Case Study Videos

Case: Ectopic Pregnancy - Part 1

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This video details how bedside transvaginal ultrasound can help emergency medicine professionals evaluate OB/GYN anatomy to diagnose possible ectopic pregnancies.

Clinical Specialties

Media Library Type

Media Library Tag

Pseudogestational Sac

Tubal Ectopic Abdominal Ectopic

Subtitles

- Hello, my name is Phil Perrera,
and I'm the emergency ultrasound coordinator
at the New York Presbyterian Hospital in New York City,
and welcome to SoundBytes Cases.
Today's module is going to focus on ectopic pregnancy.
Ectopic pregnancies constitute
about 2% of all total pregnancies,
although they're commonly seen in the emergency department.
Ectopic pregnancy is more commonly seen in women
with a history of tubal ligation
who are using interuterine devices for contraception
or have a history of sexually transmitted diseases,
such as pelvic inflammatory disease
with scarring of the tubes.
Ectopic pregnancy is also commonly seen in women
using fertility agents,
which accounts for the increasing rate of ectopic pregnancy
over all.
As a golden rule, we must consider ectopic pregnancy
in all women with abdominal pain
and/or vaginal bleeding and a positive pregnancy test,
until ruled out by sonography.
Let's begin by reviewing the OB/GYN anatomy
that we'll need to know to perform bedside ultrasound
of the uterus and the adnexa.
We'll begin by locating the lower cervical region
of the uterus.
The portion above that, the body, and the fundal region
of the uterus above the body,
which is where we define an inter-uterine pregnancy
to be located.
Notice the intersticial region of the uterus,
that region of the uterus that abuts the fallopian tube.
In a cornual uterus this is known as cornual region.
Here we also see the portions of the fallopian tube,
the proximal isthmal region,
the distal infindibulum,
and notice the ampullary region
which comprises the majority of the fallopian tube.
We also see here, the broad ligament which encases
the fallopian tube and ovary in the lateral region
of the adnexa.
Remember that the ovary is relatively mobile
within the broad ligament.
Now let's review a transvaginal long axis scan
from a women who presented with a positive pregnancy test,
who had lower abdominal pain and vaginal bleeding.
Notice the fundus, as shown here to the left,
the cervix to the right.
We see here the presence of a thickened white
endometrial stripe in the midline of the uterus.
Notice the pelvic cul de sac that potential space
posterior to the uterus.
Notice here the absence of an inter-uterine pregnancy.
Now, confirm the absence of an IUP by scanning
in the transvaginal short axis plane.
Here we have the probe marker
oriented towards the patient's right,
and we're cutting the uterus in cross section.
Notice again the thickened endometrial stripe
in the midline of the uterus,
and the pelvic cul de sac posteriorly.
Again, we see the absence of an IUP,
and also note the absence of free fluid,
dark anechoic fluid collections
within the pelvic cul de sac.
So, given these findings we're now concerned
about the presence of an ectopic pregnancy.
So, lets begin our discussion of ectopic pregnancies
by reviewing the locations that we commonly see
ectopic pregnancies to be found.
We see here a normal uterus to the left,
and a bicornuate uterus to the right.
We remember that a fundal location is the definition
of an inter-uterine pregnancy as shown smack in the middle
of the normal uterus to the left.
However, we can have variants of ectopic pregnancies
within the uterus as shown in the interstitial location
in the normal uterus to the left,
and in the cornual region in the bicornuate uterus
to the right.
We can also have implantations low
within the cervical region of the uterus,
as shown in the normal uterus to the left.
Now, most ectopic pregnancies will be located
within the fallopian tube and of those
the majority will be found in the ampullary region
as that comprises the majority of the fallopian tube.
But we can have implantations more proximal,
within the isthmal region
or distal within the infindibular region.
Now, tough ectopics to diagnose are those that implant
within the ovary,
within the abdominal cavity,
or within the peritoneal lining.
These can be very, very hard to diagnose
and commonly grow to an advanced stage before diagnosis.
So, returning to our case, given the presence of a positive
pregnancy test and the absence of an IUP
on bedside ultrasound, we were very concerned about
ectopic pregnancy and decided to scan out
to the left adnexa.
Here, notice we're scanning out to the left adnexa,
and we have a positive finding.
What we see here is a thickened fallopian tube,
comprising what is known as the bagel sign.
Notice within the thickened fallopian tube,
we have another positive finding.
That is the presence of a fetal pole.
So, in this patient we were able to diagnose
an ampullary ectopic pregnancy and our next move
was to call OB/GYN stat for a consultation.
So, in conclusion, ectopic pregnancies constitute
the greatest cause, overall, of maternal mortality.
We must consider an ectopic pregnancy in all women
with a positive pregnancy test
where an inter-uterine pregnancy is not visualized
within the fundal part of the uterus.
Most ectopic pregnancies are going to be located
in the fallopian tube,
and we may actually visualize the ectopic
with ultrasound evaluation of the adnexa
as shown in this module.
So, we'll return with ectopic pregnancy part two
which goes over the varied manifestations
of ectopics.

Brightcove ID

5750491404001

https://youtube.com/watch?v=iui0HF95XAw

Case: Ankle Tarsal Tunnel

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Ankle - Tarsal Tunnel.

Clinical Specialties

Physical Med & Rehab

Media Library Type

Case Study Videos

Subtitles

- [Voiceover] The following case study is representative
of Tarsal Tunnel Syndrome as a space-occupying lesion
is forced upon the Posterior Tibial Nerve.
In the anatomical review, we will be covering
the medial tendons identified with the ankle.
First is the Posterior Tibial Tendon
attaching to the Navicular
followed by the Flexor Digitorum Tendon
which courses to the plantar aspect of the foot,
and the Flexor Halucis Longus tendon
which also courses to the first digit underneath the foot
followed by the neurovascular structures
first beginning with the Posterior Tibial Nerve
and its anterior and posterior branches.
The neurovascular bundle also consists of typically
one artery and two to three veins.
The medial Flexor Retinaculum which begins
at the Medial Malleolus and inserts
to the medial margin of the Calcaneus.
Probe position for the Tarsal Tunnel study should begin
at the level of the Medial Malleolus and scanning distally
until this neurovasuclar bundle is traced
to the plantar aspect of the foot.
Long axis images can begin by following the direction
of the medial tendons and moving the probe posteriorly.
Here's a corresponding transverse image
at the level of the blue highlighted Medial Malleous.
We see a green Posterior Tibial Tendon highlighted
followed by the Flexor Digitorum Longus
with the normal physiologic amount of fluid here in blue.
Highlighted are the yellow Posterior Tibial Nerve,
the red Posterior Tibial Artery
surrounded by these Posterior Tibial Veins
which are easily identifiable by compression
and utilization of Doppler.
Deep to these structures noted in purple
is the Flexor Hallucis Longus which may be more difficult
to identify at this level due its more
distal musculotendinous junction.
So at this level, we are seeing more muscle than tendon
as we would see at the Posterior Tibial Tendon.
To further make the Flexor Hallucis Longus Tendon
easier to identify, just apply flexion to the first digit.
Highlighted here in white is the
representative Medial Flexor Retinaculum.
Here's a Doppler at the medial neurovasuclar structures.
If you notice that the veins are difficult to see
due to low flow state, just apply distal pressure
at the proximate arch of the foot.
This will force blood up towards your field of view.
Utilizing the Posterior Tibial Artery and Veins
as a landmark, it is easy to identify
the Posterior Tibial Nerve in this case being compressed
by a bony calculus formation.
Any time pathology is suspected, it is always important
to note these abnormalities in both longitudinal
as well as transverse planes.
Here's a transverse image of the bony calculus
which may also be turned as a space-occupying lesion.

Brightcove ID

5751505203001

https://youtube.com/watch?v=b0asYpErMQQ

Case: Supraspinatus Pathology

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Supraspinatus Pathology.

Clinical Specialties

Physical Med & Rehab

Media Library Type

Case Study Videos

Media Library Tag

Abduction

Articular Surface Tear

Bursal Surface Tear

Calcific Enthesopathy

Coracohumeral Ligament

Cortical Defects

Cortical Irregularity

Musculoskeletal Ultrasound

Painful Abduction

Painful Shoulder

Partial Thickness Tear

Rotator Cuff

Rotator Cuff Interval

Rotator Cuff Tendon

Rotator Cuff Ultrasound

Shoulder

Shoulder Ultrasound

Subacromial Bursa

Subacromial-Subdeltoid Bursitis

Subscapularis

Supraspinatus

Supraspinatus Retraction

Supraspinatus Tendon

Tendinosis

Subtitles

this is a brief introduction to super spin a dispatch ology
we will begin by describing the bony anatomy
covered by the articular hailing cartilage shown here
in blue
illustrated here is too long head of the biceps tendon passing through the bicep
ru to insert at the superior going on
labor
illustrated next is the supraspinatus tendon
as attach is to the greater tuberosity at interior
portion posteriorly the interest in a distant
wraps around the posterior surface the humeral head
to attach to the remainder the greater tuberosity is lateral
and post your your margins
as the interest Benitez tendon attaches to the post your your aspect of the
greater tuberosity
take note in about one-third Pittston anti burst share an insertion point with
two super spin eight assists
post your your one-third its tendon as well
due to the oblique nature
the interest in a dis is insertion relative to the supraspinatus insertion
to the greater tuberosity
special care should be taken while scanning through this section
to avoid false-positive tears
in developing these lateral rotator cuff structures will be D
subacromial sub deltoid versa
this illustration shows a cross-section the supraspinatus
proximal to its insertion the greater tuberosity
primary focus this video will be the relationship
on the supraspinatus tendon with the bicep tendon edits
intercapital our segment
this is the corresponding image the supraspinatus tendon in cross-section
highlighted here is the funeral at proximal to the supraspinatus insertion
the black gram is the articular cartilage
the lateral deltoid muscle run and cross section as well
at this level
the interior super spin a distant is well socialized while the posterior
supraspinatus tendon is less
identifiable due to its merger with the interest in Ames
highlighted in this image is the bicep tendon also in cross-section with the
supraspinatus tendon
anterior margin
from the transverse or cross-section image we will now
switch to the long axis more saddle cut the supraspinatus tendon
at the interior margin a greater tuberosity
here's the corresponding long axis section the supraspinatus tendon
as in search to greater tuberosity highlighted here is the humeral head
in greater tuberosity in profile it is not uncommon to see a long axis deltoid
muscle
in relation to the long axis the supraspinatus tendon highlighted in the
next image
is the long axis the supraspinatus tendon as it answers to the greater
tuberosity
super spin anus pathological images
this image demonstrates an interior full-thickness tears well as a
personal surface mid segment tear the supraspinatus tendon
here we have multiple terror citing no volume loss identified
in the transverse image
here we have interior articular surface tearing
demonstrating by in los as Hypoluxo like absence
tendon fibers
he rehashed post-operative retailer
the interior super spin a distended locating the exact site
this terror is difficult as the bicep tendon is not in its normally situated
by typical group scanning from the indeed biceps group posteriorly
will reveal arced first in best landmark the lateral greater tuberosity in
profile
scanning to post early may reveal falsely normal rotator cuff as
demonstrated in blue
here's a corresponding normal rotator cuff with the normally situated bicep
tendon highlighted in blue
where the dislocated is in red in this case a long axis greater tuberosity
would be a better
landmark
subtle interest substance carrying is often harder to identify
there is a hyper collect where over the summer Camille bursa called Perry
personal Sat
and indicating layer that is the actual bursal void
followed by the supraspinatus tendon itself area of interest here
is the Dept or the concave and what would normally be
declined backs appearing mursal layer
in long axis is normally contact Trinkaus may actually be flattened
instead of rounded as we see here again take care
to scan through the entire cast to avoid any false positives
as we have us demonstrated here as a falsely
mall cop and blue

Brightcove ID

5508117967001

https://www.youtube.com/watch?v=o8Sz7LnqMbM

Case: Shoulder: Posterior Labrum

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Shoulder - Posterior Labrum.

Clinical Specialties

Physical Med & Rehab

Media Library Type

Case Study Videos

Media Library Tag

Msk Ultrasound

Musculoskeletal Ultrasound

Shoulder

Rotator Cuff

Glenohumeral Joint

Shoulder Joint Injection

Shoulder Steroid Injection

Shoulder Intra-Articular Injection

Shoulder Injection

Subacromial

Subacromial Bursitis

Subacromial-Subdeltoid Bursa

Subtitles

- [Voiceover] The following are case studies
presenting pictures of the posterior
glenoid labrum and its abnormalities.
In our anatomical review we have the
posterior surface of the humeral head
with articular hyaline cartilage in blue,
the proximal origin of the infraspinatus
tendon here in yellow, with the more
laterally light blue landmark of the greater
tuberosity which will act as its
insertion of the infraspinatus tendon.
Highlighted here in green is the
spine of the scapula with a red
posterior acromion process, which
serves as a great palpation point to begin
the examination of the infraspinatus tendon.
Highlighted here in purple is the posterior
bony glenoid of the scapula, and the
structure here in white represents
the posterior glenoid labrum, which is
only clearly identified by ultrasound
and its approximate 9 o'clock position.
Overlying these structures is the large
infraspinatus muscle and tendon
followed by the teres minor resting
just inferior to the infraspinatus tendon.
Corresponding ultrasound image here
of the posterior glenoid labrum.
We have highlighted here the bony
glenoid of the scapula, followed by
a highlighted image of the bony
posterior humerus with a dark rim
over the bone representing the
posterior articular hyaline cartilage.
Highlighted here would be the infraspinatus
muscle belly, which is seen obliquely
in this slice, so that we can have a clear image
of the posterior glenoid labrum here,
highlighted as a hyperechoic triangle.
Internal and external rotations
are great dynamic maneuvers for the
posterior glenoid labrum, as a greater tegrocity
is brought posteriorly towards the bony glenoid,
the posterior glenoid labrum is brought under
tremendous stress, forcing a blunting
of the posterior glenoid labrum.
Seen here is a disruption
of the normally homogeneous pattern
of the posterior glenoid labrum.
On external rotation this becomes
even more noticeable as the tissue
interfaces are brought together and then relaxed
under this dynamic stress maneuver.
On internal rotation we may also see
loose bodies deeper than the joint.
This image of an external rotation
reveals a false joint effusion.
What looks like a large hypoechoic structure
protruding from the posterior joint surface
is actually just contracted muscle belly,
which contains a large amount of water,
as well as a high incidence of anisotropic
artifact due to the angle of tendon insertion.
Special care should be used when
identifying a posterior joint effusion
to overlay the infraspinatus tendon
over the joint, creating an interface
for fluid to rest that is not hypoechoic.
By bringing this hyperechoic interface over the
joint space, it is easy to identify joint effusions.

Brightcove ID

5746974994001

https://youtube.com/watch?v=GuWIz-2aRBs

Case: Morton's Neuroma

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Case study on Morton's Neuroma

Clinical Specialties

Physical Med & Rehab

Media Library Type

Case Study Videos

Media Library Tag

Ultrasound Of The Foot

Morton's Neuroma

Mulder Sign

Intermetatarsal Bursitis

Ultrasound Of The Mtp Joint

Subtitles

- The following study is imaging
of the Morton's neuroma.
Anatomical landmarks here are transverse image
over the volar aspect or plantar aspect of the MTP joints,
just proximal to the articulating surface.
In this illustration, we see a bulging
of the interdigital nerve.
At the level of the third and fourth MTP joint,
we see a hypoechoic space representing a Morton's neuroma
that is not quite accentuated without dynamic stress.
We'll highlight this structure here in yellow,
followed by a positive Mulder's sign,
which is a squeezing of the foot bringing the MTP joints
together under dynamic stress as seen here
with releasing of the metatarsal heads
and forcing back together.
Turning the probe back to a long axis direction,
we notice the hypoechoic space is long and irregular.
Using a heel to toe maneuver with the probe
will compress the soft tissue surrounding the neuroma
to further bring out the differences in tissue interfaces.
Here we have another example of a Morton's neuroma
highlighted here in yellow, which is also further brought
out by a positive Mulder's sign or Mulder's test.
Here's a less noticeable Morton's neuroma.
Even when the Mulder's sign is applied,
the difference in tissue interfaces
is not clearly visible until force is applied
from the dorsal aspect of the foot
with pressure downward towards the probe's surface
on the plantar aspect.
Forcing these tissues together creates
a more noticeable tissue interface.

Brightcove ID

5508117928001

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

Case: Knee: Quad Tendinosis

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Knee - Quad Tendinosis.

Clinical Specialties

Physical Med & Rehab

Media Library Type

Case Study Videos

Media Library Tag

Msk Ultrasound

Musculoskeletal Ultrasound

Knee Ultrasound

Quadriceps Tendon

Rectus Femoris Tendon

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

Case: Knee: Infrapatellar Enthesopathy

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Knee - Infrapatellar Enthesopathy.

Clinical Specialties

Physical Med & Rehab

Media Library Type

Case Study Videos

Subtitles

- [Voiceover] In this video, we have a case study
involving diffuse calcific tendonosis
of the proximal infrapatellar tendon.
The anatomy demonstrated in this picture,
is the white infrapatellar tendon,
the yellow Hoffa's Fat Pad,
followed by the blue articular hyaline cartilage
surrounding the anterior surface of the femur.
And, light blue would be the normal synovial recess
that is the superpatellar recess.
In this image, we see a normal
infrapatellar tendon as it inserts
to the tibial tuberocity of the proximal tibia.
Highlighted in white, is the bony surface anatomy.
In blue, is the fibrillar pattern
of the infrapatellar tendon.
In the next image, we see diffuse calcific tendinosis
of the insertion of the infrapatellar tendon
to the highlighted, in white, tibial tuberosity.
Highlighted in blue, would be the tendon fibers,
which are infiltrated by these
hyper-colored, shadowing calculi.
In this image, we see a larger, single calcific body
at the insertion of the infrapatellar tendon.
The next image is the proximal infrapatellar tendon
at the apex of the patella.
Highlighted in white is the bony anatomy
of the apex of the patella, at it's narrowest point.
In the blue, is the proximal infrapatellar tendon.
In our next image, we see diffuse thickening
of the inferior segment
of the proximal infrapatellar tendon.
Highlighted in white, is the apex of the patella.
Seems relatively unchanged.
And, here, the more normal fibrillar pattern
of the infrapatellar tendon.
And, the purple, which is the diffuse thickened portion,
followed by a hypocaloric, single vessel,
likely caused by prior needle therapies to this site.
In the next image, just millimeters over,
to the midsagittal line, we see,
a more hypercaloric insertion
of the apex of the patella, to be rigid.
The blue represents the more normal, intact tendon fibers.
The red represents the calcified portion,
that is also followed by tendinotic
fibrillar pattern change.
Using power doppler to this site,
also shows a larger vascular presence that is not
normally seen in the normal infrapatellar tendon.
Here's an example of a needle coursing through this tendon,
creating new paths for vascular formations
such as ABI therapies and PRP therapies.

Brightcove ID

5752885667001

https://youtube.com/watch?v=qktRz3Il9dM

Case: Elbow: Common Extensor Tear

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Common extensor tear case study.

Clinical Specialties

Media Library Type

Media Library Tag

Lateral Epicondilitis

Common Extensor Tendon

Elbow Joint Injection

Subtitles

- [Voiceover] This video describes pathology
to the lateral elbow, specifically at the
common extensor tendon.
The bony anatomy review will be as follows:
highlighted here is the anterior surface of the humerus,
the anterior lateral surface of the radial head,
and the anterior surface of the ulna,
which will not be described in this video.
Highlighted in blue is the common extensor tendon insertion
to the lateral epicondyle.
In green is the radial head.
Over at the radial neck will be the supinator muscle.
Over the supinator muscle will be common extensor tendon.
And then over the common extensor tendon would be
the brachioradialis.
In this clip, the probe position is as shown on the screen.
This image shows a normal common extensor tendon insertion
through the lateral epicondyle which is highlighted here,
followed by a highlighted lateral aspect of
the radial head highlighted here,
followed by the common extensor tendon,
which is highlighted here.
Observe the only insertion is taking place
in the highlighted segment in blue.
A transverse image of the common extensor tendon
over the level of the radial head
shows a thin, dark hypoechoic line
representing articular cartilage.
Superficial to that would be the common extensor tendon.
Highlighted here is the articular cartilage,
giving us an idea what part of the common extensor tendon
we're viewing.
In this image we can clearly see a large join effusion.
Here is the lateral epicondyle,
followed by the lateral aspect of the radial head.
And then something we did not see in our normal images,
highlighted here in blue would be the effusion.
Less noticeable is the full thamus tear
to the common extensor tendon.
Upon compression, the brachioradialis muscle
herniates into the void that is created by the
full thamus tear.
In this image, the fibrillar pattern of the
common extensor tendon is now dark and hypoechoic
and loses organization.
Also inside are large calcifications
peppering the insertion of the common extensor tendon
to the lateral epicondyle.
In this picture this clearly represents
diffuse calcific tendonosis.
The next image shows a large full thamus tear
of the common extensor tendon to the lateral epicondyle.
Here we also see a bony irregularity
such as an osteophyte or loose body.
Obtaining a transverse image of this tear is also important
to confirm volume loss.
Highlighted here is the lateral epicondyle
using this hyperechoic bony osteophyte
as a landmark, we turn the probe
for a long-access to transverse,
also indicating a full thamus tear.

Brightcove ID

5751336456001

https://youtube.com/watch?v=y0foHK9pwjs

Case: Carpal Tunnel: Bifid Median Nerve

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Carpal Tunnel - Bifid Median Nerve.

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

Media Library Tag

Median Nerve Swelling

Flexor Tendonosynovitis

Entrapment Neuropathy

Carpal Tunnel Release

Bifid Median Nerve

Persistent Median Artery

Subtitles

- [Voiceover] The following are case studies
of carpal tunnel, also including a bifid median nerve,
as well as median nerve compression.
The bony anatomy associated with carpal tunnel
is complex, but not difficult to learn.
Highlighted in blue is the distal radius.
Highlighted in green would be the distal ulna.
Highlighted in light blue would be the volar lunate.
Highlighted in purple would be the volar scaphoid.
Highlighted in red is the volar pisiform.
In orange, we have the bell-shaped capitate bone.
Blue is the volar trapezium bone,
and orange is the volar hamate and hamulus landmarks.
The white areas are the actual insertion points
of the carpal tunnel landmarks.
From the red pisiform, attaches to the purple scaphoid
and the orange hook of the hamate crosses over
and attaches to the trapezium tubercle.
Contained within the carpal tunnel are four
deep flexor profundus tendons,
four superficial flexor tendons,
as well as the flexor policis longus tendon
on the radial aspect and the median nerve, here in yellow.
Crossing over all of these structures,
creating the roof of the carpal tunnel,
is the flexor retinaculum.
Probe placement for the proximal carpal tunnel examination
is in blue.
Here is the corresponding image.
Highlighted here in white is the actual flexor retinaculum.
Highlighted in purple is the scaphoid insertion
and red is the pisaform.
The blue is the lunate surface.
In gray are the deep flexor tendons.
The light gray are the superficial flexor tendons.
The yellow is the median nerve.
And in blue, on the far radial aspect,
bordering the scaphoid,
is the flexor pollicus longus tendon, flexor carpi radialis,
and the ulnar nerve and ulnar artery,
creating Guyon's Canal.
It is also important to wiggle the fingers
to test for laxity in the carpal tunnel.
Now scanning from the proximal carpal tunnel
to the distal carpal tunnel.
Here is the correct probe placement
for distal carpal tunnel.
Here we have, as landmark, the capitate bone.
The bony trapezium and trapezium tubercle
and bony prominent, as well as the hamate
and hook of the hamate in red.
And the distal flexor retinaculum.
Shown in light gray here are the deep flexor tendons.
In gray would be the superficial flexor tendons.
In blue would be the flexor pollicus longus.
In yellow would be the median nerve.
Probe position, long axis carpal tunnel.
In long axis, nerves and tendons can look similar,
so dynamic flexion will determine nerve from tendon,
as the tendon will side beneath the nerve
while the nerve stays in a relatively stationary position.
Highlighted is the volar lunate surface,
followed by the volar capitate surface,
which is bell-shaped.
The deep and superficial flexor tendons,
highlighted in white, and yellow,
representing the median nerve.
Seen here is the proximal carpal tunnel.
Highlighted is the proximal capitate surface,
lunate surface, and distal radius in blue.
As seen before, we have the deep
and superficial flexor tendons,
followed by the yellow, representing the median nerve.
To confirm position within the true carpal tunnel,
Scan medial to lateral for the bony prominence,
such as the scaphoid surface or pisiform.
Here is a case study involving a bifid median nerve,
with comparison to the other hand,
showing no bifid median nerve.
When scanning from the carpal tunnel proximally,
it is easy to identify where the bifurcation takes place
in the forearm, showing this becomes one nerve.
The image on the left shows a characteristic flattening
of the median nerve.
On this image, there is a fusiform swelling,
or bulging, just proximal to the carpal tunnel.
Although not quite four millimeters,
there is slight bulging to the symptomatic side
in this wrist, where the asymptomatic side stays
completely beneath the carpal tunnel level.

Brightcove ID

5751328237001

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