<p begin="00:00:07.633" end="00:00:09.278" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.278" end="00:00:11.397" style="s2">with a musculoskeletal exam type</p>
<p begin="00:00:11.397" end="00:00:13.874" style="s2">is used to perform an<br />ultrasound examination</p>
<p begin="00:00:13.874" end="00:00:16.046" style="s2">of Guyon's canal.</p>
<p begin="00:00:16.046" end="00:00:18.047" style="s2">The patient is placed<br />in a sitting position</p>
<p begin="00:00:18.047" end="00:00:21.467" style="s2">with the dorsal hand placed<br />on an examination table.</p>
<p begin="00:00:21.467" end="00:00:23.801" style="s2">The transducer is placed<br />over the wrist crease</p>
<p begin="00:00:23.801" end="00:00:26.357" style="s2">in a transverse fashion,<br />with the orientation marker</p>
<p begin="00:00:26.357" end="00:00:28.779" style="s2">directed towards the patient's right.</p>
<p begin="00:00:28.779" end="00:00:31.123" style="s2">The pisiform bone is seen as a bright,</p>
<p begin="00:00:31.123" end="00:00:33.492" style="s2">hyperechoic, prominent structure.</p>
<p begin="00:00:33.492" end="00:00:36.599" style="s2">The ulnar artery is a<br />round, pulsatile structure</p>
<p begin="00:00:36.599" end="00:00:38.669" style="s2">above the flexor retinaculum,</p>
<p begin="00:00:38.669" end="00:00:41.274" style="s2">which appears as a hyperechoic line.</p>
<p begin="00:00:41.274" end="00:00:43.185" style="s2">The ulnar nerve is located between</p>
<p begin="00:00:43.185" end="00:00:45.424" style="s2">the ulnar artery and the pisiform,</p>
<p begin="00:00:45.424" end="00:00:48.849" style="s2">and can be seen as a darker,<br />fasciculated structure.</p>
<p begin="00:00:48.849" end="00:00:50.715" style="s2">The transducer should be slowly moved</p>
<p begin="00:00:50.715" end="00:00:53.447" style="s2">distal to the wrist crease<br />to follow the ulnar nerve</p>
<p begin="00:00:53.447" end="00:00:56.339" style="s2">until it splits into a<br />superficial sensory branch</p>
<p begin="00:00:56.339" end="00:00:58.674" style="s2">and a deeper motor branch which courses</p>
<p begin="00:00:58.674" end="00:01:00.885" style="s2">alongside the hamate hook.</p>
<p begin="00:01:00.885" end="00:01:03.924" style="s2">The arcade of the flexor<br />brevis can be seen in this view</p>
<p begin="00:01:03.924" end="00:01:06.163" style="s2">as an oval, hyperechoic structure</p>
<p begin="00:01:06.163" end="00:01:09.913" style="s2">just between the branches<br />of the ulnar nerve.</p>

<p begin="00:00:07.634" end="00:00:09.403" style="s2">- [Voiceover] A linear<br />array transducer with a</p>
<p begin="00:00:09.403" end="00:00:12.522" style="s2">musculoskeletal exam type<br />is used to perform an</p>
<p begin="00:00:12.522" end="00:00:16.027" style="s2">ultrasound examination<br />of the cubital tunnel.</p>
<p begin="00:00:16.027" end="00:00:18.815" style="s2">The patient's elbow is<br />placed in forceful internal</p>
<p begin="00:00:18.815" end="00:00:22.249" style="s2">rotation, with the<br />elbow in full extension.</p>
<p begin="00:00:22.249" end="00:00:25.700" style="s2">The transducer is placed over<br />the posterior medial elbow</p>
<p begin="00:00:25.700" end="00:00:28.441" style="s2">in a transverse fashion,<br />with the orientation marker</p>
<p begin="00:00:28.441" end="00:00:31.262" style="s2">directed towards the patient's right.</p>
<p begin="00:00:31.262" end="00:00:33.481" style="s2">The medial epicondyle of the elbow,</p>
<p begin="00:00:33.481" end="00:00:34.963" style="s2">and the olecranon process,</p>
<p begin="00:00:34.963" end="00:00:37.949" style="s2">are seen in the epicondylar<br />groove as bright,</p>
<p begin="00:00:37.949" end="00:00:40.115" style="s2">hyperechoic structures.</p>
<p begin="00:00:40.115" end="00:00:43.320" style="s2">The ulnar nerve can be<br />seen as a hypoechoic,</p>
<p begin="00:00:43.320" end="00:00:46.500" style="s2">vesiculated structure near<br />the medial epicondyle.</p>
<p begin="00:00:46.500" end="00:00:49.535" style="s2">The triceps tendon appears<br />as a hyperechoic area,</p>
<p begin="00:00:49.535" end="00:00:52.508" style="s2">overlying the olecranon process.</p>
<p begin="00:00:52.508" end="00:00:54.914" style="s2">The transducer should<br />be slowly moved distally</p>
<p begin="00:00:54.914" end="00:00:57.282" style="s2">to evaluate the cubital tunnel.</p>
<p begin="00:00:57.282" end="00:01:00.799" style="s2">The cubital tunnel retinaculum<br />appears as a hyperechoic</p>
<p begin="00:01:00.799" end="00:01:03.508" style="s2">line above the deeper structures.</p>
<p begin="00:01:03.508" end="00:01:06.617" style="s2">The ulnar head of the<br />flexor carpi ulnaris muscle</p>
<p begin="00:01:06.617" end="00:01:08.813" style="s2">can be seen as a hypoechoic structure</p>
<p begin="00:01:08.813" end="00:01:11.094" style="s2">near the olecranon process.</p>
<p begin="00:01:11.094" end="00:01:13.901" style="s2">The humoral head of the<br />flexor carpi ulnaris muscle</p>
<p begin="00:01:13.901" end="00:01:17.350" style="s2">appears similarly on the<br />medial side of the image.</p>
<p begin="00:01:17.350" end="00:01:20.103" style="s2">The ulnar nerve can be<br />seen as a hypoechoic,</p>
<p begin="00:01:20.103" end="00:01:23.603" style="s2">rounded structure between the two muscles.</p>

<p begin="00:00:07.662" end="00:00:09.398" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.398" end="00:00:11.879" style="s2">with a musculoskeletal exam type is used</p>
<p begin="00:00:11.879" end="00:00:15.670" style="s2">to perform an ultrasound<br />examination of the ulnar nerve.</p>
<p begin="00:00:15.670" end="00:00:18.249" style="s2">The patient is asked to<br />flex their elbow slightly</p>
<p begin="00:00:18.249" end="00:00:20.584" style="s2">with the hand placed on<br />the examination table</p>
<p begin="00:00:20.584" end="00:00:24.030" style="s2">and the forearm in<br />forced internal rotation.</p>
<p begin="00:00:24.030" end="00:00:27.231" style="s2">The transducer is placed<br />over the distal posterior arm</p>
<p begin="00:00:27.231" end="00:00:28.765" style="s2">in a transverse fashion,</p>
<p begin="00:00:28.765" end="00:00:30.732" style="s2">with the orientation<br />marker directed toward</p>
<p begin="00:00:30.732" end="00:00:32.380" style="s2">the patient's right side</p>
<p begin="00:00:32.380" end="00:00:35.145" style="s2">and the elecranon on facing the examiner.</p>
<p begin="00:00:35.145" end="00:00:37.952" style="s2">The ulnar nerve can be seen a hypoechoic</p>
<p begin="00:00:37.952" end="00:00:39.544" style="s2">oval structure.</p>
<p begin="00:00:39.544" end="00:00:41.742" style="s2">The medial epichondial of the humerus</p>
<p begin="00:00:41.742" end="00:00:44.923" style="s2">and the elecranon process<br />can be seen as curved</p>
<p begin="00:00:44.923" end="00:00:47.655" style="s2">bright hypoechoic surfaces that form</p>
<p begin="00:00:47.655" end="00:00:49.253" style="s2">the epoicondrial groove.</p>
<p begin="00:00:49.253" end="00:00:51.908" style="s2">The triceps tendon is seen as a hypoechoic</p>
<p begin="00:00:51.908" end="00:00:53.581" style="s2">speckled structure.</p>
<p begin="00:00:53.581" end="00:00:55.742" style="s2">tTe transducer is slowly translated</p>
<p begin="00:00:55.742" end="00:00:57.587" style="s2">down the cubital tunnel.</p>
<p begin="00:00:57.587" end="00:00:59.786" style="s2">The ulnar head and the humeral head</p>
<p begin="00:00:59.786" end="00:01:02.020" style="s2">of the flexal carbial muscle</p>
<p begin="00:01:02.020" end="00:01:05.458" style="s2">can be seen as oval, hypoechoic structures</p>
<p begin="00:01:05.458" end="00:01:07.093" style="s2">surrounding the ulnar nerve.</p>
<p begin="00:01:07.093" end="00:01:09.605" style="s2">The cubital tunnel retanaculum can be seen</p>
<p begin="00:01:09.605" end="00:01:11.921" style="s2">as a hypoechoic band-like structure</p>
<p begin="00:01:11.921" end="00:01:14.171" style="s2">that overlies the muscles.</p>

<p begin="00:00:07.379" end="00:00:09.137" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.137" end="00:00:11.666" style="s2">with a nerve exam type is used to perform</p>
<p begin="00:00:11.666" end="00:00:14.865" style="s2">a median and ulnar regional nerve block.</p>
<p begin="00:00:14.865" end="00:00:18.167" style="s2">The target depth is approximately<br />one to two centimeters</p>
<p begin="00:00:18.167" end="00:00:20.392" style="s2">in an 80-kilogram adult.</p>
<p begin="00:00:20.392" end="00:00:23.105" style="s2">The patient is placed supine with the arm</p>
<p begin="00:00:23.105" end="00:00:25.641" style="s2">externally rotated at the side.</p>
<p begin="00:00:25.641" end="00:00:28.475" style="s2">The transducer is placed<br />in a transverse plane</p>
<p begin="00:00:28.475" end="00:00:29.721" style="s2">at the wrist crease</p>
<p begin="00:00:29.721" end="00:00:31.120" style="s2">with the orientation marker</p>
<p begin="00:00:31.120" end="00:00:33.953" style="s2">directed towards the patient's right side.</p>
<p begin="00:00:33.953" end="00:00:38.214" style="s2">The hypoechoic pulsatile<br />ulnar artery is identified.</p>
<p begin="00:00:38.214" end="00:00:40.485" style="s2">It may be helpful to use color Doppler</p>
<p begin="00:00:40.485" end="00:00:42.265" style="s2">if the artery is small.</p>
<p begin="00:00:42.265" end="00:00:45.357" style="s2">The ulnar nerve is an oval, or triangular,</p>
<p begin="00:00:45.357" end="00:00:47.294" style="s2">bright, hyperechoic structure</p>
<p begin="00:00:47.294" end="00:00:50.318" style="s2">that lies immediately<br />medial to the artery.</p>
<p begin="00:00:50.318" end="00:00:52.141" style="s2">Trace the nerve up the forearm</p>
<p begin="00:00:52.141" end="00:00:54.392" style="s2">following the course of the artery.</p>
<p begin="00:00:54.392" end="00:00:57.527" style="s2">The ulnar nerve will start<br />to separate from the artery</p>
<p begin="00:00:57.527" end="00:01:00.689" style="s2">approximately 2/3 of<br />the way up the forearm.</p>
<p begin="00:01:00.689" end="00:01:03.902" style="s2">The separation allows safe<br />placement of local anesthetic</p>
<p begin="00:01:03.902" end="00:01:05.269" style="s2">around the nerve.</p>
<p begin="00:01:05.269" end="00:01:07.372" style="s2">Follow the fascial plane medially</p>
<p begin="00:01:07.372" end="00:01:10.376" style="s2">to the superficial and deep flexor muscles</p>
<p begin="00:01:10.376" end="00:01:14.030" style="s2">to identify the bright,<br />hyperechoic median nerve.</p>
<p begin="00:01:14.030" end="00:01:17.358" style="s2">The median nerve appears<br />as an oval, or triangular,</p>
<p begin="00:01:17.358" end="00:01:20.735" style="s2">bright, hyperechoic structure<br />between the muscles.</p>
<p begin="00:01:20.735" end="00:01:22.051" style="s2">The needle can be advanced</p>
<p begin="00:01:22.051" end="00:01:25.372" style="s2">using an in-plane or<br />out-of-plane technique.</p>
<p begin="00:01:25.372" end="00:01:28.332" style="s2">For an in-plane approach,<br />the needle is positioned</p>
<p begin="00:01:28.332" end="00:01:31.655" style="s2">one to two centimeters<br />lateral to the transducer</p>
<p begin="00:01:31.655" end="00:01:34.231" style="s2">and advanced under the transducer.</p>
<p begin="00:01:34.231" end="00:01:37.655" style="s2">The initial path for the needle<br />is toward the ulnar nerve</p>
<p begin="00:01:37.655" end="00:01:38.812" style="s2">to allow the needle tip</p>
<p begin="00:01:38.812" end="00:01:41.893" style="s2">to lie immediately beside the ulnar nerve.</p>
<p begin="00:01:41.893" end="00:01:45.441" style="s2">Inject three to five<br />cc of local anesthetic</p>
<p begin="00:01:45.441" end="00:01:48.604" style="s2">around the ulnar nerve<br />to perform the block.</p>
<p begin="00:01:48.604" end="00:01:52.681" style="s2">The needle is then redirected<br />laterally to the median nerve.</p>
<p begin="00:01:52.681" end="00:01:56.245" style="s2">Injection of three to five<br />cc of local anesthetic</p>
<p begin="00:01:56.245" end="00:01:57.726" style="s2">around the median nerve</p>
<p begin="00:01:57.726" end="00:02:00.809" style="s2">will complete the median nerve block.</p>