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https://www.youtube.com/watch?v=YAk6ABr4ZPM
Transcript

- Hello everybody.

Welcome to the webinar Diagnostic Hand, ultrasound Part One,

introduction to the Dorsal Hand.

My name is Chris Pennell

and I'll be moderating today's webinar.

This is the first webinar in a four-part series on the hand,

and you can sign up for all the next parts

of this webinar series on

sonosite.com/behind the scan webinar.

All of our previous webinars are available there as well,

so feel free to take a look at our archives

for even more educational material.

Before we begin, please be advised all attendees are muted.

We'll be conducting a q

and a session at the end of the presentation, so feel free

to send those questions in while the presentation is going

and we'll be sure to get to those at the q and a session.

If you're on the zoom stream,

you can type your questions into the q

and a box, into the toolbar located at the bottom

or the side of your screen.

And for our viewers on YouTube

and LinkedIn, you can enter your questions in the chat box

and we'll get to those.

This webinar will be recorded

and archive for future reference on our webinars page

and on Sono Site Institute.

Here with us today we have Daniel Shelton.

Daniel is the director of musculoskeletal market development

for FU Fujifilm Sono site.

Daniel has spent 19 years

as a dedicated musculoskeletal sonographer,

and 14 of those years have been here at Sono site.

He now leads a musculoskeletal market development

where he works to spread the word about the benefits

of point-of-care ultrasound.

And with that, I'll hand it over to Daniel

for our presentation.

- All right, let's get started with this ultrasound

of the dorsal hand

and to kick it off, here are some lists

of indications from the A IUM website about

when ultrasound is indicated clinically for the hand,

although there are lots

of other uses we'll talk about later.

But these uses typically include inflammatory arthritis

that can be effusion, synovial hy hypertrophy, or hyperemia

or bone erosion.

Now these are mostly for rheumatological applications

and we'll have a webinar dedicated to that as part three

of this four part series.

So make sure you join us if that is your topic of interest

to focus on arthritis ultrasound at the hand.

Also, Teno synovitis, I think concerns everybody,

whether it's the arthritis community, sports medicine,

pain management and acute injury.

Back to sports ortho, I think of hand surgeons,

highly specialized topic there.

Again, this is part one of a four part series,

so make sure you're joining us for part two

where we flip over and go to the bowler hand.

Part three, we'll have a guest speaker, Dr.

Dan Malone, rheumatologist out of Madison, Wisconsin

as he discusses the arthritic hand ultrasound protocols.

And then part four, the advanced hand ultrasound.

This, this list will probably change a little bit,

but we'll be covering the more extensive ligaments

that are tricky, more advanced scanning techniques, some

of the advanced anatomy that are more complexes where some

of these tendons are coming together like the extensor hood

and even the tendons around the knuckles where you,

where you end up with these musculotendinous junctions out

of the palm of the hand that go to form

the tendons over the dorsal part of the finger knuckles

and aid inflection and extension.

So we'll be covering those in the advanced webinar as well

as the, the thumb as a complex.

We'll be covering this big deep dive on the thumb

'cause the thumb is very complicated

and goes in all directions and has a crazy amount of tendons

and ligaments that are commonly injured.

Uses of ultrasound, as we mentioned, arthritis,

but joint infection, solid versus cystic soft tissue

masses, I would say is a big one.

Whether it's a ganglion cyst, is it compressible?

Is it, is it something that's old and solid?

Can we tell that with ultrasound? Yes, you can.

Anatomic variants are big,

especially if you're looking at hand for surgical planning.

You can, you can check out some of the variant tendons

for donor ligament sites, for example,

we won't be showing pathology

because of the limited amount of time, but take a minute

and look up ER deformity, swan,

neck deformity and mallet finger.

Those are very common injuries of the finger

that are viewed with ultrasound.

You can see fractures really nice with ultrasound.

It does take a bit of patience and there's a learning curve

because of the, there are some, some bony areas

around the hand that that can look like a fracture.

So it's nice to have ultrasound to compare

to the neighboring finger, for example,

because of the little tendon insertions can have bony ridges

and if you slice the bony ridge obliquely for example,

it might look like a fracture.

So we'll go over that in the scanning techniques,

particularly on the bowler hand, part two.

And then compression neuropathies.

We can talk about nerves, we can scan a little bit

of nerves today, but we're,

we're not going into a deep dive on nerves.

That'll be more advanced fracture healing

and non-union ultrasound's excellent for that.

Pediatric hand trauma, I mean, kids aren't going to stand still

or sit still for that matter.

And they're sure not going to sit in an MRI for you.

So depending on the age,

ultrasound is definitely more preferred than an MRI when it

comes to imaging, the soft tissues in the hands.

And we already talked about sports injuries,

tendon and tendonitis.

Let's start with bones of the hand.

We're not going to make an exhaustive list

of ultrasounding each one of these bones.

I'd more or less just want to show you how to troubleshoot

and navigate imaging around the bones, their landmarks

and windows and, and useful

and helpful landmarks for isolating muscles

in this particular webinar.

But just as a review, you,

and you should have seen this on the wrist webinar,

so if you haven't gone back

and looked at the dorsal wrist webinar,

go ahead and take a look at that.

But we'll, we'll do a broad overview here today.

So we've got the radius, which is on the thumb side

and the ulna, and then the, you have your first carpal row

and then your second carpal row or distal carpal row.

And then we get into the metacarpals.

There are five metacarpals

and then you have five proximal phalanxes or phalanges here.

And those are the parts of the finger that you can see.

And these are the parts of the finger inside the hand,

like the palm of the hand that you can't see.

Now, middle phalanx, you'll

notice we only have four of those.

The thumb does not have a middle phalanx

and distal phx, the thumb has a distal phalanx.

So when we're naming joints,

we're basically describing the union

between these two bones and their gaps.

So we have metacarpal flange joints, which are the joints

between the long bones inside the hand around the palm

of the hand where you don't see the fingers quite yet, and

and where they meet up with the proximal phalanx,

we would call that the metacarpophalangeal joint.

Next, in a thumb only we have a interphalangeal joint

because we have two phalanxes,

but there's no middle one, so we we're not going to call there.

There's no proximal, no distal, there's just these two.

So this is the only IP that we have here.

So this is the IP joint of the thumb.

And then we have the proximal interphalangeal joints are the

PIP joints

and the distal interphalangeal joints enter just meaning

between phx phlange,

so distal most joint on the phalanx.

And then when you're imaging these, you're basically going

to, you're, you're going to be using the

acoustic shadow of the bone.

So in this example, we have the probe over here,

over the bones, the dot, you'll see I've got it correlated

with the logo on the upper left part of the screen.

And we've got the second, third, and fourth.

So here on the bones, we've got the second, third,

and fourth in the windows here.

And then to scan bones

and cross-section, I think is the most useful to,

to establish your landmarks.

You'll be, you'll be scanning proximal distal,

proximal distal to evaluate not only the surface of

of the bone, but you're really using it for landmarks

to isolate muscles, tendons, and their path, even nerves.

So we're, we're not going to exhaust the list of these bones.

We're not going to ultrasound all these bones.

I just want you to know how

to ultrasound the cortical surface

for landmark targeting particularly

and even fracture identification later.

As I mentioned windows for example,

on this slice here we've got the second metacarpal

and third metacarpal.

And that leaves a gap between them.

So we have that gap here

and that gap is filled with muscles we'll talk about later.

But here's the second

and third, they do cast these acoustic shadows.

We can't see through bone.

This is the, the hard echo, a hyper echoic cortex.

And then you can see, because it's pretty level

with the transducer surface, we have reverberation.

We'll see that on the long axis

of the bone here pretty soon.

So going a bit long axis over a really com common

site for hand ultrasound.

Hand arthritis is the, the first CMC joint.

So we'll just use that as an here, the first

of the carpal metacarpal joints.

And there's five carpal metacarpal joints.

The other four are just plain joints.

They only have basically one direction of movement.

They're pretty boring, but the thumb is really interesting.

So if you get a chance to ultrasound even your own thumb,

you might notice you have osteophytes

or bone spurs in these joints,

just depending on your life experience.

But ultrasound this in all your patients for practice

and just look at the variability of the joint spaces, the

bone spurs, et cetera.

But the thumb is extremely complicated.

And in the advanced part four, we're going to be going over

all the ligaments around the thumb that make it tricky

to ultrasound and the tendon insertions individually.

And the variance of those insertions

that you might come across.

If you find yourself scanning the tendons around the thumb

and, and get a little lost, it might not be

that you're, you're actually lost.

It might be that you're patient has some variant

anatomy around those tendons.

So we'll, we'll talk a little bit about those.

But the thumb is a saddle joint.

It does have flexion extension ability.

It does have abduction and abduction ability,

but this is a long axis of the base

of the first metacarpal trapezium

scaffold and distal radius.

Moving down the thumb a little bit further, just

as an example, for the long bone,

we have a first metacarpal.

And earlier I mentioned the reverberation.

So are we seeing echoes below the bony surface here? No.

Anytime a hard specular reflector like cortex becomes a

level or parallel with the origin of the ultrasound source,

the footprint of the probe, the echoes will bounce back

and get kind of trapped in this hallway of mirrors

of intensity of the return of the echo.

So this is just a reverberation

of the intense echo that's re

that's returning back at about the same intensity

as it was sent out.

As that bone tilts away from the probe,

the echoes would reflect back weaker

and we wouldn't get this parallel line underneath the bone.

We would just have the, the shadow cast

because the echoes would reflect off a different direction.

So when you're scanning any long bones in the hand,

keep in mind that you're not seeing through the cortex.

This is not something down the center of the bone cavity.

You're not seeing any echoes inside the bone there.

For that matter though, if there is a bony disruption

or a periosteal lift here,

you'll see a blister on top of the bone.

And we'll scan the hand on the live demo

and just kind of show that what, what periosteum looks like.

It's just a hypo coag envelope around the bone.

You shouldn't see it in normal applications,

but sometimes you can.

All right, so let's go to the live demo.

Just scan around some of the bones.

Just get familiar with the shadows that they cast

and the various landmarks

and the behaviors of the bones as as we scan them.

All right, so let's see.

Okay, in the live demo portion we'll be using two

of the main transducers.

We've got our larger linear, this is the 15 to four

of megahertz linear, which is probably the most common

transducer people purchase for Ms K.

So that's the transducer that's used throughout a lot

of the presentation for the wider angle

or the wider field of use.

So we can catch more of a panoramic of, of everything

that is in the hand all at once.

And then the other transducer that we're going to use in kind

of debut a little bit today is this ultra high frequency 46

to 20 megahertz transducer.

So this is the highest frequency transducer

on the point of care space.

And you can see that the footprint's pretty small.

So keep that in mind.

The field of view is going to be a little bit different,

but there is something different about

the head of the transducer.

You'll notice a concavity there.

So the, the face

of this transducer is built just a little bit different

and it allows us to catch

very extreme detail in the near field.

Penetration though is where it suffers.

So the higher the, the frequency, the lower the penetration

and then the lower the frequency,

the more penetration we get, but less detail.

So you know, it would be the dream of

of anybody in ultrasound

to have a super high frequency transducer

that could still see a shoulder,

but that's just not the case.

So this is more well suited for hands parts of the foot

and ankle pediatrics in particular this amazing transducer

things that would typically be frustrating to see on

normal patients for how small it is or maybe even small

and frail with all the, you know, like I think

of arthritis, ultrasound

and elderly patients with really bad arthritis in the hand

and how much air gets

between your transducer in your skin while

you're scanning, for example.

That transducer's going to be great for those that are really,

really small and petite

and have basically no, no fat.

So it's just usually that would be annoying to scan

with a larger transducer.

But if you do have a smaller footprint,

smaller footprint probes with higher frequency,

I think you're really going to enjoy the U HF 46 today.

So starting out with this survey of the bones,

as we did on the, on the PowerPoint,

we'll start off with the long bones.

So that's that first metacarpal.

If I back up approximately just a little bit, we can see

the the first CMC joint, which is, you know,

you're going to find a lot of osteoarthritis in here.

This is a ligament ligaments cast shadows.

We did cover a little bit of the CMC joint in the dorsal

wrist webinar, so if you didn't catch that, remember go back

and catch that and we'll, we'll be covering

that more in depth on the dorsal wrist.

I'm going to go short axis across here

and you'll see that just to keep it consistent,

I think we'll flip the notch side of the probe ulnar

and right up here on the far radial side

of the radius.

So we'll be going kind of counterclockwise across the top

of the wrist like this to stay consistent with

how the slides are presented today.

But you can see these big air gaps on the side,

that's basically the lack of transducer contact.

So if you're new to ultrasound,

these over here are just air gaps where we,

we don't have any gel contact basically.

And if I wanted to just focus on the center of this picture,

I could zoom in or just add a little bit of gel on the sides

to to capture some more image.

But this is cortex of the radius,

this is the first compartment

and if I fell off the radius in, in short axis,

we had hit the first carpal row so we know that's scaphoid

and we could work our way up to the trapezium

and then the base of the first metacarpal.

So it's all about just counting your bones

by seeing the joint gaps show up.

I could keep following this first metacarpal distally,

distally distally until we come across another bone.

And that would be her proximal PHAs of her thumb.

As I go more midline, I like

to use the bony shadows of the metacarpals as a landmark

and then come over here to that first web space

so I can see the thumb over here.

So that's our first digit and we have that big web space

and a muscle that we'll get to.

And then we have the second digit casting a shadow here.

So that's just how you count.

So it'd be one, two, so second digit,

third digit, fourth digit.

And we got to add a little bit of gel.

Gel makes everything better. There we go.

So back to counting again.

We've got first digit was off screen.

Here's that, that first big web space, second, third,

fourth, and then finally the fifth.

And you're going to use these web spaces throughout the hand

exam to evaluate which group of muscles we should be seeing.

You'll notice my very, very light transducer pressure

'cause we have these veins subcutaneously up here

that were not collapsing.

So if I was looking at somebody else's images,

I could tell if they were compressing.

If I, if I don't see a little bit of air gap on the sides,

it tells me they might be,

might be compressing a little too much.

And if I don't see these little veins patent,

then somebody might not be

seeing the pathology that they're looking for.

'cause you could be collapsing things like soft tissue

masses or joint effusions if you apply too much pressure.

So just a little scanning tip there.

And then we'll be going later towards

the end of the presentation.

We'll spend quite a bit of time at the knuckles,

but when we're seeing two bones come together

like this MCP joint, we'll get to that.

Keep in mind that the tendons are going to cause kind

of an air gap sometimes if you fall off the

sides like that right there.

And you just want to fill that in with gel.

And then what I like to do is hang a finger down,

and we did this quite a bit in other webinars,

like in the ankle you'll hang a finger down

and I stick my finger right in the inner digital space.

And then just slowly the probe down in the gel

and it gets you that really, really pretty gel

heap right here.

And that also ensures me that, that

you're not collapsing synovial tissue here, you can see

that vein up there, that's still patent.

So you're not compressing things that you might be looking

for going cross sectionally.

Same thing applies if you end up with these air gaps,

you're going to fill them with gel

and you don't want to compress too much

or you might get rid of some

of the soft tissue structures that you're looking for.

We'll go back into the inter metacarpal spaces.

So we could count those out just

the same as we did the webs.

If you get lost, you go towards the web.

And just keep in mind that these aren't

fluid collections here.

These are not bursa, these are just muscles beginning

and going into the web space.

And we'll get into which muscles those

are, I think here next.

So use the web spaces to count in the hand.

That helps a lot, especially when we get into these

intrinsic muscles and especially when we go

to start counting which tendon is which

and going back into the wrist.

And then when you leave the wrist

and you come out into the hand

and you feel like you might've gotten a little bit lost on

which digits you're in, just parking it back over

to home base and keep the left side of the screen will be,

yeah, left side

of the screen will be ulnar in this case.

So we've got that first, second, third, fourth, and fifth.

So not a lot to to, you know,

belabor on bone ultrasound around the hand,

except when you're looking for fractures,

especially in long bones.

Keep in mind you're scanning a cylinder

so you don't want to pan the transducer

straight across the bone.

You want to aim to the center of the cylinder.

So like in this case I've,

I've got a nice bright hyper coic cortex of the second digit

as I go on top of it, I want to aim back to the middle

as I go across towards the thumb, I want to aim back

to the middle of the digit.

And you have to maintain that perpendicularity

all throughout your evaluation of these long bones.

So they are cylinders, you just want to aim to the middle

of the cylinder when you're evaluating a bone.

If not, if you cut a bone a little bit oblique,

you might cause a little bit of a ridge kind

of looking artifact at the

superficial surface right up there.

You might call that something like a

fracture if you're not careful.

And then always compare, keep in mind

that we've got these other digits to compare.

Alright, so with that we'll just go ahead

and go to the next part.

You get us queued up for the next slides.

Okay, so we'll get started on the muscles

of the dorsal hand, we're not going to cover all

of them in great detail, all the muscles in the hand.

But we will start off

by looking at the deeper ones as a landmark.

So we're not here to evaluate the deeper muscles.

This is the adductor lysis.

So this is a big transverse muscle across the palm.

So here we've got the probe on the backside of the hand top

of the metacarpals, and we're imaging

through the metacarpals so

that you see bony shadows right here.

And that's what we have here, second

and third, second and third.

And they're casting a shadow over this transverse muscle.

That transverse muscle is a great landmark

for this particular presentation.

We're not studying the adductor lysis in this axis.

On the next webinar, the voler hand,

we'll go over adductor lysis anatomy

and it's in pretty great detail,

but for today we're going to use it as a, not only a landmark,

but a backdrop to these other more important muscles on top.

But it is a great place to start,

almost like a home base in the hand if you get lost

or if you're just trying to find your way

around these other muscles.

The the adductor lysis is a great landmark.

Going further into the palm here,

slightly more ulnar towards the pinky,

we have the shadows cast of the third,

fourth, and fifth metacarpals.

And it's easier to see what are called the lumbrical muscles

of the hand as a landmark.

Oh, again, this is,

this is not us studying the the voler hand,

but these are great landmarks to tell you when

to stop looking at some of these other tissues.

So screen left over here would've been more

adductor lysis, right?

But as we climb more over towards the pinky,

we have these other muscles that we're going to talk about.

But you need to know when to stop looking for the muscles

and, and when to expect other structures

that are making up the backboard of your image.

So down here this would be the palm,

the skin of the palm right here.

And then you got your flexor tendons that go

to the tip of the fingers.

The deeper flexors have muscle bellies hanging off the side

of them and those are called lumbrical.

And those are just the landmark for the dorsal hand.

And we're, we're going to be more concerned about these

other muscles next.

So getting into those more important muscles.

All right, so we've got second, third,

and fourth metacarpals here, second, third, fourth.

And you can see the flashing anatomy over here.

I made these blink because some

of the anatomy looks redundant.

It looks like it's just a layer repeating on top

of itself, but it's not.

These are the palmer interosseous, they're responsible

for the abduction.

Abduction of the fingers does help the

lumbricals with flexion.

And think of the, think of the, think of pad.

So this is Palmer abduction, so palmer interosseous,

there are three of them.

You can see them blinking over here to the,

the radial side,

or sorry, the the ulnar side of of the second

and the radial side of the fourth

and the radial side of the fifth.

Alright, so now the dorsal interosseous,

these are a little bit more important, easier to see,

they're more superficial.

Going back over to the adductor lysis, which is right here.

We can see the adductor lysis

through the transparent layers here.

And we started out with the adductor lysis as

that big transverse muscle.

So in that first web space,

we've got the thumb way over here, this slight shadow,

we've got the thumb casting a shadow of the first digit.

Then you have this big web space

between your first digit and your second digit.

And that's what we're looking at right here is

that first dorsal interosseous.

You can see that one head of it starts on the thumb

and the other head of it starts on the second metacarpal.

We're going over to the next web space where you can see

the second dorsal interosseous.

And it starts on each side.

We've got the one head of it starting on the second one,

head of it starting on the third,

climbing up to the middle finger here.

And then on the opposite side of that,

if the probe were moved over,

it would just be a repeat but flipped the other way.

Basically we would have the dorsal inter ocii of the,

of the third and fourth heads coming up

to attach on the ulnar side of the middle finger.

And it should be noted that these tendons extend on

to become part of the extensor tendon complex on top

of the fingers we'll talk about here in a little bit.

And they also contribute fibers to the sagittal band,

which we'll talk or the to the dorsal hood, which is kind

of an extended exam past the sagittal bands of the finger

that we'll talk in great depth on part

four on the advanced hands.

So we'll go down sagittal band, dorsal hood,

and then these fibrous connections

and contributions from the interossei

and the lumbrical that come up and attach to these tendons.

So don't forget to join us in that webinar.

Now think of dab DAB.

So the dorsal is responsible for abduction

and there are four of those.

Alright, so off

to the pinky side there's this big lump of a muscle.

It's not one of the inter ossi

and it's not a lumbrical so it's kind of off on its own.

And the small digit, the digit mini me.

So there's a whole group of these muscles

that we'll talk about and they're all referred to

as digit mini me.

And here we've got abductor digit MiniMe.

It originates from the pisiform.

I can't say that I was super well versed in this muscle

going into this presentation.

I've always just looked at the muscle belly and its tendon,

but not really its origin so much.

So I did go ahead and put those in my notes here.

So we've got origin of the pisiform insertion, the base

of the proximal phalanx,

and it's shared with the flexor digit team mini me.

And it sends fibers to the ulnar lateral band

and extensor hood of the fifth digit.

And it functions to help with the MCP joint flexion

and PIP joint extension.

Now let's go ultrasound those intrinsic muscles

and make 'em move with the live demo.

All right, so we've got

same linear array transducer we'll start with.

And then on the next part of the,

when we get into these extensor tendon compartments,

we'll switch over to our smaller footprint.

But this is more of a survey approach

through these muscles of the hand.

As we started out in that first web space,

now we can explore that first muscle

belly that we looked at earlier.

So we've got, let's find our deeper landmark that lysis.

So I've, I've given my myself a little bit

of depth here on the machine

and that's that abductor lysis right

here headed towards the thumb.

If I followed that anatomy diagram, I would angle

but actually spread the thumb a little bit like

this and stretch it out.

So if you don't get that nice s strided pattern,

just try having them do, do the function,

the abduction there and you'll see

that nice striation there.

So we're, we're focused now on this superficial group here.

So I'm going to go more shallow and

that's our first dorsal inter oii.

So we've got that more thumb first metacarpal head

that starts right up against the

inside of the first metacarpal.

You can see that belly out.

And as a landmark it's kind of cool.

There's this neurovascular complex from the radial

that comes up from the palm.

So that is the radial artery branching to become dorsal

and it wraps around the thumb right here.

So it's the perfect dive straight up and down.

And then this is the second metacarpal head of

that first dorsal interosseous.

But if we wanted to put color on that,

I think it's very helpful to just say, Hey,

that's not a ganglion cyst or something.

We could open the color box

and just show that that is just a fluid collection.

Now the little dots next to that are not showing flow.

These are nerves and we'll get into that

with the part four webinar.

On the more advanced hand structures,

we'll get into neurovascular structures,

but let's keep following that dorsal interosseous.

So we've got second metacarpal, I'm all the way back here at

that inter metacarpal row.

If I were to go a little bit more proximal,

I'd be at the distal carpal row here.

So first row of metacarpals,

far radial side, we've got the thumb.

Here's that go into the pointer finger, the second finger,

and you can see the origin of

that inter oii muscle right here, this head.

And you can see those two heads from the illustration

diagram come together right here.

Boom. So there they meet

and then they head over to the far ulnar side

of the second digit.

So they become this kind of common musculotendinous muscle.

And then we start to see these flat kind of facets of the

distal metacarpal head

and that's where our collateral ligaments are diving.

So these, these dark shadows that we're seeing

are the beginning of the MCP joint.

So if I were to keep following that, you would see that the

tendon, let's follow this bright stripe in the middle,

the tendon of the dors, dorsal interosseous becomes one

of these dark shadows on the side of what is going to be

the sagittal band.

And we'll get into that in the advanced webinar.

But that's where you would start tracing it as it dives

to go inside part of the sagittal band.

And unless they have symptoms to go any further,

just like in the shoulder, you would stop scanning a biceps

at the pec or other structures in the body

where you know you don't have to go out

to their terminal ending.

This is a good place to stop

because we're looking at muscle quality here for atrophy.

And then I'll go over here to the second web space.

So we're in the second web space now I can go back

to the proximal portion again

and you can see the two heads start right up across the top

of those base of the fir base of

that second and third metacarpal.

We can see the heads of the muscle begin.

And same thing, there is a little artery

that pokes out from the palm of the hand

and makes its way dorsal.

But we'll follow that muscle belly

just straight on to the end.

And remember that backdrop right there.

So we still see the lysis down here,

that abuc abductor lysis as horizontal

or at least we'll see it behind the second and third.

But remember it attaches to the third.

So we're not going to see it beyond that.

Over here would be purely dorsal inter oii here

and palmer inter oii.

So we, we get those two layers right here,

but here's that lysis right there.

So dorsal inter oii

here, palmer inter oii.

And then here's that abductor lysis.

And remember we can shoot all the way

to the table in the hand.

So that's the table down at the bottom.

So we're getting a cross section through the whole hand.

And here's the flexor. So that's the first flexor

or you can just call it the lysis.

So that's flexor lysis longest right there.

Here's the flexor tendon to the second digit, which is here,

which flexor tendon to the third.

And it's just really neat to me,

especially on the Palmer side, this will be a lot more

pretty to look at these muscle bellies.

But just as a landmark, you can see a a superficial

or close to the table flexor and a deep flexor.

So you can see those two stacked on top of each other

before they reach the knuckle

and become, you know those areas in the A one pulley

where we look for trigger finger and stuff.

So you could see the muscle belly kick off the side of

that just as a landmark.

That's a lum goal. And when we get to the bowler hand,

we'll evaluate those in a lot more detail,

do some dynamic maneuvers.

But just as a landmark on the dorsal hand we can see

I don't need to be looking for interosseous structures past

this fascial plane of the lumbrical and that flexor tendon.

So I can just stay in this, in this area here

and not worry about going any deeper.

I, and that's one big benefit

of having a larger footprint transducer

for this particular exam.

When we get to the rest of the wrist tendons going out

to the extensor mechanisms of the fingers,

we're going to switch to the small

footprint transducer for sure.

But just falling across these rows, again,

just going in between the spaces.

Looking at the dorsal and palmer inter oii right here

and here dorsal.

So we do have a dorsal inter oii in each web,

but we don't have a palmer inter oii in every web.

So in the middle finger they're skipped.

So Palmer in Oii not involved in the middle,

but dorsal everything leans towards the middle finger

for dorsal inter oii,

everything goes away from the middle finger for Palmer.

So you don't even want to look for Palmer inter oii in the

middle, but you will look

for Palmer inter oii on the surrounding fingers.

And then way over here, pinky side, you can see that

digit mini me muscle over here just as another landmark.

Not one of the interosseous, not a lumbrical,

it's kind of its own thing.

And it becomes a part of

that same extensor tendon hood

complex that we talked about a little bit.

Now this was not in the slides,

but I do think it's important to do so do need

to get these images in two planes.

So as a landmark, we have the first

web space here and I'm just going to fall off the second

metacarpal until I see these muscles here.

So superficially, first off, let's go screen.

Left is proximal screen, right is distal.

So you can see that MCP joint that we looked at earlier.

I'm just going to fall right off of that.

And you can see the dorsal interossei

muscle heads right here.

So we've got muscle tendon

and then remember that we have a long

axis dorsal interossei.

Now we have a short axis abductor lysis.

So if she were to wiggle her thumb just in

and out like this, yep

or isolated that that abductor lysis right here.

So if I go long axis on that, we'll see the abductor

lysis moving again, this is ultrasound, we make it move

'cause the muscles may be wasted away

and the margins

between these muscles might not be so obvious.

So you're going to want to move them in your landmarks.

So now I'm going to jump from that first web space

to the second web space.

And in the second web space we can still see first

superficially or the dorsal inter ossi.

Now we have a palmer inter ocii

and now we have that abductor lysis still sitting right here

'cause it hasn't attached yet.

It won't attach and I won't lose it until the third digit.

So it's still right here. So go ahead

and move the thumb again, make it move

it's ultrasound, make it move.

And then we go over to the third space

and we don't see that anymore

because it's attached to the shadow underneath

of the third metacarpal.

So always image these things in two planes if you're

suspecting pathology.

But use that abductor lysis as your roadmap

to get through the palm of the hand.

The thing superficial to it are your inner ossi.

And the things deep to it down here are

lumbrical right down here.

So we have a flexor tendon.

Remember we're going all the way to the table here.

So this is the table, this is lumbrical,

this is flexor tendon, this is abductor lysis, this

is dorsal inter

ocii and palmer.

So keep in mind the metacarpals are your roadmap

and so is this big abductor lysis guy in the middle.

All right, so now we're going to move over to the

extensor tendons.

So let me get that slide queued up and we'll get going.

Okay, let's start ultrasound of the dorsal

extensor tendons.

And there's lots of them, there are nine,

six compartments over the wrist.

And then we'll watch them branch out to their various

insertion trajectories.

We're, we're not going to ultrasound these all

the way to their thesis.

We'll do that in the advanced webinar

because some of them blend out

to be more complicated structures over the knuckles.

But for today, I think you should walk away with

quite a bit of confidence when it comes to

tracing out these tendons in their variable anatomy.

So if you didn't catch how this pertains to a wrist exam,

like arthritis synovitis the carpal bones of the wrist,

go back to the dorsal wrist webinar and review that today.

We're not going to be covering these ligaments

around the wrist or the the wrist recesses.

We're just going to do a a review on how

to find these extensor tendons in their various compartments

so that you can use the compartment of the landmark

to track them out

and eventually see them over the more

relevant anatomy in the hand.

So just as a review, we've got this,

this wrist diagram over here on the left, which is great.

And then we have this example MRI on the right

of the compartments and cross-section.

So we should see something like these shapes when

we start ultrasounding.

But I did want to share a helpful mnemonic.

It's always helped me, it was taught by a radiologist

that I used to work under

is very helpful for me to remember.

So basically if you're starting over here at compartment one

and working your way to compartment three, that's

where this mnemonics going to help you.

So all peanut levers eat peanut butter.

So if you can just remember that phrase, it's a good way

to kind of kickstart your wrist exam in compartment one.

And after that phrase, these just alternate so they go

longest brevis longest, brevis longest.

So all peanut lovers eat peanut butter.

Then you've got your E-C-R-L-E-C-R-B.

So it just keeps alternating until you get

to extensor policy's longest.

And then over here there's some some neat variation

of the scanning planes that it takes to see the difference

between extensor digitorum, communists and indices.

Think about index finger indices.

This is another tendon going over to your pointer finger.

And then in extensor digit MiniMe.

So we talked earlier about

what digit MiniMe means small digit, so you can only guess

where it's going to terminate.

And then extensor carpe nearest, which is more

of a wrist exam, but it does technically insert

on the base of the fifth.

And we'll talk about that because it insert in the hand.

So here we've got the all peanut levers.

So we've got the A PL, the abductor.

So abduction is is bringing away from the body,

thinking about abduction in the shoulder.

Lysis means thumb longest, so abductor lysis longest

and extensor lysis brevis.

So that's those two tendons here in the thumb.

And then they have their own individual Retin AUM

and they share a common tendon sheath here.

Here's the ultrasound distal radius.

Dorsal is marked here, Voller is marked here.

There's a little vein up here that's compressible.

It's a good landmark. And then you have a artery.

The radial artery on the voler side is a landmark.

So EPB and A PL are here.

Not reading from left to right, but right to left.

We're going to go counterclockwise around the wrist.

So all peanut lovers eat peanut butter.

The A PL is the bigger of the two

and it's got varied variable branches of tendon insertion.

We like to think it's always going to insert right here on the

base of the first metacarpal,

but that's not always the case.

And we'll do that in our live demonstration

because our model does have variant anatomy

with multiple tendon insertions of the apl.

So you'll get exposure to that today.

Extensor CARite radiologist longest

and extensor CARite radiologist brevis.

So this is your alternating.

We went from all peanut lovers eat peanut butter.

So now we're back to longest brevis, right?

So ECRB and ECRL.

And then they have their own Retin acular tendon sheets.

I say sheets because there are two here,

but we're going to find those

and isolate the base of the second and third metacarpal

and be able to ultrasound these tendon

insertions really, really well.

There's also some anatomic variation that people can have

down here at the base of these metacarpals

that can hang down as a big bony prominence.

Might just check out from a pathology standpoint

or just something that's for troubleshooting carpal boss.

And you'll see some variation of

what the anatomy might look like down there.

Here's the ultrasound. So we've got ECRL again,

we're going counterclockwise here.

So we've got longest brevis

because up here in the third department we will

alternate back to longest.

So we've got E-C-R-L-E-C-R-B

and here's the the highlighted compartment in in its own ulu

here going long axis again, we went into a good deep dive

around these compartments on the dorsal wrist.

Then we have the extensor lysis longest.

I think this is the most fun to look at

because we have this cool landmark called listers tubercle

on the top of the wrist you should be able to palpate.

Then if you just wiggle your thumb,

you'll see this tendon move.

So it's a very small tendon, it does jump up

and over compartment number two, so E-C-R-B-E-C-R-L

and there can be intersection pathology that happens there.

There can be rubbing teno synovitis that happens there.

So take a look at that in the anatomic snuff box

that's formed in this triangle.

And you might see some pathology right there.

It does have its own retina neck, gu and tendon sheath.

Here's what it looks like on ultrasound.

You can see lister's tubercle that high prominence.

You should be able to palpate that right on the slight thumb

side of the midline of the top of your wrist.

And then count over from the ulnar side.

You should see compartment number three,

this little bitty strap here, compartment number four,

you wiggle the fingers, you'll see compartment four move.

The number two doesn't move a lot

for you if you're holding the wrist still, you'd have

to do some abduction maneuver there and

but wiggling the thumb highlights,

extensor lysis, longis really, really well.

And another way to highlight extensor lysis longis really,

really well is to use an ultra high frequency transducer.

So today we'll be scanning a little bit with the UHF 48

from the sono site LX system

where we can see these tendons in great detail.

And there are variations.

I will say that being able to see anatomic variations

with such a high frequency clears them up completely.

So you really, really know just the normal anatomy versus

people with anatomic variation really, really well.

And we'll get to that when we get to digit

team MiniMe as well.

So this is an example, a video clip of the

extensor lysis longus, it's muscle belly

as we wiggle the thumb, you see the muscle

belly, it's not fluid.

Some people might call that fluid

with a lower frequency probe, it may not highlight as well.

And then also take a look at the space

between this third and fourth compartment.

You see this little bright white triangle.

This little fatty triangle contains a nerve for the advanced

webinar, which we can cover a little bit.

It's more of a wrist structure in anything,

but that's the distal branches of

that posterior interosseous nerve

sitting right there in that triangle.

Okay, back up to the extensor digitorum communis.

Okay, so that insertion is right up here way at the,

at the tip of the finger.

And you've got a central tendon slip

inserting right at the PIP joint.

And we'll cover those at the last parts of these slides.

And then it's got a neighbor.

So I'm going to go back and forth, back

and forth just to show you what we're looking for here.

So there's an ulnar sided muscle that jumps off the ulna,

goes under extensor digitorum right there

and joins the second metacarpal pathway

of extensor communis.

So the second extensor communis tendon, you'll follow

that extensor tendon just like you would expect to see it.

But if you're counting these bundles here,

you'll count four bundles of tendons

and you might expect four to go to four fingers here.

And and for some people that's true,

some people you're going to get a fourth one to go out

to the fifth digit over here.

But it's really the two of them shoot off

and follow the second metacarpal, which is really,

really fun to kind of train your eye to pick up.

So they also share the their own retin ulu and tend sheath

and here's what they look like on ultrasound.

But if you wanted to isolate the indices,

think about index finger indices.

So communes is more of a common tendon with these

three digits here mostly and sometimes fifth.

But we're really looking at this extensor digitorum

compartment of compartment four.

And there's an indices layer.

If you were to just wiggle the pointer finger,

you would see it isolate

and trace that proximally into the muscle bellies

and then go distally and see what you find Extensor.

Digitate MiniMe, we've hinted at this a couple times,

where would it eventually go?

So small digit digitate MiniMe.

And we could see it over here

and it does have a lot of variation.

So I, I've seen this not have a branch

and it just kick off one tendon.

I've seen it kick off tendon over here to the fourth digit,

which we have, I think in a variant

anatomy in our model today

where there's a teeny tiny offshoot that that actually goes

and communicates back into the fourth.

And then there's, there's others that can have up to four

or five tendon slips that wrap around the knuckle here

and eventually become a part of that dorsal hood complex

that we'll cover in the fourth webinar.

But just be aware, this is a, a pretty fun site

to learn about anatomic variation

watching this tendon split.

There is some variation between the extensor digitorum,

communist, the the fourth digit

that will jump over to the fifth.

I actually have that in my hand. In my hand.

It shows up really nice. So I might plop the probe down at

the end for q and a or something just

to show the differences between our model that we have a,

a tiny cord off shooting from here

where it looks like it's most people's, it seems

to bifurcate here.

This tendon on our model here today, there's a trifurcation,

basically there's a teeny tiny cord

that goes right up into the fourth

and combines with the dorsal head here.

And then there's a variant Retin aum.

Our model has it, I have, and I'm not sure how variant it is

because when you look into it, there's 71%.

We will have another little retin aum

that hangs onto the extensor digit team mini right here.

And it kind of looks like it adds like a pivot point

to go over here to your fifth digit.

And here's the ultrasound.

So we've got the probe placement here,

compartment number five.

So you should just be able to lift the pinky

and get this guy to wiggle around and see it.

And then we'll trace it out distally.

But on the ultra frequency 46 megaherz transducer,

we can see those two branches already here where,

and here it's kind of averaged together.

So you have what's called volume averaging where we,

we can't resolve certain things at certain frequencies

'cause of the thickness of the ultrasound beam.

And we've got very little of that happening here.

We can see these divisions. Very nice.

Alright, extensor carpe narrows to wrap up the compartments.

It does insert at the base of the fifth. It's easy to find.

It jumps over the TFCC,

which we covered in the dorsal wrist webinar.

So we're not going to go over that again.

But we will cover the tendon and thesis here.

And it does have its own reticulum and tendon sheath.

Here's what it looks like on ultrasound,

just like the other compartments,

it's got its own strap that holds it down.

You might look for erosions here.

This pretty common spot to look

for erosions and rheumatology.

We'll get to that in webinar number three.

And here's what it looks like on our ultra high frequency 46

megahertz transducer.

So you could see it just fine at 15 megahertz or just fine.

So you thought you might catch a lot more intrasubstance

detail here if you're studying more detailed anatomy

for particular procedures,

precise needle placement, et cetera.

I think 46 megahertz as a place to play here.

Alright, let's go scan those tendons

and we will show the examples of them going out

to their trajectories and we may

or may not follow them all the way out to

their visible insertions depending on the digit.

But let me get, let me get set up for the the live demo

and then we'll we'll come back

to wrap up the top part of the knuckles.

All right, so we're going to get started, just a quick overview

with the larger linear as we showed.

And then we're going to switch over to the 46 as promised.

So here we are in the extreme radial side

to catch compartment number one

and when we're catching compartment number one, there we go.

Let the depth catch up to me here.

Remember I said that the, that the

abductor lysis longest had some variation.

And here you can already see we've got the A PL

and EPB separating as I leave the radius

and go into the suff box.

And on our model here, we've got three tendon heads.

We've got 1, 2, 3.

Instead of it just going very simply to the base

of the first metacarpal,

hers actually goes extremely palmer.

And there is insertions

that take place at the open ends here.

So we're following these heads right here

and one goes to trapezium

and the other goes to the open ends.

So I'm going to have her kind of go into a karate chop position

just to make that a little bit easier for me

and for the probe to be visualized where we're going.

But there's, there's nice variation in here to be seen.

So here's

A-P-L-E-P-B-A-P-L branching

off, there we go.

And then that one tendon head going into the open end.

All right, we'll switch over to ultra

high frequency for that one.

And I see that the time is time's counting down on me here.

So I'm going to switch over to 46

megahertz for the sake of time.

And I might just do the rest

of these compartments at the ultra high frequency.

I was going to do a comparison of the tube,

but I think you'll make up your mind based on the slides.

They were done with the 15.

So here we are compartment number one,

let's get a bony landmark.

So we've got

counterclockwise, A, P, LE, PB right here.

EPB keeps going straight A PL dives under the palm.

And there's those three heads right there.

So we've got 1, 2, 3, 1 is more direct to the base

of the first two goes.

And obliquely starts to dive

and I'm going to rotate my transducer.

You see it dive right there to the trapezium right there.

So trapezium. And then here's some muscle fibers of that.

Open ends and let's go back cross-sectionally

and see that start back all the way at the compartment.

There it is. So that most palmer side,

here's some radial nerve branches, radial artery underneath.

But we're going to follow this tendon.

And you see that tendon turned into musculotendinous

with the 46 megahertz

and very clear, I would say it's a little more ambiguous

with the 15,

but you can very clearly see this tendonous oval

branching out to the openings.

There we go. So I'm going to go back up compartment number two.

So mnemonic time if it

was longest brevis.

Now we have longest brevis. So this is E-C-R-L-E-C-R-B.

So we'll follow ECRL to its insertion on the radial side

of the second metacarpal right here.

So that's the cross section.

And everything has to be done in two planes.

We'll catch that in short or sorry, long axis here.

Left side of the screen will be proximal

and it's just so clear with 46 megahertz, I would say

that looks like the lateral epicondyle

of an elbow more than anything.

If I was, if I was glancing at this as a still shot,

I would say that was an elbow picture

until I really started seeing that, that skin.

But yeah, here's that radial side of the base of the second.

And then we would go cross-sectionally again, find our

our next tendon head.

So let's go back to the compartment.

We've got three,

or sorry, not three, compartment number two, this is ECRB.

And we're going to follow it to the base of the third.

So here's EPL jumping over it, but this is ECRB

and then you can see it starting to flatten out,

turn into a bit of a shadow, straddling that base

of the third metacarpal.

So that's third metacarpal.

And if I were to keep going, remember you see the,

the interosseous muscle start up.

So that should be a review for you right now.

So that's interossei, dorsal interossei right there.

And then here's the insertion of that ECRB.

So let's go back to its compartment

and then we'll jump over that landmark of lister's tubercle.

So no more karate chop there.

We're just going to go straight top.

I've got my finger down to the side of the patient's skin

and I'm feeling for lister's tubercle, there it is.

So here's lister's, tubercle, and here's EPL.

So let's wiggle the thumb

and we can follow that wiggling thumb,

this big oval of a tendon all the way out over the second

compartment, tendons into the snuff box.

And following the ECR or the E-C-R-L-E-C-R-B.

And then we've got extensor lysis long.

It's right here, just making it move all the

time with ultrasound.

Do everything you can just to make the anatomy move

and we can follow it out.

And it looks like it's going to split,

which is probably a variation.

I didn't see that. But you'll see it not only splits

but joins up with some of the the, the EPB.

So we'll go back up to lister's,

tubercle as a landmark.

There it is. Now let's go to the dorsal

extensor tendons right here.

So this is compartment four,

and if we were to have her point her finger, we would reveal

what I suspect to be indices,

which is the guy on the bottom.

So let's follow the guy on the bottom

and see if it goes in inserts

or originates, I should say, on the ulna.

Yep. So here it is, it, it's originating on the ulna

and she's pointing her finger

and I can see the tendon starting.

So go ahead and point your finger again up and down. Yep.

And then we'll go follow that. So that's indices.

The rest is real obvious. That's all Communis.

So she just wiggles her fingers we'll see Communis move

around and then we want to follow those

out here.

Very easy with a transducer like this following comm, Eunice

and indices, they, they travel as a pair.

This is the second metacarpal here.

And you're going to see ulnar sided commis and radial sided.

I got that backwards ulnar cied indices,

radial sided communists going right over the second

metacarpal until they reach the

sagittal band area, the metacarpal phalangeal joint.

So if I go long axis just to check my work here, yep,

here's the MCP joint.

And if I were on the radial side of the MCP joint,

I know that's communis.

If I were on the ulnar side of the MCP joint, I would know

that that is indices.

There we go. And we're up on the minute run flat out of time

to finish all of this up, let's go over here to

the fifth compartment,

which is going to rest in the radial ulnar joint

space right here.

So let's wiggle the finger.

So here we have extensor digit mini me

and I promise to anatomic variation here.

So we're going to find it. So here's digit e MiniMe.

You can, you can see it start to split

and then the split will eventually go around

that fifth metacarpal real nice.

Let's add some gel. Start to drag the skin. There we go.

Gel makes everything better. Here we go.

Okay, so instead of just two pieces,

we end up seeing this third guy right here

and that third guy

or girl wants to go split off and head to four.

And that's an anatomical variant and it may

or may not influence her ability to have a tendon transfer

as a ligament reconstruction.

So let's follow that back. I don't have that in my hand

when I follow that little slip all the way

back to the fifth compartment.

I usually just see two heads.

I just see two heads

of extensor digit mini right here.

And then finally we've got ECU compartment six.

What I like about this transducer's ability

to see the reticulum with striations,

I'd say that's pretty unique.

And you can also see probably some

septations in that tendon too.

So, so here we are in extensor Caral narrows,

jumping over TFCC over the

triquetrum onto the

base of the fifth.

And then as we mentioned, that anatomic variant,

Retin ulu is right here over that fifth compartment group.

So you can follow that shadow out laterally.

It wraps around the the ECU.

Chris, I know we've run out of time.

I'm going to keep scanning over knuckles,

but if we want to start taking some questions,

we can get the q and a teed up.

I know that I've run over on time.

- Yeah, absolutely. Yeah, if anybody has any questions,

feel free to submit them.

If you're on Zoom, the q and a box is either at the bottom

or the side of your screen.

And if you're on one of the other streaming services,

go ahead and put your questions in the chat box

and we'll be able to get to those.

- There's just so much to talk about when you

start adding frequencies like this.

It's just truly amazing.

So here I am back following that,

that second metacarpal that I've got, the extensor

digitorum, communists

and indices just bordering each other there.

There we go. That's how we were oriented earlier.

So screen left would be ulnar screen, right would be radial

metacarpal head muscle bellies in the middle.

We've got our, almost trying

to quiz everybody here first, muscle belly,

second web space.

This will be the the second dorsal

interossei or interosseous.

We can go over to the third web space.

We can see the third interosseous,

but way more cool to see the little neurovascular

structures that are out there.

And it can be a lot to take in to see that kind of anatomy.

So you can activate what's called trapezoid mode

and we can make this more of a wide angle view.

So let's do that really quick over

the dorsal wrist compartments.

I'm just going to activate trapezoid,

make this a little bit bigger picture on the sidewall.

You'll notice it just got a little bit bigger,

probably not necessary to get that bright.

I think zoom was a little over regained. There we go.

But where there's anatomy, that's typically a,

a big challenge is just picking out these little variants

of the extensor tendons

because it's very helpful when you could find a variant

tendon that could be used

for a tendon transfer and orthopedic surgery.

Like maybe a,

an ulnar collateral ligament reconstruction on the thumb.

If you can go grab a an extensor tendon

that's redundant somewhere.

I think that that definitely

saves everybody a little bit more incisions

and other body parts looking for other other portions.

Here's a little sneak peek of the advanced webinar.

We're just going to go right over her on her

collateral ligament in the thumb.

We will cover the UCL in depth on the advanced,

but here's her UCL on the thumb.

Let's give that a wiggle on top.

See the app in a roses, move around

and still no questions.

I take it. I know we've gone over on time.

I want to be respectful of everybody's time.

- We do have one question that just came in. Perfect.

We have please show us your technique

for evaluating cortical fracture in either metacarpal or

- Phalanges.

So we're going to cover that on the bowler hand,

but just at, for the people that have stuck around,

it's kind of nice 'cause our not really nice,

but our model here has been recovering from a voler

plate avulsion.

So if you, you know, go ahead

and flip your hand over, we'll see that she's got

a very irregular voler plate surface.

I know we didn't go over this anatomy

and we will on the next webinar next week,

but the, the bone should look nice and smooth.

Let me go to the neighbor like this right here.

And then here's voler plate, this homogeneous tissue here.

Joint capsule, flexor tendon.

But the voler plate should attach here really smooth

and we shouldn't see anything floating out in the,

the voler plate tissue.

But as you're scanning for fracture, you really want

to scan back into the structure

'cause we're scanning a cylinder, right?

So I have to scan up and over

and back into the center of the cylinder.

Now this was a union that started to heal up.

I I think the injury's three months old now, maybe four.

But it's, it's been neat to just kind

of follow it on ultrasound.

But yeah, seeing, seeing Avulsions

is very useful in ultrasound and if they're moving

or not was one of the big questions the surgeon had.

But yeah, we're looking at a fracture right there.

I would say we're four months into healing

and always confirm things in two planes.

So we're looking for a step off deformity here.

So let me go back to the normal knuckle here.

So we have a normal volar plate here.

I'm going to go distal so I know I'm at the proximal edge

of the middle phx right there.

And then I'm just going to pick a side, you don't want

to go dead center and you want to pick a side

and we're going to follow this lip

until it reaches the homogeneous foer plate right there.

Nope, I went the wrong way. Okay, so

that's proximal edge of the middle phalanx.

This is the homogeneous foer plate.

Now let's go to the bad one.

So proximal edge

is here and then we start

to see these little bony flex hanging

out in the boulder plate.

So we don't want to see that. But see the angle I'm having

to maintain so that I don't lose one skin contact.

Two, I want the echoes to reflect back really nicely.

So I have to maintain perpendicularity

to the center of the object.

I'm scanning. So in this case I'm mentally just trying

to aim my beam to the center of the cylinder And

to put things into two views,

you always want to split your screen

and have a have a two view

and one so left side would be our short axis view

of that bony avulsion looks a lot better than it

did four months ago.

All the tissues are way more connected now,

but you can see just how irregular that is.

And then I'll go here and go long axis

and you'll see that little bony edge

hanging out and I'll hit save

and we could compare that to a traditional linear

and just see what we see

for anybody that's still hanging out.

It looks like we have, I don't know,

we still have almost 30 people here so I'm going to switch

to the regular linear while we wait on the next question.

It's been a while since we've looked at this. Might as well.

There we go. So you can see

it and I have to aim right back into it.

So this, this probe is definitely putting things more into

context when it comes to the wide field of view.

But if I were going over fracture assessment,

I always caution people at the flexor tendon insertions

because there's little tubercle on the sides.

The mid shaft of the middle metacarpal right here.

So this is a good place to practice not getting

faked out by a fracture.

'cause that's not a fracture, that's the insertion of the

superficialis layer of your flexor tendons.

But you got profundus in the middle

and superficialis dives down to the side

and we're going to go over that in in great detail next week.

But that's a pitfall to practice.

Hey, am I seeing a fracture or not?

Does it look like this or not?

And then you would go and short axis

and see that that's just a ridge

of flexor tendon insertion right there.

See that ridge? So you're just catching the

ridge in one slice.

But if you obliquely slice it, then you're going to end up with

something that looks like a fracture and it's not.

Good question. And as painful as it sounds,

you can also just try to displace the fracture a little bit,

make it move, apply a little pressure.

'cause I've seen and heard of many cases

where x-ray misses a small fracture

but you can actually get the fracture to move a little bit

with ultrasound and document that.

- Alright, well I'm not seeing any other questions

so I think we could probably close this one out

before you get too far into the next,

into the next week, the next webinar.

Yeah,

- Already already practicing here. Yeah.

- Alright, well thank you so much everybody for joining us.

You can see on the screen here, this is the,

this is the schedule for our next parts

of the the hand webinar series.

You can see that the next one is going

to be on September 16th

and that's the Voler hand that Daniel was talking about.

And then on September 29th we have the arthritic hand

and we'll be joined with Dr. Daniel Malone for that one.

And then on October 7th we'll have advanced hand

and you can go ahead and scan the QR code there to get

to our webinar series page.

I believe just part two is up for signups, but part three

and four should be up there shortly as well.

So I'd like to thank Daniel so much

for this incredibly in depth look into the hand here.

And thank you all for joining us for our introduction

to the Dorsal hand.

Dan, thanks again for joining us.

We appreciate you sharing your expertise

and thanks everybody else for joining us today.

We'll see you at the next one.

- Thanks everybody.

Evaluating soft tissue, connective tissue, and neurovascular structures of the dorsal hand is made possible with ultrasound and now elevated with Sonosite’s new ultra-high frequency transducer: UHF 46-20 MHz. Join Daniel Shelton for Part 1 of the Diagnostic Hand Ultrasound Series: ‘Introduction to the Dorsal Hand’ to review superficial anatomy of the dorsal hand, the benefits of ultra-high frequency for detailed precision, and learn techniques that help enhance image clarity and distinguish tissue layers.

What You'll Learn

  • To select the optimal transducer for imaging superficial structures of the dorsal hand.
  • The applications and advantages of scanning the dorsal hand with ultra-high frequency.
  • To apply transducer handling techniques to help enhance image clarity.
  • Dynamic maneuvers to help effectively distinguish tissue layers and planes.
  • Benefits and limitations of hand ultrasound.
Daniel Shelton
Presenter: Daniel Shelton, RT(R)
Job title: Director, Musculoskeletal Market Development, FUJIFILM Sonosite

Daniel Shelton, RT(R) is the Director of Musculoskeletal Market Development for FUJIFILM Sonosite. Daniel spent 18 years as a dedicated musculoskeletal sonographer and 12 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.

This educational webinar is intended for healthcare professionals and not for patients or consumers. The material is provided for general educational purposes, as a reference and a supplement to professional experience, education and training, and should not be considered the exclusive source for this type of information. This educational webinar is not intended to recommend any device for a particular indication or to provide indications for use for any device. At all times, it is the professional responsibility of the practitioner to exercise independent clinical judgment in each particular situation. Fujifilm assumes no responsibility or liability for any misuse of the information imparted in this webinar. This educational webinar does not supplement, replace, or supersede device labeling, including instructions for use, which accompanies any FUJIFILM Sonosite product.