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https://www.youtube.com/watch?v=BUivky-BLtY
Transcript

- Thank you all for joining us.

Welcome to the webinar Diagnostic Hand, ultrasound part two,

introduction to the Voler Hand.

My name's Chris Pennell and I'll be

moderating today's webinar.

This is the second webinar in a four part series on the hand

and you can check out the first part

and sign up for the next part

of the webinar series on sono

site.com/behind the scan webinar.

And you can go ahead and scan that QR code

that's on the screen right now to go to right

to our webinars page.

All of our previous webinars are also up there, so feel free

to take a look at those archives

for 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 them at the q and a session.

If you're on the zoom stream, you can type your questions

into the q and a box in the toolbar located at the bottom

or the side of the screen.

And for our viewers on YouTube at LinkedIn,

you can enter your questions in the chat box.

This webinar will be recorded

and will be featured on sono site.com

and on the Sono Site Institute.

Here with us today we have Daniel Shelton.

Daniel is the director of musculoskeletal market development

for Fujifilm Sono site

and Daniel, Daniel has spent 21 years

as a dedicated musculoskeletal sonographer

and 16 of those years have been here at Sono site.

He now leads 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.

- Thanks Chris and welcome everybody.

This is part two, it's Chris mentioned

and a little bit about the equipment today

because we are on the hand.

I will start off by presenting on the L 15

to four linear array transducers, the most common

transducer I think everybody gets when they start,

especially with the soy machines.

This is the workforce transducer

and then we'll be transitioning in the live demonstration

between either the L 19

or the new newly released ultra high frequency, 46

to 20 megahertz transducer.

Just as kind of a nice preview of

what you can see in the hand.

Maybe it applies to your research solutions

or really, really detailed clinical practice.

So let me click over to the slide, get us started here.

Alright, so we're going to go ahead

and get started on the quick talk, mostly a review

of the bones and some of the indications.

So we'll talk about the A IUM statement of the,

the indications for doing ultrasound on the hand.

In general, these aren't specific to dorsal or volar

or fingers, but we did,

we did go over these in the last webinar.

So if you didn't catch all those and

and us talking about that and go back

and catch the part one for this part two, we're going to stick

to the bony landmarks which change a little

bit on the Waller hand.

We're going to go to the interosseous muscles, flexor tendons,

lumbrical muscles

and if there's time we'll get down to the flexor tendon

and pulleys of the finger.

But that'll very likely also be kicked to the,

to the advanced section.

We'll cover more detailed finger

because we have extensor hood to cover on the advanced,

so maybe keep an eye out for that to be added

to the advanced section since we'll already be talking about

the extensor hood complex uses

of ultrasound in the bowler hand,

very similar to the last one.

Mostly solid cystic i I think is going to be a

big answer for you.

High yield would be, you know, ganglion cysts for example,

or tendon tears if if it's a retracted

tendon or a ganglion cyst.

We see that quite a bit in the hand.

Muscle atrophy will be a big one.

We're going to go over all these muscles

and if you have muscle muscle wasting in the hand,

you might want to go check out the nerves

and the nerves will be covered in the advanced part.

Four bones of the ball are hand very similar,

so I just kept the same graphic.

We do have the same distal radius and ulna carpals.

We have a first and second carpal row.

Metacarpals didn't change, neither did the rest

of the carpals, so we're just going to keep going here.

Starting at the wrist crease, they're about a little bit

after or distal to the wrist crease.

We have two bony prominent landmarks.

On the ulnar pinky side we have the hook of the hamate

and on the thumb side we have the trapezium

and that's going to bridge a gap here.

We'll talk about a little bit of the carpal tunnel later,

but we are going to reference hook

of the ham eight quite a bit when it comes to the origins

of some of these hypothenar on the,

on the pinky side of the hand.

And as we scan a little bit distal, you can see the region

of interest has changed down here to more

of the palm getting into the palm.

We've got the second on the radial side, third in the middle

and fourth base of the metacarpals.

We'll talk a little bit about tendon insertions from the

forearm on that and origins of some of the, some

of the tendon heads of the hand.

Oh, I clicked once too far. Go back one.

The mid shafts of the metacarpals look the same

as dorsally, just deeper.

And so there's more posterior acoustic enhancement.

They, they do look a little bit brighter.

They have a more interesting surface on the Waller side

because some of the muscles originate

along the mid shaft of these metacarpals.

And we're going to focus mostly on the cross section

because it is the best way to survey the

hand and the live demo.

We'll switch over to long axis of each of these,

but the best reference for the hand is

to get really familiar with cross-sections.

We're going to stick with cross-section on these.

And then as we go distal, we travel towards the metacarpals

metacarpal phlange joints,

but without quite getting into the joint space just

before the joint space is a volar plate

that we'll talk about towards the end.

And in between these volar plates,

there's a big thick connective tissue layer called the inter

metacarpal ligaments or the transverse metacarpal ligaments.

And these are great landmarks

to differentiate the superficial layer from the deep layer.

For example, there's a muscle belly here,

we'll go over here shortly called a lum brickle

and it stays shallow to this ligament

and the deeper interosseous structures dive deep

and then the flexor tendons stay on top

and the tendons

of the interossei stay towards the dorsal hand for example.

And for that, let's just survey the bones really quick

and there are contours

and some of the tricky areas where they cast shadows.

One sec while I go to the live demo.

All right, just like last time, we've got the hand here

with two camera planes kind of go off of,

we've got a top view and a side view.

So everything is kind of seen orthogonally.

I'm going to lay down some gel right at the

beginning of the wrist crease.

That's a good landmark to go off of here.

We're going to go distal to the wrist crease on the pinky

side on the pisiform.

It's easy to image, easy to

palpate even though it wasn't on the PowerPoint.

Okay, so left side of the screen is ulnar,

so that would represent this side of the screen, this side

of the screen's over here, the right side

of the screen would be the thumb side.

You can see these things move a little bit, hold on,

let me get an arrow up so we can start

talking about the landmarks.

So let me go back to the risk crease

where we see the pisiform, which is not on the PowerPoint

and I apologize for that.

But it is on the carpal tunnel PowerPoint if you want to get a

good idea of all these layers.

But if you could find this palpable pisiform on the pinky

side and over here you don't

so much palpate the scaphoid side.

So we stick with the pinky side.

So if you pull the transducer towards the pinky side a

little bit or towards distally a little bit,

you'll see the bones drop off

and we get another bony landmark

and that's the hook of the handmaid.

We will plant the hook of the handmaid side of the probe

and windshield wiper the radial side of the probe.

And we see the trapezium tubercle right here.

How do we make sure that's not the cavo?

We sweep proximally

and we can see the scaphoid here

with a tendon on top called the FCR flexor carpi radius.

And we can sweep distally

and see the flexor carpi radialis sitting in the groove

of the trapezoid.

Here we see the floor of the carpal tunnel

and the tendons inside the tunnel,

but if we move distal in the tunnel,

we can see the two distal bony landmarks which make up the

distal carpal tunnel.

And then we scan distally

until our transducer goes over the proximal metacarpals.

Now we can see these shadows

of the posterior acoustic enhancement

because of the posterior acoustic enhancement

of these muscles on top, on the pinky side

and less posterior acoustic enhancement is

because we have all these tendon edge artifacts

that don't have so much muscle water filled muscle.

It's because we see these edges casting shadows on the sides

of the tendons and it makes the shadow under the tendons

create a blurrier shadow than the enhanced shadow

of the muscles on each side.

So as we go over here to the palm, towards the thenar side,

which is the thumb side will describe the bones

of the thenar side.

If you were to ultrasound fracture for the hand,

for example, it would be tricky to ultrasound

fracture down the middle

because of the edge artifacts

until you get these posteriorly acoustic enhanced

bones from the, from the muscles

because the muscles are more water dense.

But bones can also be tricky to image in the hand

because of these ridges on the

bone in the middle of the bone.

So if you slice a ridge

and long axis slightly obliquely,

you can artificially create what looks like a fracture

where you're just slightly obliquely slicing

a ridge in the bone.

So here we see that right here we see this little shadow

that's cast from what looks like a lip

or it looks like a step off deformity.

You want to be careful of that

because it's not a fracture,

it's just you obliquely slicing these ridges

where tendons are inserting.

Now we have a muscle here that we'll go over later in the

PowerPoint as a, as a great reference point,

but you can see where the long shafts of the bone can

can create a bit of a problem if you're trying

to assess a fracture

because of these ridges where tendons attach.

So that's why we stick to the cross section when it comes

to the hand for the most part is these big muscle landmarks

to help you count structures and see muscles.

As we go distally, we see the metacarpal heads flatten out,

there's a little fibro structure sitting on top

of the distal metacarpal head.

That's more for an advanced structure on PowerPoint number

four, part four of the hand webinar.

And then the inner metacarpal ligament

or transverse metacarpal ligament is a good landmark here.

So we're going to use that as a landmark of where

to stop when we're ultrasounding the hand.

As we go more distal to that, we, we start to see muscles

that taper like the lumbrical, dorsal interosseous

and pulmonary interosseous

and the lumbar lumbrical are a primary part of this exam.

So we're able to trace lumbrical really easily

because they're not so deep

and we're able to start really

superficial and count our way down.

But how far distal do you go?

You you stop basically at the transverse metacarpal

ligaments or transverse, yeah,

transverse metacarpal carpal ligaments here.

So on a separate part of the exam, we'll go over the thumb.

It has unique musculature,

but we're, we're pretty much going to stick

around the middle of the palm.

For this part of the PowerPoint.

We're going to focus on the palm, the shadows that are cast

and how far deep in the image can you see?

You can, you can basically see all the way through the hand

with most transducers.

In fact, you can see if you just poke on the bottom

of the, of the of the hand,

we could see all the way through the hand musculature.

As I mentioned this larger linear is great

for the hand for surveys.

You may want to get into more detailed looks at the hand

with something like a smaller 19 to five megaherz

footprint where it fits into those web spaces nicely.

We also have a 13 to six hockey stick

also fits into the tight spaces.

And then we'll get into the, the more advanced stuff

with our 46 to 20 megahertz transducer later.

But we go back and find a stopping point here

and we will start up our next round of slides

for the muscles and tendons in the hand

as we talk about muscles in the voler hand.

I I will say we're going to stick to cross-section again,

there are some beautiful long axis images

that we could obtain here, but cross-sectionally is

where I want your mind to go

and it's, it is just going to be the best

way to tackle the hand.

Long axis structures are typically very easy to find.

It's the cross-sectional ones that you really have

to wrap your head around for spatial kind

of cognitive commitment to what each layer is doing.

So let's tackle the muscles of the hand again, kind

of like the dorsal webinar.

I've got the graphics blinking for layer for layer.

And we're first going to start off with the dorsal inter oii.

Again, think about dab DAB, the dorsal

or responsible for abduction or spreading the fingers apart.

The origin of these are the sides of the metacarpals

between each web and they insert at the,

the first one inserts at the radial base of the second

and the second on the radial base of the third.

And on the third on the ulnar side, you see it switches and

because these are responsible

for pulling the fingers together.

So on the, on the third dorsal interi, they,

they switch sides a bit

and go to the ulnar base of the third metacarpal.

And then on the last one, the fourth one goes

to the ulnar base of the fourth.

So you can see those in the graphic here,

these little thin little tendons, they, they tend

to all point towards the middle finger.

So just imagine that middle finger is the center point

and that these dorsal interosseous are in each web.

So there's not a web that they're not in.

And there are four of them

and they do between each web make their way

to point to the middle finger.

So the first web, for example, it can't cross over here.

So it's got to stay on this side

and it's going to point towards the middle finger

by inserting on this side of the second digit.

Same thing on the opposite side.

When we come over here to the fourth web, you can see

that it, it originates on five and four

and points itself over to the middle finger again.

And then when we get into the second

and third webs, they just straddled the, the, the gap

between the metacarpals and point

to the mid shaft of the middle.

Again, palmer inter oii, there's only three of those.

So seven inter oii total.

And just think pad, which is pretty easy to remember.

We're talking about kind of the palm, the pad.

These are, these are deeper,

these aren't the more superficial ones.

So they're not on the dorsal side,

but they're on the, the pad of the hand.

So responsible for ab that says a, a B deduction,

it should be abduction.

So that's my mistake here. It should,

this should say abduction.

So this brings the fingers together

or adds them to the body.

So think about it that way. So you can see these guys,

they're subtle, they're small and sometimes hard to trace.

But we've got the, the first palmer inter oii right here.

And it origin is the mid shaft of the second metacarpal

and it inserts on the ulnar base

of the second proximal phalanx.

There are contributions of these fibers that go

to the dorsal extensor hood,

which will cover in the advanced portion.

The second jumps, skips the middle finger completely

and goes all the way over here to the fourth digit.

And its origin is the bowler mid shaft of the fourth.

And it inserts on the radial base of the proximal phalanx,

also contributes fibers to the dorsal hood.

And then the third, the last one you see it originates on

the radial base of the fifth attaches, same

away from the middle finger.

There's kind of a pattern there. These all they, they try

to point themselves away from the middle finger,

not towards the middle finger

because they're responsible

for bringing the fingers together.

So they have to think about

that mechanical leverage right here you've got this little

blinking muscle here, it's going to pull the pinky towards the

middle finger whereas the dorsal inter ossi have a tendon

to spread the fingers apart.

So that's one great way to remember it.

And there's only three of those on the bottom,

other muscles that involve the hands.

So we do have the flexor carpi radis,

which is a wrist structure that we typically talk about

and we went over in a little bit

of detail in the carpal tunnel webinar.

But blinking down here, you can see its path

that traverses over the carpals.

Second, the proximal and and distal carpal row

and sometimes splits to insert on two of the base

of the metacarpals, but primarily the base of the second.

And, and, and it's responsible for flexion of the wrist

and will also aid in abduction of the hand.

So it is an important structure. You can have injuries here.

It does dive very steep.

So this is, this is following the palm of the hand,

not rocking the transducer.

So it travels past the trapezium here.

We'll go cross-section in just a second.

But you can see how it dives like a

biceps tendon, the elbow.

So you have to accommodate for that, an isotropic here

by rocking, putting distal pressure on the transducer

and it will level that tendon out

so you can catch those fibers.

Really nice transverse carpal ligament is a

landmark that we're going to have for the rest

of these muscles also

because many of them, as you can see on thenar side and

and the hypo thenar, they will originate from parts

of the transverse carpal ligament sharing,

sharing their fibrous origin.

So we've got handmaid or hook of the handmaid over here

and trapezium, the trapezium has a little tunnel,

this groove here that the flexor carpe

radiologist travels through.

And this other little tendon that's highlighted, which is

inside the tunnel is your flexor lysis longest.

We covered that in the carpal tunnel webinar.

So if you wanted to see that

and how it differentiates itself from

inside the tunnel versus outside the tunnel, go back to

that carpal tunnel webinar and check it out.

But for the purposes of this, this talk, we're going to,

we're going to follow the FCRs, it travels distally.

I think it's helpful to take that

trapezium tunnel right here, this groove.

And we'll go back one slide so you can see

it leaves the trapezium

and dives that diving shadow has to be corrected

with distal transducer pressure.

So we'll go back where we were Right flexor lysis long,

this is probably the most fun tendon to image in the hand.

It's a big easy tendon to to visualize.

It's highly susceptible to an isotropic artifact.

So this is a good one to practice that on. And short axis.

If you don't see this tendon loading in this in the sea

of muscles, it's because you don't have it in the right

angle and we'll do that in the life scan.

But you just want to toggle your transducer,

make this tendon go in

and out of an isotropy versus maximum reflection

and then go long axis and really check it out

and then wiggle the thumb or flex the thumb

and watch this tendon move.

It's a beautiful tendon because it's easily highlighted

by the posterior acoustic

enhancement of the surrounding muscle.

The overlying muscle is more water dense,

so it's going to enhance whatever's under it

and it makes it look really, really nice.

It does insert to the palmer aspect of the base

of the first distal phalanx.

Like I said, it's a great tendon for dynamic maneuvers.

It's blinking over here and it's pathway.

Okay, so now that we've kind of built up the back

of the hand, we're going to work our way over to the pinky side

or the fifth digit side.

This is the small digit

and digit MiniMe

as we covered in the dorsal hand means small digit.

So this is the small finger

and anything that references the thumb will be called lysis.

So lysis means thumb or of the thumb.

So there's also a pattern here

between both on these meaty kind of muscles.

When you feel the palm here on the pinky side,

I'm going to start with the deeper layer called the open ends,

which just means opposite or opposing.

And it's responsible for touching this pinky

and the thumb together or this pinky, if you can get it

to touch these other fingers.

It basically is abducting the hand together from

the metacarpal level.

It originates from the hook of the ham eight

and the transverse carpal ligament

and search near the ulnar aspect of the shaft

of the fifth metacarpal.

So it's blinking here.

And next we're going to work our way superficially

and just remember this pattern, it's open ends

and then the next one is flexor and then abductor.

We're going to get to that. And it repeats on the thumb side

too, so it's open ends flexor and abuc abductor.

So just watch that pattern.

So it's less intimidating when you see this stacking

of all these crazy muscles here that it,

it's not that hard to remember.

If you can just remember that they repeat on both sides

and they just change names from small digit to lysis.

That's the only thing that changes is about the name.

So they repeat their order, the name changes

because one's going to the small digit

and the other's going to the lysis, which is the thumb.

All right, so the next digit here we've got

the next muscle is blinking,

is the flexor digit mini me originates again at the hook

of the handmaid transverse carpal ligament inserts on the

ulnar side of the base

of the fifth proximal phalanx way up here.

So it passes the MCP joint level.

Now we've got the function of the abductor,

so the abduction digit minimi.

So think about this, it spreads the pinky out.

It's going to see the leverage you get on this.

This tendon actually travels all the way up past

the DIP level.

It originates on the pisiform this time,

so it's a little bit more proximal.

So you see the illustration has this tail coming off all the

way down to the pisiform and then it wraps

superficially over all of these.

And it's kind of for usually the first one that you see.

We saw it when we laid our hand on the table in the

first dorsal webinar.

It inserts on the ulnar side

of the base of the proximal phalanx.

Some contributing fibers go up to the extensor hood.

It's pretty easy to follow. Now we're on the thumb side.

Remember we have a pattern it's going to repeat.

So we have this deep guy here.

It's the O open ends, the opposing one.

It's the one that lets the thumb come touch the pinky.

So lysis means of the thumb.

So don't forget that it originates at the transverse carpal

ligament and the tubercle of the trapezium and the scaphoid.

So way down in here. So we don't see those deeper fibers

going to the trapezium and the scaphoid,

but you see how wide it's footprint is when it,

when it originates here.

Next we've got the flexor again.

So just like the digit side,

we went from open ends to flexor.

Same thing on the lysis side.

We, we went from open ends to flexor.

The only difference is there's a superficial

and a deep head that are pretty common and easy to see.

If you catch that FPL tendon,

that was really fun to look at.

And you oblique your probe, you'll elongate the fibers

of the muscle, not necessarily the tendon.

And you get this really, really pretty straddling muscle

that goes up and over, kind of like it looks like

a feather shaped muscle going on each

side of this tendon here.

So the superficial head originates on the transverse carpal

ligament and the trapezium tubercle, if you want to chase

that down, it's kind of hard to do.

Deep head originates at the trapezoid and the,

and the capitate and the palmer ligaments of the,

and the distal carpal bones.

Sometimes it's absent though, it inserts on the radial side

of the base of the proximal phalanx

and the radial side is sesamoid.

So you're going to be looking at it there.

Actually that's a, that's a typo. It's the ulnar side moid.

So go look for it at the ulnar moid.

And then we have that last one.

The more superficial one,

it repeats exactly like the pinky side did.

It's the ab deduction or the abductor lysis.

Brevis originates from the transverse carpal ligament

and the scaphoid and the trapezium tubercle,

it inserts on the lateral side of the base

of the first proximal phx.

So we see it up more shallow, more superficial, same

as the repeated pinky side.

Right? So now that we've built up the walls of the palm

of the hand, we're going to go through the middle

of the hand now and introduce this really cool transversely

oriented muscle

that we saw in the dorsal hand is a landmark.

So this is the oblique head.

If you start from distal

and work your way proximal, the oblique head is larger

and this is the adductor lysis.

So abduction or adding to the body.

So taking the thumb and adding it to the rest of the hand.

Lysis meaning thumb.

So this is the tendon that does attach to the thumb.

So it originates at the palmer surface of the capitate

and the base of the second

and third metacarpal inserts on the ulnar side of the base

of the proximal phalanx.

As we travel further north,

there's a broader muscle, but it is thinner.

So these two kind of switch where the,

the bottom one is less broad but it's thicker.

The top one or the more distal one is thinner

but more broad across the the third metacarpal shaft origin.

So this is the adductor, again lysis,

but this is the transverse head.

It originates on the palmer surface of the shaft

of the third metacarpal inserts on the ulnar side

of the base of the first proximal phx.

It does have that contributing a neurosis that

that we will talk about on the advanced webinar as it wraps

around, becomes the dorsal hood complex.

And we get the ulnar collateral ligament exam

or what you might have heard of is a st thinners lesion that

that's the, the origin of that, a neurosis

that we'll go look at in the advanced webinar is

this giant muscle here.

Alright, let's move over to the live demo.

So as we talked about, we left that, that wrist crease

and we're going to work our way distally.

And then we're going to take a look at the walls.

I call it the walls of the palm. Remember that?

Repeating patterns, we're going to image that really quick.

And then we'll work our way down the middle

with the adductor complex there.

So add a little bit of gel.

We should have done that before we got started.

Okay, so that last landmark, you can see this really cool

triangle that's formed at the palm

and it puts everything into those groups

that I just talked about.

So down the middle we've got these tendons

that will end up being the flexor

tendon and they go to the finger.

So for this part of the exam,

we're going to ignore this whole layer in the middle

where you see these stacked balls.

That'll be the second part of our live demo.

Or third, if I go to the thumb side screen right,

you can see how this, this triangular pattern

of the carpal tunnel opens up

and outside the tunnel are these big muscles traveling over

to the first metacarpal.

And we're going to follow that first metacarpal

and those thumb structures right here.

Okay? And then the same angle,

just opposite side follows the fifth metacarpal

creating those walls, the pinky side walls of the palm.

And then let's go down the middle.

Remember remember we did the bones earlier,

so we're going to go just shallow to the bones.

So metacarpals again,

here's that, that transversely oriented, really big

landmark adductor lysis, it adds to the body

and you can make it move and everything in MSK, ultrasound,

just make sure you're making it move if,

if there's any question of what something might be.

And as we go distal, you'll see that that fiber disappears

and there's a gap between the adductor layer

that we just covered in the PowerPoint

and then the structures underneath it down here.

So the structures underneath it down here

where your interossei come into play.

And we're going to ignore lumbrical

'cause we're going to do those last.

And we're, we're just following everything

that's bordering the skin.

So here's the table. So we're going to be

scanning all the way through that.

Here's that first dorsal interossei.

First dorsal interosseous.

And because the dorsal interosseous occupy each web, we know

that over here we have the second dorsal interosseous.

Let's go over here to the third. Third dorsal interosseous.

And then the fourth dorsal interosseous.

Now enter meaning between osseous bones, so between bones,

that means if I go further lateral,

there's no interosseous over here

that's out there to the table.

And those meaty walls of the palm

that we kind of talked about earlier.

So we've left the boundaries of where I expect

to find anything interosseous related.

And then remember in the PowerPoint we talked about

how there are three palmer interosseous muscles

and they skip the middle finger altogether.

So we're not worried about palmer interosseous muscles

starting on the middle finger, at least a normal anatomy.

But on the first I do expect to see a palmer interossei

or palmer interosseous right here.

So this is the first palmer on the second. Okay?

And we could follow that muscle belly out.

And then I promise some long axis picture.

So let's, let's take this here where I expect

to see a long axis muscle here

and a short axis muscle on top of it.

So I'm just going to spin the probe, keeping

that metacarpal in place.

We have a short axis ad adductor, so

that's moving right there.

And then underneath it is a

long axis Palmer interosseous

'cause it's closer to the transducer.

So right where my arrow is, that's a palmer interosseous.

So palmer and dorsal palmer dorsal.

And then here's that adductor, that big, that big landmark

that's in the middle of the palm right there.

We'll go short axis again, follow it over

to the next web space here.

This is the one that involves the middle finger right here.

So third digit, I don't expect

to see pulmonary interosseous on either side of it.

And I could come over here to four

and on four I expect to see a palmer interosseous

right here in the ulnar side.

And they're very hard to trace past that ligament.

That's why I say the ligament's kind

of a good place to stop.

You can try to trace past that ligament

and get really, really frustrated.

You can follow the little heads,

these little bright spots right here.

These are tendon heads. They're about the only thing

that continue to show between the metacarpal heads.

The muscles not very impressive.

So don't be

frustrated if you can't trace these muscles past that level.

They mostly turn tendus and turn into sagittal band

anatomy for the advanced webinar.

And then over here in the last web space,

we have a pulmonary interosseous on the fifth

and we could trace it down also.

So that's your row of inter oii.

And remember there's a little ball, a little space right,

right here, actually middle finger where I expect to go.

Proximal, proximal, proximal.

And then we see this big transverse,

or I say transverse,

it's a longitudinal muscle transversely

crossing the whole palm.

And to me that's the home base

of a hand exam is the adductor.

And it's a home base of a hand exam

because it's in the middle of the hand.

It goes against all the other fibers that we're evaluating.

So it's a good landmark to say, okay, I'm,

I'm distal to that landmark.

I'm proximal to this landmark

and it's a, it's the most, I think, movable landmark.

To get yourself oriented, all you have

to do is just move the thumb a little bit

and it will tell you where you are in the palm.

So the bigger that moving thumb muscle, the adductor a d,

D for add, the bigger

that muscle belly, you're on the oblique head.

And as you go distal, distal, distal, see

how I'm holding the transducer?

Pretty stationary on the radial side

and I'm windshield wiping the palmer side.

And then you get a thin band that's your transverse.

So transverse is thin but more broad.

Oblique is thicker but shorter on the footprint.

And you can track that footprint down to the middle.

Metacarpal the third right here.

And the oblique head has

origins all the way back to the capitate.

Nobody really looks back that far.

It was just fun to find

for the purpose of this presentation.

But what you're looking for is muscle wasting

and atrophy due to nerve compression of radial

and ulnar nerve branches here, which we'll get into the,

the advanced webinar, we'll go over those.

So after we've traversed those big easy to scan structures,

also get long axis and short axis.

So here's your long axis adductor lysis will go short axis,

adductor lysis.

And then we can follow that short axis structure right on

top of the metacarpals.

So that's metacarpal two

and then three, you see it dive down to next to nothing.

We're going to add some gel to the palm right there.

So here we're just following that transverse structure

as it dives down, down, down, down to the third.

And then you'll see those contributions that

or originate all the way back here to the capitate.

All right, so now let's go to thumb and pinky.

So remember there's a repeating pattern here

on the thumb side.

The deep one on both.

Okay is think about that test that you would do

for a pul MaRous longest, we covered

that in the carpal tunnel PowerPoint.

When those two come together,

you're going to activate the open ends and the open ends.

Let's just wiggle the thumb towards actually the whole

metacarpal, maybe even roll the metacarpal.

But the open ends will be this,

this deepest layer right here.

So we have open ends

and then little bitty fashion plane right there.

And that would be where the flexor portion

of the lysis starts.

So open ends plys flexor polys,

abductor abductor lysis.

Remember ab deduction is away from the body.

So when she spreads her thumb out, it'll activate

that most outer muscle.

A deduction.

Adding to the body is that big transverse landmark

that we were working with earlier.

So you have adding to the body adductor lysis

and then you have abductor pulling away from the body.

So spread towards my hand.

Yep, you're activating that most lateral part

of the thumb there.

So that pattern just repeats.

It's easiest to do in cross-section

where you have open ends flexor

and abductor, you can check 'em out in long axis.

I just think it's, it's a little less useful than the short

axis 'cause you get volume in the short axis

and they're so close together depending on the health

of your patient's muscle content, if it,

if it's super healthy muscle, it'll look just like this

where you have this hypoechoic muscle all the way

to the border, the fascia between the next one,

if it's less healthy muscle, you might get a more fatty rim

around the muscle making it easier to see

and delineate that that line.

But in our patient here today,

I don't see any delineation between fascia here.

So what you would have to do is move something

and get it to, to cause the fascial plane to move.

All right? And so on the flexor side, remember we,

we called out flexor lysis longest earlier right here.

And on each side of flexor lysis longest you have a flexor

lysis brevis.

So you have a brevis muscle one and a brevis muscle two.

So you, you have a superficial brevis

head and a deep brevis head.

And I'm stopping my arrow here

because if I go deep to that,

this little fascial line right here, we get into adductor.

And if I wanted to find out if that was adductor

or not, just knowing

where the adductor in search right up here on the inside

of the thumb, what I can do is just twist the MCP joint.

So I'm going to grab her thumb and I'm just going to twist it

and you'll see the underlying muscle differentiate itself,

especially in that slightly oblique long axis right here.

So we'll go to this plane where we had that, the abductor

lysis right here, the deep head

and superficial head in the PowerPoint right next

to adductor right here.

And all I'm going to do is just make it move by moving

and twitching the fiber by twisting the MCP joint

or even bend the DIPA little

and cause a little bit more leverage.

But that's how you get that fascial layer to show itself.

You just want to kind of twist

and rotate the thumb a little bit

and you'll get the layers to show themselves that way.

So you can see that this,

this whole layer down here is rocking back

and forth when I take the thumb and twist it back

and forth, harder

to do with the whole thumb I've found, just grab the, the,

the IP joint down there and just twist.

Okay? So that's the difference between your superficial

and your deep head of your flexor

lysis brevis with the flexor lysis.

Longest tendon in the middle, like I said,

this is the easiest one in the thumb I think the most fun.

And if you are teaching M ms K ultrasound to beginners

or your beginner yourself practice that artifact,

the angle artifact right here on on FPL

'cause it's such an easy tendon.

And watch how very slight of an angle it takes

to make a tendon disappear

and look like it's completely gone.

So practice your inotropic artifact here

and then I'm going to rotate the transducer

and go long axis on the tendon there.

And you can see the tendon takes

that turn the FPL into the carpal

tunnel right here.

That's why it falls off. I would have to turn the corner

and rotate the transducer in.

And the nice thing about ultrasound is you can make it move.

So I'm just going to twitch the tip of the thumb

and I can follow this exact tendon into the carpal tunnel

as I twitch the thumb and follow twitch the thumb

and follow twitch the thumb and follow.

And that's how you can know that you're on the FPL

and not the FCR, the flexor carpe radialis that we covered.

So if I go more radial from here, we'll catch FCR diving,

which is here, see I'm wiggling the thumb

and fpl l's wiggling on the side.

And you remember that deep steep diving tendon here.

So that's the base of the second metacarpal.

So this is flexor carpe radialis.

And if I give a a heel toe maneuver here, you'll get

that tendon to brighten up really nice.

And you'll see it's insertion here.

And if I keep my transducer planted on the left,

pivot on the right to the third,

you'll catch the other head.

So there's two tendon heads inserting.

So we've got base of third, that was the second.

So this is still second, here's third.

I see some fibers going to third but not much.

That's probably just a ligament.

And then to check your work, you could always go short axis.

So here we are, short axis trapezium tubercle here, here's

that groove that we talked about in the PowerPoint.

And there's that FCR tendon right here.

So FPL is the neighbor wiggle the thumb.

So that's inside the tunnel.

And FCR is outside the tunnel

and it's got its own groove right

here on the trapezium tubercle.

And we'll follow that shadow as it dives distal, distal,

distal to the base of the,

of the second metacarpal here.

And then there is usually a fiber

or you know, the anatomy books

and everything says there's a fiber

that's going to go over here to three.

I don't, I'm not too impressed with what I'm seeing here.

So maybe not so much on our model,

but we can definitely trace it, that shadow right there

to the base of the second.

I don't know, there's probably a fiber there.

Easier to see the second. All right,

so I talked about it repeating a pattern.

Let's, let's check it out again just to review.

So base of the first metacarpal here, we've got open ends,

flexor and abductor.

And then we're going to come all the way over here

to the pinky side, go through that triangle

of the carpal tunnel and

and find our base of our fifth metacarpal here.

And it repeats, same thing.

So we have open ends, flexor and abductor

and then the name changes to digit mini.

So if you're looking at all these on an anatomy diagram,

it looks really intimidating

with all the labels going everywhere,

but it is just a pattern.

So we have open ends for opposing,

we have the flexor digit mini

and the ab abductor digi mini

and that will be responsible for taking the pinky,

spreading the fingers out.

That's what pulls the pinky away from the palm.

Remember we had the inter oii to pull the pinky in.

Now we have this abductor dige mini me on the outside

to pull the pinky out.

So that's that pattern there. 1, 2, 3.

You could go long access here to just like anything,

two planes, so long axis of your open ends,

which has a long tendon attachment all the way across the

shaft of the fifth.

So we're following all of this is the tendon

of open ends right here, right there.

See those little look like waves on top

of the bone right there.

There's a long attachment across this whole surface.

And that's open ends. And then

above it is flexor flexor digi mini.

And then if we keep rolling on the far, far outside,

we'll see a, a shift in the muscle belly there.

And that's your ab duct

digit mini on the outside.

So that takes care of the side walls.

And then let's go down the middle really quick.

Actually we're going to get into flexors next.

So as we transition, we're going to follow this out

and we're going to go over these

superficial and deep flexor heads.

Okay, just more mid

section of the hand.

And superficial, let's look at these kind

of confusing flexor tendons.

We've already covered these muscles deep.

So we have our metacarpals mid shaft.

So your probe is right here, not quite to the

inner metacarpal ligament there,

but we're going to look at the flexor tendons.

So these start in the forearm,

which we've covered in the elbow

and we've covered in the carpal tunnel exam.

They start way up in the forearm all the way up

to the medial epicondyle.

And then they finally come down

and they insert at the distal base

of the distal phalanx right here.

And I'm not going to read this whole thing out, it's more

of just a reference for you.

But just notice that each of the profundus,

which means deep, the profundus layers

have a muscle belly coming off of them that starts roughly

around the carpal tunnel level.

Like if I'm squeezing my hand,

I see these muscles when I squeeze travel into the tunnel,

for example, it could be confused for fluid.

So you don't want to call a supposed

fluid in the carpal tunnel.

It's not always fluid.

Sometimes it's lumbrical depending on the hand pulling

and retracting back into the carpal tunnel.

If they become hypertrophic, I suppose they would contribute

to the compression of the median nerve.

But just take a look at their path, you'll see

that they kick off on the radial side

of each of the flexors.

And the first two don't have a kind

of a double-headed origin.

But the last two share the, the walls of each

of the tendons here.

So you can see the, the fifth

and fourth have an originating layer on the fifth

and fourth bellies of those tendons.

The third has an originating start at the, the walls

of the tendon here.

And then you could say something similar about the second

lumbrical here, but it only starts on the

radial side of the third.

And then same with the first lumbrical to the second digit

only starts on the radial side of that one tendon.

So don't go chasing

and looking for the, the origins to all be the same.

They're similar but not the same.

And they do travel the most superficially here when it comes

to the rest of the muscle

groups in the hand that we've looked at.

They're the most superficial round balls

that we look at in the palm as we get closer to the

superficialis layer.

So there's two tendon heads if you're scanning the palm.

So if you should already be familiar with the metacarpals,

the inter oii and the, and the adductor.

So those are your common

landmarks that we've already been through.

Now we're just focusing on this whole shallow row of

what just kind of looks like beads and,

and those are the different layers of profundus

flexor tendon, which has the muscle bellies on each

side of the lum rickles.

And then we have superficialis.

So the superficialis are very easy to scan,

but it's neat once you know that there's two layers

that can be seen in the palm, it's kind of like one

of those things that doesn't leave you, you always see it.

It's just such a a pattern recognition thing from there.

Now the interesting thing about,

and I hope we get to this in the life scan maybe during q

and a interesting thing about this one is the

superficialis layer.

It starts near the base of the middle phalanx.

So we've got middle phalanx here where it's splits.

So you see a split more on this oblique view on the fifth

where the superficialis layer has a divide right

after the MCP joint.

And then you'll see the two heads

of the superficialis go on each side of the profundus

and then under the profundus.

So they switch spots right around the PIP level.

So at the PIP level you should see superficialis

underneath profundus

and attaching at the middle phx walls on the sides.

So a little bit of a challenge during the live scan.

I'll, I'll flesh that out a little bit more.

And then the advanced webinar will cover the pulley system

that holds all that together

and also makes a really nice landmark for

where you should see what when it comes

to these flexor tendons.

And then each of these has its own tendon sheath.

So the fifth has its own solo sheath that kind

of contributes down to the,

the main bursal complex of the carpal tunnel.

And the FCR has its own blinking over here

or FPL, sorry, this is a flexor policy's longest.

And then these two, these three have their own

that don't communicate and don't contribute.

There are anatomical variants here.

Some surgical hand atlases show you the various

communications and the percentages, which is a good way

to chase down infection

as something down here might cause pain

and infection up here because there might be a bural

communication to attend and chief,

okay, so this will be the live demo

and then we'll go to q and a after that.

So I have your questions ready for Chris

and we'll address those during the live demo.

All right, so here we're back on the palm,

we're going to focus on that very, very superficial row

and we're definitely going to switch out

to a higher frequency transducer

after we get through this survey.

So again, screen left radial screen, right?

Oh, I got that backwards screen left.

Pinky side digit, minimi side screen, right thumb side,

radial side first digit side

superficially we've got go more shallow.

There we go. Okay, back all the way to the palm.

So we can see the first

set of flexors that we care about.

And that's going to the second digit.

So we have superficialis and profundus,

let's follow profundus.

All right, so I have seen carpal tunnel exams

where people call this bursitis bur synovitis right here.

So I'm just going to have our model just slowly

wiggle the fingers a little bit.

And how about a slow squeeze?

Now if those lumbrical are really originating close

to the carpal tunnel, when she does a squeeze,

the lumbrical will come into the tunnel

and it looks like fluid,

but it's not fluid 'cause you can't compress it.

There's no posterior acoustic enhancement.

Other, other ultrasound skills should provide you clues

that this isn't fluid.

So go ahead and make a fist slowly. Yep.

See the lumbrical travel towards the carpal tunnel.

Now I'm in the co, I'm in the tunnel itself.

See that right there? That's a

lumbrical, lumbrical lumbrical.

And then I could go long axis on that lumbrical.

So that would be a pitfall if you're not familiar

that these profundus tendons have a lumbrical

traveling with them.

You'll see a lumbrical go all the way into the carpal tunnel

in her case well into the tunnel.

And you might call that a bursitis or synovitis.

And you might even inject a lumbrical.

So follow the profundus layer

and see its adjacent.

Let's go ahead and extend the fingers.

You'll see that the lumbrical kick off

of the profundus layer.

This is a unique one, the second one in

that the lumbrical travels more superficial than the rest.

Just an observation I made

where this muscle covers superficialis as well.

So it looks like it's coming off both of them.

And it might very well be that that's an anatomic variant.

I, I'll, I'll say of all of the structures in the body,

I feel like the the biggest landmines for anatomy

variance is in the hand.

But this is lumbrical.

Now let's go over here to the second lumbrical,

which is coming off of the radial side

of the profundus four, the third flexor tendon.

And you could follow that back. And then the pattern,

remember these lumbrical share a wall,

these lumbrical share a wall.

And what I mean by that is this lumbrical is originating one

head of it on the owner side of the third

and the radial side of the fourth.

And they will eventually separate

that lumbrical from both of those

and it will head over to the radial side of three.

And we go back up to four

and five flexors to find the fourth lumbrical.

Same thing. You can actually see those two muscle

bellies split right there.

Or at least they originate slightly right here.

Share, share, share. And then one kicks off the other.

And now the lumbricals going to follow

to the radial side of the fourth.

There you can see that lumbrical dive

after that, that inter metacarpal ligament

that we talked about right here,

or transverse metacarpal ligament.

Watch the lumbrical take a steep dive boom

and it will become the extensor hood complex too.

It's going to go up and contribute fibers

to the extensor tendons.

Superficially we see the superficial ones.

It's not as exciting to scan as the ones with lumbricals.

I just feel like there's more, more patho,

not not pathology, just more anatomy to see

with these lumbricals now floating on tops

of the lumbricals not covered here today necessarily,

but in the advance we'll trace out the nerves.

So if you had been through the carpal tunnel webinar

with us, here's median nerve just as a bonus

and you'll see it split out to the inner digital branches.

So between each of these superficial flexors

and use an isotropy to your advantage.

See me tilt and rock. So what's flexor

and what's nerve, what's flexor and what's muscle?

So the more compact the fibers an atrophy is,

is more prevalent.

So if I tilt slightly, the lumbrical will stay lit up

but the tendons dropped on their echos

and the nerves will be the last to drop their echos

because nerve nerves are mostly consisting

of fatty epi nearium and,

and you know, fat's going to stay pretty echogenic

'cause it's not so linear and striated.

So these are in our digital nerves

and we'll cover those in more detail and where they go

and where they split in the advanced webinar.

But we could follow the superficialis layer

as it gets really, really close.

I'm just going to stick with digit three. Pick a digit, right?

So here we are in digit three

and now we're at the metacarpal head level.

'cause I see cartilage. And if I go distal to that,

you'll see the joint space drop.

And now we're at the proximal

phalanx where there's no cartilage.

And I talked about the split

of superficialis in the, in the PowerPoint.

So let's get to that really quick

and I'm going to switch to a a higher

frequency transducer for that.

Let's get some gel in the track

and this will be a good time

to start getting questions loaded.

Chris, I, I think we're good on

time for the first time ever.

We have five minutes left

and I'm just going to do a quick demonstration on

how this superficialis splits over the profundus.

So metacarpal head level, we have profundus here.

Superficialis will split into two heads right here as we go,

more distal right there.

And what's neat, depending on the anatomy,

but you're looking at, but if you're just ultrasounding,

you can see that profundus has a little septum to it too.

And it'll be that way all the way to its inthe.

So you can trace profundus all the way to its insertion

and you'll see two tendon heads.

But if you're looking at anatomy books, most

of them don't show a a tendonous septum in there

unless you ultrasound it yourself and then you'll it.

So I'm just going to switch to the 46 while we have time

and taking questions

and I can answer those questions while I switch

and we will do the q and a

and then we will let everybody get on with their day.

- Okay? Yeah, just to remind everybody,

you can send those questions in if you're on the zoom

stream, it's the q and a box on the bottom

or the side of your screen.

And if you're on one of the other ones,

you could just put your question in the chat box

and I'll make sure that gets to Daniel.

- Okay, so I'm back up in the palm following number three

and look how cool all those little bitty

nerves that I described earlier.

Look, now we have interdigital nerves that look as big

as the median nerve did on the other probe.

So this is the common Palmer digital nerves.

So watch 'em split into three groups. 1, 2, 3, right there.

They just fell right off the third flexor.

And you can already see the big gap

between superficial and profundus.

Here, shoot a little bit deeper.

So Profundus superficialis,

and you can see the lumbrical coming off of that profundus

there you see the Lumbrical separate from Profundus kind

of becomes its own thing as we go.

Interdigital. And the Lumbrical will ride on top of

that inner metacarpal ligament

as they dive.

Because this probe has such a thin ultrasound beam,

it is highly susceptible to anti isotropic artifact.

All right, let's watch the split.

So just for our own edification here,

I'm on the second now.

I deviated, I was on the third. Let's go back to third.

Everything stays nice and uniform on the third.

What's weird about the second when you're,

when you're scanning the second, you'll see

that it turns into kind of this yin yang shape

and it will almost look like it's twisting

because the direction of those fibers are headed back

to the midline of the wrist.

But if you go to number three,

they're more stacked right on top of each other.

So we see Profundus here, superficialis superficialis head,

and as we go a little bit more distal, you'll see 'em split.

So there's the split. And for today's lesson,

I would just say, you know,

if you're not already scanning these distally, be aware of

that swap that happens.

So now I'm at the PIP level

and now we have profundus on top.

These are superficialis tendons on each side

and the superficialis will keep

going, keep going, keep going.

Right there. That's the tropic insertion

to these little tubercle that sit on the base

of the proximal phalanx.

Middle phalanx, sorry.

But you can see this dark layer right here.

Watch when I go long axis, you'll see a long,

a long axis tendon attaching to that little tubercle.

So I've seen that called a fracture that tubercle.

And I've seen these tendons,

the an isotropic called Tino synovitis quite a bit,

but that's a long insertion to this,

these little side tubercle on the middle phalanx

of the superficialis right there.

So I'm, I'm extremely radial on this finger.

So there's the PIP joint

and voler plate complex,

which we'll get into on the advanced,

but we can see her cartilage and her voler plate

and no distal, distal, distal.

But there you see a divide right here.

You see that little septum right here

where one is going to continue on and the other is deeper.

They switch places.

When I go proximal, when I go proximal,

that divide is in the middle of the tendon here

and that becomes superficialis right there.

So what it is, it looks like this

and you're just taking a slice through that twist

and it casts that, that crazy shadow that makes it a little,

you either think it's hard to scan

or you think something's wrong with the patient's tendon.

You might call like a longitudinal split tear

or something of a flexor tendon.

And really we're just looking at that divide

where the two tendons are, you know,

one's overtaking the other easier to see in short axis.

So here's that septum between superficialis

heads, there we go.

And then there you can see it wrap around.

So if you want to see how to scan that

and the troubleshooting it takes

to really evaluate those flexor tendon slips into their

insertions and the pulley system.

Catch the fourth webinar, the final one in the hand series.

The next one, I think Chris will have the date offhand.

I think it's September 29th is our arthritic hand webinar.

But we could take questions now if anybody had any.

- Yeah, as Daniel said, our next webinar is on

September 29th and that is on the arthritic arthritic hand.

And we all also will have a guest on that one,

Dr. Daniel Malone.

So yeah, you can go to our webinars page to go ahead

and sign up for that one.

Doesn't look like we have any questions coming in.

Not sure if there's anything else

that you want to show off at all,

but we can take a look at that.

- Oh, there's so much with the ultra frequency.

You can just geek out so much. It's crazy.

- Oh, sorry. Just had one come in.

Can you show us how to scan UCL for the thumb?

- That'll be on the advanced webinar,

but to tease it out a little bit, I will say, you know,

we have that transverse muscle, the adductor

'cause we're adding to the body, right?

So we've got that big transverse muscular landmark right

here and on her hand we can actually see it still.

You know, we're told that at these super high frequencies

you'll never penetrate, you know, deep

to a centimeter or so.

And in some cases that's true, it just depends on the skin.

But there we're removing the a duc

and where it's fascia,

where its tendon becomes fascia right there on the

undersurface right there.

We'll pick up where I'm leaving off in the advanced webinar,

we'll be able to trace these fibers up and over

and then we'll flip the hand over

and really catch the right here on the bottom

or bottom of this, the top side of the, the knuckle.

But we're definitely going to cover not only the UCL

of the thumb, we're going to cover the collateral ligaments

of the MCP joints, what you can see, what you can't see,

so you're not just spinning, spinning your wheels trying to

to see things that ultrasound's really not great at.

And then you'll see the the parts

where ultrasound is really strong.

So yeah, yeah, don't, don't miss that.

I think the advanced webinar is the first week

of October, isn't that right Chris?

Like October 7th,

- I believe it's October 7th.

- Seventh, yeah,

definitely excited.

'cause ligaments are kind of a final frontier

of diagnostic exam for a lot of people.

So there's a lot of nuances

to the bony landmarks like here in the thumb

without totally giving it away.

We've got sesamoids to deal with, right?

And everybody has sesamoids of the thumb,

but not everybody has sesamoids

of the fingers, but some people do.

So there's a whole slew

of anatomic variants we're going to cover in the advanced

things to watch out for little landmines.

And then we're going to cover other structures like the

ligaments and nerves

and some of the vascular structures that'll help you

navigate a hand exam.

And then we're also going to go back to the dorsal hand

for the advanced hand webinar.

And we're going to go over the sagittal bands,

the collateral ligaments, the whole extensor hood mechanism.

Remember I talked about those contributing fibers

that come off the lum briles?

We're going to, we're going to scan some of those down

to their terminations, so very excited for that.

But if that, if that's all the questions, it sounds like I,

I've talked enough for everybody, they're just ready to go.

I understand.

- Yeah, it looks like we don't have any more questions.

Let's see. Oh, we have one. Can you scan the TFCC?

- So in the wrist webinar we did a dorsal wrist webinar

where we covered that this transducer's not super famous

for penetrating those tropic ligaments really well.

So I'd probably want to change over,

but go catch that the dorsal wrist webinar

where we did cover the TFCC in more detail.

But if it's your first time, first exposure at ultrasound,

I don't mind just giving you a glance while we're

waiting on another question.

But yeah, that would be more of the wrist exam.

And we've done wrist webinars already,

so there's screen left.

We've got the OMA screen right down low.

We've got lunate

and then triquetrum is the far guy.

And then we have an old TFCC injury here

where you can see there is an vols segment popping off

that triquetrum right here.

So kind of fun to see a little bit of pathology there.

This was a problem a long time ago with her.

She had extreme pain that radiated down the outside

of her wrist into her palm.

And this was rubbed right up against some

of those nerdy ulnar nerves, right?

So there's a superficial and deep ulnar nerve.

We'll cover in the advanced,

but just for fun, while we're waiting here, here's pisiform.

Here's ulnar nerve and guillen's canal.

And then as we go past Guillen's canal, you'll see the hook

of the Hamm, that one bony landmark we covered.

So follow the nerve and you'll see it split

before the hamate and one will follow deep to the neck

of the hamate right here, deep motor.

And we'll cover that in the advance.

And we're going to go down the whole palmer arches.

And then here, superficial,

you can see the superficial branch right there,

but right up in that split in that area, just proximal

to this.

It's where she had, yeah, she had a cyst and some fluid.

And then eventually we found that fragment of bone,

which was not, not cool.

But yeah, TFCC, here's your major cortical lamars, ulna,

lunate, triquetrum.

Far, far distal in the image down here as far

as you can shoot deep, you'll catch the

shadow of the radius.

Turn the gain up way down there. Yep. This is radius.

And then here's the cartilage complex,

more like the ligaments

as they cross hatch across each other.

The fibro triangular fibro cartilage

complex would be right here.

So meniscal homolog being this triangle space here.

So we've got meniscal homolog on one side.

The names of the ligaments on the ulnar are slip slipping my

mind because of I'm fried from the hand prep.

But what you're looking for is what we see right here.

You can see that of old segment coming off the quiram

and it's not bothering her today.

So that's good. But it looks cool for the webinar.

Thank you. All right,

looks like we've hit the hour

and I thank you everybody for joining

and can't wait to have you catch us

with our guest speaker, Dr.

Dan Malone, September 29th.

- Yeah, absolutely. As you can see here, you can go ahead

and scan that QR code to visit our webinars page.

And I know part three is up on the webinars page.

I think part four will be up pretty soon here.

So yeah, we look forward to seeing you with those.

Daniel, thanks again for the amazing insight into the hand.

And yeah, we'll catch you all next time.

- Thanks everybody.

Ultrasound enables the detailed assessment of soft tissue, connective tissue, nerves, and vascular structures of the volar hand, now enhanced with Sonosite’s new ultra-high frequency transducer: UHF 46-20 MHz. Join Daniel Shelton for Part 2 of the Diagnostic Hand Ultrasound Series: ‘Introduction to the Volar Hand’ to review superficial anatomy of the volar hand, the advantages of ultra-high frequency for detailed volar hand imaging, and 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 volar hand.
  • Applications and advantages of scanning the volar 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 volar 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.