<p begin="00:00:09.075" end="00:00:12.587" style="s2">- This is a demonstration<br />only for injecting</p>
<p begin="00:00:12.587" end="00:00:16.948" style="s2">the Median Nerve, placing<br />steroids into the carpal tunnel.</p>
<p begin="00:00:16.948" end="00:00:20.210" style="s2">So, I'm not using sterile technique,</p>
<p begin="00:00:20.210" end="00:00:22.878" style="s2">sterile gel or cleansing the area.</p>
<p begin="00:00:22.878" end="00:00:25.140" style="s2">This is for demonstration purposes only.</p>
<p begin="00:00:25.140" end="00:00:29.579" style="s2">And I am going to be doing an<br />injection in this direction.</p>
<p begin="00:00:29.579" end="00:00:32.101" style="s2">Again, I am going to be placing the needle</p>
<p begin="00:00:32.101" end="00:00:34.562" style="s2">parallel to the transducer.</p>
<p begin="00:00:34.562" end="00:00:36.562" style="s2">Apply some gel here.</p>
<p begin="00:00:36.562" end="00:00:39.019" style="s2">By placing the transducer transversely,</p>
<p begin="00:00:39.019" end="00:00:43.028" style="s2">I have in the middle of the<br />screen, the Median Nerve.</p>
<p begin="00:00:43.028" end="00:00:43.861" style="s2">I can find</p>
<p begin="00:00:45.529" end="00:00:48.480" style="s2">the Ulnar Artery on this side.</p>
<p begin="00:00:48.480" end="00:00:50.897" style="s2">And you can see it pulsating.</p>
<p begin="00:00:53.222" end="00:00:57.882" style="s2">I mark the Ulnar Artery<br />with an indelible pen.</p>
<p begin="00:00:57.882" end="00:01:02.412" style="s2">And then move just a little<br />bit to the radial side,</p>
<p begin="00:01:02.412" end="00:01:04.778" style="s2">so that the Ulnar Artery is down here.</p>
<p begin="00:01:04.778" end="00:01:07.028" style="s2">And place a 25 gauge needle</p>
<p begin="00:01:08.290" end="00:01:11.088" style="s2">in this direction, very superficially,</p>
<p begin="00:01:11.088" end="00:01:14.874" style="s2">because it's only two millimeters deep.</p>
<p begin="00:01:14.874" end="00:01:19.099" style="s2">And bring that needle in from<br />the left side of the screen.</p>
<p begin="00:01:19.099" end="00:01:23.589" style="s2">In this image, the Median<br />Nerve is sitting right here.</p>
<p begin="00:01:23.589" end="00:01:27.172" style="s2">The Retinaculum is<br />along this surface here.</p>
<p begin="00:01:28.237" end="00:01:29.545" style="s2">And the needle is coming in</p>
<p begin="00:01:29.545" end="00:01:31.749" style="s2">from the left side of the screen.</p>
<p begin="00:01:31.749" end="00:01:34.117" style="s2">This is bone down here.</p>
<p begin="00:01:34.117" end="00:01:37.867" style="s2">You'll see the needle<br />advanced superficial to</p>
<p begin="00:01:39.095" end="00:01:41.348" style="s2">the nerve and fluid,</p>
<p begin="00:01:41.348" end="00:01:45.265" style="s2">which includes steroids<br />and Lidocaine injected.</p>
<p begin="00:01:47.849" end="00:01:50.586" style="s2">In the next brief video,</p>
<p begin="00:01:50.586" end="00:01:54.223" style="s2">the needle is seen deep<br />to the Median Nerve,</p>
<p begin="00:01:54.223" end="00:01:55.940" style="s2">so the nerve is here.</p>
<p begin="00:01:55.940" end="00:01:59.976" style="s2">And the needle can be seen underneath it</p>
<p begin="00:01:59.976" end="00:02:00.809" style="s2">and again,</p>
<p begin="00:02:02.130" end="00:02:06.297" style="s2">injection with Lidocaine<br />and steroid is performed.</p>
<p begin="00:02:08.629" end="00:02:11.443" style="s2">The other approach that some people use</p>
<p begin="00:02:11.443" end="00:02:14.836" style="s2">is with the transducer longitudinal.</p>
<p begin="00:02:14.836" end="00:02:18.183" style="s2">Here's the Median Nerve on the screen.</p>
<p begin="00:02:18.183" end="00:02:22.586" style="s2">And you can approach the<br />Median Nerve this way,</p>
<p begin="00:02:22.586" end="00:02:24.419" style="s2">so distal to proximal.</p>

<p begin="00:00:09.622" end="00:00:11.637" style="s2">- We're going to examine the wrist today,</p>
<p begin="00:00:11.637" end="00:00:14.759" style="s2">and the best transducer<br />for this examination</p>
<p begin="00:00:14.759" end="00:00:17.869" style="s2">is the L25, the small footprint.</p>
<p begin="00:00:17.869" end="00:00:20.225" style="s2">We'll check that the exam type is correct.</p>
<p begin="00:00:20.225" end="00:00:22.892" style="s2">We're doing an MSK type of exam.</p>
<p begin="00:00:24.490" end="00:00:27.783" style="s2">For orientation, there<br />is a marker here which</p>
<p begin="00:00:27.783" end="00:00:31.791" style="s2">corresponds to the<br />turquoise dot on the screen.</p>
<p begin="00:00:31.791" end="00:00:35.958" style="s2">Keep this marker proximal when<br />I'm examining longitudinally</p>
<p begin="00:00:36.850" end="00:00:40.290" style="s2">and medial when I'm<br />examining transversally.</p>
<p begin="00:00:40.290" end="00:00:43.082" style="s2">We'll start the wrist<br />on the dorsal surface</p>
<p begin="00:00:43.082" end="00:00:45.568" style="s2">and examine transversally first.</p>
<p begin="00:00:45.568" end="00:00:47.860" style="s2">There are six compartments, beginning with</p>
<p begin="00:00:47.860" end="00:00:51.608" style="s2">the first compartment at<br />the base of the thumb,</p>
<p begin="00:00:51.608" end="00:00:54.768" style="s2">and the sixth compartment<br />near the ulnar styloid.</p>
<p begin="00:00:54.768" end="00:00:57.826" style="s2">When we look at the wrist structures,</p>
<p begin="00:00:57.826" end="00:01:01.440" style="s2">we're looking not only<br />at tendons and bones,</p>
<p begin="00:01:01.440" end="00:01:05.440" style="s2">but we're also looking<br />at a multitude of joints.</p>
<p begin="00:01:08.787" end="00:01:12.120" style="s2">If I come over here to a middle portion,</p>
<p begin="00:01:14.809" end="00:01:17.823" style="s2">we're looking at carpal bones here.</p>
<p begin="00:01:17.823" end="00:01:20.855" style="s2">With the presence of synovitis,</p>
<p begin="00:01:20.855" end="00:01:25.107" style="s2">we would have hyperechoic<br />or anechoic fluid</p>
<p begin="00:01:25.107" end="00:01:29.249" style="s2">and thickening of synovium<br />at these recesses,</p>
<p begin="00:01:29.249" end="00:01:31.196" style="s2">which are the joints.</p>
<p begin="00:01:31.196" end="00:01:32.860" style="s2">None of that is present here.</p>
<p begin="00:01:32.860" end="00:01:37.027" style="s2">We'll move over to the<br />extensor tendons of the thumb,</p>
<p begin="00:01:38.837" end="00:01:42.913" style="s2">where you can sometimes see<br />de Quervain's tenosynovitis,</p>
<p begin="00:01:42.913" end="00:01:45.303" style="s2">and here is a nice view of one of</p>
<p begin="00:01:45.303" end="00:01:48.436" style="s2">the long tendons of the thumb.</p>
<p begin="00:01:48.436" end="00:01:51.805" style="s2">These extensor digitorum tendons here</p>
<p begin="00:01:51.805" end="00:01:55.193" style="s2">are normal in appearance on cross-section.</p>
<p begin="00:01:55.193" end="00:01:58.373" style="s2">These are the two thumb<br />tendons that you see</p>
<p begin="00:01:58.373" end="00:02:01.700" style="s2">right over the distal end of the radius,</p>
<p begin="00:02:01.700" end="00:02:04.019" style="s2">which is right here.</p>
<p begin="00:02:04.019" end="00:02:08.186" style="s2">This then can be traced<br />distally out toward the thumb,</p>
<p begin="00:02:09.945" end="00:02:13.064" style="s2">and these tendons and<br />their peritendinous tissue</p>
<p begin="00:02:13.064" end="00:02:15.732" style="s2">can be examined carefully.</p>
<p begin="00:02:15.732" end="00:02:18.580" style="s2">On the other side of the<br />wrist toward the ulna,</p>
<p begin="00:02:18.580" end="00:02:20.201" style="s2">we have a very nice view of the</p>
<p begin="00:02:20.201" end="00:02:23.416" style="s2">extensor carpi ulnaris tendon, which is</p>
<p begin="00:02:23.416" end="00:02:26.310" style="s2">one of the largest extensor<br />tendons in the wrist</p>
<p begin="00:02:26.310" end="00:02:28.501" style="s2">and easiest to see.</p>
<p begin="00:02:28.501" end="00:02:32.173" style="s2">It also is frequently<br />surrounded, in a patient</p>
<p begin="00:02:32.173" end="00:02:35.310" style="s2">with an inflammatory process, with fluid</p>
<p begin="00:02:35.310" end="00:02:39.440" style="s2">or synovium, and that<br />can be seen as either</p>
<p begin="00:02:39.440" end="00:02:42.719" style="s2">anechoic or hyperechoic shadow around the</p>
<p begin="00:02:42.719" end="00:02:46.624" style="s2">distinct oval-shaped tendon, which is</p>
<p begin="00:02:46.624" end="00:02:51.117" style="s2">hyperechoic, and you can see<br />the fibrillar nature within it.</p>
<p begin="00:02:51.117" end="00:02:55.284" style="s2">If we look longitudinally,<br />keeping this dot proximal,</p>
<p begin="00:02:56.705" end="00:03:00.243" style="s2">and find that extensor<br />carpi ulnaris tendon,</p>
<p begin="00:03:00.243" end="00:03:03.057" style="s2">you can see these parallel lines,</p>
<p begin="00:03:03.057" end="00:03:05.369" style="s2">which are going from left to right.</p>
<p begin="00:03:05.369" end="00:03:07.544" style="s2">There are areas that are hyperechoic</p>
<p begin="00:03:07.544" end="00:03:09.971" style="s2">alternating with hypoechoic.</p>
<p begin="00:03:09.971" end="00:03:12.661" style="s2">This is a normal appearance of the tendon,</p>
<p begin="00:03:12.661" end="00:03:15.851" style="s2">and also visualize peritendonous tissue.</p>
<p begin="00:03:15.851" end="00:03:18.684" style="s2">The retinaculum, which is up here,</p>
<p begin="00:03:19.642" end="00:03:23.963" style="s2">in deep to this, this is<br />the distal part of the ulna.</p>
<p begin="00:03:23.963" end="00:03:26.101" style="s2">First part of carpal bones,</p>
<p begin="00:03:26.101" end="00:03:28.593" style="s2">and triangular ligament is in here.</p>
<p begin="00:03:28.593" end="00:03:32.760" style="s2">Next, we look at the volar, or<br />palmer surface of the wrist.</p>
<p begin="00:03:34.730" end="00:03:36.679" style="s2">Most of the time, we're going to be</p>
<p begin="00:03:36.679" end="00:03:39.490" style="s2">looking at the median nerve in this area.</p>
<p begin="00:03:39.490" end="00:03:43.855" style="s2">Again, the transducer<br />marker is placed medially.</p>
<p begin="00:03:43.855" end="00:03:47.630" style="s2">This structure here is the median nerve.</p>
<p begin="00:03:47.630" end="00:03:52.353" style="s2">We can go toward the radial<br />side and see the artery,</p>
<p begin="00:03:52.353" end="00:03:56.520" style="s2">the hyperechoic or anechoic<br />area that has a small pulsation.</p>
<p begin="00:03:58.271" end="00:04:01.991" style="s2">Sometimes checking color Doppler signal</p>
<p begin="00:04:01.991" end="00:04:06.790" style="s2">or Doppler signal is helpful,<br />and the median nerve, then,</p>
<p begin="00:04:06.790" end="00:04:09.779" style="s2">is seen right here in the middle.</p>
<p begin="00:04:09.779" end="00:04:13.832" style="s2">On the ulnar surface,<br />going in this direction,</p>
<p begin="00:04:13.832" end="00:04:17.278" style="s2">is the ulnar artery, and<br />we can freeze the image</p>
<p begin="00:04:17.278" end="00:04:20.282" style="s2">and take a measurement of the median nerve</p>
<p begin="00:04:20.282" end="00:04:24.396" style="s2">if it's desired to see<br />whether this is enlarged</p>
<p begin="00:04:24.396" end="00:04:28.227" style="s2">using direct correlation<br />between this measurement</p>
<p begin="00:04:28.227" end="00:04:30.579" style="s2">and the presence of<br />carpal tunnel syndrome.</p>
<p begin="00:04:30.579" end="00:04:34.045" style="s2">So I have placed my calipers on both sides</p>
<p begin="00:04:34.045" end="00:04:38.180" style="s2">of the median nerve, just<br />inside the perineurium,</p>
<p begin="00:04:38.180" end="00:04:40.914" style="s2">and then I'm going to<br />hit this ellipse button.</p>
<p begin="00:04:40.914" end="00:04:45.466" style="s2">Then I can actually take an<br />approximate surface area.</p>
<p begin="00:04:45.466" end="00:04:49.633" style="s2">She has a .08 centimeter<br />squared area, which is normal,</p>
<p begin="00:04:50.746" end="00:04:54.056" style="s2">and so by ultrasound<br />criteria does not have</p>
<p begin="00:04:54.056" end="00:04:55.973" style="s2">carpal tunnel syndrome.</p>

<p begin="00:00:09.853" end="00:00:13.771" style="s2">- I'm going to examine the<br />MCM and PIP joints now.</p>
<p begin="00:00:13.771" end="00:00:17.492" style="s2">We'll be looking at the<br />dorsal, or extensor, surfaces,</p>
<p begin="00:00:17.492" end="00:00:20.795" style="s2">as well as the palmar surface of the MCPs</p>
<p begin="00:00:20.795" end="00:00:23.853" style="s2">and just take a brief look at the PIP.</p>
<p begin="00:00:23.853" end="00:00:27.872" style="s2">The best transducer for<br />this exam is the L25,</p>
<p begin="00:00:27.872" end="00:00:31.268" style="s2">which has a small<br />footprint and it allows you</p>
<p begin="00:00:31.268" end="00:00:34.768" style="s2">to retain contact with the skin's surface.</p>
<p begin="00:00:36.283" end="00:00:40.684" style="s2">There is a marker on the<br />transducer, which represents</p>
<p begin="00:00:40.684" end="00:00:44.851" style="s2">this turquoise dot, so in keeping<br />your orientation straight,</p>
<p begin="00:00:47.649" end="00:00:51.443" style="s2">you always want to keep this<br />proximal, so this is held</p>
<p begin="00:00:51.443" end="00:00:55.193" style="s2">that way for longitudinal<br />images, and medial,</p>
<p begin="00:00:56.310" end="00:00:59.226" style="s2">so this marker should be on the outside.</p>
<p begin="00:00:59.226" end="00:01:02.083" style="s2">As a rheumatologist, we're<br />going to be looking for</p>
<p begin="00:01:02.083" end="00:01:06.346" style="s2">boney detail tendon<br />anatomy, and the presence</p>
<p begin="00:01:06.346" end="00:01:09.919" style="s2">or absence of synovitis and erosions.</p>
<p begin="00:01:09.919" end="00:01:12.868" style="s2">I'll look, today at the<br />second and third MCPs,</p>
<p begin="00:01:12.868" end="00:01:16.104" style="s2">both in the transverse<br />and longitudinal planes,</p>
<p begin="00:01:16.104" end="00:01:17.780" style="s2">and we'll take a brief look at the PIP</p>
<p begin="00:01:17.780" end="00:01:21.613" style="s2">and then the palmar<br />surface of the second MCP.</p>
<p begin="00:01:22.658" end="00:01:26.896" style="s2">We'll look longitudinally<br />over the second MCP first</p>
<p begin="00:01:26.896" end="00:01:29.896" style="s2">and see the skin surface on the top.</p>
<p begin="00:01:31.343" end="00:01:34.247" style="s2">The bones, this is proximal, so this is</p>
<p begin="00:01:34.247" end="00:01:36.747" style="s2">the end of the 2nd Metacarpal.</p>
<p begin="00:01:37.733" end="00:01:41.108" style="s2">Here's the Articular<br />Surface, and then here is</p>
<p begin="00:01:41.108" end="00:01:44.781" style="s2">the proximal portion of the 1st Phalanx.</p>
<p begin="00:01:44.781" end="00:01:48.698" style="s2">The black anechoic surface,<br />here, is Cartilage,</p>
<p begin="00:01:49.605" end="00:01:51.245" style="s2">and there's some cartilage here,</p>
<p begin="00:01:51.245" end="00:01:56.183" style="s2">and this is a normal joint<br />structure at the second MCP.</p>
<p begin="00:01:56.183" end="00:02:00.481" style="s2">There is frequently a small<br />articular cortical defect</p>
<p begin="00:02:00.481" end="00:02:04.425" style="s2">on the dorsal surface of this metacarpal.</p>
<p begin="00:02:04.425" end="00:02:06.271" style="s2">That is not an erosion.</p>
<p begin="00:02:06.271" end="00:02:08.868" style="s2">An erosion would appear elsewhere</p>
<p begin="00:02:08.868" end="00:02:11.205" style="s2">with this type of an appearance.</p>
<p begin="00:02:11.205" end="00:02:14.115" style="s2">We can also see the Extensor<br />Tendon superficially</p>
<p begin="00:02:14.115" end="00:02:16.484" style="s2">right under the surface of the skin.</p>
<p begin="00:02:16.484" end="00:02:19.252" style="s2">Could you move your finger<br />just up a little bit,</p>
<p begin="00:02:19.252" end="00:02:22.970" style="s2">and you can see that tendon<br />moving and the joint moving.</p>
<p begin="00:02:22.970" end="00:02:27.228" style="s2">We'll then take a transverse image and see</p>
<p begin="00:02:27.228" end="00:02:31.392" style="s2">a transverse oval image<br />of that Extensor Tendon.</p>
<p begin="00:02:31.392" end="00:02:33.577" style="s2">We're going to look for hyperechoic</p>
<p begin="00:02:33.577" end="00:02:37.097" style="s2">or anechoic fluid or synovium around it.</p>
<p begin="00:02:37.097" end="00:02:40.181" style="s2">In this case, none of that is present.</p>
<p begin="00:02:40.181" end="00:02:43.378" style="s2">We can also now look at the third MCP.</p>
<p begin="00:02:43.378" end="00:02:47.948" style="s2">Here, again, we see the<br />extensor tendon, the joint</p>
<p begin="00:02:47.948" end="00:02:50.023" style="s2">is V-shaped structure.</p>
<p begin="00:02:50.023" end="00:02:53.925" style="s2">This is anechoic where the<br />cartilage is and hypoechoic</p>
<p begin="00:02:53.925" end="00:02:58.874" style="s2">where the actual joint<br />material is within the capsule.</p>
<p begin="00:02:58.874" end="00:03:01.190" style="s2">The joint extends from approximately here</p>
<p begin="00:03:01.190" end="00:03:02.686" style="s2">all the way over to here.</p>
<p begin="00:03:02.686" end="00:03:04.353" style="s2">That's quite normal.</p>
<p begin="00:03:05.221" end="00:03:06.846" style="s2">We'll look at the PIP.</p>
<p begin="00:03:06.846" end="00:03:10.690" style="s2">This is the distal end of the 1st Phalanx.</p>
<p begin="00:03:10.690" end="00:03:15.075" style="s2">The Joint is this space,<br />here, and she happens</p>
<p begin="00:03:15.075" end="00:03:18.520" style="s2">to have a small amount<br />of osteoarthritis, here,</p>
<p begin="00:03:18.520" end="00:03:22.208" style="s2">with some Irregularity<br />of this Cortical surface.</p>
<p begin="00:03:22.208" end="00:03:25.713" style="s2">I can slip my finger in<br />here and show you where</p>
<p begin="00:03:25.713" end="00:03:28.016" style="s2">this is actually moving and you can see</p>
<p begin="00:03:28.016" end="00:03:30.766" style="s2">that joint flexing and extending.</p>
<p begin="00:03:31.916" end="00:03:36.083" style="s2">We'll look at the flexor<br />surface of the second MCP.</p>
<p begin="00:03:39.716" end="00:03:41.870" style="s2">These tendons are quite a bit bigger.</p>
<p begin="00:03:41.870" end="00:03:45.010" style="s2">We see the Flexor Tendon<br />moving very nicely</p>
<p begin="00:03:45.010" end="00:03:48.106" style="s2">as she flexes and extends<br />her finger, and you can see</p>
<p begin="00:03:48.106" end="00:03:50.675" style="s2">the superficial border<br />between the tendon and the</p>
<p begin="00:03:50.675" end="00:03:53.754" style="s2">Subcutaneous Tissues, and you can see</p>
<p begin="00:03:53.754" end="00:03:55.959" style="s2">the Joint very nicely, here.</p>
<p begin="00:03:55.959" end="00:03:59.087" style="s2">This Hypoechoic area is the A1 pulley,</p>
<p begin="00:03:59.087" end="00:04:02.170" style="s2">which is just proximal to this joint.</p>