Thigh

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 .

3D How To: Quadriceps Tendon Exam

Read more about 3D How To: Quadriceps Tendon Exam

/sites/default/files/QuadricepsTendon_Disclaimer_Thumbnail_edu00549.jpg

3D animation demonstrating an ultrasound exam of the Quadriceps Tendon.

Clinical Specialties

Media Library Type

Media Library Tag

Anesthesiology (Regional)

Subtitles

- [Voiceover] A linear array transducer
with a musculoskeletal exam type
is used to perform an ultrasound
examination of the quadriceps tendon.
The patient is in a supine position
with the knee flexed 90 degrees.
The transducer is placed longitudinally just proximal
to the patella with the orientation marker directed
to the patient's head.
The compact fibrillar pattern of the quadriceps tendon
is seen superficial to the bright hyperechoic signal
of the distal femur.
The bright hyperechoic patella is seen
on the right of the image.
The suprapatellar fat pad can be seen as a triangular,
bright hyperechoic structure just superficial
to the suprapatellar bursa.
The transducer should be swept from medial to lateral to
evaluate the entire quadriceps tendon.
The transducer should then be rotated 90 degrees
counterclockwise for a short axis view of the tendon.
The medial and lateral condyles are seen
as bright hyperechoic lines.
The cartilage of the knee is seen superficial to the bone
as a black anechoic line.
The pancake shaped speckled suprapatellar tendon is seen in
cross-section anterior to the suprapatellar bursa.
The transducer should be swept from the patella
to the musculotendinous insertion of the tendon
to complete the examination.

Brightcove ID

5508120152001

https://youtube.com/watch?v=7Ep7SW8eHdg

3D How To: Saphenous Nerve Block

Read more about 3D How To: Saphenous Nerve Block

/sites/default/files/Saphenous_edu00504_thumbnail.jpg

3D animation demonstrating an ultrasound guided saphenous nerve block.

Clinical Specialties

Media Library Type

Media Library Tag

Subtitles

- [Voiceover] A linear array transducer
with a nerve exam type is used to perform
an ultrasound-guided saphenous nerve block.
The target depth is approximately
one to three centimeters in an 80 kilogram adult.
The patient is positioned in a supine position
with the leg slightly abducted and externally rotated.
The transducer is placed in the middle of the thigh
in a transverse plane, with the orientation marker
directed to the patient's right.
The leg is scanned medially to laterally
to identify the superficial femoral artery,
which lies underneath the sartorius muscle.
The saphenous nerve can lie either
anterior or posterior to the artery.
The saphenous nerve may not be visible.
If it is, it will appear as a bright,
hyperechoic oval or triangular structure.
The needle is positioned one to two centimeters lateral
to the transducer, and advanced under the transducer.
Local anesthetic is injected incrementally,
superficial and deep to the artery
to complete the saphenous nerve block.

Brightcove ID

5508114714001

https://youtube.com/watch?v=54VG2GhJ3w4

Body

3D animation demonstrating an ultrasound guided saphenous nerve block.

Case: Knee: Quad Tendinosis

Read more about Case: Knee: Quad Tendinosis

/sites/default/files/Cases_knee_quad_tendinosis_thumb.jpg

Knee - Quad Tendinosis.

Clinical Specialties

Media Library Type

Case Study Videos

Media Library Tag

Subtitles

- [Voiceover] The following video is a description of the
fuse quadriceps tendonosis primarily to the rectus
femurus portion.
Here's the bony anatomy,
associated with the suprapatellar region
of the anterior knee.
Superimposed CAT scan will be modeling the quadricep
tendon insertion to the base of the patella,
followed by the quadricep fat pad,
which is seen here highlighted in yellow.
Also here highlighted in yellow is the prefemoral
fat pad which surrounds the anterior aspect of the femur.
And highlighted here in blue is the
Anterior Articular Hyaline Cartilage,
and in light blue would be the normal synovial recess,
the Suprapatellar Bursa.
Here is the corresponding Normal Quadricep Tendon Image
as the tendon fibers insert to the highlighted
Patellar base, the proximal surface.
Highlighted here is the anterior margin of the femur.
Highlighted here in blue is the fibrillar pattern
of the normally situated quadriceps tendon.
Highlighted here in yellow is the Quadricep Fat Pad,
also highlighted here in yellow is the Prefemoral Fat Pad,
and next we have highlighted here in light blue as the
normally appearing synovial recess
of the superpatellar bursa.
To further demonstrate the extensor mechanism of the
quadricep tendon having the patient tighten their quad
will also force fluid into the superpatellar recess.
If no joint effusion is identified,
this is one way to bring out normal physiologic fluid
between the two fat pads.
This image shows a diffuse formation of the more
superficial layer of the quadricep tendon.
Highlighted in white is a normal
appearing base of the patella.
Highlighted here is the normal appearing interior
surface of the femur followed by a thickened quadricep
tendon insertion proximal to its insertion
of the patella.
Highlighted here in yellow is the normal appearing
quadriceps fat pad followed by the normal appearing
prefemoral fat pad.
Here we have in light blue a more normal appearing
physiologic amount of synovial fluid,
and then red represents the superficial layer
of the quadricep tendon which is now diffuse,
indicating diffuse tendonosis of the rectus
femurus portion.

Brightcove ID

5752875132001

https://youtube.com/watch?v=D77y0fhfr7M

How To: Knee Exam Set Up

Read more about How To: Knee Exam Set Up

/sites/default/files/Coach_sampson_knee_exam_set_up_thumb.jpg

Dr. Steven Sampson demonstrates how to set up a knee exam.

Clinical Specialties

Media Library Type

Media Library Tag

Knee Intra-Articular Injection

Subtitles

- We're going to review the knee exam,
but before we get started, there are a few
important principles to be aware of.
Some of the ultrasound settings need to be
taken care of before we do the exam.
Firstly, we look to see that we have the machine
set up for musculoskeletal.
We do this by pressing the exam button
on the machine, which will identify
that we are in musculoskeletal mode.
We will click select, and we are ready to begin.
I recommend using a linear transducer,
which is between eight and 13 hertz.
When using this transducer, it's important
to stay with a consistent method,
so that you're always confident
of where you are when you're scanning the patient.
I recommend keeping the notch of the transducer
always in the superior aspect, always pointing upwards
toward the patients head, as well as immediately
toward the patient's body.
You can correlate this with the machine,
because there's a dot in the upper left hand corner
of the screen, which will orientate you
as far as your scanning or injection techniques.
We're going to begin scanning the right knee.
I like to begin the scan by starting
at the quadriceps tendon, with the transducer
with the notch facing towards the patient, upwards,
In a longitudinal plane.
As my landmarks, I'm going to use
so the bottom of the transducer is touching the top
of the patella tendon.
I can clearly see the fibers of the quadriceps tendon
attaching on the patella here at the distal end.
It's important to maintain contact on both ends
of the transducer, to get an accurate image.
I'm going to scan up and down the quadriceps
to detect any abnormality.
Clinically, if I suspected a tear more approximately,
I would examine further, but for most purposes,
this is sufficient.
Next, we are going to take a look
at the patient's cartilage, with the knee
in the flex position.
By holding the transducer with the notch facing
towards the patient, in the medial position
and placing the probe in cross section,
just above the patient's patella.
Here, I see a clear image of the patient's
medial and lateral epicondyles,
with cartilage shown in the area of blackness.
In demonstration of arthritis or chondropenia,
we can measure from the center of the cartilage,
as well as at the edge of each epicondyle and compare them
to standards to determine the grade of osteoarthritis.
By freezing the image, I can now measure
the cartilage thickness.
I press the caliper button and I locate the center
of the cartilage and I can measure the distance
of cartilage thickness.
I can measure the cartilage thickness at the point
of each lateral condyle and compare these to normal values.

Brightcove ID

5508105587001

https://youtube.com/watch?v=4yKMfxaAfgI

How To: Knee Injection

Read more about How To: Knee Injection

/sites/default/files/Coach_sampson_ultrasound_guided_knee_injection_thumb2.jpg

Dr. Steven Sampson demonstrates how to perform an ultrasound guided knee injection.

Clinical Specialties

Media Library Type

Media Library Tag

Knee Intra-Articular Injection

Subtitles

- Next we're going to review injection of the knee.
Before we get started, keep in mind that this is
just a demonstration, and normally these are performed
under sterile environments, with Betadine, and prepping
the area properly, this is just an idea to show
the physician exactly the approach that we use in doing
injections with the proper needle placement and approach.
The most common target that physicians typically inject
the knee joint, is the Suprapatellar Recess, or Bursa.
We begin by placing the transducer in a longitudinal
plane, with the end of the transducer just above
the patient's Patella.
Next, in setup for the injection, I'm going to rotate
my transducer to cross-section, and here we can visualize
the physiologic fluid of the Suprapatellar Recess,
which is the band of darkness above the Cortex.
This will be the target site of our knee injection.
The proper landmarks associated with a knee injection
are palpating the Iliotibial Band, which is a structure
that runs down the Lateral Thigh, and in between
the Iliotibial band and the Vastus Lateralis
is the soft spot.
Palpated right here.
A needle as it's inserted in this soft spot,
between the Iliotibial Band and the Vastus Lateralis,
in a direction directly beneath the center of the transducer
to ensure an accurate localization.
The needle will be guided into the Suprapatellar Bursa,
and Lidocaine is typically injected to ensure proper
location, and we'll see the Bursa expand.
In addition to injections of Cortisone or Lidocaine,
or other medications, we often aspirate the knee
if there is a significant effusion
of the Suprapatellar Recess.
By doing this, we use the same approach as the described
injection technique, however, initially we'll use
an 18-gauge needle.
Insert the Suprapatellar Recess, and drain the fluid out.

Brightcove ID

5752880497001

https://youtube.com/watch?v=2s2bZGDcT7M

How To: Quadriceps Tendon Exam

Read more about How To: Quadriceps Tendon Exam

/sites/default/files/Coach_sampson_quadriceps_tendon_exam_thumb.jpg

Dr. Steven Sampson demonstrates how to perform a Quadriceps Tendon exam.

Clinical Specialties

Media Library Type

Media Library Tag