus

Fig. 5.1  Assessment of the distance to the sulcus glutealis for correct positioning of the probe

Fig. 5.2  Exact transverse position of the probe – here two fingerbreadths proximal to the sulcus glutealis

5  Gluteal Region

Fig. 5.3  Musculus gluteus maximus (GM), hamstring muscles (HAM), spatium subgluteale (SGLU, arrowheads)

Fig. 5.4  As the nerves loop around the inferior border of the musculus gluteus maximus, you will depict their cross sections twice (arrows)

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Nervus gluteus inferior* ELM IPOP ILM

POV VAR AP C

1. Spina iliaca posterior superior 2. Tuber ischiadicum At the center of the reference line between the spina iliaca posterior superior and tuber ischiadicum (“S – Tu – Linie”; Anton Hafferl: Lehrbuch der topographischen Anatomie, 3. Auflage, 1969) 1. A. glutea inferior 2. M. piriformis 3. N. ischiadicus At the position of IPOP The N. glutealis inferior forms a common trunk with the N. cutaneus femoris posterior The N. cutaneus femoris posterior forms a loop around the A. glutea inferior** None *Use a curved array probe **In this case a differentiation is rather tricky

Fig. 5.5  Palpation of the spina iliaca posterior superior and the tuber ischiadicum for the definition of the reference line

Fig. 5.6  Slightly oblique and tilted probe position in the middle of the above-defined line

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Fig. 5.7  The internal landmarks are the arteria glutea inferior (AGI), the musculus piriformis (PIR), and the nervus ischiadicus (rather hyperechogenic ventral to the PIR!). Musculus gluteus maximus (GM)

Fig. 5.8  At the POV the nervus gluteus inferior (large arrows) lies directly dorsal to the arteria glutea inferior at the inferior border of the musculus piriformis and medial to the nervus ischiadicus. A branch of the nervus gluteus inferior (small arrows)

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Nervus gluteus superior* ELM IPOP ILM

POV VAR AP C

1. Spina iliaca posterior superior 2. Apex of the trochanter major Slightly oblique and tilted probe position between the middle and the medial third of the abovementioned bony ELM (“S – Tr – Linie”, Anton Hafferl: Lehrbuch der topographischen Anatomie, 3. Auflage, 1969) 1. A. glutea superior (or branches) 2. Os ilium 3. M. gluteus medius At the IPOP, between A. glutea superior and Os ilium None None *Use a curved array probe

Fig. 5.9  Palpation of the spina iliaca posterior superior and the tuber ischiadicum for the definition of the reference line

Fig. 5.10  Slightly oblique and tilted probe position with the midpoint between the middle and the medial third of the above-defined line

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Fig. 5.11  Os ilium (ILIUM) and arteria glutea superior (AGS) at the cranial border of the musculus piriformis (PIR) and the musculus gluteus medius (GMe) are the internal landmarks. Musculus gluteus maximus (GM)

Fig. 5.12  The POV of the nervus gluteus superior (arrows) – directly above the musculus piriformis – is usually between the artery and the bone

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Nervus ischiadicus 1: subgluteal segment* ELM IPOP ILM

POV VAR AP C

1. Trochanter major 2. Tuber ischiadicum Slightly oblique, medial end of the probe at the tuber ischiadicum 1. Tuber ischiadicum 2. Trochanter major/crista intertrochanterica 3. M. quadratus femoris** On the dorsal surface of the M. quadratus femoris** next to the tuber ischiadicum Two separate nerves (N. tibialis and N. fibularis communis) possible in cases of high bifurcation None *Use a curved array probe; keep leg in neutral position; cave: anisotropic effects – scan perpendicularly **The M. quadratus femoris is, when compared to the M. gluteus maximus, always more hypoechogenic

Fig. 5.13  Palpation of the external landmarks: trochanter major and tuber ischiadicum

Fig. 5.14  The center of the probe has to be positioned slightly lateral to the tuber ischiadicum

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Fig. 5.15  The musculus quadratus femoris (QUAD) and the tuber ischiadicum (TUB) are the most important internal landmarks. Musculus gluteus maximus (GM)

Fig. 5.16  Depiction of the extremely hyperechoic nerve (arrows) at the POV positioned between the musculus gluteus maximus and the musculus quadratus femoris; the excellent contrast of the nerve is provided by the hypoechogenic tissue dorsal to the nerve: the spatium fibro-­adiposum subgluteale

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Nervus pudendus* ELM IPOP ILM

POV VAR

AP C

1. Palpable tuber ischiadicum Transverse, about one fingerbreadth cranial to the upper border of the tuber ischiadicum 1. M. obturatorius internus** 2. Os ischii 3. A. pudenda interna Next and medial to the M. obturatorius internus*** Branching proximal to the Alcock channel >> two nerve cross sections Lacking of the A. pudenda interna (at IPOP) Nerve is perforated by the A. pudenda interna (or a branch) None *Use a curved array probe **“Waterfall sign” ***Cave: do not mix up with the resembling but more laterally found ligamentum sacrotuberale

Fig. 5.17  Palpation of the whole tuber ischiadicum (use two fingers!)

Fig. 5.18  Strict transverse probe position, center of the probe a little medial to the aforementioned landmark

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Fig. 5.19  The internal landmarks are the arched course of the musculus obturatorius internus (MOI, “waterfall sign”) around the Os ischii (OSI, incisura ischiadica minor). Neighboring arteria pudenda interna (AP), lateral (LAT), and medial (MED)

Fig. 5.20  Optimal delineated nerve (arrows) at its entry into the “Alcock channel” (next and medial to the musculus obturatorius internus!)

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Thigh, Lower Leg, and Foot Hannes Gruber, Philipp Koch, and Bernhard Moriggl

Contents 6.1  Thigh Nervus cutaneus femoris lateralis Nervus cutaneus femoris posterior Nervus femoralis Nervus femoralis: Rr. cutanei anteriores Nervus ischiadicus 2: infragluteal segment* Nervus obturatorius: “trunk” (if present*, otherwise “most proximal segments”) Nervus obturatorius: R. anterior and R. posterior Nervus obturatorius: R. cutaneus Nervus saphenus 1: Trigonum femorale Nervus saphenus 2: Canalis adductorius Nervus saphenus 3: sub-sartorial Compartment Nervus saphenus: R. infrapatellaris 1 (Regio femoralis anterior)

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6.2  Lower Leg and Foot Nervus cutaneus dorsalis lateralis Nervus cutaneus dorsalis medialis and Nervus cutaneus dorsalis intermedius Nervus cutaneus surae lateralis Nervus cutaneus surae medialis Nervus(i) digitalis(es) plantaris(es) communis(es) Nervus(i) digitalis(es) plantaris(es) proprius(i) Nervus fibularis communis Nervus fibularis profundus 1 (Dorsum pedis) Nervus fibularis profundus 2 (terminal segment) Nervus fibularis superficialis Nervus plantaris lateralis: R. profundus Nervus plantaris lateralis: R. superficialis Nervus plantaris lateralis and Nervus plantaris medialis: Planta pedis (entrance) Nervus plantaris lateralis and Nervus plantaris medialis within the Canalis tarsi Nervus saphenus 4: Regio cruralis posterior Nervus saphenus 5: terminal segment at the calf Nervus saphenus: R. infrapatellaris 2 (terminal segment) Nervus suralis Nervus suralis: Rr. calcanei laterales Nervus tibialis Nervus tibialis: Rr. calcanei mediales

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H. Gruber (*) · P. Koch Department of Radiology, Medical University Innsbruck, Innsbruck, Austria e-mail: [email protected]; [email protected]

B. Moriggl Division of Clinical and Functional Anatomy, Medical University Innsbruck, Innsbruck, Austria e-mail: [email protected]

© Springer Nature Switzerland AG 2019 H. Gruber et al. (eds.), Sonographic Peripheral Nerve Topography, https://doi.org/10.1007/978-3-030-11033-8_6

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Thigh

Nervus cutaneus femoris lateralis ELM IPOP ILM

POV VAR AP C

1. Spina iliaca anterior superior 2. Palpable groove between M. sartorius and M. tensor fasciae latae* Transverse about three to four fingers distal to the spina iliaca anterior superior, center of the probe at the palpable groove** 1. M. sartorius 2. M. tensor fasciae latae 3. Fascia lata 4. Fat-filled flat tunnel (FFFT)*** Within the FFFT between the M. sartorius und M. tensor fasciae latae, about four fingerbreadths distal to the spina iliaca anterior superior The transition of the N. cutaneus femoris lateralis concerning its course proximal to the ligamentum inguinale and on the crista iliaca, respectively, is very variable! It is additionally often split None *Patient should “lift the leg” **No compression ***There is a general rule: all big sensory nerves run through such tunnels; here they are easy to find as being contrasted by surrounding fat

Fig. 6.1  Simultaneous palpation of the spina iliaca anterior superior and the groove caudal to that (in some subjects even visible) between the musculus tensor fasciae latae and the musculus sartorius

Fig. 6.2  Transverse probe position distal to the spina iliaca anterior superior (dotted oval), center of the probe over the identified groove

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Fig. 6.3  The musculus tensor fasciae latae (TFL), the musculus sartorius (SAR), and the fascia lata (arrowheads) border the “fat-filled flat tunnel” (FFFT; rather hypoechogenic because it is mainly filled with fat!)

Fig. 6.4  The nerve (arrows) at the POV within the FFFT (arrowheads)

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Nervus cutaneus femoris posterior ELM

IPOP ILM

POV VAR AP C

1. Sulcus glutealis [2. Tuber ischiadicum] [3. Trochanter major] Transverse and two fingerbreadths distal to the sulcus glutealis, center of the probe at the middle of the thigh [more exactly: axial projection of the center of the line between the tuber ischiadicum and the tip of the trochanter major (Tu-Tr-Linie)]* 1. Caput longum musculi bicipitis femoris 2. Fascia lata 3. Fat-filled flat tunnel (FFFT) Between fascia lata and caput longum musculi bicipitis femoris in a FFFT (see also N. cutaneus femoris lateralis!) More medial or lateral than given by IPOP Look for the nerve in the gluteal region deep to the M. gluteus maximus and medial to the N. ischiadicus (use lower frequency!) *No compression

Fig. 6.5  The sulcus glutealis is indicated by the middle finger; the index finger indicates the point of IPOP

Fig. 6.6  Transverse and two fingerbreadths distal to the sulcus glutealis; positioning of the center of the probe in the middle of the thigh

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Fig. 6.7  The fascia lata (FL, arrowheads) and the long head of the musculus biceps femoris (BIC) must be depicted

Fig. 6.8  In this case the POV of the nerve (arrows) is lateral (and not dorsal) to the long head of the musculus biceps femoris but still within the “fat-filled flat tunnel” (hypoechogenic!)

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Nervus femoralis ELM IPOP ILM

POV VAR C

1. Pulsation of the A. femoralis 2. Ligamentum inguinale (or line between the spina iliaca anterior superior and the tuberculum pubicum) Center of the probe a little lateral to the A. femoralis, directly below or on the ligamentum inguinale* 1. A. femoralis 2. M. iliopsoas 3. Fascia lata [4. Head of the femur (in slim people)] Lateral to the A. femoralis, directly below the ligamentum inguinale** The distance of the nerve and the artery is variable (however always lateral to it!) *Important as further distal the nerve is already split into its branches **In a typical groove of the M. iliopsoas

Fig. 6.9  The pulsation of the arteria femoralis is palpable directly distal to the middle of the inguinal ligament

Fig. 6.10  The probe position is more or less transverse, its center a little lateral to the pulse of the arteria femoralis (index finger)

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Fig. 6.11  Here at the level of the ligamentum inguinale (ING, arrowheads) and the arteria femoralis (AF) and the musculus iliopsoas (PM)

Fig. 6.12  The echogenic cross section of the nerve’s main (deep) portion* (large arrows) directly lateral to the arteria femoralis and in a groove of the musculus iliopsoas. Note: in this individual a small artery (arrowhead) divides the nerve* (small arrows indicate superficial part)

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Nervus femoralis: Rr. cutanei anteriores ELM IPOP ILM

POV VAR AP C

1. Ligamentum inguinale 2. Basis patellae Transverse probe position in the middle third* of the antero-medial thigh 1. Subcutaneous fat with septi 2. Fascia of the thigh 3. Muscles of the thigh (e.g., M. quadriceps femoris, M. sartorius, etc.) Within the fat of the subcutis** Rr. cutanei anteriores nervi femoralis may split off the N. femoralis above the ligamentum inguinale None *Basing on the line between the spina iliaca anterior superior and the basis patellae **The Rr. cutanei anteriores nervi femoralis must pass all depths of the subcutis (follow them proximally and distally!); tip: some of the medial Rr. cutanei anteriores pierce and/or run deep to the M. sartorius before entering the subcutis

Fig. 6.13  The rami cutanei anteriores of the nervus femoralis may be found between the inguinal ligament proximally (small finger) and at least the basis patellae distally (index finger)

Fig. 6.14  The probe is transversely centered in the middle of the ventromedial thigh; then move the probe parallel from proximal to distal (double arrow)

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Fig. 6.15  The entire subcutaneous fat (SC) of the thigh is structured down to the fascia lata (arrowheads) by thin, echoic soft-tissue septa; muscles of the thigh: musculus quadriceps femoris (QUAD) and musculus sartorius (SAR)

Fig. 6.16  From proximal to distal, the rami cutanei anteriores (arrows) travel from deep to superficial and are thus to be found in different subcutaneous layers (depending on probe position)

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Nervus ischiadicus 2: infragluteal segment* ELM

IPOP

ILM POV VAR AP C

1. Sulcus glutealis [2. Tuber ischiadicum] [3. Trochanter major] Transverse probe position with its center in the middle of the thigh, one to maximum two fingerbreadths distal to the sulcus glutealis* [more exactly: divide the line tuber ischiadicum – tip of the trochanter major (“Tu-Tr-line”) into thirds, the perpendicular through the border between medial /middle third indicates the probe placement] 1. M. biceps femoris (caput longum) 2. M. adductor magnus Between the M. biceps femoris (caput longum, lying dorsal) and M. adductor magnus (lying ventral) Two nerves (N. tibialis and N. fibularis communis) in case of high division None *Leg in neutral position

Fig. 6.17  The sulcus glutealis is indicated by the middle finger, and the index finger indicates the point of IPOP

Fig. 6.18  Transverse probe position with its center in the middle of the thigh, just a little distal to the sulcus glutealis

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Fig. 6.19  Cross section of the long head of the musculus biceps femoris (BIC) and the musculus adductor magnus (ADDM)

Fig. 6.20  At the level of IPOP, the large nerve (arrows) lies very superficial and is thus best seen: POV between the muscles

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Nervus obturatorius: “trunk” (if present*, otherwise “most proximal segments”) ELM

IPOP ILM

POV VAR AP C

1. Pulsation of the A. femoralis 2. Ligamentum inguinale (or line between the spina iliaca anterior superior and the tuberculum pubicum) 3. Groin 4. Palpable tendon of the M. adductor longus Slightly oblique between the ELM (1) and (4) in the groin (about two fingerbreadths distal to the ramus superior ossis pubis)** 1. M. pectineus 2. M. obturatorius externus 3. Ramus inferior ossis pubis Between M. pectineus and M. obturatorius externus* (“sandwich”) R. posterior of the N. obturatorius often penetrates the M. obturatorius externus **The use of a lower-frequency probe may help (in some cases even a curved array probe) Hip slightly flexed and rotated externally *Very often, the N. obturatorius is already split when entering the thigh (but both branches lie close together)

Fig. 6.21  In the groin the pulse of the artery is palpated, and medial to that, the origin (tendon) of the musculus adductor is palpable too

Fig. 6.22  After positioning of the probe at the groin, beam orientation has to be marked cranially and dorsally

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Fig. 6.23  To clearly identify the internal landmarks, a curved array probe is often recommended: musculus pectineus (PECT), musculus obturatorius externus (OE), ramus inferior (RI) ossis pubis, and ramus superior (RS) ossis pubis

Fig. 6.24  The nerve (arrows) is depicted interposed between musculus pectineus and musculus obturatorius externus: (first) “sandwich.” Mind the hourglass shape of the cross section of the nerve as it begins to split

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Nervus obturatorius: R. anterior and R. posterior ELM

IPOP ILM POV VAR AP C

1. Pulsation of the A. femoralis 3. Groin 4. Palpable tendon of the M. adductor longus Medial to the A. femoralis and two fingerbreadths distal to the groin in a strictly transverse probe orientation 1. V. femoralis* 2. M. adductor brevis R. anterior ventral and R. posterior dorsal to the M. adductor brevis** None None *After identifying the vein, move the probe medial (until the M. adductor brevis appears) **The R. anterior is usually flat but wide compared to the R. posterior

Fig. 6.25  In the groin the pulse of the artery is palpated, and medial to that the origin (tendon) of the musculus adductor is palpable too

Fig. 6.26  The probe must be positioned a little more distal (about two fingerbreadths) than the IPOP for the main stem of the nerve and must be aligned strictly transverse

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Fig. 6.27  Medial to the vena femoralis (FV), the striking arrangement of the muscles in layers is depicted: musculus adductor longus (ADDL), musculus adductor brevis (ADDB), and the musculus adductor magnus (ADDM). Keep in mind: in this scanning position, there is often a tendon-­ like septum within the ADDB (not to be mixed up with one of the two branches of nervus obturatorius!)

Fig. 6.28  Second “sandwich”: Ramus anterior interposed between musculus adductor longus and brevis (large arrow from above together with a small arrow = side branch), the Ramus posterior interposed between the musculus adductor brevis and magnus (large arrow from below); mind the different shapes of the two nerves

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Nervus obturatorius: R. cutaneus ELM

IPOP ILM

**POV VAR AP C

1. M. adductor longus 2. M. gracilis 3. M. sartorius Distal third of the medial thigh 1. M. gracilis 2. M. sartorius [3. M. adductor longus 4. M. adductor magnus] Between the M. gracilis and M. sartorius If present* – none None *Two thirds of the population lacks this branch **Even when present it is not always “optimal”

Fig. 6.29  Palpation of the groove between musculus adductor longus and musculus gracilis; the palmar side of the index finger lies at the medial border of the musculus sartorius

Fig. 6.30  Strictly transverse probe position at the inner aspect of the middle to distal thigh (move the probe for a distance!)

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Fig. 6.31  At the transition between the middle to the distal third of the thigh (where the musculus sartorius [SAR] and musculus gracilis [GRA] meet), the fascia lata (arrowheads) forms a duplication: a “fat-­filled flat tunnel” (FFFT; see also nervus cutaneus femoris lateralis and posterior!)

Fig. 6.32  The small FFFT (hypoechogenic area between the arrowheads) between the surfaces of the musculus gracilis and musculus sartorius contains the ramus cutaneus (arrow)

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Nervus saphenus 1: Trigonum femorale ELM IPOP ILM

POV VAR AP C

1. Spina iliaca anterior superior 2. Basis patellae Transverse probe position at inner aspect of the middle of the thigh 1. A. femoralis 2. M. sartorius 3. M. vastus medialis 4. M. adductor longus Lateral to the A. femoralis within the trigonum femorale (over the whole middle third of the thigh!)* N. saphenus lies on or even medial (!) to the A. femoralis None *The motor branch to the M. vastus medialis runs lateral to the N. saphenus and might thus be mixed up

Fig. 6.33  Definition of the length of the thigh from the spina iliaca anterior superior to the basis patellae

Fig. 6.34  Transverse probe orientation in the mid of the thigh and clearly medial to the line between spina iliaca anterior superior and basis patellae

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Fig. 6.35  The musculus vastus medialis (VM), the musculus sartorius (SAR), and the musculus adductor longus (ADDL) form a triangular “landmark” which contains the arteria femoralis (A)

Fig. 6.36  Within the trigonum femorale, the nervus saphenus (arrows) is found lateral to the arteria femoralis, covered by the musculus sartorius

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Nervus saphenus 2: Canalis adductorius ELM IPOP ILM

POV VAR AP C

1. Spina iliaca anterior superior 2. Basis patellae Transverse probe position in the distal third of the thigh medial to the line spina iliaca anterior superior-basis patellae (farther medial than in N. saphenus 1!) 1. A. femoralis 2. M. sartorius 3. M. vastus medialis 4. M. adductor magnus 5. Membrana vasto-adductoria In the proximal segment of the canalis adductorius, anterolateral to the artery N. saphenus medial to the A. femoralis None None

Fig. 6.37  Definition of the length of the thigh: from the spina iliaca anterior superior to the basis patellae

Fig. 6.38  Transverse probe position at the beginning of the inner aspect of the distal third of the thigh

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Fig. 6.39  The membrana vasto-adductoria (MVA, arrowheads) spans from the musculus adductor magnus (ADDM) to the musculus vastus medialis (VM). The musculus sartorius (SAR) covers the MVA; the arteria femoralis (AFS) runs within the adductor canal

Fig. 6.40  The nervus saphenus (arrows) runs within the canalis adductorius and is clearly visible ventrolateral to the artery

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Nervus saphenus 3: sub-sartorial Compartment ELM *IPOP ILM

POV VAR AP C

Basis patellae Transverse probe position at the inner aspect of the thigh, four fingerbreadths proximal to the basis patellae 1. Membrana vasto-adductoria 2. M. vastus medialis 3. A. genus descendens Between membrana vasto-adductoria and M. sartorius next to the A. descendens genus** None **In tricky cases the artery might “show the way to the nerve” *Slight abduction and external rotation in the hip joint facilitates IPOP

Fig. 6.41  With the hand lying on the ventral thigh: the index finger of the left hand touches the basis patellae; the little finger exactly defines the level (not the spot!) where the probe has to be positioned

Fig. 6.42  Transverse probe position at the innermost surface of the distal thigh; note the position of the leg

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Fig. 6.43  The membrana vasto-adductoria (arrowheads) is depicted as a double layer and is covered by the musculus sartorius (SAR). Arteria descendens genus (A), musculus vastus medialis (VM)

Fig. 6.44  The nervus saphenus (arrows) within the sub-sartorial compartment. Mind the size of the cross-sectional area of the nerve

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Nervus saphenus: R. infrapatellaris 1 (Regio femoralis anterior) ELM IPOP ILM

POV VAR

AP C

Basis patellae In the area of the medial thigh, one palm proximal to the basis patellae* (compare to N. saphenus 3!) 1. N. saphenus 2. M. sartorius 3. M. vastus medialis Nearly unpredictable due to the numerous variants The level of parting the main stem of the N. saphenous and the course relative to the M. sartorius (medial, lateral, or even perforating the muscle!) is highly variable** Rather common the nerve consists of several branches (with variable courses and anastomoses!) **Check the M. sartorius and its surroundings precisely (beginning at mid-thigh level!) *Begin (at least) here with checking the N. saphenus for giving off branches

Fig. 6.45  With the hand lying on the ventral thigh: the thumb of the left hand touches the basis patellae, and the little finger exactly defines the level (not the spot!) where the probe has to be positioned

Fig. 6.46  Transverse probe position at the inner surface of the distal thigh; note the position of the leg

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Fig. 6.47  Resembling to the sub-sartorial nervus saphenus 3, the striking internal landmarks are the musculus sartorius (SAR) and the nervus saphenus (arrows) itself! Arteria descendens genus (A), musculus vastus medialis (VM)

Fig. 6.48  Variant course of the ramus infrapatellaris (arrows) anterolateral to the musculus sartorius and directly on the musculus vastus medialis

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Lower Leg and Foot

Nervus cutaneus dorsalis lateralis ELM IPOP ILM POV VAR AP C

1. Malleolus lateralis (tip) 2. Visible or palpable tendons of the Mm. fibulares* Oblique, two fingerbreadths antero-inferior to the tip of the malleolus lateralis; center of the probe on the tendon of the M. fibularis brevis 1. Tendons of the Mm. fibulares 2. Subcutaneous vein(s) of the lateral foot border (>>V. saphena parva)** Exactly at the IPOP None None *Pronation helpful; also a standoff pad may help in coupling the probe sufficiently **No compression

Fig. 6.49  Palpation of the tip of the malleolus lateralis (index finger) and definition of the IPOP (middle finger) of the center of the probe; the orientation of the fingers defines the orientation of the probe

Fig. 6.50  The center of the probe lies on the tendon of the musculus fibularis brevis (visible during pronation of the foot!)

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Fig. 6.51  The tendons of the muscles of fibula: musculus fibularis longus (SFL) and musculus fibularis brevis (SFB; uneven echogenicity of the muscles due to anisotropy effects basing on different orientation of the tendon fibers!). Feeding vein of the vena saphena parva (VSP)

Fig. 6.52  The nervus cutaneus dorsalis lateralis (arrows) on the tendon of the musculus fibularis brevis. Enhanced contrast within the subcutis due to a crossing vein

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Nervus cutaneus dorsalis medialis and Nervus cutaneus dorsalis intermedius ELM IPOP ILM POV VAR AP C

1. Malleolus lateralis 2. Malleolus medialis Oblique at the distal end of the extensor loge, two fingerbreadths proximal to a reference line (connecting the ankles) Retinaculum musculorum extensorum superius* At the crossing of the retinaculum musculorum extensorum superius More proximal division of the nerves “More than two” at POV None *Only seen with high-resolution probes (triple-layer appearance: “white-black-white”)

Fig. 6.53  Defining the connecting line between the malleoli

Fig. 6.54  Position and orientation of the probe according to the (oblique) course of the retinaculum musculorum extensorum superius

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Fig. 6.55  The retinaculum musculorum extensorum superius (RETS, arrowheads) appears as a triple-layer structure in the ultrasound image: “white-black (=artifact)- white.” Extensors (tendons) (EXT). Arteria tibialis anterior (ATA)

Fig. 6.56  Both (see also VAR!) nerves (arrows) are sharply delineated clearly within the subcutis ventral to the retinaculum

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Nervus cutaneus surae lateralis ELM

IPOP ILM

POV VAR AP C

1. Caput fibulae 2. Tendon of the M. biceps femoris 3. M. gastrocnemius, caput laterale Transverse with the midpoint of probe at the tibial border of the M. biceps femoris, two fingerbreadths proximal to the caput fibulae* 1. M. gastrocnemius, caput laterale 2. N. fibularis communis 3. Caput fibulae On the caput laterale of the M. gastrocnemius at the level of the caput fibulae (and so far more distal to the POV of the N. fibularis communis) Two nerves given off by the N. fibularis communis* Variable level of branching off IPOP exactly at the level of the caput fibulae *Begin more proximal than POV says in order not to overlook VAR! Then move further distally (see also AP!)

Fig. 6.57  Palpation of the tibial border of the musculus biceps femoris and of the caput fibulae

Fig. 6.58  Transverse probe position, level of the caput fibulae; the center of the probe is clearly distant to the tibial border of the musculus biceps femoris (centered over the caput laterale of the musculus gastrocnemius)

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Fig. 6.59  The musculus gastrocnemius, caput laterale (GCL), and the caput fibulae (CF) are covered by the fascia poplitea (arrowheads)

Fig. 6.60  The nervus cutaneus surae lateralis (small arrows) lies subfascial (arrowheads!), directly on the caput laterale of the musculus gastrocnemius. Nervus fibularis communis (NF, large arrows)

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Nervus cutaneus surae medialis ELM IPOP ILM

POV VAR AP C

1. Palpable caput laterale 2. Palpable caput mediale of the M. gastrocnemius* Transverse in the groove between the two heads of the M. gastrocnemius; three to four fingers distal to the center of the popliteal fossa 1. Caput laterale m. gastrocnemii 2. Caput mediale m. gastrocnemii 3. V. saphena parva In the abovementioned groove or dorsal to the caput mediale of the M. gastrocnemius (but – almost always** – next to the V. saphena parva!) V. saphena parva is lacking** V. saphena parva epifascial (if confluence is more proximal) – with the nerve subfascial ** None *Forceful plantar flexion! In extreme obesity or edema, the caput fibulae may serve as ELM for the IPOP

Fig. 6.61  Palpate the groove between the two heads of the musculus gastrocnemius

Fig. 6.62  Strictly transverse probe position about four fingerbreadths distal to the center of the fossa poplitea

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Fig. 6.63  See the medial head of the M. gastrocnemius (GCM) and the subfascial position of the vena saphena parva (VSP)

Fig. 6.64  The nerve (arrows) is found directly next to the vena saphena parva and according to the vein covered by the fascia poplitea/cruris (in this case on the caput mediale of the musculus gastrocnemius). Please note the subfascial fat (hypoechoic) and compare to the nervus cutaneus femoris posterior and lateralis (“FFFT”)

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Nervus(i) digitalis(es) plantaris(es) communis(es) ELM

IPOP ILM

POV VAR AP C

1. Common bale of toes 2. Bale of the big toe [3. Intermetatarsal spaces] Proximal end of the bale in a transverse probe position, moved a little toward the heel 1. Base of the Os metatarsale 1 2. Long flexor tendons and the Mm. lumbricales 3. (Longitudinal bundles of the) Plantar aponeurosis At/or very near to IPOP None None Do not use too-high-frequency probes (due to the special connective tissue architecture of the sole of the foot!)

Fig. 6.65  Palpation and definition of the proximal borders of the common bale of the toes and the bale of the big toe

Fig. 6.66  Aligning to the abovementioned borders in a transverse probe position (ELM), move a little toward the heel

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Fig. 6.67  Os metatarsale primum (OM1), long flexor tendons (BS, note anisotropic effects!), musculi lumbricales (LUM), musculi interossei (IO), and longitudinal bundles of the plantar aponeurosis (PLA, arrowheads) must be differentiated

Fig. 6.68  The nerves (arrows) always run between the plantar aponeurosis (arrow heads) and the plantar muscles

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Nervus(i) digitalis(es) plantaris(es) proprius(i) ELM IPOP ILM POV VAR AP C

1. Proximal flexion furrow of the big toe 2. Soles-toes furrow Immediately proximal to the ELM (metatarso-phalangeal transition) 1. Heads of the ossa metatarsalia 2. Flexor tendons = IPOP None None Active or passive extension of the toes Maybe a standoff pad for coupling is needed

Fig. 6.69  Indication of both, the soles-toes furrow and the proximal flexion furrow of the big toe

Fig. 6.70  Transverse probe position just proximal to the described ELM

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Fig. 6.71  Heads of the ossa metatarsalia (e.g., OM2 and OM3), flexor tendons (BS), and arteriae digitales plantares communes (A; division more distal than the nerves!) serve as ILM. Ligamenta intermetatarsalia (IM)

Fig. 6.72  The nerves (arrows) are always found medial and lateral to the arteria digitalis plantaris communis at the metatarso-phalangeal transition (POV)

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Nervus fibularis communis ELM IPOP ILM POV VAR AP C

1. Caput fibulae 2. Palpable tibial border of the M. biceps femoris (and its tendon, respectively) Oblique (=perpendicular to the course of the bicep tendon!), with the center of the probe at the tibial border of the M. biceps femoris, three fingerbreadths proximal to the caput fibulae 1. M. biceps femoris 2. M. gastrocnemius, caput laterale Direct at or one fingerbreadth distal to the IPOP at the dorsal surface of the M. gastrocnemius and caput laterale None None None

Fig. 6.73  Palpation and indication of the tibial border of the musculus biceps femoris and of the caput fibulae

Fig. 6.74 Oblique positioning of the probe at the lateral part of the popliteal fossa with the center directly on the tibial border of the musculus biceps femoris

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Fig. 6.75  The posterior border of the musculus biceps femoris (BF) and the caput laterale of the musculus gastrocnemius (GCL) may always be depicted easily! Arrowheads: fascia poplitea

Fig. 6.76  The nerve (arrows) is shown best interposed between the border of the musculus biceps femoris and the caput laterale of the musculus gastrocnemius. Arrowheads: fascia poplitea

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Nervus fibularis profundus 1 (Dorsum pedis) ELM

IPOP ILM

POV VAR AP C

1. Tendon of the M. extensor hallucis longus 2. Tendon of the M. extensor digitorum longus* 3. Palpable pulsation of the A. dorsalis pedis 4. Tips of both malleoli** Transverse positioning of the probe between the (tendons of the) M. extensor hallucis longus and M. extensor digitorum longus at the intermalleolar line** 1. (Tendon of the) M. extensor hallucis longus 2. (Tendon of the) M. extensor digitorum longus 3. A. dorsalis pedis 4. Talus Directly next to the A. dorsalis pedis*** Nerve distant to the artery Multiple variations of the arteries (e.g., rudimentary/lacking A. dorsalis pedis) None *Dorsal extension ***Nerve runs tibial (more often) or anterior to the artery

Fig. 6.77  The tendons of the musculus extensor hallucis longus and of the musculus extensor digitorum longus are clearly seen through dorsal extension of the toes. A line connecting the palpable tips of the malleoli** defines the level of IPOP

Fig. 6.78  Positioning of the probe at the intermalleolar line**

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Fig. 6.79  See all the internal landmarks: musculus extensor hallucis longus (EH), musculus extensor digitorum longus (EDL), arteria dorsalis pedis (ADP), and talus (T); additionally, the ventral surface of the lateral malleolus (F) is shown

Fig. 6.80  The nerve (arrows) runs within a fascia duplication along the arteria tibialis anterior. Noteworthy: in this individual the nerve is located fibular and distant to the artery (see VAR)

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Nervus fibularis profundus 2 (terminal segment) ELM IPOP ILM POV VAR AP C

1. Palpable spatium interosseum metatarseum primum Transverse, center of the probe at the spatium interosseum* 1. A. metatarsea dorsalis I 2. Ossa metatarsalia I and II Fibular of the arteria metatarsea dorsalis I None None *Standoff pad might be useful; note: the artery is compressed easily

Fig. 6.81  Palpation of the spatium interosseum metatarseum primum; foot grounded

Fig. 6.82  Perpendicular to the course of the tendons (musculi extensor hallucis longus and digitorum longus), the probe has to be positioned at half distance of the intermetacarpal space

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Fig. 6.83  The arteria metatarsea dorsalis prima (AMT) is the vascular landmark. Os metatarsale I (OM1), Os metatarsale II (OM2), and musculus interosseus dorsalis primus (MI)

Fig. 6.84  The nerve (arrows) runs fibular and very next to the arteria metatarsea dorsalis prima

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Nervus fibularis superficialis ELM

IPOP ILM

POV VAR AP C

1. Palpable anterior border of the fibula (in its distal segment) 2. Palpable M. extensor digitorum longus 3. Palpable M. fibularis longus (and brevis) Slightly oblique*, center of probe between ELM (2) and (3) 1. Fibula** 2. M. extensor digitorum longus 3. M. fibularis longus Subfascial(!) between M. extensor digitorum longus and M. fibularis longus within a fat-filled flat tunnel*** Two nerves, which perforate the fascia cruris at different levels (move the probe!) None *Remember the course of the nerve **The nerve lies on a perpendicular through its anterior border ***Common concept: all large sensory nerves use such tunnels; thus these nerves show good contrast

Fig. 6.85  Palpation of the anterior border of the fibula in a groove between the musculus extensor digitorum longus and musculi fibulares

Fig. 6.86  According to the known course of the nervus fibularis superficialis (probe position always perpendicular!), the positioning of the probe is given

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Fig. 6.87  The fascia cruris (arrowheads) is aponeurotic in the area of the musculus extensor digitorum longus (EDL) and musculus fibularis longus (FIBL); this fact substantiates the “multilayer” appearance (“white-black-white”). Fibula (F)

Fig. 6.88  The nerve (arrows) runs within a fat-filled flat tunnel (FFFT; by duplication of the fascia) what provokes optimal depiction. Arrowheads: three-layered fascia cruris

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Nervus plantaris lateralis: R. profundus ELM

IPOP ILM

POV VAR AP C

In extension of the toes  1. Palpable borders of the plantar aponeurosis  2. Palpable plantar groove between M. abductor digiti minimi and plantar aponeurosis Transverse probe position at the level of the tuberositas of the Os metatarsale V, centered to the groove between the M. abductor digiti minimi and the aponeurosis plantaris 1. R. profundus of the A. plantaris lateralis 2. M. quadratus plantae 3. Base of Os metatarsale V At the IPOP The position of the R. profundus of the A. plantaris lateralis is variable – although the artery lies always next to it None Vary the tilt of the probe due to the plantar connective tissue septa

Fig. 6.89  Under extension of the toes: palpable borders of the aponeurosis plantaris and palpable groove between musculus abductor digiti minimi and the (lateral border of the) aponeurosis plantaris. The finger of the left hand defines the tuberositas ossis metatarsalis V

Fig. 6.90  Transverse probe position at the level of tuberositas ossis metatarsalis V, centered on and transverse to the groove between the musculus abductor digiti minimi and aponeurosis plantaris

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Fig. 6.91  The ramus profundus of the arteria plantaris lateralis (A), the musculus abductor digiti minimi (ABDM), and the musculus flexor digitorum brevis (FDB) must be shown clearly. Base of the Os metatarsale V (OM5) and the Os metatarsale IV (OM4)

Fig. 6.92  Depiction of the nerve (arrows) works best where it is covered by the musculus flexor digitorum brevis next to the ramus profundus of the arteria plantaris lateralis (the visible shadowing is due to the sagittal septum of the aponeurosis plantaris!)

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Nervus plantaris lateralis: R. superficialis ELM

IPOP ILM

POV VAR AP C

In extension of the toes  1. Palpable borders of the aponeurosis plantaris  2. Palpable plantar groove between M. abductor digiti minimi and aponeurosis plantaris Transverse probe position at the level of the tuberositas of the Os metatarsale V centered to the groove between the M. abductor digiti minimi and aponeurosis plantaris 1. R. superficialis of the A. plantaris lateralis 2. M. abductor digiti minimi 3. M. flexor digitorum brevis At the IPOP The position of the R. superficialis of the A. plantaris lateralis is variable – although the artery lies always next to it None Vary the tilt of the probe due to the plantar connective tissue septa

Fig. 6.93  Under extension of the toes: palpable borders of the aponeurosis plantaris and palpable groove between musculus abductor digiti minimi and the (lateral border of the) aponeurosis plantaris. The finger of the left hand defines the tuberositas ossis metatarsalis V

Fig. 6.94  Transverse probe position at the level of tuberositas ossis metatarsalis V, centered on and transverse to the groove between the musculus abductor digiti minimi and aponeurosis plantaris

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Fig. 6.95  The ramus superficialis of the arteria plantaris lateralis (A), the musculus abductor digiti minimi (ABDM), and the musculus flexor digitorum brevis (FDB) must be shown clearly. Base of the Os metatarsale V (OM5) and the Os cuboideum (C)

Fig. 6.96  Best visualization of the nerve (arrows) is between the musculus abductor digiti minimi and the musculus flexor digitorum brevis next to the ramus superficialis of the arteria plantaris lateralis

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Nervus plantaris lateralis and Nervus plantaris medialis: Planta pedis (entrance) ELM

IPOP ILM

POV VAR C

1. Calcaneus 2. Palpable groove between M. abductor hallucis and the medial border of the Plantar aponeurosis 3. Plantar aponeurosis* At the abovementioned groove, the probe is almost perpendicular to the medial border of the sole of foot** 1. M. abductor hallucis 2. M. flexor digitorum brevis 3. M. quadratus plantae 4. Aa. plantares At the plantar surface of the M. quadratus plantae None *Big toe in plantar flexion! (The “abductor” is rather a functional flexor!) **“Heel-in” – maneuver necessary (push in the plantar end of probe!)

Fig. 6.97  Starting with the insertion of the Achilles tendon, the index finger of the left hand palpates a groove between the musculus abductor hallucis and the medial border of the aponeurosis plantaris

Fig. 6.98  Positioning of the probe perpendicularly to the medial border to the sole of foot; the center points toward the medial border of the aponeurosis plantaris – the proximal end of the probe looks slightly anterior to the tip of the malleolus medialis

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Fig. 6.99  The most important muscular structures are musculus abductor hallucis (AH), musculus flexor digitorum brevis (FDB), and musculus quadratus plantae (QP); on the latter lie the arteriae plantares (here only the medial one is seen, the lateral one is compressed). Sustentaculum tali (SUS), tendons of the musculus flexor digitorum longus (FDL), and of the musculus flexor hallucis longus (FH)

Fig. 6.100  The two nerves (nervus plantaris medialis [arrows next to the cross section of the arteria plantaris medialis] and nervus plantaris lateralis [arrows adjacent to the cross section of the musculus quadratus plantae]) lie in a fascial duplication on the medioplantar surface of the M. quadratus plantae

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Nervus plantaris lateralis and Nervus plantaris medialis within the Canalis tarsi ELM IPOP ILM

POV VAR AP C

1. Malleolus medialis 2. Calcaneus (tuber) Along the line between the palpated ELM 1. A. tibialis posterior (and veins) 2. Flexor tendons 3. Retinaculum musculorum flexorum (stratum superficiale and profundum!) In the first segment of the tarsal tunnel, fibular to the A. tibialis posterior (and neighboring veins) Division of the N. tibialis far plantar (“only one nerve” within the tarsal tunnel) None None

Fig. 6.101  Palpation of the malleolus medialis and the tuber calcanei for orientation

Fig. 6.102  Positioning of the probe according to the line between to aforementioned ELM (Fig. 6.98), with the center of the probe more orientated toward the tuber calcanei (the upper end is a little more distant to the malleolus medialis)

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Fig. 6.103  The retinaculum musculorum flexorum and stratum superficiale (RF; arrowheads) cover the neurovascular bundle: arteria tibialis posterior (A) with venae comitantes (V). The flexor tendons (B) are divided from the neurovascular bundle by the stratum profundum of the retinaculum flexorum (impressively clear at the right bottom of the image: “white-black-white”). Deep to that in the right corner of the picture, the calcaneus produces bony shadowing

Fig. 6.104  Both nerves (arrows) are very well depicted owing to their positions next to the vessels (“dorsal enhancement”); retinaculum flexorum, stratum superficiale (RF, arrowhead). Nervus plantaris medialis (PM) and nervus plantaris lateralis (PL)

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Nervus saphenus 4: Regio cruralis posterior ELM

IPOP ILM POV VAR AP C

1. Tuberositas tibiae 2. M. gracilis (tendon) 3. Pes anserinus superficialis Transverse, center of the probe two fingerbreadths distal to the pes anserinus* V. saphena magna Dorsal to the V. saphena magna; if the vein is lacking (e.g., after surgery): None Nerve ventral to the vein None *No compression! Use the highest frequency available

Fig. 6.105  Palpation of the dorsal border of the pes anserinus superficialis (in external rotation/abduction of the leg and slight flexion of the knee joint!); the radial edge of the index finger marks the inferior border of the tuberositas tibiae

Fig. 6.106 Strictly transverse probe position at the medial calf, probe center two fingerbreadths distal to the pes anserinus superficialis

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Fig. 6.107  The vena saphena magna (VSM) next to the facies medialis tibiae is the crucial ILM

Fig. 6.108  When using very high probe frequencies (e.g., here >20 MHz), even the echoic epineurium is clearly (arrows) depicted

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Nervus saphenus 5: terminal segment at the calf ELM IPOP ILM POV VAR AP C

Malleolus medialis Approximately transverse probe position, four fingerbreadths proximal to the malleolus medialis* V. saphena magna Ventral and dorsal to the vein at the IPOP None None *No compression! Use the highest frequency available

Fig. 6.109  Definition of the level of the IPOP by palpation of the medial tibia/medial malleolus

Fig. 6.110  If visible or palpable (compression proximal to IPOP!): the center of the probe must be positioned directly on the vena saphena magna

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Fig. 6.111  The vena saphena magna (VSM, main trunk, within a fascial duplication)

Fig. 6.112  Clear delineation of the terminal branches of the nervus saphenus (arrows) ventral and dorsal to the vein

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Nervus saphenus: R. infrapatellaris 2 (terminal segment) ELM

IPOP ILM POV VAR AP C

1. Apex patellae 2. Tuberositas tibiae 3. Ligamentum patellae On a line between the apex patellae and the pes anserinus superficialis Tendon of the M. sartorius (near the pes anserinus superficialis) In the middle between the anterior border of the M. sartorius and the medial border of the ligamentum patellae Splitting of the R. infrapatellaris into several branches: in this case no POV None A standoff pad may help

Fig. 6.113  Simultaneous palpation of the apex patellae and the tuberositas tibiae (the ramus infrapatellaris is usually heading toward the middle of the ligamentum patellae!)

Fig. 6.114  Very oblique probe position; perpendicular to the assumed course of the nerve (search!)

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Fig. 6.115  Insertional tendon of the musculus sartorius (SAR; hypoechoic due to anisotropic effects); fascia cruris (arrowheads)

Fig. 6.116  The nerve is found epifascial (fascia cruris: arrowheads) in the subcutis ventral to the tendon of musculus sartorius

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Nervus suralis ELM

IPOP ILM

POV VAR AP C

1. Malleolus lateralis 2. Palpable Mm. fibulares 3. Palpable M. soleus 4. Shallow groove between (2) and (3) Transverse probe position four fingerbreadths proximal to the malleolus lateralis* 1. V. saphena parva 2. M. soleus 3. Mm. fibulares Exactly at IPOP** Position relative to the V. saphena parva mirror-inverted None *No compression **Subcutaneous and usually ventral/fibular of the V. saphena parva

Fig. 6.117  Starting with the malleolus lateralis (in proximal direction), a shallow groove is palpable between the musculi fibulares and the musculus soleus

Fig. 6.118 Strictly transverse position of the probe with its center on the abovementioned groove

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Fig. 6.119 The vena saphena parva (VSP) is the vascular landmark! Musculus soleus (SOL), musculus fibularis longus (FIBL). Fascia cruris (arrowheads)

Fig. 6.120  The nerve (arrows) lying typically next to the epifascial vein (fascia cruris: arrowheads), though ventrally and dorsally (see VAR)

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Nervus suralis: Rr. calcanei laterales ELM

IPOP ILM

POV VAR AP C

1. Malleolus lateralis 2. Tendo calcaneus (Achilles tendon) 3. Visible and palpable tendon of the M. fibularis longus Transverse, three to four fingerbreadths proximal to the malleolus lateralis; consecutively, move the probe toward the insertion of the Achilles tendon* 1. Fascia cruris 2. N. suralis (farther proximal) 3. Calcaneus (distal) [4. “Branches” of the V. saphena parva** Within the subcutis** often next to the Achilles tendon; before all of the nerves cross underneath “branches” of the V. saphena parva (dorsal enhancement!) None None *Standoff pad often helpful **Quite contrary to the Rr. calcanei mediales of the N. tibialis, the rami calcanei laterales run always subcutaneously

Fig. 6.121  The following landmarks are palpated as shown: malleolus lateralis and the insertion of the Achilles tendon

Fig. 6.122  Start proximal not to overlook the nerve in case of very proximal separation; then move the probe distally in the direction of the dotted arrow

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Fig. 6.123  The fascia cruris (arrowheads) extends as far as to the calcaneus (C)

Fig. 6.124  The nerves (arrows) are clearly visible in the hypoechoic subcutis; see the defined border of the cutis (arrowheads) by very high-­ frequency probe

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Nervus tibialis ELM IPOP ILM POV VAR AP C

1. Deep flexors: M. flexor digitorum longus and M. tibialis posterior 2. Palpable M. soleus (distal end) Transverse, about six fingerbreadths proximal to the malleolus medialis* 1. M. soleus at its transition into the Achilles tendon 2. A. tibialis posterior and Vv. comitantes Beginning with the IPOP until some centimeters further distal None None *Here “even” surface (=better coupling >>less artifacts) … than more distal

Fig. 6.125  Palpation of the dorsal surface of the calf between the musculus tibialis posterior and musculus flexor digitorum longus anterior, musculus soleus, and the Achilles tendon posterior, respectively

Fig. 6.126  Center of the transversely oriented probe in the area of the aforementioned indentation

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Fig. 6.127  The bellies of the deep flexors (FLEX) at the transition of the M. soleus (SOL) into the Achilles tendon as well as the accompanying arteria tibialis posterior and venae tibiales posteriores (A/V) are guides to the nerve; tibia (T)

Fig. 6.128  The cross section of the nervus tibialis (arrows) at the POV, i.e., proximal to the regio retromalleolaris medialis together with the accompanying vessels

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Nervus tibialis: Rr. calcanei mediales ELM

IPOP ILM POV VAR AP C

1. Deep flexors: M. flexor digitorum longus and M. tibialis posterior 2. Palpable M. soleus (distal end) 3. Fossa retromalleolaris medialis Transverse, about six fingerbreadths proximal to the malleolus medialis* 1. N. tibialis 2. Fascia cruris and/or retinaculum musculorum flexorum ** Just before entry of the N. tibialis into the tarsal tunnel subfascial or even within the tarsal tunnel Level of separation is very variable* None *The Rr. calcanei mediales may leave the N. tibialis at almost any level distal to IPOP: follow the N. tibialis to detect them **Note: rami calcanei are subfascial! (In clear contrast to those of the N. suralis! See there!)

Fig. 6.129  Assessment of the segment of the nervus tibialis where the rami may be given off

Fig. 6.130  Center of the probe at the aforementioned shallow groove and parallel shift toward distal (large arrow)

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Fig. 6.131  Here in the far distal scanning plane: inside the proximal tarsal tunnel. Retinaculum flexorum (RF, arrowheads) and nervus tibialis (arrows), M. abductor hallucis (ABH), calcaneus (C)

Fig. 6.132  Well visible rami calcanei (arrows) within the canalis tarsi. The arrowheads define the stratum superficiale of the retinaculum musculorum flexorum

Appendix

2. Neck • • • • • • • • • • • • • • • • • • • •

Ganglion cervicale medium Nervus accessorius Nervus auricularis magnus Nervus dorsalis scapulae Nervus facialis: Ramus colli Nervus hypoglossus 1 (diaphragma oris) Nervus hypoglossus 2 (trigonum caroticum) Nervus laryngeus inferior Nervus laryngeus recurrens Nervus laryngeus superior Nervus laryngeus superior: Ramus externus Nervus laryngeus superior: Ramus internus Nervus occipitalis major Nervus occipitalis minor Nervus occipitalis tertius Nervus phrenicus Nervus subclavius Nervus(i) supraclavicularis(es) Nervus suprascapularis Nervus thoracicus longus 1 (fossa supraclavicularis major) • Nervus transversus colli • Nervus vagus • Plexus cervicalis: Ramus trapezius

• • • • • • •

Nervus cutaneus brachii lateralis superior Nervus cutaneus brachii medialis Nervus cutaneus brachii posterior Nervus medianus Nervus musculocutaneus Nervus radialis Nervus ulnaris

3.2. Lower Arm/Hand • • • • • • • • • • •

Nervus(i) digitalis(es) palmaris(es) communis(es) Nervus(i) digitalis(es) palmaris(es) proprius(i) Nervus medianus: Ramus muscularis thenaris Nervus medianus: Ramus palmaris Nervus radialis: Nervus interosseus antebrachii posterior Nervus radialis: Ramus profundus (proximal approach) Nervus radialis: Ramus superficialis (proximal approach) Nervus radialis: Ramus superficialis (distal approach) Nervus ulnaris: Ramus dorsalis manus Nervus ulnaris: Ramus palmaris Nervus ulnaris: Ramus profundus 1 (hypothenar, ulnar-proximal) • Nervus ulnaris: Ramus profundus 2 (hypothenar, palmar-distal) • Nervus ulnaris: Ramus superficialis

4. Trunk 3. Upper Arm: Lower Arm/Hand 3.1. Upper Arm • • • • • •

Medianus fork Nervus axillaris [anterior approach] Nervus axillaris [posterior approach] Nervus cutaneus antebrachii lateralis Nervus cutaneus antebrachii medialis 1 (axilla) Nervus cutaneus antebrachii medialis 2 (sulcus bicipitalis medialis) • Nervus cutaneus antebrachii posterior

• • • • • • • • • • •

Nervi clunium medii Nervi clunium superiores Nervus coccygeus Nervus genitofemoralis: Ramus femoralis Nervus genitofemoralis: Ramus genitalis Nervus iliohypogastricus and nervus ilioinguinalis Nervus iliohypogastricus: Ramus cutaneus anterior Nervus iliohypogastricus: Ramus cutaneus lateralis Nervus(i) intercostobrachialis(es) Nervus intercostobrachialis II Nervi pectorales mediales et laterales (cranial approach)

© Springer Nature Switzerland AG 2019 H. Gruber et al. (eds.), Sonographic Peripheral Nerve Topography, https://doi.org/10.1007/978-3-030-11033-8

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• • • • •

Nervi pectorales mediales et laterales (caudal approach) Nervus subscapularis Nervus thoracicus longus 2 (fossa infraclavicularis) Nervus thoracicus longus 3 (regio thoracica lateralis) Nervus thoracodorsalis

5. Gluteal Region • • • • •

Nervi clunium inferiores Nervus gluteus inferior Nervus gluteus superior Nervus ischiadicus 1 (subgluteal) Nervus pudendus

6. Thigh: Lower Leg/Foot 6.1. Thigh • • • • • • • • •

Nervus cutaneus femoris lateralis Nervus cutaneus femoris posterior Nervus femoralis Nervus femoralis: Rami cutanei anteriores Nervus ischiadicus 2 (infragluteal) Nervus obturatorius Nervus obturatorius: Ramus anterior et posterior Nervus obturatorius: Ramus cutaneus Nervus saphenus 1 (trigonum femorale)

Appendix

• Nervus saphenus 2 (canalis adductorius) • Nervus saphenus 3 (subsartorielles Kompartiment) • Nervus saphenus: Ramus infrapatellaris 1 (suprapatellar: regio femoralis anterior)

6.2. Lower Leg/Foot • • • • • • • • • • • • • • • • • • • • •

Nervus cutaneus dorsalis lateralis Nervus cutaneus dorsalis medialis et intermedius Nervus cutaneus surae lateralis Nervus cutaneus surae medialis Nervus(i) digitalis(es) plantaris(es) communis(es) Nervus(i) digitalis(es) plantaris(es) proprius(i) Nervus fibularis communis Nervus fibularis profundus 1 (dorsum pedis) Nervus fibularis profundus 2 (terminales segment) Nervus fibularis superficialis Nervus plantaris lateralis: Ramus profundus Nervus plantaris lateralis: Ramus superficialis Nervus plantaris medialis et lateralis 1 (planta pedis) Nervus plantaris medialis et lateralis 2 (tarsal tunnel) Nervus saphenus 4 (regio cruralis posterior) Nervus saphenus 5 (terminales Segment am Unterschenkel) Nervus saphenus: Ramus infrapatellaris 2 (infrapatellar, regio genus) Nervus suralis Nervus suralis: Rami calcanei laterales Nervus tibialis Nervus tibialis: Rami calcanei mediales

Index

G Ganglion cervicale medium, 8 M Medianus fork, 56 N Nervi clunium inferiores, 146 Nervi clunium medii, 112 Nervi clunium superiores, 114 Nervus accessorius, 10, 43, 53 Nervus auricularis magnus, 10 Nervus axillaris anterior approach, 58 posterior approach, 60 Nervus coccygeus, 116 Nervus cutaneus antebrachii lateralis, 62 Nervus cutaneus antebrachii medialis, 64 axilla, 64 sulcus bicipitalis medialis, 66 Nervus cutaneus antebrachii posterior, 68 Nervus cutaneus brachii lateralis superior, 70 Nervus cutaneus brachii medialis, 72 Nervus cutaneus brachii posterior, 74 Nervus cutaneus dorsalis intermedius, 184 Nervus cutaneus dorsalis lateralis, 182 Nervus cutaneus dorsalis medialis, 184 Nervus cutaneus femoris lateralis, 158, 173, 189 Nervus cutaneus femoris posterior, 160, 173, 189 Nervus cutaneus surae lateralis, 186 Nervus cutaneus surae medialis, 188 Nervus(i) digitalis(es) palmaris(es) communis(es), 85, 190 Nervus(i) digitalis(es) palmaris(es) proprius(i), 192 Nervus(i) digitalis(es) plantaris(es) communis(es), 193 Nervus(i) digitalis(es) plantaris(es) proprius(i), 192 Nervus dorsalis scapulae, 14 Nervus facialis, Ramus colli, 16 Nervus femoralis, 162 Rami cutanei anteriores, 164 Nervus fibularis communis, 187, 194 Nervus fibularis profundus dorsum pedis, 196 terminal segment, 198 Nervus fibularis superficialis, 200 Nervus genitofemoralis Ramus femoralis, 119 Ramus genitalis, 121 Nervus gluteus inferior, 148 Nervus gluteus superior, 150 Nervus hypoglossus

diaphragma oris, 18 trigonum caroticum, 20 Nervus iliohypogastricus Ramus cutaneus anterior, 124 Ramus cutaneus lateralis, 126 Nervus ilioinguinalis, 122 Nervus(i) intercostobrachialis(es), 130 Nervus ischiadicus infragluteal segment, 166 subgluteal segment, 152 Nervus laryngeus inferior, 22 Nervus laryngeus recurrens, 24 Nervus laryngeus superior Ramus externus, 27 Ramus internus, 29 Nervus medianus Ramus muscularis thenaris, 89 Ramus palmaris, 2 Nervus musculocutaneus, 79 Nervus obturatorius Ramus anterior, 170 Ramus cutaneus, 172 Ramus posterior, 170 Nervus occipitalis major, 32, 37 Nervus occipitalis minor, 34 Nervus occipitalis tertius, 36 Nervus(i) pectoralis(es) lateralis(es) et medialis(es) caudal approach, 134 cranial approach, 132 Nervus phrenicus, 38 Nervus plantaris lateralis planta pedis, 206 Ramus profundus, 202 Ramus superficialis, 204 tarsal tunnel, 208 Nervus plantaris medialis planta pedis, 206 tarsal tunnel, 208 Nervus pudendus, 154 Nervus radialis nervus interosseus antebrachii posterior, 92 Ramus profundus (proximal approach), 94 Ramus superficialis (distal approach), 98 Ramus superficialis (proximal approach), 96 Nervus saphenus canalis adductorius, 176 Ramus infrapatellaris, (suprapatellar: regio femoralis anterior), 180 Ramus infrapatellaris (terminal segment), 214 regio cruralis posterior, 210 sub-sartorial compartment, 178 trigonum femorale, 174

© Springer Nature Switzerland AG 2019 H. Gruber et al. (eds.), Sonographic Peripheral Nerve Topography, https://doi.org/10.1007/978-3-030-11033-8

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228 Nervus subclavius, 40 Nervus subscapularis, 136 Nervus(i) supraclavicularis(es), 24, 40, 44, 46 Nervus suprascapularis, 44 Nervus suralis, 216 Rami calcanei laterales, 218 Nervus thoracicus longus fossa infraclavicularis, 138 fossa supraclavicularis major, 46 regio thoracica lateralis, 140 Nervus thoracodorsalis, 142 Nervus tibialis, 220 Rami calcanei mediales, 222

Index Nervus transversus colli, 48 Nervus ulnaris Ramus dorsalis manus, 101 Ramus palmaris, 103 Ramus profundus, (hypothenar: palmar-distal), 106 Ramus profundus, (hypothenar: ulnar-proximal), 104 Ramus superficialis, 109 Nervus vagus (X), 50 P Plexus cervicalis, Ramus trapezius, 43, 53