- This webinar is on examining hip anatomy
and structure with point-of-care ultrasound the
posterior hip.
This is part four of a four-part series on the hip,
and you may view the recordings of the rest
of the series on this website listed up here.
Before we begin, please be advised all attendees are muted.
You may type your questions into the q
and a box in the toolbar located at the bottom
of your screen at any time.
We will conduct a q and a session at the end
of the presentation and demonstration.
This webinar will be recorded in Archive
for future reference as well.
Our presenters today are Daniel Shelton and Bill Medford.
Daniel Shelton is the director
of musculoskeletal market development
for Fujifilm Sona site.
Daniel spent 16 years
as a dedicated musculoskeletal sonographer
and 10 of those years have been here at SonoSite.
He now leads musculoskeletal market development
where he works to spread the word about the benefits
of point-of-care ultrasound.
Bill Medford is the lead musculoskeletal specialist
for Fujifilm SonoSite with 40 years of experience
as a sonographer, including 22 years specializing in
musculoskeletal sonography.
Bill is an expert in using point-of-care ultrasound across
the breadth of MUS musculoskeletal specialties.
Bill, I will turn it over to you to get started.
- Well, thank you Laura and welcome to everybody
to the final presentation in our posterior
hip webinar series.
And with that we'll move along.
Today what you're going to see are images produced off
of the Sono site PX newly launched
about six months ago.
The PX office PX offers unmatched image clarity
and a system design that will be found to be very adaptable
in examination rooms.
Transducers cover the full breadth of transducers
that you're used to seeing with socy products.
Transducers that you'll see utilized today include the
linear 15 to four megahertz transducer as well
as the curved five to one megahertz transducer.
Also, when we're doing looking at structures with
that have SU anatomy, that's very superficial.
We want to use a higher frequency probe
and our linear 19
to five megahertz transducer offers the highest frequency
ever developed with sono site products
and results in
exceptional image clarity.
We won't have any demonstrations of that today,
but for any superficial imaging,
certainly a transducer to consider.
The anatomy that we will be covering today include D SI
joint, the gluteus maximus, piriformis,
quadrat, ephemeris, the hamstring complex, as well
as the sciatic nerve
bony acoustic landmarks.
Always. Our starting point in identifying anatomy
include the posterior superior iliac spine,
- The sacro iliac joint,
the dorsal iliac wing,
the sacral foramina,
the greater sciatic foramen,
and the ischial tuberosity.
- Let's start with the SI joint.
The SI joint is a di arthrodial joint.
It's sacral surface is covered with hy lung cartilage
and the iliac surface is lined with fibrocartilage.
It is smooth in the young and becomes irregular with age.
It can become unstable due to ligamentous injury
or laxity, which can result in instability and discomfort.
Ultrasound can be the procedure of choice
for therapeutic injection.
We begin our examination at the posterior
superior iliac spine
with the transducer placed in a transverse body plane.
At the level of the PSIS either identify a
viable on the image or by palpation.
Once we've identified the PSIS, we're going
to move the transducer distally
until we get this wider portion of the SI joint,
which we see on this sonographic image.
And then we'll want to move the transducer even a little bit
more distal to recognize this narrower point of
the SI joint.
Note that when we're more proximal, that the iliac side
has a steeper contour down to this wider joint
as opposed to when we're more distally.
The iliac side is more flattened
and we see that the joint is narrower.
Injections can be delivered at any location.
Some feel that the injection,
therapeutic injection is more effectively delivered at this
narrower place where up
above in the wider portion
of the SI joint there are more ligamentous constraints
and it's felt that the delivery of injections may not be
as effective in in sliding down into this narrower
portion of the joint space.
A needle is guided from medial to lateral
in plain when we're doing injection guidance procedures
under ultrasound of the sacroiliac joint,
the gluteus maximus we covered in our lateral hip,
but it is a posterior structure,
but it becomes a lateral insertion,
so we're covering it both places.
The gluteus maximus is the primary extensor
muscle of the hip.
It also assists with external rotation and abduction.
It is the largest
and most superficial of the gluteal complex
and is innervated by the inferior gluteal nerve.
Its origin is along the posterior aspect
of the dorsal ileum
and along the lateral aspect
and postal lateral aspect of the sacrum.
It will also blend with the lumbar fascia
and the sacral tubus ligament along
with the tensor fascia lata.
Its connection to the
IT band stabilizes the femur along the surface
of the tibia while standing during relaxation
of the extension extensors ultimately
to insert on on gertie's tubercle of the tibia.
A more proximal point
of insertion is along the gluteal tuberosity of the femur.
Daniel, I'll turn it over to you to demonstrate the SI joint
and gluteus maximus.
- All right, thank you Bill. I am gonna wait on
that to go full screen.
There we are. Thanks for joining us again today.
In front of me, I've got a sono site PX
and our live model here.
Just to orient everybody,
because you're gonna see a few different camera angles.
We've got proximal this way,
which may be I'll be doing the right hip.
They're laying down on their belly, so
proximal distal is this way.
And then from our upper camera angle,
I've labeled in the corners up here, proximal and distal.
And then you can see the same camera on the bottom.
So I know when we're, when we're zoomed in here,
it can be a little bit disorienting,
but I do want to kind of point that out ahead of time so
that everybody's familiar with what we're viewing here.
So we've got proximal this way, we distal this way.
And then just like we do in all the other hip
and pelvis courses,
I do wanna talk a little bit about patient modesty here.
This is the posterior hip. This is no exception.
So what I've got is two blankets here
that I'll be scanning kind of through a window
that I open up.
I've already tucked the blanket into the upper part of the
pants because we're gonna be right up here on the SI joint
and working our way inferiorly.
So for this first part of the presentation,
I'm coming from the top side down
and I've got the shorts pulled down here,
and they are tucked in here.
I've got this second blanket here just
to expose the upper part of the hip there.
So our, our ileum being
here and sacrum being here, I can, I can palpate that PSIS,
which will be the beginning of our examination.
Gonna have a little bit of gel here.
Again, this is the 15 to four L 15 four transducer.
I'm gonna spin the transducer around.
I had the orientation marker facing medial
or to the midline, and I just went ahead
and maybe by luck plop down right on the PSIS.
That may not always happen.
So if it doesn't, let's talk about going
and finding that that more superficial bony landmark.
So if you just set the transducer down and, and,
and you're kind of wondering where you might be, we need
to find a bony prominence, okay?
And if it's this with the slope on it,
this is the ileum here.
And what we're gonna do is just follow that ileum up high,
high, high, high until it's meets its most peak.
And then I'm gonna go proximal to distal to find the,
the absolute apex of that thing right there.
Now, if you start more midline,
you may catch this flat plate of the sacrum
and the spine of the sacrum.
So here's one of the spinous processes of the sacrum here,
and we're just gonna follow that down laterally.
Now, don't stumble on the first thing
that looks like a joint.
Those are just sacral foramen.
This could be S two or S one depending on how proximal I am.
But I need to go even more lateral until we see
that high riding bony peak of the PSIS.
So what I'm doing there is I'm, I'm planting the medial side
of the transducer with a finger like I did in a lot
of other body parts like the elbow
where we pivot and windshield wiper.
And I'm just gonna be moving my thumb across this way
until I see that PSIS really nice.
And what that does is it, it really nicely opens the joint
for the upper SI joint or the superior SI joint.
And you can even see the anti tropic
artifact of these ligaments here.
So that that lets you know that we're in the ballpark.
And as Bill mentioned, if we're coming in for an injection,
it's gonna be from midline to lateral this way.
Now let's follow that joint, the PSIS being easier
to follow inferiorly.
We're gonna follow that inferiorly, inferiorly inferiorly
until it completely disappears into the superior sciatic
framing, which would be here in the piriformis is
down here, which we'll get to.
But that tells me that I've gone
beneath the inferior SI joint, which is right here.
You can see that joint really nicely right there.
Not this space right here.
So this is the most inferior margin of the ileum.
And if I drop my thumb inferiorly,
you'll see it disappear completely and the sacrum remains.
So right here is that scro iliac joint,
and you can see the joint really nicely on the cyte px.
Superficial to that, these are the fibers of the glute max.
They're oblique, they dive this way.
So they're crossing my transducer obliquely
and you can see them jumping up
and over to dive onto the sacrum here.
So what I'm gonna do, I know that they slant this way
to wrap over the tr so I'm just gonna pivot
the transducer this way
until we elongate the muscle fibers of the glute max.
And it's a very broad muscle.
I can follow it right across the ileum.
And it's not necessarily a part of a examination protocol
on the posterior hip, even though
the more applications we find to do ultrasound on the hip,
especially the posterior hip,
the more it may become somebody's protocol.
But if clinically indicated, you would want to chase these,
the, the, the origin of these fibers,
you can actually see the glute max jump up
and over the sacrum here to that lumbar fascia
that bill mentioned right there, that little feathery edge.
So that's pretty neat. I'm gonna go even more inferior.
More inferior, more inferior until we see the glute max
really tapered up onto what looks like
the spine of the sacrum.
And we're actually down here at the coddle epidural anatomy.
So that's actually the sacral cornew that we're seeing here.
Maybe for a different subject in pain management
or something, we'll go over the cocal epi epidural anatomy.
But following that glute max laterally, laterally,
laterally, you can see how nice and parallel the fibers are.
And I'm sure Bill will mention when we get to piriformis,
which is right here, just how nice
and parallel they are to each other.
Bill, did I miss anything so far
while Bill unmutes I'll, I'll keep scanning that glute max.
I'm gonna add a little bit of gel getting a little
dry. There
- We go.
Daniel, I'm back on the PowerPoint now.
- Alright. All right,
go ahead Bill.
- Okay, let's move to the piriformis.
Daniel mentioned
that piriformis fibers do parallel the fibers
of the overlying gluteus maximus
and the piriformis courses like the gmax diagonally
its origin is on the anterior sacrum,
specifically three bundle attachments between the first
and second, second and third and third
and fourth anterior sacral foramina.
It exits through the greater sciatic foramen
and inserts onto the superior aspect
of the greater trocanter.
Also to be aware of is a sciatic nerve
as it comes out from what is
behind the piriformis muscle to cross over in front
of the Jemele eye and raders.
And ultimately the quadratus femes us 17%
of sciatic nerves, however, run through the piriformis
and predisposes this subgroup to tingling, numbness
and pain along the sciatic nerve and deep into the buttocks.
So where do we begin when we look for the look
for the piriformis muscle, we're going
to begin at the PSIS
and our transducer is going to, as where we started
with the SI joint is going to be placed as the PSIS.
Our next transducer movement is going to slide laterally
with the lateral aspect of the transducer towed in.
We're going to employ the heel toe maneuver,
this being the heel, this being the toe.
We're gonna tow in to
to level out this iliac wing so that
we have a continuous appearance
of bone on the under surface of
what here is gluteus medias.
Once we have established that we're going
to slide the transducer distally
and oblique the transducer to correspond
with the diagonal course of the piriformis.
So directly transverse up here
to demonstrate the iliac wing slide down until we lose
that continuous iliac wing
and begin to see the sciatic foramen.
Once we lose that bit of bone up here
and we come to
the sciatic foramen, we begin to see,
once we oblique the transducer along the diagonal course,
we'll begin to see the piriformis
adjacent anatomy that might help us identify.
This is again, the sciatic nerve
and the superior gluteal nerve.
And the associated vessels in particular
might turn on color doppler
and recognize the inferior gluteal nerve,
gluteal artery here.
So the sonographic appearance is again,
fiber's very parallel to one another,
gmax piriformis.
And we can use a dynamic maneuver by flexing the knee
and rotating the femur to see translation
of the piriformis back and forth.
I'm sure Daniel will be demonstrating
that in our lives scanning.
Moving a little further south, we'll go from the piriformis.
We'll cross over the GLI
and the OB trait to the quadratus fems.
Quadratus femoris is an external rotator
and adductor of the thigh.
It also assists in stabilizing the hip joint.
Its origin is at the lateral margin of the
- Ator ring.
And
- And I, I'm sorry, its lateral margin is
that the ator ring just superior to the ischial tuberosity,
which is where we'll find the hamstrings inserts.
It's distal insertion is on the quadrat tubercle
and the inter tro enteric crest of the posterior
medial femur right along here
and here on the sonographic image.
So this is the quadratus femes. Where do we begin?
We place the transducer at
or near the gluteal fold
where we'll recognize the bony acoustic landmark
of the ischial tuberosity medially.
And laterally we'll recognize the femur
quadratus femoral bridges that gap.
This is the ischial femoral space
and is a zone of impingement
of the overlying sciatic nerve.
Dynamic maneuvers can help
us recognize snapping that may occur due to a lessening
of this distance
and snapping at the ichi femoral space.
Okay, Daniel, I'll turn it over to you.
- All right, thanks Bill. As Bill mentioned, we are going
to go inferiorly on the hip now,
and I've re draped the hip, we're still proximal this way,
but I've got the shorts now up
and I've, I've taken the time to tuck
and protect the the patient's undergarments.
And then what we're gonna do is just expose
down to the gluteal fold.
So what we're gonna be looking at now is the inferior SI
joint, and we're gonna walk our way to the ilium
and then we're gonna go south into
that superior sciatic foramen.
And that will help us find the piriformis.
So left side of the screen again is gonna be medial,
and we're looking for a bony landmark there.
So let's find out which part of the, the
inferior SI joint that is.
It looks like I fell right on it.
So what we're gonna do is follow this ileum.
Now let's follow the ileum laterally, laterally, laterally.
There we go. And all I'm gonna do is just fall into
that superior satic notch.
So it's just a little short movement
and I can already tell I'm in that ballpark
because I can see that superior gluteal artery just resting
right here.
And what we're gonna do is throw our color feature on,
and I wanna be able to see that little artery.
And what that's doing is just a clue to say, Hey, I'm about
to hit the superior satic foram.
And you're gonna see that that artery start
to shoot straight up and down, headed towards my transducer
as it wraps up and around the inferior margin of the ileum.
So the very, very next structure underneath that
is gonna be our piriformis here.
So diagnostically, L 15,
great transducer to look at all these little fibers.
And I can see this big pizza slice headed laterally over
the isum.
So here we have isum piriformis,
inferior gluteal artery, superior gluteal artery.
And I think the, I always relate things
to food for some reason.
So I do, I think the piriformis just
looks like a big pizza slice.
It's a triangular shape structure.
It's gonna go up and over the isum.
As Bill mentioned, we start
to see the superior jamella right here
as it rests right on top of there.
And then just before we get to the isum down here, we've got
that sciatic nerve,
or at this point could be the distal lumbar complex still,
but here it is as a nice tight group of nerve.
So it's probably already sciatic at this point,
but this is nerve.
And then up over the isum is the superior jamella.
And then just resting on top of that superior jamella,
if I keep going laterally, is the piriformis
muscle in this thin strand is starting
to make itself into the piriformis tendon procedurally
and dynamically.
I like to switch over to the curvilinear probe.
So I'm gonna take a second to do that.
And I'm gonna select the C five one transducer
with a musculoskeletal exam type
to get a broader field of view.
And if your general patient population is not
of the body habitus of our model today,
you're really gonna want to consider
getting a carline probe.
So I'm starting with the left side of the screen again
to the patient's medial side,
things are gonna look a little bit different.
So I wanna go find a familiar landmark.
So what I have to do is find my inferior SI joint
or any of the part of the sacrum is fine,
and then move the probe laterally to the ileum.
So here this big ski slope here is the ileum,
the inferior part of that slope.
I'm aiming the beam all the way
to the anterior pelvis actually.
So here's minimus medias maximus.
So just to give you an idea of the broad field of view
that we get with the C five one transducer.
It's really nice just to get you oriented.
So let's follow the ileum now south.
And I need to see the ileum split into two pieces there.
So left side of the screen, sacrum side of the screen,
I see this opening, but I still see two bony landmarks.
So sacrum here and the beginnings of the isum here.
Back to our pizza slice piriformis here.
If I wanted to check my work on the inferior part
of the ileum, you can see
that superior gluteal artery pulsating really nicely
activate the color feature.
Again, check your work,
make sure you're still familiarizing yourself,
but you can just see the more broad field of view
that you get outta the coline and more appreciation
for the whole structure as that
that superior gluteal artery is just hugging the border,
the piriformis there.
Get my arrow back out here. So this is the
piriformis. Yeah, bill, go ahead
- Real quick.
Show how the angle of the transducer is
because frequently the most, one
of the most common mistakes I see,
and I I'm sure you do too, is
that the transducer isn't oblique
to go along the diagonal course of the piriformis.
- That's true, bill, I just kind of instinctively did that
because I've just, I've just scanned so many of the hips.
But when you're first learning this,
and I stumbled through a lot of things on the posterior hip,
it's kind of the final frontier on in terms of the joints
that we typically cover for me.
And I did find it useful to go ahead
and elongate the glute max.
Remember that those are running parallel to each other.
And the glute max is such an oblique structure.
We need to pivot our transducer
and set ourselves up for the long axis of the piriformis.
So there you can see
and I can palpate the trope to find out.
So here's tr and I'm aiming right at the trope.
It's not a horizontal structure,
it's a very much a vertically oriented oblique structure.
So here we have GL glute, max, max,
long axis, piriformis, long axis,
and you can even see some of the central tendon
of the piriformis starting to show itself here.
As we get over to the is yum superior isum here,
right on the upper margin of the isum,
here's our superior Jamila.
With more penetration out of a lower frequency transducer,
you can very nicely see the inferior gluteal artery,
the sciatic nerve down a little deeper.
We get into some pudendal structures, maybe
for a pain management talk we could get into.
But for the general survey, we're gonna keep following
that piriformis out laterally.
And we start to see that that posterior
femoral acetabular joint here, neck
of the femur trope starting to make itself known here.
I do see a lot
of people struggle when they're looking for a piriformis.
They start at the trope and they call just any
of these rotating structures.
A, a piriformis.
When when I was first learning
to do posterior hip a while back, I made the miss
call when doing external rotations
and just looking for the trope here.
And we call, oh, there's our piriformis.
And we got really excited. I'm gonna bring the arrow
to the spot that we got excited about.
Saw a huge wavy flag tear right there.
I mean, what else could that be?
It's the big it it,
it's the big rotating muscle we see on the anatomy scan.
And we sent it out for an MRI
and it came back as an wouldn't, you know,
as a quadratus femoris tear.
And that's when we really got to learn, hey, we need
to take a little bit more time
and start with our bony landmarks from the pelvis,
from the ileum, work our way south
from the superiors static notch where, you know,
it originates on the anterior sacrum there.
And so the two bones we have in the, in the,
in the view here,
and I'm gonna try to bring the leg where
you can see me rotate.
Upper left is sacrum.
Mid screen right is the isum.
And all I'm gonna do is just rotate passively.
Don't let the patient do it for you
because it'll start activating all the,
the surrounding gluteal structures
and it'll move your transducer.
Also an angle consideration is not
to stay per just perpendicular to the skin
because these structures tend to dive away
when the patient is laying down
and you are looking, say at a skeletal model, the
the ileum is not flat this way the ileum is diving this way
like two plates obliquely oriented.
And what I need to do is aim into
that big ileum wing this way, not this way.
So I need to be 90 degrees to the ileum
before I get down into the piriformis.
So starting with our familiar bony landmarks, again,
we have our big ileum here.
We can see glute max and mead
and I'm just gonna fall into that superior satic notch.
You can see the bones opening up right there closing up.
So I'm scanning superior, inferior, superior, inferior.
And now I'm gonna oblique the probe and go long axis there.
And all I'm doing now is, is just confirming my location
of the piriformis with the internal
and external rotations passively.
Gotta do this passively or it'll be a very frustrating exam.
- Daniel, while you're there, we have a question
and we usually wait until we're finished.
But while you're there, we have a request
to see if you can show the sciatic nerve
pause just a little bit and point it out for people to see.
Please.
- You bet. Right here,
see this triangular wedge resting against the isum.
So this is sciatic nerve, it's lateral
to the arterial structures
of the inferior gluteal artery in the pudendal.
And you could follow it down
and watch it stay on the edge of the isum and then jump up
and over that neck of the isum here.
And we'll get into the remainder
of the sciatic nerve when we get into quadratus femoris.
But I'm still just following that sciatic nerve
where my arrow is using.
Well it gets lost in a little bit of anisotropy.
Let's start right back up here again.
There, there is where, lemme go right back to where I was.
So here's our piriformis.
Sciatic is sitting just right here
and it's not just a centimeter
or so of motion,
you're gonna see the sciatic nerve climb upwards
there
and it is still subject to anti atropy.
So I kind of, kind of let it get away from me there,
but here it is, it's a flat ribbon at this
point over the isum.
So let's follow that, that nerve right here.
I keep remembering to move my arrow
and more distally.
It's really nicely, reliably found right here on top
of the quadratus femoris as this little triangle.
So screen left, we've got our ischial tuberosity
and our hamstring origins.
And then right here is the sciatic nerve.
And then here's that quadratus femoris.
And we could try to trace that proximally to see
that little, see the, an isotropic transition it's trying
to make right there.
So this is inferior jamella here it is on top
of there, there's the sciatic.
What I'm having to do is rotate my probe
and head back up towards the sacrum.
And here's where it's still kind of a flat ribbon.
- I would say that I've found it helpful to go down
to the quadratus femes and the ischial tuberosity
and identify it at that label
and then follow it up to the piriformis.
- That's what I just, that's what I just did.
And it kind of highlighted that anti isotropy,
but here it is trying to, trying
to maintain that perpendicularity.
But I'm, what I'm finding myself having
to do is almost like a rainbow of the transducer
to stay 90 degrees to the nerve
as it curves up and over theum.
So here it is, nerve sciatic, sciatic, sciatic, sciatic.
Remain that 90 degree relationship as I climb up
and over and I'll find myself
down at the quadratus.
Oh, there it is.
- I think that's great. Daniel. One other, one other thing.
Sure. One more time.
Could you demonstrate the dynamic,
dynamic motion of the piriformis?
- Sure. So back to our familiar landmark,
I'm gonna lose the arrow for a minute
because I need two hands.
Come up here to the sacrum
and the big tip here is as you go laterally
to aim back into the ileum, okay,
so we're aiming into the ileum, not 90 degrees,
to the skin, into the ileum.
And we see that big ski slope of the ileum.
And what I'm gonna do is just fall down keeping the sacrum
in the upper left portion of the screen.
That would be one of my other scanning tips, pearls
that I'm observing while I'm, while I'm sitting here talking
to you guys, sacrum upper left
and I'm gonna watch this, this horizontal bony structure
split into two pieces here.
When I see those two pieces,
I know I'm in the superior sciatic foramen.
You're gonna tilt the probe or rotate it.
In this case I just went clockwise
and that opens up that big triangular
pizza slice shaped piriformis.
And I'm gonna confirm that just
by doing passive rotations internally and externally.
And I'm on the medial or yeah, more medial side of the isum.
And you can see this muscle,
the more external rotation I apply,
which would be internal rotation I guess.
I hope that answers your question.
- Very good, thank you.
We, I'll share my screen
and we'll move on to the hamstrings.
So the hamstrings originate from the ischial tuberosity.
They can, they contribute to assisting with hip extension
and knee flexion as each
of the hamstrings muscles traverse the both the hip joint
and the knee joint.
There are three muscle tendon structures
that comprise the the hamstrings,
the semimembranosus muscle tendon, as well
as the semi tendonosis and long head of the biceps.
The semimembranosus muscle tendon group originates off the
sup lateral issue, tuberosity
and inserts onto the medial epicon dial.
So the semimembranosus here comes underneath
the semit
and the biceps to insert right here
on the ischial tuberosity.
And then it comes down
and inserts on the medial tibial condyle.
The semi tendinosis
and long head of the biceps are conjoined
the postal and the insert on the postal lateral ischial
tuberosity as one point of origin.
There are two heads to the bicep tendon, a long head
and a short head proximally.
The short head originates from the line aspera of the femur.
The in the insertion
of the biceps femorals is on the fibular head.
And at this point the long head
and the short head have become a common tendon
to insert as
as a single tendon onto the fibular head.
The semi tendinosis, on the other hand,
inserts on the antrum medial tibia as one of the pez
and serene tendons.
All of the hamstrings are innervated by the tibial branch
of the sciatic nerve.
So where do we begin?
We begin again at the gluteal fold
or near it,
at which point we'll recognize the hyper coic bony
acoustic landmark
of the issue tuberosity shape much like a matter horn
with a bony prominent peak over the, over the top
of which we will see on the lateral aspect,
the conjoin tendon of the semit
and the biceps femoris also just lateral,
as Daniel just covered nicely in his live demo.
The sciatic nerve will be identified
if we turn the transducer 90 degrees now.
And we look at
these structures in the long axis,
we'll see the ischial tuberosity superficial,
we'll see the conjoint tendon
and deep to that as we fall off the bone,
we'll see the semimembranosus tendon.
This, these are the tendon only portions
of the hamstrings complex proximally.
If we follow them more distally, we'll we'll see.
And we'll want to interrogate the myotendinous junction.
The biceps is the most commonly torn,
the most common running tear is a
musculo tenderness tear that you'll only see
that you frequently will see just immediately adjacent
to the central tendon.
A little further distal from here,
the sciatic nerve.
We're going to begin where Daniel demonstrated
before, I like
to interrogate it beginning at the piriformis.
We're going to position our transducer along the piriformis
so that again, we see the,
the thicker portion of the piriformis.
By the way, piriformis, the Latin
for piriformis is pear shaped as opposed to the pizza slice
that you were talking about, Daniel.
I must agree though that it is shaped more like a pizza,
a slice of pizza than a pear.
But the piriformis than we'll see the sciatic
nerve and adjacent to it,
the inferior gluteal artery.
If we slide the transducer distally now
past the gli
and the ator to the isum, again this is
that same image where we see the ischial tuberosity,
the conjoin tendon and slightly lateral to it.
We'll see the sciatic nerve
always good when you're looking at the
sciatic nerve at this level.
See this is, we don't, the depth of this image isn't set
to image the quadratus femes.
But at this level, always wise
to just look at the quadratus femes,
there are dynamic maneuvers that can be done
to demonstrate ischial femoral impingement
and snapping that may occur due to that.
And recognize decrease in
space here that could contribute to irritation
of the sciatic nerve.
Once we move slightly more distal, we're going
to be in the upper portion of the posterior thigh
where we'll see the conjoining tendon
and its myo tendonous component
with the biceps femoris laterally,
the semi tendinosis medially.
We'll see the typical tadpole shape
of the semimembranosus tendon
and the underlying semimembranosus muscle.
So myo tendinous junction
and laterally we'll identify the
- Sciatic nerve.
That concludes
- The PowerPoint presentation.
Daniel, I'll let you finish it up
with a live model demonstration of structures please.
- Alright, thanks Bill. So I've switched back over
to the L 15, linear 15 megaherz transducer.
There we go. And I'm gonna re-expose the hip back here
and pick up where we left off.
This time my bony landmark is gonna be the ischial
tuberosity and lateral.
I should see that, that sciatic nerve really nicely.
And to check my work,
we'll look at the quadratus femoris again, left side
of the screen will be medial.
And if, if you joined late, you can see in the upper corner.
This is superior, this is inferior, this is lateral,
this is medial here.
So I'm gonna place the transducer down here
where I believe I should find initial tuberosity.
If I don't see one right off the bat, what I have
to do is just follow these shadowing structures
up more medially.
Here we go. So let's find out which kind of bone this is.
I'm gonna follow it down and see if it, it comes
to a nice point and that's gonna be our ischial tuberosity.
I've run outta gel, so I'm just gonna squeegee some gel
down more inferiorly.
There we are. So we've got this, this prominent
bony peak here, just lateral to
that prominent bony peak of the ischial tuberosity.
We can see that conjoin tendon structure
starting to show itself.
I'm gonna keep moving laterally just
to orient myself a bit more.
So here's quadratus femoris, here's that sciatic nerve.
So we can see all those structures really nice.
So we know we're in the ballpark, we
know where we need to be.
Do now to differentiate these fibers,
I'm gonna bring my depth up because I can,
we want a more shallow depth and a more high resolute image
and we're gonna use tropic artifact to our advantage
and kind of split apart these layers here. So Dan,
- I'm gonna interrupt just for a second.
I know the image from your PX doesn't translate
to the zoom presentation perfectly.
I'm gonna have you just decrease your
gain just a little bit.
- Oh good. Good call Bill Zoom definitely does.
- Thank you.
- Hopefully that's better. Very good.
So we could see these layers differentiate themselves here
on the, on the hamstrings kind of common origin.
Deep down here we've got the deeper semi menos,
semi tendinosis, overlaying that
and laterally at that conjoin structure.
We've got our biceps femoris and we could trace these down
and watch the biceps femoris tendon move its way laterally
and its extended muscle belly here.
And semi tendinosis would be our next landmark,
just slightly medial to that.
And underneath the semi tendon
or the biceps femoris, here's our s static nerve just
as a a reference.
So I'm down at the, the, the gluteal fold again,
here we've got tendinosis.
Let's use isotropy to our advantage here. This.
So even though there's a component here,
our more superior showing tendon right here medially is our
semimembranosus, this little cleft edge.
And let's watch it join up with the semi tendinosis
and then the, the biceps femoris laterally.
So you can almost get all three of 'em in a row,
even though there is a conjoin component to it.
Here is biceps femoris,
semi tendinosis, semi menos.
This this little isolated shadow here.
So I'm just barely rocking the transducer like we do the
biceps tendon in the groove to see
what subtleties we can get.
What you don't wanna do is get in the habit of calling
that a tendinosis, even though that's in the name of one
of the, one of the tendons.
That is not a, a pathology if you can get it to fill in.
So an isotropy back here is really helpful,
but it can also be very misleading
and we don't wanna call things degenerated if they're not.
So now I'm gonna take one of these tendons here in this case
we'll we'll focus on menos
and rotate the probe so that the pro, the left side
of the screen is facing proximal.
So we've got our isum here
laterally.
It's really nice to see biceps femoris go ahead
and shoot off and go do its own thing.
And I could follow that, that more laterally oriented
structure pretty easily.
I'm gonna bring my pro more medial now
and focus more on the semi menos
and tendinosis area here, which we
can see really, really nicely.
It looks like a lot of tendons always insert
like a big bird's beak.
And we see that same pattern back here on another tuberosity
on the body, on the ischial tuberosity.
So we've got our conjoin tendon here superficially
and then deep, deep, deep down here where
as Bill pointed out, I'm not sure if gains
coming through on zoom.
I'm gonna auto this,
- Try your TGC deep.
- Yeah, there we go.
Hopefully that helps.
- Yeah, notice that we're trying to go. There we go.
You're seeing a little bit there Daniel.
The semimembranosus deeper,
but this is with the, give you an idea of how
nice the penetration is with the linear 15
to four megahertz transducer.
- Very true. Most of these higher frequency transducers
don't have much of a range to them.
And this, you know, we're scanning 15 to four
so really depends on where we are in the screen,
how deep we're trying to shoot, whether I'm in res or gen.
And I've dropped my frequency down to the gen spectrum.
So I'm on the lower lower end of that bandwidth,
which is really helping me with penetration here.
I'm gonna move laterally to my sciatic
and I'm gonna go cross section again,
find our ischial tuberosity, check our gain
with zoom, which looks a little hot.
I'm gonna hit auto. There we go.
Auto's doing a really good job.
So ischial tuberosity again here we have our,
our sciatic nerve
and quadratus femoris just to check our work.
And I kind of already went through the sciatic so I'd,
I'd find that to be redundant
to trace the sciatic approximal
time on it just a short time ago.
- Let's just follow distally, Daniel to the upper thigh to
- You. Got it.
- Yeah. - So what I'm gonna do is add a little bit of gel
'cause I know, I know I'm about to follow a track here
and it might even be nice to see it split
if, if, if I've set the camera
to go down there.
- Oh, very - Good. Looks like I did.
Okay, so quadratus femoris
back up here at the isum.
Here we are and let's
follow this structure here.
Sciatic nerve distally distally,
distally cross-section is the way to go.
I know that these nerves look really,
really pretty and long axis.
- Let's just turn, let's just turn the game
down just a little.
Daniel. Thank you. Perfect.
- You bet it's blinding you.
Okay, so sciatic nerve distally, distally distally.
Keep following it distally.
And we should start seeing an offshoot here
of the common peroneal
or common fibular nerve depending on when you went
to med school or started learning this,
I figured we'd already see it start
to bifurcate, but we're not quite there.
So here's the popliteal fossa where my hand is
and maybe I missed the bifurcation.
It should have already. There it is.
Okay. So right where my arrow is, you can see the
bifurcation take place right there.
That's just not separated. Hang on.
Oh that's not right 'cause it's gonna follow the
biceps femoris just as a scanning pearl
because I sure would not think to see,
- I think the main thing is Daniel, let's just go down
as far as the Mercedes-Benz sign to show how
to identify the conjoin tend,
and you're right there, the conjoin tendon, more superficial
between the biceps femorals and the, and the semi tendinosis
and then the semiosis,
that tad pole shaped structure there to the left.
Yep. And then the sciatic nerve so
that folks can identify at that level
where the nerve is and the two tendons in question.
That's a very common location for hamstring,
my tendonous injury.
- Great point Bill. And I really like that Mercedes-Benz,
that's a thing to put in the slides.
- I also wanna leave a little time
for questions if there are any.
- Now's the time. - Yeah, go ahead.
If you have any questions, put 'em into the q and a box
and we will address those.
- Yeah, this has concluded the normal part of the exam
and we're happy to stick around for a few minutes and,
and just answer these questions on the fly
however you want them to, to be addressed.
If there's something that you'd like reviewed again
that we did cover.
And depending on the subject that we didn't cover,
there's also an opportunity
to cover a few of those things too.
But I think, you know, posteriorly bill
orienting to the superior
sciatic foramen is just, it's just the way to go.
I'm just following the sciatic of long axis,
which has seemed, seems
to be helping me out quite a bit compared
- To earlier.
Good question here, Daniel is issue bursa, right?
As it arcs over the top of the conjoint tendon.
- That's another one of those bursa
that we're really not gonna see it
unless there's some pathology there,
- Right?
- But if you want, if you wanted to see that interface, it,
it's not a bad idea to add a little dynamic component
to your exam and just kind of roll,
roll the glute max a little bit by getting the femur
to rotate so you could at least delineate, hey, where does,
where do all of these connective tissue layers
begin and end?
And, and the answer to that,
sometimes depending on the patient's body habitus,
which we don't have a problem with today,
but when you're out in the, out in the real clinical world,
sometimes these tissue interfaces are not so obvious.
So what I'm doing is just causing an external rotation
by moving the leg
and I'm isolating that glute max superficially
over the ischial tuberosity in a, in a, in the hamstrings.
And I'd be looking for a bursa right up in that spot that
- Was so similar to what we do with the,
with the trocanter bursa.
- Absolutely. You know, this is ultrasound, make it move.
You know, static images are not going
to help you answer a lot of questions.
So anytime you get a chance, you need
to make these structures move
and oppose each other as frequently as you can.
And then, and sometimes you're gonna expose some additional
pathology like adhesions that are not
so obvious on a static image.
- Daniel, one other question we had was to
revisit the where, where it's common
to see a myo tendonous tear of the hamstrings.
So maybe down, start
with the conjoin tendon at the Mercedes-Benz sign
level and Sure.
Just follow that central tendon.
And that's basically what we're doing as we're following
that central tendon there
and we're looking right adjacent to it for any change in
what is normal echo architecture where the my,
where the muscle comes into the tendon right
- There.
Yeah. This nice little interface right here.
And now I'm tenderness Yeah,
I've left the myo tendus portion and now
- I'm as, as you proximally.
- That's correct. - So it's just
that myotendinous location kind like what we see
with gastro tears right up against the tendon
and you're looking for fluid defect, you're looking
for a change in that normal penate pattern
or starry eye appearance.
If you're short axis to the course of muscle,
you're just looking for a change in that.
What otherwise is a typical
echo architectural appearance right there.
Beautiful. See how you follow, see
how he's following that down.
So anywhere along
and adjacent to that central tendon is where you're going
to see changes, appearance change there,
you see the semimembranosus tendon deep to it.
See that tadpole looking structure there.
Hope that answers the question.
Are there any other questions that we have?
I'm not seeing any, Laura.
I think with that we'll turn it back over to you.
- Great. Bill, by any chance, do you have
that last slide that you can show? Or do you
- Want Oh yes, I, I do.
Thank you.
- Just so everyone knows, we will be posting the recordings
of all these webinars at this website that you see here,
secure dot sona site.com/behind theskin webinar
and look forward to some new webinars posting in January.
We'll have a few on in the MSK market
on dorsal wrist and carpal tunnel.
So I just wanted to let everyone know
that those are coming soon.
- Great. And we wish you all a happy holidays.
- Absolutely. And thank you all for joining us today
and thank you Bill and Daniel again
for an exceptional presentation and demonstration.
Very well done.
- Thanks everybody.

https://www.youtube.com/watch?v=A666VIJhqQ0

Transcript

0:00 - 本次网络研讨会的主题是检查髋关节解剖结构

0:01 床旁超声检查仪的结构和性能。

0:02 后臀部

0:03 本文是关于臀部的四部分系列报道的第四部分、

0:04 您还可以查看其他内容的录音

0:05 网站上的系列报道。

0:06 在我们开始之前，请注意，所有与会者都被静音。

0:07 您可以将问题输入 q

0:08 以及工具栏底部的一个方框

0:09 您可以随时在屏幕上查看。

0:10 我们将在最后进行问答，。

0:11 的介绍和演示。

0:12 本次网络研讨会将录制成存档文件

0:13 供今后参考。

0:14 今天的主持人是丹尼尔谢尔顿和比尔-梅德福。

0:15 丹尼尔-谢尔顿是总监

0:16 肌肉骨骼市场的发展

0:17 用于富士索纳网站。

0:18 丹尼尔度过了 16 年

0:19 作为一名专职肌肉骨骼超声技师

0:20 其中有 10 年是在 SonoSite 度过的。

0:21 他现在负责肌肉骨骼的市场开发。

0:22 在那里，他致力于传播

0:23 护理点超声波。

0:24 Bill Medford 是的首席肌肉骨骼专家。

0:25 富士胶片SonoSite的40年经验

0:26 担任超声波技师，其中22 年专门从事

0:27 肌肉骨骼超声。

0:28 Bill 是使用床旁超声波的专家。

0:29 MUS肌肉骨骼专业的广度。

0:30 比尔，我将把交给你来开始。

0:31 - 谢谢 Laura，欢迎大家的到来

0:32 到我们后部的最后介绍

0:33 时髦的网络系列讲座。

0:34 就这样，我们继续前进。

0:35 今天，您将在上看到的是由以下设备生成的图像

0:36 新推出的 Sono 网站 PX

0:37 大约六个月前。

0:38 PX office PX 可提供无与伦比的图像清晰度

0:39 ，并发现系统设计具有很强的适应性

0:40 检查室。

0:41 传感器涵盖所有传感器

0:42 。

0:43 目前使用的传感器包括

0:44 线性 15 至 4 兆赫传感器以及

0:45 作为弯曲的 5 至1 兆赫传感器。

0:46 此外，当我们使用查看具有

0:47 有 SU 解剖学，，这是非常肤浅的。

0:48 我们希望使用频率更高的探头

0:49 和我们的线性 19

0:50 至 5 兆赫的换能器提供最高频率

0:51 曾使用 sono site 产品开发

0:52 并导致

0:53 卓越的图像清晰度

0:54 今天，我们不会有任何的演示、

0:55 但对于任何表面成像来说都是如此、

0:56 这无疑是一个值得考虑的传感器。

0:57 今天我们将介绍的解剖学知识包括 D SI

0:58 关节、臀大肌、梨状肌、

0:59 四肢、星历、腿筋复合体，以及

1:00 坐骨神经

1:01 骨性声学地标

1:02 总是这样我们的出发点

1:03 包括髂上棘后部、

1:04 - 骶髂关节

1:05 髂背翼

1:06 骶骨孔、

1:07 坐骨大孔、

1:08 和髂骨结节。

1:09 - 让我们从 SI 关节开始。

1:10 SI 关节是一个二关节。

1:11 它的骶骨表面覆盖着。

1:12 ，髂骨表面有纤维软骨衬里。

1:13 年轻时光滑，，随着年龄的增长变得不规则。

1:14 由于韧带损伤，它可能会变得不稳定

1:15 或松弛，这会导致不稳定和不适。

1:16 超声波可作为首选程序

1:17 用于治疗性注射。

1:18 我们从后部开始研究

1:19 髂上棘

1:20 将传感器放置在横向体平面上。

1:21 在 PSIS 一级，确定一个

1:22 可在图像上或通过触诊确定。

1:23 一旦我们确定了PSIS，我们将

1:24 向远端移动传感器

1:25 直到我们得到 SI 关节更宽的部分、

1:26 我们在这张超声波图像上看到了这一点。

1:27 然后，我们要将传感器稍微移动一下

1:28 更远地识别这个较窄的点

1:29 SI 关节。

1:30 请注意，当我们更靠近时，髂骨一侧

1:31 有一个较陡的轮廓，向下延伸到这个较宽的连接处

1:32 相比之下，我们的距离更远。

1:33 髂骨一侧更加扁平

1:34 我们可以看到接头处更窄了。

1:35 注射可在的任何位置进行。

1:36 有些人认为，注射

1:37 治疗性注射在这里更有效。

1:38 窄处

1:39 上面较宽的部分

1:40 SI 关节有更多的韧带限制。

1:41 而且人们认为，注射可能不

1:42 ，并有效地滑向这个更狭窄的区域。

1:43 关节间隙的一部分。

1:44 将针头从内侧引向外侧

1:45 在我们进行注射指导程序时，在普通情况下

1:46 骶髂关节的超声波检查、

1:47 、

1:48 但它是一个后置结构、

1:49 但它变成了横向插入、

1:50 所以我们在两个地方都有覆盖。

1:51 臀大肌是的主要伸肌。

1:52 髋部肌肉

1:53 它还有助于外旋和外展。

1:54 它是最大的

1:55 和最浅层

1:56 并由下臀神经支配。

1:57 其源头位于后方

1:58 回肠背侧

1:59 并沿侧面

2:00 和骶骨后外侧。

2:01 它还会与腰部筋膜相融合

2:02 和骶管韧带沿

2:03 与筋膜张力有关。

2:04 它与

2:05 IT 带沿表面稳定股骨

2:06 站立放松时的胫骨位置

2:07 伸展伸肌最终

2:08 以插入胫骨的结节上。

2:09 更近点

2:10 插入部位是股骨的臀大结节（）。

2:11 丹尼尔，下面请你来演示 SI 关节。

2:12 和臀大肌。

2:13 - 好的，谢谢Bill。我要等待

2:14 即可全屏显示。

2:15 我们到了。感谢今天再次加入我们。

2:16 在我面前的是一个声纳站点 PX

2:17 以及我们的现场模型。

2:18 只是为了给大家指明方向、

2:19 因为你会看到几个不同的拍摄角度。

2:20 这边是近端、

2:21 这可能是我做对了。

2:22 它们是匍匐前进的，所以

2:23 近端远端是这样的。

2:24 然后从上方的摄像机角度拍摄、

2:25 我在的角落里标注了近端和远端。

2:26 然后你可以看到底部的同一个摄像头。

2:27 所以我知道，当我们，，当我们在这里放大、

2:28 这可能会让人有点迷失方向、

2:29 但我确实想提前指出，以便

2:30 。

2:31 因此，我们近端是这样的，远端是这样的。

2:32 然后，就像我们在所有其他髋关节中做的那样

2:33 和骨盆课程、

2:34 。

2:35 这是髋关节后。这次也不例外。

2:36 所以，我这里有两张毯子

2:37 我将通过窗户扫描

2:38 我打开的。

2:39 我已经把毯子塞进了毯子的上半部分。

2:40 裤子，因为我们要在 SI 关节处

2:41 而我们的工作方式却低人一等。

2:42 因此，第一部分、

2:43 我从上往下看

2:44 我把短裤拉到了这里、

2:45 它们就藏在这里。

2:46 我这里还有第二条毯子

2:47 以露出臀部的上半部分。

2:48 因此，我们的回肠

2:49 这里和骶骨在这里，我可以，我可以触摸到 PSIS、

2:50 这将是我们考察的起点。

2:51 这里有一点凝胶。

2:52 同样，这是 15 至四 L 15 四换能器。

2:53 我要把传感器转一圈。

2:54 我把方向标朝向内侧

2:55 或中线，我只是继续

2:56 也许运气好的话，，就在 PSIS 上。

2:57 这种情况不一定会发生。

2:58 所以，如果没有，我们就来谈谈去

2:59 并发现更多表层骨性地标。

3:00 所以，如果你把传感器放下来，然后，然后、

3:01 你想知道你可能在哪里，我们需要

3:02 找到一个骨性突起，好吗？

3:03 如果是这个，上面还有斜坡、

3:04 这里是回肠。

3:05 我们要做的是沿着回肠往上走

3:06 高、高、高，直到达到最高峰。

3:07 然后，我将从近端到远端寻找、

3:08 的绝对顶点。

3:09 现在，如果从中线开始

3:10 您可能会抓到骶骨上的这块平板

3:11 和骶骨的脊柱。

3:12 这里是骶骨的一个棘、

3:13 我们只需沿着横向向下看。

3:14 现在，不要被第一件事绊倒

3:15 这看起来像一个关节。

3:16 这些只是骶骨孔。

3:17 这可能是 S 2 或 S 1，取决于我的距离有多近。

3:18 但我需要更多的横向，直到我们看到

3:19 那座高耸入云的 PSIS 峰。

3:20 因此，我在这里做的是，，我在种植内侧。

3:21 ，就像我在很多地方做的那样。

3:22 其他身体部位，如肘部

3:23 在这里，我们枢轴和挡风玻璃刮水器。

3:24 我就这样移动我的大拇指从这里穿过

3:25 直到我看到 PSIS 真的很不错。

3:26 这样一来，，就能很好地打开关节。

3:27 用于 SI 上关节或 SI 上关节。

3:28 你甚至还能看到反回归线

3:29 这些韧带的神器就在这里。

3:30 这样，你就可以知道，我们的目标是一致的。

3:31 正如比尔提到的，如果我们是来打针、

3:32 从中线到外侧。

3:33 现在，让我们沿着接头走，PSIS 比较简单

3:34 以次充好。

3:35 我们要追随劣等、劣等、劣等

3:36 直到完全消失进入坐骨神经上端

3:37 在回旋肌这里，。

3:38 在这里，我们会说到的。

3:39 但这告诉我，我已经

3:40 SI下关节下方，也就是这里。

3:41 你可以看到连接处，非常漂亮。

3:42 不是这里

3:43 因此，这是回肠最下端边缘。

3:44 如果我自卑地放下拇指

3:45 你会看到它完全消失，而骶骨依然存在。

3:46 这里就是髂胫关节、

3:47 在 Cyte Px 上，您可以看到接合处，非常漂亮。

3:48 表面上看，这些是臀大肌的纤维。

3:49 它们是斜的，向这边潜来。

3:50 所以它们斜着穿过了我的传感器

3:51 你可以看到它们跳起来

3:52 然后俯冲到骶骨这里。

3:53 所以我要做的是，我知道，他们是这样倾斜的

3:54 因此，，我只是要去枢轴

3:55 换能器

3:56 直到我们拉长臀部最大肌纤维。

3:57 这块肌肉非常宽大。

3:58 我可以跟着它穿过回肠。

3:59 而且，这不一定是考试规程的一部分

4:00 髋关节后侧，尽管

4:01 我们发现在臀部进行超声波检查的应用越多、

4:02 尤其是臀部后侧、

4:03 某人的协议。

4:04 但如果有临床指征，，你会想要追逐这些、

4:05 这些纤维的来源、

4:06 实际上，你可以看到臀部最大力量跃升了

4:07 骶骨上方到腰部筋膜

4:08 在这里提到的那个法案，那个小羽毛边。

4:09 所以这很不错。我会更加自卑。

4:10 更下放，更下放，直到我们看到臀部最大力量

4:11 真的变细了，看起来像

4:12 骶骨的脊柱。

4:13 我们实际上是在下面在蝶形硬膜外解剖。

4:14 因此，我们在这里看到的实际上是骶骨cornew。

4:15 也许是为了不同的疼痛管理主题

4:16 或其他什么的，我们将在上介绍硬膜外麻醉的解剖结构。

4:17 但在臀部最大横向、横向之后、

4:18 横向看，你可以看到，纤维的平行度非常好。

4:19 我相信比尔会在我们讨论到腓肠肌时提到、

4:20 就在这里，多好啊

4:21 以及它们之间的平行关系。

4:22 比尔，我错过了什么吗？

4:23 当比尔解除我的静音时，我会继续扫描臀部最大值。

4:24 我要加一点凝胶，得到一点

4:25 干。

4:26 - 我们走

4:27 丹尼尔，我现在回到 PowerPoint 上了。

4:28 - 好吧。好的

4:29 去吧，比尔。

4:30 - 好了，我们来看看梨状肌。

4:31 丹尼尔提到

4:32 梨状肌纤维确实与梨状肌纤维平行

4:33 臀大肌

4:34 而梨状肌的走向，就像对角线上的 gmax

4:35 其起源于骶骨前部、

4:36 具体地说，是在第一个之间的三个捆绑附件。

4:37 和第二、第二、第三和第三

4:38 和第四骶椎前孔。

4:39 通过坐骨大孔流出

4:40 并插入上部

4:41 的大鸟。

4:42 还要注意坐骨神经

4:43 因为它来自于

4:44 在梨状肌后面在前面交叉

4:45 的杰梅尔之眼和雷达。

4:46 最终，股四头肌占 17% 。

4:47 然而，坐骨神经中的穿过梨状肌。

4:48 并使这一亚群容易出现刺痛、麻木和眩晕。

4:49 以及沿坐骨神经深入臀部的疼痛。

4:50 那么，当我们寻找外观时，我们该从哪里开始呢？

4:51 对于梨状肌，我们要

4:52 从 PSIS 开始

4:53 我们的换能器将到，就像我们开始时那样

4:54 作为 PSIS 安放。

4:55 我们的下一个传感器移动将横向滑动

4:56 的横向。

4:57 我们将采用脚跟脚尖动作、

4:58 这是脚跟，这是脚趾。

4:59 我们要拖到

5:00 平整髂骨翼，以便

5:01 我们连续出现

5:02 的下表面的骨质

5:03 什么是 "臀中肌"？

5:04 一旦我们确定要

5:05 向远端滑动传感器

5:06 并使换能器倾斜，以对应

5:07 以梨状肌的对角线。

5:08 所以直接横向到这里

5:09 演示髂骨翼向下滑动，直到我们失去

5:10 那连续的髂骨翼

5:11 并开始看到坐骨神经孔。

5:12 一旦我们失去了这块骨头

5:13 我们来到

5:14 我们开始看到坐骨孔、

5:15 一旦我们沿对角线方向倾斜换能器、

5:16 我们将开始看到梨状肌

5:17 邻近的解剖结构，，也许可以帮助我们识别。

5:18 这又是坐骨神经

5:19 和臀上神经。

5:20 特别是相关船只

5:21 可能会打开彩色多普勒

5:22 并识别下臀神经、

5:23 这里是臀部动脉

5:24 所以声像图的外观又是这样的、

5:25 纤维与纤维之间非常相似、

5:26 gmax piriformis。

5:27 我们还可以通过屈膝来进行动态操作。

5:28 并旋转股骨以观察平移情况

5:29 前后摆动。

5:30 我相信丹尼尔会展示

5:31 在我们的生活中扫描。

5:32 再往南一点，，我们将从梨状肌开始。

5:33 我们将越过 GLI

5:34 而转播特质则是四肢女性的特质。

5:35 股四头肌是一种外旋肌

5:36 和大腿内收肌。

5:37 它还有助于稳定髋关节。

5:38 其源头位于

5:39 - 阿托尔戒指

5:40 因此

5:41 - 对不起，它的横向边缘是

5:42 、

5:43 这就是我们要找到的腿筋插入处。

5:44 它的远端插入在四肢结节上。

5:45 和肠道间的后嵴

5:46 股骨内侧

5:47 和这里的声波图像。

5:48 因此，这就是四肢femes。我们从哪里开始？

5:49 我们将传感器放置在

5:50 或臀部褶皱附近

5:51 在这里，我们将认识到骨性声学地标

5:52 髂骨结节的内侧。

5:53 从侧面我们可以看到股骨

5:54 股四头肌弥补了这一差距。

5:55 这是股骨峡部间隙

5:56 是一个撞击区

5:57 坐骨神经

5:58 动态操控可以帮助

5:59 我们认识到，。

6:00 的距离

6:01 并在股骨一间隙处折断。

6:02 好吧，丹尼尔，我把它交给你。

6:03 - 好的，谢谢比尔。正如比尔提到的，我们将

6:04 胯下、

6:05 我把臀部重新垂了下来，，我们还是往这边走、

6:06 但我已经把短裤穿上了

6:07 我还花时间掖了掖被子

6:08 并保护患者的内衣。

6:09 然后，我们要做的就是揭露

6:10 直到臀部褶皱。

6:11 因此，我们现在要看的是劣质 SI

6:12 关节，我们要走到髂骨处

6:13 然后向南进入

6:14 坐骨神经上孔

6:15 这将帮助我们找到梨状肌。

6:16 因此，屏幕左侧又将是内侧、

6:17 我们正在寻找那里的一个骨质地标。

6:18 那么，让我们来了解一下，"...... "的哪个部分？

6:19 也就是 SI 下关节。

6:20 看来我正好掉在上面了。

6:21 所以我们要做的就是沿着这条回肠走

6:22 现在，让我们沿着回肠，横向，横向，横向。

6:23 好了而我所要做的，只是陷入

6:24 那卓越的 Satic 凹槽。

6:25 因此，这只是一个小的短动作

6:26 我已经可以告诉我就在这个范围内了

6:27 因为我可以看到臀上动脉正在休息

6:28 就在这里。

6:29 我们现在要做的就是添加色彩功能、

6:30 我希望能看到那条小动脉。

6:31 这样做的目的是一条线索，告诉人们："嘿，我就要来了。

6:32 击中上骶骨孔。

6:33 你会看到，动脉开始

6:34 直上直下，，朝我的换能器飞去。

6:35 当它向上缠绕回肠下缘时。

6:36 因此，下一个结构是

6:37 就是我们的腓肠肌

6:38 因此，在诊断方面，L 15、

6:39 伟大的传感器，可以查看所有这些小纤维。

6:40 我看到这个大披萨片横向飞了过来

6:41 isum。

6:42 这就是我们所说的梨状肌腱膜、

6:43 臀下动脉，臀上动脉。

6:44 我认为，我总是把事情

6:45 食物的原因。

6:46 因此，我认为梨状肌只是

6:47 看起来像个大披萨片

6:48 这是一个三角形结构。

6:49 它将上升并越过伊瑟姆。

6:50 正如比尔提到的，我们从

6:51 在这里看到卓越的 Jamella

6:52 因为它就在上面。

6:53 然后，就在我们开始下面的 "isum "之前，我们已经有了

6:54 坐骨神经

6:55 或者此时仍然是远端腰椎复合体、

6:56 但在这里，它是一个漂亮的紧绷的神经群。

6:57 所以，这时候可能已经坐骨神经了、

6:58 但这是神经。

6:59 然后，在伊苏姆（Isum）上部是上佳果酱。

7:00 然后就躺在的上等果酱上、

7:01 如果我继续横向移动，是梨状肌

7:02 这根细绳上的肌肉开始

7:03 在程序上使自己成为梨状肌腱

7:04 而且是动态的。

7:05 我喜欢改用曲线探头。

7:06 所以我要花点时间来做这件事。

7:07 我将选择C 五一个传感器

7:08 肘内侧的

7:09 以获得更广阔的视野。

7:10 如果您的一般患者群体没有

7:11 我们今天的模特的身体习惯、

7:12 你真的需要考虑

7:13 获取汽车线路探测器。

7:14 所以，我又从屏幕左侧开始了

7:15 到病人的内侧、

7:16 ，情况会有些不同。

7:17 所以我想去找一个熟悉的地标。

7:18 因此，我需要做的是找到我的椎间关节下端

7:19 或骶骨的任何部位都可以、

7:20 然后将探针横向移至回肠。

7:21 这个大滑雪坡就是回肠、

7:22 该斜坡的下部。

7:23 我把光束一直对准目标

7:24 实际上是骨盆前部。

7:25 所以，这就是 "最小中庸最大"。

7:26 因此，为了让您了解的广阔视野

7:27 C 五个一个转换器。

7:28 这真的很好，让你有方向感。

7:29 现在我们沿着回肠往南走。

7:30 我需要看到回肠分裂成两块。

7:31 因此，屏幕左侧，骶骨一侧、

7:32 我看到了这个开口，但我还是看到了两块骨质地标。

7:33 因此，这里是骶骨，这里是髂骨的起点。

7:34 回到我们的披萨片梨状肌这里。

7:35 如果我想检查我的劣质部件的工作情况

7:36 的回肠，可以看到

7:37 臀上动脉搏动得非常好

7:38 激活色彩功能。

7:39 请再次检查您的工作、

7:40 确保您仍在熟悉自己、

7:41 但您可以看到更加宽广的视野

7:42 Coline 和更多赞赏

7:43 对整个结构而言

7:44 臀上动脉就在边界附近、

7:45 在那里的腓肠肌。

7:46 把我的箭拿回来这就是

7:47 是的，比尔，说吧

7:48 - 真快

7:49 说明换能器的角度是如何变化的。

7:50 因为在大多数情况下

7:51 我看到的最常见的错误、

7:52 我相信你也是这样想的，那就是

7:53 换能器不是斜的

7:54 沿梨状肌的对角线。

7:55 - 没错，比尔，我只是本能地这么做了。

7:56 因为我刚刚，我刚刚扫描了这么多的臀部。

7:57 但当你第一次学习时

7:58 我跌跌撞撞地经历了很多后臀部的事情、

7:59 就关节而言，这是一种最后的边界on

8:00 我们通常为我提供的服务。

8:01 我发现，继续前进

8:02 并拉长臀部最大肌群。

8:03 请记住，这些是相互平行的。

8:04 而最大臀部就是这样一个斜结构。

8:05 我们需要将我们的传感器

8:06 并为自己设置了梨状肌长轴。

8:07 因此，你可以看到

8:08 我可以摸摸这个特例就知道了。

8:09 因此，这里是 tr，而我正瞄准了这个特例。

8:10 这不是一个横向结构、

8:11 这是一个非常垂直的斜向结构。

8:12 因此，在这里我们有 GL 臀部、最大值、最大值、

8:13 长轴，梨状肌，长轴、

8:14 您甚至可以看到中央肌腱的一些

8:15 开始在这里显示出来。

8:16 当我们进入yum superior isum 的时候、

8:17 右侧的um 上缘、

8:18 这是我们的上司杰米拉

8:19 ，频率较低的换能器穿透力更强、

8:20 下臀动脉、

8:21 坐骨神经的位置更深一些。

8:22 我们进入一些阴茎结构，也许

8:23 谈话。

8:24 但对于一般调查，，我们将继续遵循以下原则

8:25 将回旋肌向外侧拉开。

8:26 我们开始看到，后

8:27 此处的股骨髋臼关节，颈部

8:28 的股骨特例开始在上崭露头角。

8:29 我确实看到很多

8:30 当寻找回旋肌时，很多人都在挣扎。

8:31 他们从特例开始，把任何

8:32 的旋转结构。

8:33 A，腓肠肌。

8:34 当我第一次学习

8:35 前不久，我在上做后臀部按摩时，错过了

8:36 在进行外部旋转时调用

8:37 而只是在这里寻找特例。

8:38 我们称之为 "哦，这就是我们的梨状肌"。

8:39 我们非常兴奋。，我要把箭带过来。

8:40 到我们为之兴奋的地方。

8:41 就在那里，我看到一面巨大的波浪形旗帜撕裂了。

8:42 我是说，还能是什么呢？

8:43 这是个大问题、

8:44 这是我们在解剖扫描中看到的旋转大肌肉。

8:45 我们把它送去做核磁共振

8:46 结果是 "不会"、

8:47 股四头肌撕裂。

8:48 这时，我们才真正认识到，嘿，我们需要

8:49 多花一点时间

8:50 从骨盆的骨性地标开始、

8:51 从回肠开始，一路向南

8:52 来自上级的静态notch where, you know、

8:53 它起源于前骶骨。

8:54 因此，、

8:55 这里的风景、

8:56 我要把腿伸到

8:57 你可以看到我旋转。

8:58 左上方为骶骨。

8:59 屏幕中间右侧为 isum。

9:00 而我要做的就是，只是被动地旋转。

9:01 不要让病人代劳

9:02 因为它会开始激活所有、

9:03 周围的臀部结构

9:04 它就会移动你的传感器。

9:05 此外，角度考虑也不是

9:06 保持与皮肤垂直

9:07 因为这些结构往往会潜入地下

9:08 当病人躺下时

9:09 比如说，一个骨骼模型，那么

9:10 这样回肠就不平了这样回肠就下潜了

9:11 就像两块倾斜的板子。

9:12 我需要做的是瞄准

9:13 那个大回肠翼这边，不是这边。

9:14 所以我需要与回肠成 90 度

9:15 在我进入梨状肌之前。

9:16 所以，还是从我们熟悉的骨性地标开始吧、

9:17 这里有我们的大回肠

9:18 我们可以看到最大臀围和米德

9:19 而我只是要陷入这个卓越的系统缺口。

9:20 你可以看到骨骼打开，就在那里闭合。

9:21 因此，我在扫描上级、下级、上级、下级。

9:22 现在我要把的探针斜着移到长轴上。

9:23 我现在要做的就是确认我的位置

9:24 腓肠肌与内

9:25 和被动外旋。

9:26 必须被动地完成这项工作，否则，这将是一场非常令人沮丧的考试。

9:27 - 丹尼尔，既然你在，我们有一个问题

9:28 我们通常会等到我们完成之后。

9:29 不过，既然你们来了，我们有一个请求

9:30 看能否显示坐骨神经

9:31 稍稍停顿一下，，让人们看到。

9:32 请。

9:33 - 那还用说。就在这里

9:34 看到这个三角形的楔形靠在石碑上。

9:35 这就是坐骨神经，它的外侧

9:36 到动脉结构

9:37 下臀。

9:38 你可以沿着它往下走

9:39 看着它停留在的边缘，然后跳起来

9:40 和这里的伊瑟姆颈部。

9:41 我们将进入其余部分

9:42 当我们进入股四头肌时，坐骨神经就会受到影响。

9:43 但我仍然只是跟着坐骨神经走

9:44 我的箭正在使用的地方。

9:45 一点点的各向异性。

9:46 让我们从这里重新开始。

9:47 那里，就是那里，让我回到刚才的地方。

9:48 这就是我们的腓肠肌。

9:49 坐骨神经正好坐在这里

9:50 而不仅仅是一厘米

9:51 左右的运动、

9:52 您将看到坐骨神经向上攀升

9:53 那儿

9:54 而它仍然受到反熵的影响。

9:55 所以，我有点，有点让它离开了我、

9:56 但在这里，它是一条扁平的丝带。

9:57 点在等离子体上。

9:58 所以，让我们跟着它走，这根神经就在这里。

9:59 我一直记得移动我的箭头

10:00 和更远处。

10:01 它真的很好，可靠，就在这里的顶部

10:02 股四头肌的就是这个小三角。

10:03 因此，左侧屏幕上有我们的胯骨结节

10:04 以及我们的腿筋起源。

10:05 然后这里就是坐骨神经。

10:06 然后是股四头肌。

10:07 我们可以尝试追踪的近端，看看

10:08 在这一点上，请看等向过渡，它正在尝试

10:09 就在那里。

10:10 因此，这是劣质jamella，放在上面

10:11 在那里，有坐骨神经。

10:12 我要做的是旋转探头

10:13 并向骶骨方向返回。

10:14 这里仍然是一种扁平的丝带。

10:15 - 我想说的是，我发现下一页对我很有帮助

10:16 到股四头肌和跗骨结节

10:17 并在该标签上标识

10:18 然后再跟进到梨状肌。

10:19 - 我就是这么做的，。

10:20 这也凸显了的反等向性、

10:21 但在这里，它正试图

10:22 以保持垂直度。

10:23 但我，我发现自己有

10:24 要做的几乎就是换能器的彩虹

10:25 与神经保持 90 度

10:26 当它弯弯曲曲地上升并越过穹顶时。

10:27 就是这样，坐骨神经，坐骨神经，坐骨神经，坐骨神经。

10:28 当我往上爬时，保持 90 度的关系

10:29 我发现自己

10:30 向下看四肢。

10:31 哦，原来在这儿。

10:32 - 我觉得这很好。丹尼尔。还有一件事，还有一件事。

10:33 当然。再来一次

10:34 你能演示一下动态效果吗？

10:35 腓肠肌的动态运动？

10:36 - 当然。回到我们熟悉的地标、

10:37 我要把箭丢掉一会儿

10:38 因为我需要两只手。

10:39 来到骶骨这里

10:40 这里的重要提示是，当你横向移动时

10:41 对准回肠好的

10:42 所以我们的目标是回肠，而不是 90 度、

10:43 皮肤，进入回肠。

10:44 回肠的滑雪坡。

10:45 而我要做的就是，保持骶骨的位置倒下。

10:46 在屏幕左上方。

10:47 这将是我的其他扫描技巧之一，珍珠

10:48 当我坐在这里聊天时，我正在观察

10:49 给你们，骶骨左上方

10:50 我要看这个，这个水平的骨骼结构

10:51 这里分成两块。

10:52 当我看到这两块

10:53 我知道我在坐骨神经上孔。

10:54 你要倾斜探针或旋转它。

10:55 在这种情况下，我只是顺时针

10:56 这就打开了那个大三角形

10:57 披萨片状的腓肠肌

10:58 我要确认的是

10:59 通过内外被动旋转。

11:00 我在内侧，或者是更内侧的位置。

11:01 你可以看到这块肌肉、

11:02 外旋的幅度就越大、

11:03 我猜这就是内旋。

11:04 希望这能回答你的问题。

11:05 - 很好，谢谢。

11:06 我们，我将分享我的屏幕

11:07 然后我们继续练习腘绳肌。

11:08 因此，腘绳肌起源于的髂骨结节。

11:09 它们可以帮助帮助髋关节伸展

11:10 和屈膝，因为每个

11:11 腘绳肌穿过髋关节

11:12 和膝关节。

11:13 有三种肌肉肌腱结构

11:14 构成腘绳肌、

11:15 半膜肌肌腱，以及

11:16 如肱二头肌半腱化和长头。

11:17 半膜肌肌腱群起源于

11:18 上侧问题，小瘤

11:19 并插入内侧外显子刻度盘。

11:20 因此，半膜肌在此下方

11:21 半人马

11:22 肱二头肌插入此处

11:23 在髂骨结节上。

11:24 然后是

11:25 并插入胫骨内侧髁。

11:26 半腱鞘炎

11:27 肱二头肌长头和肱二头肌长头连在一起

11:28 邮政和插入邮政外侧腋窝

11:29 小结节为一个起源点。

11:30 二头肌肌腱有两个头，一个长头和一个短头。

11:31 近端有一个短头。

11:32 短头源自股骨的aspera线。

11:33 在插入

11:34 。

11:35 此时，长头

11:36 和短头已成为一种常见的肌腱

11:37 插入为

11:38 作为一条肌腱连接到腓骨头。

11:39 另一方面，半腱鞘炎、

11:40 插入胫骨前内侧，作为腓肠肌的一部分。

11:41 和宁静的筋骨。

11:42 所有腘绳肌均由胫骨支支配

11:43 坐骨神经的胫骨部分。

11:44 那么，我们从哪里开始呢？

11:45 我们再次从臀部褶皱处开始

11:46 或其附近、

11:47 届时，我们将认识到骨质疏松症的严重性

11:48 声学地标

11:49 形状很像喇叭

11:50 有一个骨质的突出山峰在，在上面

11:51 其中，我们将在侧面看到、

11:52 半月板连腱

11:53 股二头肌也正好位于外侧、

11:54 丹尼尔在他的现场演示中很好地介绍了。

11:55 确定坐骨神经

11:56 如果我们现在将传感器旋转 90 度。

11:57 我们看看

11:58 长轴上的这些结构、

11:59 结节浅表、

12:00 我们将看到联合肌腱

12:01 当我们从骨头上掉下来的时候，就会深深地体会到这一点、

12:02 我们将看到半膜肌腱。

12:03 这，这只是肌腱的部分

12:04 腘绳肌复合体的近端。

12:05 如果我们在的远端跟踪它们，我们就会看到。

12:06 我们将询问肌腱连接处的情况。

12:07 最常见的是二头肌撕裂、

12:08 最常见的跑步撕裂是

12:09 肌肉酸痛撕裂，你只会看到

12:10 你经常会看到就在附近

12:11 到中央肌腱。

12:12 从这里再往远一点、

12:13 坐骨神经

12:14 我们将从丹尼尔演示的开始。

12:15 以前，我喜欢

12:16 从梨状肌处开始。

12:17 我们要将传感器沿梨状肌定位

12:18 这样，我们又看到了

12:19 腓肠肌的较厚部分。

12:20 顺便提一下，梨状肌，拉丁文

12:21 梨状，而不是披萨片状

12:22 丹尼尔

12:23 但我必须同意，，它的形状更像披萨、

12:24 一片披萨比一个梨更好吃

12:25 但比起，我们会看到坐骨神经

12:26 神经及其附近、

12:27 臀下动脉

12:28 如果我们现在向远端滑动传感器

12:29 经过

12:30 和 "ator "到 "isum"，这又是

12:31 在同一张图片上，我们可以看到髂骨结节、

12:32 连接肌腱，，稍偏向外侧。

12:33 我们将看到坐骨神经

12:34 当你看到

12:35 坐骨神经在这个位置。

12:36 请看，我们没有设置深度。

12:37 对股四头肌进行成像。

12:38 但在这个层面上，永远明智

12:39 只看女性四头肌、

12:40 可以进行动态演习

12:41 显示股骨峡部撞击情况

12:42 以及因此可能发生的断裂。

12:43 并承认减少

12:44 这里的空间可能会造成刺激

12:45 坐骨神经的胫骨部分。

12:46 一旦我们稍稍向远端移动，我们将

12:47 在大腿后侧上部

12:48 在这里我们会看到连接肌腱

12:49 及其肌腱部分

12:50 与股二头肌横向连接、

12:51 内侧半腱鞘炎

12:52 我们将看到典型的蝌蚪形状

12:53 半膜肌肌腱的损伤

12:54 和下层的半膜肌。

12:55 肌腱交界处

12:56 横向我们将确定

12:57 - 坐骨神经

12:58 结论是

12:59 - PowerPoint 演示文稿。

13:00 丹尼尔，我让你把它写完

13:01 。

13:02 - 好的，谢谢比尔。所以我又换回来了

13:03 到 L 15，线性 15兆赫传感器。

13:04 好了我将在上重新暴露臀部后方的位置

13:05 并继续我们的工作。

13:06 这次我的骨质地标将是峡部

13:07 小结节和外侧。

13:08 我应该看看，坐骨神经真的很好。

13:09 并检查我的工作、

13:10 股四头肌，左侧

13:11 屏幕的中间位置。

13:12 如果您加入得晚，。

13:13 这是上部，这是下部，这是侧部、

13:14 这里是中轴线。

13:15 所以我要把传感器放在这里

13:16 我相信我应该在找到最初的结节。

13:17 如果我没有看到，我所拥有的

13:18 要做的就是遵循这些阴影结构

13:19 更内侧。

13:20 开始了让我们来看看这是哪种骨头。

13:21 我要跟踪它到，看看它是否来了。

13:22 到一个很好的点，那就是我们的胯骨结节。

13:23 我的凝胶用完了，所以我，只想挤点凝胶。

13:24 更加自卑。

13:25 我们到了。因此，我们了这个，这个突出的

13:26 这里的骨峰，就在

13:27 。

13:28 我们可以看到连接肌腱的结构

13:29 开始显现。

13:30 我要继续横向移动

13:31 来确定自己的方向。

13:32 这里是股四头肌，这里是坐骨神经。

13:33 因此，我们可以很清楚地看到所有这些结构。

13:34 因此，我们知道我们是在球场上，我们

13:35 知道我们需要去哪里。

13:36 现在就来区分这些纤维、

13:37 我要把我的深度提高，因为我可以、

13:38 我们需要更浅的深度和更高解析度的图像

13:39 我们将利用热带神器来发挥我们的优势

13:40 并将这几层分割开来。那么丹

13:41 - 我要打断一下。

13:42 我知道您的 PX 的图像无法翻译

13:43 与变焦演示完美结合。

13:44 我要你减少你的

13:45 获得一点点。

13:46 - 哦，很好。说得好，比尔变焦肯定是这样。

13:47 - 谢谢。

13:48 - 希望这样会好一些。非常好

13:49 因此，我们可以看到这些层在这里进行了区分

13:50 腘绳肌上种共同的起源。

13:51 在这里的深处，我们有，越深半米、

13:52 半腱鞘炎

13:53 和横向连接结构。

13:54 我们的股二头肌，我们可以沿着这些部位向下追踪

13:55 并观察股二头肌肌腱的横向移动情况

13:56 及其延伸的肌肉腹部。

13:57 半腱鞘炎将成为我们的下一个里程碑、

13:58 只是稍稍偏向内侧。

13:59 半腱下方

14:00 或股二头肌，这里是我们的静态神经，只是

14:01 作为参考。

14:02 所以我又在臀部褶皱处，、

14:03 在这里，我们得了腱鞘炎。

14:04 让我们利用各向同性，我们的优势。这。

14:05 因此，即使这里有一个组成部分、

14:06 我们的更上部显示肌腱，这里的内侧是我们的

14:07 半膜肌，这个小裂缝的边缘。

14:08 让我们一起欣赏与半肌腱病的结合。

14:09 然后是股二头肌。

14:10 因此，你几乎可以连中三元，、

14:11 即使有conjoin 成分。

14:12 这里是股二头肌、

14:13 半腱鞘炎，半失明。

14:14 这个孤立的小阴影

14:15 因此，我只是勉强摇动传感器，就像我们做的那样。

14:16 二头肌肌腱的凹槽，以查看

14:17 我们能得到什么微妙的东西。

14:18 你不想做的是，养成打电话的习惯。

14:19 腱鞘炎，尽管，但它的名称中却有一个

14:20 的一条肌腱。

14:21 这不是病理，如果你能让它填上的话。

14:22 因此，这里的等向回真的很有用、

14:23 但也可能产生很大的误导

14:24 如果不是的话，我们也不想称其为退化。

14:25 因此，现在我要从这些肌腱中抽出一条来。

14:26 我们将我们将专注于menos

14:27 并旋转探针，使的左侧、右侧和右侧的探针与探针的左侧、右侧和右侧的探针相吻合。

14:28 的屏幕朝向近端。

14:29 所以，我们在这里找到了我们的 "isum

14:30 横向。

14:31 很高兴看到股二头肌继续前进

14:32 然后飞走，做自己的事情。

14:33 我可以跟踪它，，更加横向。

14:34 结构非常容易。

14:35 我现在要把我的专业技术带得更中规中矩了

14:36 而更多地关注半成品

14:37 和腱鞘炎区域，我们

14:38 看得非常非常清楚。

14:39 看起来很多肌腱总是插不进去

14:40 就像一只大鸟的喙。

14:41 我们还可以在另一个结节上看到同样的模式。

14:42 在身体上，在跗骨结节上。

14:43 因此，从表面上看，肌腱。

14:44 然后深深地，深深地，深深地在这里

14:45 正如比尔指出的，我不确定收益是否

14:46 通过变焦。

14:47 我要自动驾驶

14:48 - 试试你的 TGC 深。

14:49 - 对，就是这样。

14:50 希望能有所帮助。

14:51 - 是的，请注意，我们正在试图离开。好了

14:52 丹尼尔，你看到了一点。

14:53 半膜肌更深、

14:54 但这是与，让你了解一下

14:55 线性 15 的穿透力很好

14:56 到四兆赫的传感器。

14:57 - 非常正确。大多数高频率传感器

14:58 没有太大的范围。

14:59 这个，你知道，，我们正在扫描 15 至 4

15:00 所以真的取决于我们在屏幕中的位置、

15:01 我们试图拍摄多深，我是在 res 还是 gen。

15:02 我把频率降到了基因频谱。

15:03 因此，我的带宽较低，、

15:04 这确实有助于我在这里的渗透。

15:05 我要横向移动到坐骨神经处

15:06 我又要去横切面了、

15:07 找到我们的骶骨结节，检查我们的增益

15:08 变焦，看起来有点热。

15:09 我要按自动好了

15:10 汽车公司做得非常好。

15:11 因此，髂骨结节这里又有我们的、

15:12 我们的坐骨神经

15:13 和股四头肌只是为了检查我们的工作。

15:14 而且我已经通过坐骨神经，所以我会、

15:15 我觉得这是多余的

15:16 追踪坐骨神经近端

15:17 就在不久前

15:18 - 让我们沿着远端，丹尼尔的大腿上部，以

15:19 - 你知道了

15:20 - 是啊 - 因此，我要做的就是加入一点凝胶

15:21 因为我知道，我知道，我将在这里沿着一条轨道前进

15:22 如果能将其拆分，也许会更好

15:23 如果，如果，如果我设置了相机

15:24 去那里。

15:25 - 哦，非常- 很好。看来我做到了。

15:26 好的，那么股四头肌

15:27 回到这里的ISUM。

15:28 我们到了，让我们

15:29 请在此处遵循这一结构。

15:30 坐骨神经远端

15:31 远端横截面是一种方法。

15:32 我知道，这些神经看起来真的、

15:33 真的很漂亮，而且是长轴。

15:34 - 让我们转动，，让我们转动游戏

15:35 再往下一点

15:36 丹尼尔谢谢大家。太完美了

15:37 - 你肯定被它迷住了。

15:38 好的，坐骨神经远端，远端，远端。

15:39 继续向远端移动。

15:40 我们应该开始，在这里看到一个分支

15:41 腓总神经

15:42 或腓总神经，取决于您何时就诊

15:43 或开始学习这个、

15:44 我想我们已经看到它开始了

15:45 分叉，但我们还没到那一步。

15:46 这里是腘窝，我的手就在那里

15:47 也许我错过了分岔点。

15:48 应该已经有了。就在那儿。

15:49 好的因此，就在我的箭头所在的位置，你可以看到

15:50 分叉就发生在这里。

15:51 这只是没有分开。坚持住

15:52 哦，那不对，因为它将遵循

15:53 股二头肌就像一颗扫描珍珠

15:54 因为我肯定不会想到去看、

15:55 - 我认为最重要的是丹尼尔，让我们往下看。

15:56 梅赛德斯-奔驰（Mercedes-Benz）标志，以显示如何

15:57 以确定连体倾向、

15:58 你说得没错，conjoin肌腱，更浅表一些

15:59 股二头肌和之间，以及半腱鞘炎

16:00 然后是符号学、

16:01 左侧的那个蝌蚪杆形状的结构。

16:02 是的。然后是坐骨神经

16:03 人们可以在这个层面上确定

16:04 神经所在的位置，以及两条有关的肌腱。

16:05 这是很常见的腿筋位置、

16:06 我的肌腱受伤了。

16:07 - 比尔说得好，我非常喜欢那辆梅赛德斯-奔驰、

16:08 这是要放在幻灯片里的东西。

16:09 - 我还想留一点时间

16:10 如有问题，请提问。

16:11 - 现在是时候了。。

16:12 如果您有任何问题，，请在 "问与答 "框中提出。

16:13 我们将解决这些问题。

16:14 - 是啊，这已经结束了考试的正常部分

16:15 我们很高兴能在上停留几分钟、

16:16 并即时回答这些问题

16:17 无论您希望如何处理。

16:18 如果中有您希望再次回顾的内容

16:19 我们确实报道过。

16:20 根据我们没有涉及的主题、

16:21 还有一个机会

16:22 也会涉及其中的一些内容。

16:23 但我认为，你知道，后置法案

16:24 面向上级

16:25 坐骨孔就是，，就是这样。

16:26 我只是在跟踪长轴的坐骨神经、

16:27 这似乎，似乎

16:28 相比之下

16:29 - 更早。

16:30 问得好，丹尼尔是问题囊吧？

16:31 当它在连接肌腱的顶部上划出弧线时。

16:32 - 这又是一个囊肿

16:33 我们真的看不到了

16:34 除非那里有病变、

16:35 - 对不对？

16:36 - 但是，如果你想，如果你想让看到这个界面，它、

16:37 添加一点动态组件也不失为一个好主意

16:38 到你的考试，只是一种滚动、

16:39 通过让股骨在最大限度上滚动一点。

16:40 旋转，这样你至少可以划出，嘿，哪里有、

16:41 这些结缔组织层在哪里？

16:42 开始和结束？

16:43 答案是

16:44 有时取决于患者的体型、

16:45 今天，我们已经没有问题了、

16:46 但当你在真实的临床环境中，、

16:47 有时，这些组织界面并不那么明显。

16:48 因此，我所做的只是，造成外旋。

16:49 通过移动腿部

16:50 我正在浅层隔离臀部最大力量

16:51 在胫骨结节上，在腘绳肌上。

16:52 我想找一个滑囊，就在那个地方。

16:53 - 这与我们的工作非常相似、

16:54 与套管囊。

16:55 - 当然可以。你知道，这个是超声波，让它动起来。

16:56 要知道，静态图像不会

16:57 帮你回答很多问题。

16:58 因此，只要有机会，你就需要

16:59 使这些结构移动

17:00 并尽可能频繁地相互反对。

17:01 然后，有时你会暴露一些额外的

17:02 病理变化，如粘连，而不是

17:03 在静态图像上如此明显。

17:04 - 丹尼尔，我们还有一个问题是

17:05 旧地重游，屡见不鲜

17:06 腿筋肌腱撕裂。

17:07 所以，也许下来，开始

17:08 在梅赛德斯-奔驰标志处与连体腱

17:09 当然。

17:10 只要顺着中央的肌腱走就行。

17:11 这基本上就是我们在做的事情，因为我们在跟踪

17:12 那条中心肌腱

17:13 我们正在查看附近是否有任何变化。

17:14 什么是正常回声architecture where the my、

17:15 肌肉与肌腱连接处右侧

17:16 - 在那儿

17:17 是啊界面。

17:18 现在我很温柔

17:19 我离开了肌腱部分，现在

17:20 - 我和你一样，都是近亲。

17:21 - 没错。- 所以它只是

17:22 肌腱位置就像我们看到的那样

17:23 胃撕裂，右侧，紧贴肌腱

17:24 如果您正在查找流体缺陷，您正在查找

17:25 改变正常的忏悔模式

17:26 或星眼外观。

17:27 如果你是短轴，肌肉的过程、

17:28 你只是在寻求改变。

17:29 这就是典型的

17:30 与建筑外观相呼应。

17:31 真漂亮看看你是如何追随的，看看

17:32 他是怎么跟下来的。

17:33 因此，沿着

17:34 与中央肌腱相邻的地方就是你要去的地方。

17:35 看到那里的变化、外观变化、

17:36 你可以看到半膜肌肌腱在它的深处。

17:37 看到那个看起来像蝌蚪的结构了吗？

17:38 希望这能回答你的问题。

17:39 还有其他问题吗？

17:40 我没看到，劳拉。

17:41 我想就这样吧，，请大家继续讨论。

17:42 - 好极了比尔，你有没有

17:43 最后一张幻灯片，，你能展示一下吗？还是你

17:44 - 想哦，是的，我，我想。

17:45 谢谢大家。

17:46 - 让大家都知道，我们将发布录音

17:47 所有这些网络研讨会，请访问网站、

17:48 secure dot sonasite.com/behind theskin 网络研讨会

17:49 并期待网络研讨会在一月份发布新内容。

17:50 我们将在 MSK 市场推出几款产品

17:51 腕背和腕管。

17:52 所以我想让大家知道

17:53 这些即将到来。

17:54 - 好极了我们祝愿节日快乐。

17:55 - 当然。感谢各位参加今天的会议

17:56 再次感谢比尔和丹尼尔

17:57 进行出色的介绍和演示。

17:58 做得非常好。

17:59 - 谢谢大家。

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