Lower Extremity

- [Voiceover] A linear array transducer
with a musculoskeletal exam type
is used to perform an ultrasound examination
of the metatarsal phalangeal joint in the foot.
The patient is placed in a supine position,
with the knee flexed and the foot on the bed.
The transducer is placed over the dorsal surface
of the metatarsal phalangeal joint
in a longitudinal fashion,
with the orientation marker directed
toward the patient's head.
The metatarsal head is seen
as a bright, hyperechoic rounded structure.
The proximal phalanx can be seen
as a hyperechoic linear structure,
just distal to the metatarsal.
The extensor tendon lies above the bony structures,
and appears as a hyperechoic fibrillar structure.
The metatarsal phalangeal joint can be seen
as a dark hypoechoic region between the metatarsal head
and the first phalanx.
The transducer should be slowly moved
along the medial surface of the metatarsal phalangeal joint
to evaluate the joint space.
The transducer is rotated 90 degrees counterclockwise
to obtain a transverse view.
The extensor tendon appears as an elliptical structure
above the metatarsal head.
The transducer should be slowly moved
to allow a full view of the metatarsal phalangeal joint.

Brightcove ID

5751488312001

https://youtube.com/watch?v=Wb6gFe_TZZw

S Series: Sciatic Nerve Gluteal Level

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S Series: Sciatic Nerve Gluteal Level.

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

Image

M-Turbo: Popliteal Nerve Block with Needle

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M-Turbo: Popliteal nerve block with Needle.

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

Image

Body

M-Turbo: Popliteal nerve block with Needle.

How To: Deep Vein Thrombosis

Read more about How To: Deep Vein Thrombosis

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Demonstration on how to perform a deep vein thrombosis exam.

Media Library Type

How To Videos

Media Library Tag

Lower Extremity

Deep Venous Thrombosis

Three-Point Compression

Patency

Mid Thigh

Superficial Femoral Vein

Common Femoral Vein

Subtitles

- So, it's actually quite easy to do
an ultrasound examination in the E.D.
to determine if a patient has deep vein thrombosis,
and this is a well established practice of ultrasound.
We're gonna do a modified version of that
for the E.D. exam though.
To set up for this examination you want to tilt
the gurney, so that you're in a reverse trandelenburg.
So this encourages venous extension in the leg,
so it's easier to visualize the veins with ultrasound.
We're going to use a linear transducer for this examination,
and the views that we do for this exam
will just be in a transverse orientation only.
So when you're setting up for this examination
make sure the orientation marker again is to the right.
For this examination technique we're gonna use
a compression technique where we just
slightly compress the vein with some downward motion.
When you set up the exam on the system,
just select the exam key,
then from your menu select the venous exam type,
and hit select.
When you do this you're optimizing the system,
so it's automatically configured
for your best resolution of the veins.
We're gonna use a little bit of ultrasound gel,
and we're gonna assess two areas.
The femoral area and the popliteal area.
I'm gonna start with the femoral area.
We're going to place the ultrasound transducer
at the inguinal crease...
in a transverse view.
When I do this, immediately below the transducer and the
ultrasound image I'm going to see two anechoic structures.
The one that's gonna be more
medial is the common femoral vein.
The one that's more lateral is the common femoral artery.
The way I can landmark this is by looking for
the junction with the saphenous vein,
or the long saphenous vein.
And we see this emptying into the
anterior aspect of the common femoral vein.
And in this image we actually see the
venous valves separating
the long saphenous and common femoral veins.
So at this point what I do, is I just
use my compression technique.
So I just push with the transducer down until I see
both walls of the vein coapt or touch and meet each other.
If I get a complete coapt like this
I know there's nothing between those two walls,
so there's no venous thrombosis in the vein.
So again, just compress down until
you see those two walls meet completely.
You'll see that the artery does not compress,
and is pulsatile beside the vein.
Now that you've identified your landmarks,
you wanna do a thorough evaluation of that area.
So again placing the transducer at the inguinal crease,
we're going to compress the area of the common femoral vein.
We wanna move a few centimeters proximal to this,
so superiorly on the body,
and we'll start a compression technique.
Making sure that those walls collapse completely,
and we just work through this area
compressing every centimeter.
We see our common femoral vein and saphen junction here,
and we can continue compressing
just a few centimeters below this.
On the ultrasound we've seen the division to
superficial femoral artery and profunda artery.
Just lateral to the vein,
and then we should see the vein divide to
femoral vein and profunda vein.
Again, compressing all the way down,
until you see this junction.
From here I'm going to move down to the popliteal region.
Just move the system down towards the knee,
and we're going to actually go behind the knee.
Putting the transducer into the popliteal fossa.
Once you've identified the popliteal artery and vein,
mid-popliteal fossa level,
you wanna evaluate above and below this area
to make sure you evaluate all those areas
for deep vein thrombosis.
So we're going to start mid-level,
and just work our way superiorly in the leg.
To the superior aspect of the popliteal fossa.
Compressing all the way.
We go up a few centimeters,
and then we start to move down the leg
compressing into the inferior aspect of the popliteal fossa.
Again making sure that those vein walls
actually touch and meet each other,
so we know that there's no deep vein thrombosis
that's fresh which would be h-ai-p-oe-c-u-g.
Could be difficult to see if we did not
do this compression technique.
Those are the two steps for assessing the leg
for deep vein thrombosis.
It's just these two evaluation points.
But just make sure that you evaluate each area thoroughly,
and you do your compression technique completely.

Brightcove ID

5508114175001

https://youtube.com/watch?v=FHerMNhCR54

How To Perform A Popliteal Nerve Block

Read more about How To Perform A Popliteal Nerve Block

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A popliteal sciatic nerve block done with the Sonosite SII ultrasound machine is a clinically valuable technique that results in anesthesia of the calf, tibia, fibula, ankle, and foot. Anesthesiologist Dr. David Auyong MD of Seattle, Washington here reviews scanning techniques and sonographic landmarks for the procedure, discussing important structures, techniques to visualize the popliteal vein, types of probe used, and needle/injection choices. The Sonosite II allows precise placement of local anesthetic, much reducing patient discomfort, providing superior visualization of the nerve and the needle during block placement.

Media Library Type

How To Videos

Subtitles

- The Popliteal Sciatic Nerve Block
is a good block to do for the sciatic nerve
because this is where the sciatic nerve
is found most shallow.
This block can be performed for post year knee pain
after knee surgery, as well as, calf, foot
and ankle surgery.
This is the main nerve that supplies the lower leg.
I find a lateral position gives you good control
of the patients airways if you sedate them
as well as good ergo-dynamics to do the block.
Here we have our patient positioned laterally
with a pillow between the legs for comfort.
To do the Popliteal Sciatic Nerve Block
we use a linear probe.
The linear probe allows us to see structures well
in the shallow plane,
but gives us a wide field of view
to see our needle approaching the nerve.
To perform the Politeal Sciatic Nerve Block
we put the probe directly in the back of the knee.
Placement of the probe in the back of the knee
reveals a structure of the nerve, the vein, the artery.
I call this structure, the snowman in the back of the knee.
You have three circles on top of each other.
The upper most circle represented by the tibial
component of the sciatic nerve.
The middle structure represented by the vein
and the deep structure represented by the popliteal artery.
If we put color Doppler on the screen
we are able to see the pulsating artery
in this area.
Sometimes it's difficult to see the popliteal vein
because this is a low-flow state,
such as we see here.
To visualize the popliteal vein better
we can squeeze the back of the calf,
increasing venous flow through the popliteal vein,
such as this.
There we can see increased venous flow
through the popliteal vein represented better
by color Doppler.
Now, as I mentioned, this is only the tibial component
of the sciatic nerve.
We wanna get the nerve where it comes together
and has both components, the peroneal
and the tibial component.
As we scan up the leg, here we now see
the peroneal component laterally,
the tibial component medially,
the popliteal vein and popliteal artery.
On the medial side we see the semitendinosus
and semimembranosus muscles.
On the lateral side we see
the biceps femoris, long and short heads.
As we keep going up the leg
the tibial and peroneal components join into one nerve.
Sometimes we block the nerve at this level
where the two components are joining.
This allows us to get both components
with a single injection at the nerve.
My needle approach for these blocks
are gonna be from lateral to medial.
What I typically do is measure the depth
of the sciatic nerve in this setting.
Here the sciatic nerve is approximately
one-and-a-half to two centimeters deep to the probe.
So if I measure one-and-a-half to two centimeters deep,
my needle is gonna come in completely perpendicular
and have a very bright view of the needle
and needle shaft as it advances to the nerve.
Now, I typically like to inject deep to the nerve
as well as superficial to the nerve
in order to get complete surrounding
of the popliteal sciatic nerve
for the most rapid onset for this block.
Typical volumes used are 20 to 30 milliliters
of local anesthetic.
This block takes some time to onset
and studies have shown even with complete surrounding
of the nerve, it takes up to 30 minutes
for the nerve block to onset in most patients.
Here we see the popliteal sciatic nerve
surrounded by the biceps femoris laterally
and the semitendinosis/semimembranosis medially.
Our needle is advanced directly above the nerve
and the local anesthetic is injected,
pushing the nerve deeper.
We then withdraw the needle
and readvance the needle again close to the nerve
so we can get local anesthetic spreading
to the medial side of the nerve,
which is more of the tibial component.
Now you can visualize both the peroneal and tibial component
with a local anesthetic completely surrounding the nerves.

Brightcove ID

5508136021001

https://youtube.com/watch?v=X0wqmWXEcTg

Body

How To Perform A Saphenous Nerve Block

Read more about How To Perform A Saphenous Nerve Block

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Dr. David Auyong reviews scanning techniques and sonographic landmarks for an ultrasound guided nerve block.

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

How To Videos

Subtitles

- The saphenous nerve block is useful for
medial knee surgery, medial leg surgery,
and medial ankle and foot surgery.
The saphenous nerve is a continuation
of the femoral nerve below the knee.
This is a good block to do in conjunction
with a popliteal sciatic nerve block to give you
complete anesthesia below the knee.
To perform the saphenous nerve block,
we typically use a linear probe.
The linear probe allows us to get
good resolution and reasonable penetration.
Typical settings for the saphenous nerve block
start between four and six centimeters total depth,
expecting the nerve to be between two and four centimeters.
Now the saphenous nerve is a small nerve,
and we may not see it in everybody.
In fact, most people we don't see it in.
The reason we do a saphenous nerve block
is that we don't take away any quadriceps muscles,
and so the patient will have no quadriceps muscle weakness.
To get a saphenous nerve, you may also do a femoral block,
but by doing a femoral block, you may
or you will take out all your quadriceps.
So this technique I'm going over is a great technique
for outpatient surgery, because their
quadriceps muscle strength will be intact.
This technique I'm using is useful in elderly
and obese patients because we're using muscle landmarks
rather than nerve or other small landmarks.
So we usually start about 10 centimeters above the knee.
Put the probe on the medial side of the leg.
We can abduct the leg a little bit
to give us better visualization here.
Now when we put the probe on here,
we like to start more anterior.
This gives us a view of the femur,
the hyperechoic stripe here, as well as the vastus medialis.
The vastus medialis can pretty much be found in everybody.
We're going to slide the probe posterior next.
The next muscle we'll come across is the sartorius muscle.
Now we see the vastus medialis muscle ending
and see the sartorius muscle in view now.
There are many anatomical differences in patient to patient.
The saphenous nerve can run anterior
to the sartorius muscle, posterior to the
sartorius muscle, and I've even seen it
piercing the sartorius muscle.
So the whole key is, is that we will put
our local anesthetic below the sartorius muscle
in order to get a good saphenous nerve block.
Most of the time we're doing a field type block
where we deposit the local behind the sartorius muscle,
and expect that that local will get to the nerve,
because these nerves can be difficult
to see in obese or elderly patients.
So now, our needle approach is
gonna be using a 10 centimeter needle.
This needle will be inserted a few centimeters
away from the probe in this angle.
We like to see the needle in a shallow plane
and then advance it deeper below the sartorius muscle.
This block can also be performed if the patient is prone,
imagine my needle coming from the other side.
Typical volumes used here are between
five and 20 milliliters of local anesthetic; if a good
nerve is seen, usually represented by a hyperechoic
structure, then I'll just place five milliliters.
Most patients, we do not see the individual
nerve here, and we will place 10 milliliters
as a type of field block in this area.
Here, our needle is advancing through the vastus medialis.
We try to position the tip of the needle
underneath the sartorius muscle,
which is located to the right of the screen.
You can see the hyperechoic areas,
some of which may represent the nerve.
Our needle is now directly below the sartorius muscle,
and you can see the local anesthetic
spreading below the sartorius muscle
to track to the saphenous nerve.

Brightcove ID

5508114742001

https://youtube.com/watch?v=E1tmS9Lv1bU

Body

Dr. David Auyong reviews scanning techniques and sonographic landmarks for an ultrasound guided nerve block.

How to: Subgluteal Sciatic Nerve Block

Read more about How to: Subgluteal Sciatic Nerve Block

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Dr. David Auyong reviews scanning techniques and sonographic landmarks for an ultrasound guided nerve block .

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

How To Videos

Subtitles

- The Sciatic Nerve Block can be used for surgery of the
leg, knee, foot and ankle.
To do the Sciatic Nerve Block,
you can block it at the Popliteal region
or you can block it higher.
Some benefits of blocking it higher
are to be above the tourniquet,
so you don't have to worry so much about nerve ischemia.
You may also get the Posterior Femoral Cutaneous nerve
of the thigh, which comes off very high on the Sciatic nerve
and it's also medial to the Sciatic nerve, as well high up.
This way, you can cover any kind of pain of incision
in the upper thigh area.
To position patients for Subgluteal Sciatic Nerve Block,
we position the patient lateral.
This way, the patient is comfortable,
they can be well-sedated and you can place a probe
on the posterior side of the leg and advance the needle
from lateral to medial.
The probe we use for a Sciatic Nerve Block
is a curvilinear low-frequency probe.
The reason we use this probe is because
it penetrates deeper and this is useful in larger patients.
So some of the landmarks we use
for the Subgluteal Sciatic Nerve Block
are the Greater Trochanter laterally,
the Ischial Tuberosity medially, and
directly in between these two is where we place the probe
The initial view we see is the Greater Trochanter
on the left side of the screen.
On the right side of the screen,
we see the Ischial Tuberosity.
There is a large muscle, the Gluteus Maximus
at the superficial level of the screen.
Underneath the Gluteus Maximus is a hyperechoic nerve,
the Sciatic Nerve.
Between the two bony landmarks is the Quadratus Femoris.
So on this level, the nerve is sandwiched between
the Gluteus Maximus and the Quadratus Femoris.
The nerve here can appear wide, flat or triangular.
It is not a circular structure like some people imagine.
Needle approaches for the Sciatic Nerve Block,
whether is be here, at the Mid-Femoral region,
or higher up at the Subgluteal region,
are performed from a lateral-to-medial approach.
The lateral-to-medial approach usually starts
three to four centimeters away from the probe in this angle.
Now, higher up we'll use the same needle approach.
We can see the triangular Sciatic Nerve here,
and we'll start the needle angle about here.
Now you typically put my nerve
on the distal side of the screen from where my needle
is entering, in order to see the needle better
and travelling across the screen to the nerve.
Typical volumes are 20 to 30 milliliters
of local anesthetic.
Because this nerve is so deep in some people,
some anesthesiologists like to approach this nerve
from an Out-of-Plane needle angle.
And Out-of-Plane needle angle would be in this direction
into the Sciatic Nerve.
Other people like to turn this probe in a longitudinal
direction and see the nerve in long axis.
So here we are turning the probe in the long axis
and following that nerve in the longitudinal pattern here.
So now we see the Sciatic Nerve going down the leg.
The needle approach in this orientation would be in
this angle in plane of the ultrasound beam
down to the Sciatic nerve.
- (Dr. Auyong) Here you can see the Greater Trochanter
on the left side of the screen, the Ischial Tuberosity
on the right side of the screen, the Gluteus Maximus
superficial and a 21 gauge needle
advancing to the Sciatic Nerve.
The Sciatic Nerve is below the Gluteus Maximus
and above the Quadratus Femoris.
Our needle is advancing above the Sciatic Nerve
to attempt to get local anesthetic to spread
to the medial side of the nerve.
Which would be more likely to get the larger
Tibial component, as well as the posterior femoral
cutaneous nerve of the thigh.
Now you can see the nerve, which very hyperechoic,
below the local anesthetic.

Brightcove ID

5508120191001

https://youtube.com/watch?v=IL4qqETpb0k

Body

Dr. David Auyong reviews scanning techniques and sonographic landmarks for an ultrasound guided nerve block .

How to: Femoral Nerve Block

Read more about How to: Femoral Nerve Block

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Dr. David Auyong reviews scanning techniques and sonographic landmarks for an ultrasound guided nerve block .

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

How To Videos

Subtitles

The femoral nerve block is used
for many different surgeries.
The femoral nerve block can be used for knee surgery,
hip surgery, femur surgery,
or even medial ankle surgery to get the saphenous nerve.
To perform the femoral nerve block,
there's a few key positioning tips.
We want to put the patient completely supine.
Many of our patients are larger and have larger abdomens,
so putting the patient supine allows us to get
high enough in the femoral region.
Also, if their adipose tissue hangs over the femoral region,
we want to put tape here and tape their abdomen away
out of the way, so you can put your probe
comfortably in the femoral region.
To do an ultrasound guided femoral nerve block,
we use a linear high frequency probe.
To start the femoral nerve block,
we usually put the probe right in the femoral crease.
On our screen now, we see several important features.
From medial to lateral, we see the Iliacus muscle,
we see the nerve sitting right on the Iliacus muscle,
and we also see the femoral artery,
and then to the right we see the femoral vein.
There are a few fascia coverings in this area
that are important.
The Facia Iliaca runs above the femoral nerve
and below the artery.
The Fascia Lata runs above all of this,
above the artery and vein as well.
Now for the femoral nerve, we want to see a hyperechoic
or bright nerve sitting on the Iliacus muscle.
The true femoral nerve is a wide, flat nerve
laying directly on the muscle.
If you inject above the Facia Iliaca,
this will create a barrier to your nerve
and allow a block that is not complete.
So as we move up and down the leg,
we're gonna see some key that will help you find
the femoral nerve in all patients.
More medially, you see the pulsating femoral artery,
and medial to that you see the femoral vein.
Here the vein collapses with pressure.
Now some keys to find the femoral nerve
in every patient are as follows.
If the probe is placed too cranially,
your femoral artery and vein and nerve
drop deep on the screen.
The femoral vein, artery, and nerve
are too deep, then you need to move the probe caudally.
If you probe is placed too distally,
that femoral artery is going to split
into two femoral arteries.
Here you can see a pulsating Profunda femoral deep
as well as a true femoral artery superficial.
Now I'm gonna put some color flow on that,
and you can see a pulsating artery deeper,
and a superficial femoral artery as well.
Now the vein is on the left,
represented in red in this picture.
As we move cranially, those two arteries come together.
When we look laterally from there,
the nerve has also come together from
many branches, forming one femoral nerve.
This way we can see the femoral nerve the best
when the artery also comes together as well.
Now our needle approach to the femoral nerve
is going to be from lateral to medial.
Typically, we use a 10-centimeter needle
because we use these in-plane approaches
to the femoral nerve.
I like to put my target on the further side of the screen
so I can see my needle coming in from the lateral side.
So I'll put my first injection lateral to the nerve
just above the Iliacus muscle
to ensure injection below the Fascia Iliaca
but not within the Iliacus muscle.
By using typical volume, such as 20 to 30 milliliters,
we'll get spread above the nerve
or below the nerve, without poking into
the nerve, and damaging the nerve.
In this femoral nerve block, you can see a single
injection needle being advanced lateral to the nerve
which is lying right on the Iliacus muscle.
You can see the pulsating femoral artery medially,
and the local anesthetic now spreading over
the wide, flat femoral nerve.
Our needle tracks in with the local anesthetic
so we can get local anesthetic spreading
all the way medial around the femoral nerve here.

Brightcove ID

5765925239001

https://youtube.com/watch?v=Z-O_EaAE_rg

Body

Dr. David Auyong reviews scanning techniques and sonographic landmarks for an ultrasound guided nerve block .