<p begin="00:00:07.432" end="00:00:09.095" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.095" end="00:00:11.235" style="s2">with a musculoskeletal exam type</p>
<p begin="00:00:11.235" end="00:00:13.676" style="s2">is used to perform an<br />ultrasound examination</p>
<p begin="00:00:13.676" end="00:00:15.475" style="s2">of the biceps tendon.</p>
<p begin="00:00:15.475" end="00:00:17.318" style="s2">The patient is in a sitting position</p>
<p begin="00:00:17.318" end="00:00:20.061" style="s2">with the hand placed palm up on the knee.</p>
<p begin="00:00:20.061" end="00:00:22.230" style="s2">The transducer is placed transversely</p>
<p begin="00:00:22.230" end="00:00:23.766" style="s2">over the head of the humerus</p>
<p begin="00:00:23.766" end="00:00:28.067" style="s2">with the orientation marker<br />directed to the patient's right.</p>
<p begin="00:00:28.067" end="00:00:29.698" style="s2">The deltoid muscle is seen as</p>
<p begin="00:00:29.698" end="00:00:32.001" style="s2">the most superficial structure.</p>
<p begin="00:00:32.001" end="00:00:35.322" style="s2">The bright hyperechoic greater<br />and lesser tuberosities</p>
<p begin="00:00:35.322" end="00:00:38.758" style="s2">of the humerus surround the<br />oval-shaped biceps tendon.</p>
<p begin="00:00:38.758" end="00:00:40.408" style="s2">The transverse humeral ligament,</p>
<p begin="00:00:40.408" end="00:00:42.151" style="s2">which covers the biceps tendon,</p>
<p begin="00:00:42.151" end="00:00:44.621" style="s2">can be seen as a thin, bright line.</p>
<p begin="00:00:44.621" end="00:00:48.055" style="s2">The biceps tendon is seen<br />in the bicipital groove</p>
<p begin="00:00:48.055" end="00:00:51.014" style="s2">and can appear artificially bright or dark</p>
<p begin="00:00:51.014" end="00:00:53.628" style="s2">due to anisotropy, which<br />occurs if the transducer</p>
<p begin="00:00:53.628" end="00:00:55.700" style="s2">is rocked over the tendon.</p>
<p begin="00:00:55.700" end="00:00:57.933" style="s2">The transducer should<br />be moved down the arm</p>
<p begin="00:00:57.933" end="00:01:01.182" style="s2">to evaluate the tendon to<br />its musculotendinous junction</p>
<p begin="00:01:01.182" end="00:01:04.277" style="s2">and the insertion of the<br />pectoralis major tendon.</p>
<p begin="00:01:04.277" end="00:01:07.211" style="s2">The transducer is returned<br />to the starting position</p>
<p begin="00:01:07.211" end="00:01:10.990" style="s2">at the bicipital groove and<br />rotated 90 degrees clockwise</p>
<p begin="00:01:10.990" end="00:01:14.008" style="s2">to obtain a long axis view of the tendon.</p>
<p begin="00:01:14.008" end="00:01:15.976" style="s2">The fibular tendon should be scanned</p>
<p begin="00:01:15.976" end="00:01:20.143" style="s2">from proximal to distal to<br />the musculotendinous junction.</p>

<p begin="00:00:09.520" end="00:00:11.106" style="s2">- I'm examining the bicep tendon.</p>
<p begin="00:00:11.106" end="00:00:14.170" style="s2">Again it's important to<br />keep the notch of the probe</p>
<p begin="00:00:14.170" end="00:00:16.670" style="s2">immediately facing towards the patient.</p>
<p begin="00:00:16.670" end="00:00:18.838" style="s2">I'm gonna maintain contact at all times</p>
<p begin="00:00:18.838" end="00:00:20.574" style="s2">with my hand on the patient,</p>
<p begin="00:00:20.574" end="00:00:23.719" style="s2">using my second through fifth fingers</p>
<p begin="00:00:23.719" end="00:00:25.886" style="s2">to form a base on the patient's shoulder,</p>
<p begin="00:00:25.886" end="00:00:28.774" style="s2">and almost pinching the<br />probe between my two fingers.</p>
<p begin="00:00:28.774" end="00:00:32.136" style="s2">And it's fairly easy<br />to identify the bicep,</p>
<p begin="00:00:32.136" end="00:00:33.895" style="s2">which lies in the groove between</p>
<p begin="00:00:33.895" end="00:00:36.718" style="s2">the greater and lesser tuberosities.</p>
<p begin="00:00:36.718" end="00:00:41.294" style="s2">A helpful tip is to aim the<br />probe both upwards and downwards</p>
<p begin="00:00:41.294" end="00:00:42.566" style="s2">until you get a nice image</p>
<p begin="00:00:42.566" end="00:00:45.767" style="s2">of the bicep tendon in its groove.</p>
<p begin="00:00:45.767" end="00:00:49.172" style="s2">On top of the bicep tendon<br />lies the transverse ligament,</p>
<p begin="00:00:49.172" end="00:00:52.875" style="s2">which covers the bicep tendon<br />in its circular pattern.</p>
<p begin="00:00:52.875" end="00:00:55.955" style="s2">And here is a good image<br />of the bicep tendon,</p>
<p begin="00:00:55.955" end="00:00:58.195" style="s2">in its cross-section.</p>
<p begin="00:00:58.195" end="00:01:00.388" style="s2">And if there are abnormalities you may see</p>
<p begin="00:01:00.388" end="00:01:03.246" style="s2">some increased black fluid<br />surrounding the tendon,</p>
<p begin="00:01:03.246" end="00:01:05.692" style="s2">and there's some normal<br />physiologic fluid there,</p>
<p begin="00:01:05.692" end="00:01:08.044" style="s2">but this is a normal bicep tendon.</p>
<p begin="00:01:08.044" end="00:01:10.276" style="s2">I'm going to follow the<br />bicep tendon distally</p>
<p begin="00:01:10.276" end="00:01:12.445" style="s2">to examine if there's any pathology</p>
<p begin="00:01:12.445" end="00:01:15.612" style="s2">which is a commonplace of bicep tears.</p>
<p begin="00:01:16.692" end="00:01:19.380" style="s2">Next I'm gonna go back to<br />my initial starting point,</p>
<p begin="00:01:19.380" end="00:01:20.636" style="s2">and find the bicep tendon</p>
<p begin="00:01:20.636" end="00:01:23.668" style="s2">between the greater and<br />lesser tuberocities.</p>
<p begin="00:01:23.668" end="00:01:27.317" style="s2">I'm going to turn the probe<br />in a longitudinal manner,</p>
<p begin="00:01:27.317" end="00:01:30.652" style="s2">again maintaining the<br />notch of the probe upward.</p>
<p begin="00:01:30.652" end="00:01:32.996" style="s2">And what this is gonna<br />do, is change my view</p>
<p begin="00:01:32.996" end="00:01:34.060" style="s2">from cross-sectional</p>
<p begin="00:01:34.060" end="00:01:37.236" style="s2">to longitudinal of the<br />patient's bicep tendon.</p>
<p begin="00:01:37.236" end="00:01:40.359" style="s2">And a tendon tends to<br />have a fibular pattern.</p>
<p begin="00:01:40.359" end="00:01:42.804" style="s2">And we can follow this tendon</p>
<p begin="00:01:42.804" end="00:01:45.932" style="s2">as it runs along the humerus distally,</p>
<p begin="00:01:45.932" end="00:01:47.940" style="s2">looking for any abnormalities,</p>
<p begin="00:01:47.940" end="00:01:50.932" style="s2">until we begin to see<br />the pectoralis tendon</p>
<p begin="00:01:50.932" end="00:01:55.099" style="s2">coming in (slurred) here distally.</p>

<p begin="00:00:09.404" end="00:00:13.825" style="s2">- So I'm going to show a technique<br />for injection of fingers,</p>
<p begin="00:00:13.825" end="00:00:17.911" style="s2">and we'll do on the Dorsal<br />surface or Extensor surface,</p>
<p begin="00:00:17.911" end="00:00:22.078" style="s2">a simulation of injection<br />of either a PIP or MCP joint</p>
<p begin="00:00:23.072" end="00:00:27.011" style="s2">and then turn the hand<br />around on the Palmar surface,</p>
<p begin="00:00:27.011" end="00:00:31.241" style="s2">and show you an injection<br />approach for Flexor tendons.</p>
<p begin="00:00:31.241" end="00:00:33.991" style="s2">I'm gonna use the L25 transducer.</p>
<p begin="00:00:35.700" end="00:00:39.568" style="s2">Normally we would be dealing<br />with a sterile field,</p>
<p begin="00:00:39.568" end="00:00:43.735" style="s2">and a sterile gel, and most<br />likely a transducer cover,</p>
<p begin="00:00:45.699" end="00:00:48.375" style="s2">which is also sterile, but<br />for the purposes of this,</p>
<p begin="00:00:48.375" end="00:00:51.999" style="s2">we're just showing you an approach.</p>
<p begin="00:00:51.999" end="00:00:55.926" style="s2">If the joint is swollen and has Synovitis,</p>
<p begin="00:00:55.926" end="00:00:59.355" style="s2">or a joint diffusion, it's<br />quite easy to see the space</p>
<p begin="00:00:59.355" end="00:01:01.639" style="s2">that you're aiming for.</p>
<p begin="00:01:01.639" end="00:01:05.637" style="s2">This particular exam, we<br />don't have that finding.</p>
<p begin="00:01:05.637" end="00:01:09.804" style="s2">Normally for an injection<br />into a small joint like this,</p>
<p begin="00:01:10.659" end="00:01:14.826" style="s2">I like to approach the joint<br />with the transducer placed</p>
<p begin="00:01:15.785" end="00:01:19.952" style="s2">transversely, in this type<br />of a plane, and then have</p>
<p begin="00:01:22.371" end="00:01:26.538" style="s2">the needle in the same<br />direction parallel, or in plane</p>
<p begin="00:01:27.542" end="00:01:32.292" style="s2">with the transducer, so my<br />needle and my transducer are</p>
<p begin="00:01:32.292" end="00:01:37.022" style="s2">parallel, and I'm going as<br />superficial as possible,</p>
<p begin="00:01:37.022" end="00:01:40.567" style="s2">with a very small needle<br />so it doesn't hurt,</p>
<p begin="00:01:40.567" end="00:01:44.123" style="s2">and trying to place the<br />needle into the skin,</p>
<p begin="00:01:44.123" end="00:01:47.623" style="s2">and in the one millimeter ultrasound beam,</p>
<p begin="00:01:49.237" end="00:01:51.320" style="s2">into the target this way.</p>
<p begin="00:01:52.641" end="00:01:57.143" style="s2">On the other side, we'll be<br />looking at a Flexor tendon,</p>
<p begin="00:01:57.143" end="00:01:59.785" style="s2">which travels in this direction.</p>
<p begin="00:01:59.785" end="00:02:03.368" style="s2">I will place the<br />transducer longitudinally,</p>
<p begin="00:02:04.521" end="00:02:08.438" style="s2">and approach with the<br />needle in this direction.</p>
<p begin="00:02:09.588" end="00:02:13.205" style="s2">If you keep the needle<br />parallel to the surface</p>
<p begin="00:02:13.205" end="00:02:15.777" style="s2">of the transducer, it shows up the best.</p>
<p begin="00:02:15.777" end="00:02:19.371" style="s2">The insertion point can be quite close</p>
<p begin="00:02:19.371" end="00:02:23.440" style="s2">to the transducer's edge,<br />especially if you're going</p>
<p begin="00:02:23.440" end="00:02:27.492" style="s2">very superficially; in a<br />small area like a finger,</p>
<p begin="00:02:27.492" end="00:02:31.270" style="s2">or a tendon around here, you<br />don't have a lot of space</p>
<p begin="00:02:31.270" end="00:02:34.388" style="s2">and so you have to go<br />very close, and can insert</p>
<p begin="00:02:34.388" end="00:02:37.638" style="s2">the needle very flat and superficially.</p>
<p begin="00:02:38.656" end="00:02:42.953" style="s2">Because there's very little<br />space between the skin surface</p>
<p begin="00:02:42.953" end="00:02:45.997" style="s2">and the tendon, and here it's probably</p>
<p begin="00:02:45.997" end="00:02:48.683" style="s2">about two or three millimeters.</p>
<p begin="00:02:48.683" end="00:02:51.251" style="s2">And watch exactly where<br />the tip of the needle</p>
<p begin="00:02:51.251" end="00:02:52.834" style="s2">and the bevel goes.</p>