Hand

Subtitles

- [Voiceover] A linear array transducer with a nerve
exam type, is used to perform an ultra sound
guided axillary regional nerve block.
The target depth is approximately one to two
centimeters in an 80 kilogram adult.
The patient is positioned supine with the arm
abducted 90 degrees, and the elbow bent 90 degrees.
The transducer is placed high as possible in the axilla,
with the orientation marker directed to the patient's head.
Slowly slide the transducer in a lateral to medial
direction to identify the axillary artery.
The axillary artery is a dark, round, pulsitile structure
with a hyperechoic wall.
The axilalry veins lie around the periphery of the artery
and are easily compressed.
Slide the transducer up the arm to a proximal
position, so the terrace major muscle,
which helps control the distribution of local
anesthetic during injection, is postero-medial
to the artery and nerves.
The biceps and coracobrachialis muscles, will appear
lateral to the artery.
The median, ulner, and radial nerves appear as
hyperechoic circles, with a honey comb appearance
surrounding the artery.
The nerve positions will vary around the artery.
The transducer is slowly moved laterally over
the biceps and corocobrachealis muscles.
The musculocutaneous nerve can be seen between
these muscles as a small, bright, hyperechoic circle
or triangle.
The needle is positioned one to two centimeters
lateral to the transducer, and advanced using
an in plane technique.
The needle path is directed through the biceps muscle,
toward the musculocutaneous nerve.
The initial end point for the needle is immediately
beside the musculocutaneous nerve, where three
to five CCs of anesthetic should be injected.
The needle is then advanced to a position immediately
post-terior to the artery.
As local anesthetic is injected, the terrace muscle
is pushed down, and the local anesthetic should
spread medial and lateral underneath the artery.
The needle can be advanced through hydrodisection
to facilitate appropriate spread of local anesthetic.
Finally, the needle is withdrawn and redirected anterior
to the artery.
Local anesthetic should be injected over the artery
to finish with a circumferential spread of local anesthetic
around the artery.

Brightcove ID

5765653161001

https://youtube.com/watch?v=3MBmUFMoH7w

How To: Wrist Injection

Read more about How To: Wrist Injection

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Dr. Scott Pollock demonstrates how to perform an ultrasound guided wrist injection.

Clinical Specialties

Physical Med & Rehab

Media Library Type

Media Library Tag

Hand

Wrist

Extensor Tendon

Synovial Prolipheration

Subtitles

- This is a demonstration only for injecting
the Median Nerve, placing steroids into the carpal tunnel.
So, I'm not using sterile technique,
sterile gel or cleansing the area.
This is for demonstration purposes only.
And I am going to be doing an injection in this direction.
Again, I am going to be placing the needle
parallel to the transducer.
Apply some gel here.
By placing the transducer transversely,
I have in the middle of the screen, the Median Nerve.
I can find
the Ulnar Artery on this side.
And you can see it pulsating.
I mark the Ulnar Artery with an indelible pen.
And then move just a little bit to the radial side,
so that the Ulnar Artery is down here.
And place a 25 gauge needle
in this direction, very superficially,
because it's only two millimeters deep.
And bring that needle in from the left side of the screen.
In this image, the Median Nerve is sitting right here.
The Retinaculum is along this surface here.
And the needle is coming in
from the left side of the screen.
This is bone down here.
You'll see the needle advanced superficial to
the nerve and fluid,
which includes steroids and Lidocaine injected.
In the next brief video,
the needle is seen deep to the Median Nerve,
so the nerve is here.
And the needle can be seen underneath it
and again,
injection with Lidocaine and steroid is performed.
The other approach that some people use
is with the transducer longitudinal.
Here's the Median Nerve on the screen.
And you can approach the Median Nerve this way,
so distal to proximal.

Brightcove ID

5751328524001

https://youtube.com/watch?v=sxNqVWDwmd0

How To: Wrist Exam

Read more about How To: Wrist Exam

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Dr. Scott Pollock demonstrates how to perform a wrist exam.

Clinical Specialties

Media Library Type

Media Library Tag

Rheumatoid Arthritis

Rheumatology

Synovial Prolipheration

Subtitles

- We're going to examine the wrist today,
and the best transducer for this examination
is the L25, the small footprint.
We'll check that the exam type is correct.
We're doing an MSK type of exam.
For orientation, there is a marker here which
corresponds to the turquoise dot on the screen.
Keep this marker proximal when I'm examining longitudinally
and medial when I'm examining transversally.
We'll start the wrist on the dorsal surface
and examine transversally first.
There are six compartments, beginning with
the first compartment at the base of the thumb,
and the sixth compartment near the ulnar styloid.
When we look at the wrist structures,
we're looking not only at tendons and bones,
but we're also looking at a multitude of joints.
If I come over here to a middle portion,
we're looking at carpal bones here.
With the presence of synovitis,
we would have hyperechoic or anechoic fluid
and thickening of synovium at these recesses,
which are the joints.
None of that is present here.
We'll move over to the extensor tendons of the thumb,
where you can sometimes see de Quervain's tenosynovitis,
and here is a nice view of one of
the long tendons of the thumb.
These extensor digitorum tendons here
are normal in appearance on cross-section.
These are the two thumb tendons that you see
right over the distal end of the radius,
which is right here.
This then can be traced distally out toward the thumb,
and these tendons and their peritendinous tissue
can be examined carefully.
On the other side of the wrist toward the ulna,
we have a very nice view of the
extensor carpi ulnaris tendon, which is
one of the largest extensor tendons in the wrist
and easiest to see.
It also is frequently surrounded, in a patient
with an inflammatory process, with fluid
or synovium, and that can be seen as either
anechoic or hyperechoic shadow around the
distinct oval-shaped tendon, which is
hyperechoic, and you can see the fibrillar nature within it.
If we look longitudinally, keeping this dot proximal,
and find that extensor carpi ulnaris tendon,
you can see these parallel lines,
which are going from left to right.
There are areas that are hyperechoic
alternating with hypoechoic.
This is a normal appearance of the tendon,
and also visualize peritendonous tissue.
The retinaculum, which is up here,
in deep to this, this is the distal part of the ulna.
First part of carpal bones,
and triangular ligament is in here.
Next, we look at the volar, or palmer surface of the wrist.
Most of the time, we're going to be
looking at the median nerve in this area.
Again, the transducer marker is placed medially.
This structure here is the median nerve.
We can go toward the radial side and see the artery,
the hyperechoic or anechoic area that has a small pulsation.
Sometimes checking color Doppler signal
or Doppler signal is helpful, and the median nerve, then,
is seen right here in the middle.
On the ulnar surface, going in this direction,
is the ulnar artery, and we can freeze the image
and take a measurement of the median nerve
if it's desired to see whether this is enlarged
using direct correlation between this measurement
and the presence of carpal tunnel syndrome.
So I have placed my calipers on both sides
of the median nerve, just inside the perineurium,
and then I'm going to hit this ellipse button.
Then I can actually take an approximate surface area.
She has a .08 centimeter squared area, which is normal,
and so by ultrasound criteria does not have
carpal tunnel syndrome.

Brightcove ID

5508120239001

https://youtube.com/watch?v=txMGtvWb2XI

How To: Ultrasound Guided Hand Injection

Read more about How To: Ultrasound Guided Hand Injection

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Dr. Scott Pollock demonstrates how to perform an ultrasound guided hand injection.

Clinical Specialties

Physical Med & Rehab

Media Library Type

Media Library Tag

Hand

Wrist

Extensor Tendon

Subtitles

- So I'm going to show a technique for injection of fingers,
and we'll do on the Dorsal surface or Extensor surface,
a simulation of injection of either a PIP or MCP joint
and then turn the hand around on the Palmar surface,
and show you an injection approach for Flexor tendons.
I'm gonna use the L25 transducer.
Normally we would be dealing with a sterile field,
and a sterile gel, and most likely a transducer cover,
which is also sterile, but for the purposes of this,
we're just showing you an approach.
If the joint is swollen and has Synovitis,
or a joint diffusion, it's quite easy to see the space
that you're aiming for.
This particular exam, we don't have that finding.
Normally for an injection into a small joint like this,
I like to approach the joint with the transducer placed
transversely, in this type of a plane, and then have
the needle in the same direction parallel, or in plane
with the transducer, so my needle and my transducer are
parallel, and I'm going as superficial as possible,
with a very small needle so it doesn't hurt,
and trying to place the needle into the skin,
and in the one millimeter ultrasound beam,
into the target this way.
On the other side, we'll be looking at a Flexor tendon,
which travels in this direction.
I will place the transducer longitudinally,
and approach with the needle in this direction.
If you keep the needle parallel to the surface
of the transducer, it shows up the best.
The insertion point can be quite close
to the transducer's edge, especially if you're going
very superficially; in a small area like a finger,
or a tendon around here, you don't have a lot of space
and so you have to go very close, and can insert
the needle very flat and superficially.
Because there's very little space between the skin surface
and the tendon, and here it's probably
about two or three millimeters.
And watch exactly where the tip of the needle
and the bevel goes.

Brightcove ID

5751328215001

https://youtube.com/watch?v=cdXuffySPJI

How To: Hand Exam

Read more about How To: Hand Exam

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Dr. Scott Pollock demonstrates how to perform a hand exam.

Clinical Specialties

Physical Med & Rehab

Media Library Type

Media Library Tag

Hand

Wrist

Extensor Tendon