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Transcript

- Okay, I think we'll go ahead and get things going here.

Hi everybody. Welcome to the webinar Diagnostic Hand

Ultrasound Part four Advanced Hand.

My name is Chris Pennell

and I'll be moderating today's webinar.

Now this is the final webinar in our four part series on the

hand, and if you missed any of the first parts

of the webinar series, you can watch them on our webinars

page on sonos site.com/behind the scan webinar.

Or you can check them out on the Sonos Site

Institute as well.

And if you go ahead and scan

that QR code on the screen right there,

that'll take you right to our webinars page.

All of our other previous webinars are also available there

and on the Sonos Site Institute.

So feel free to take a look at our 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 I'll make sure that we get to them at the q

and a session at the end.

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 your screen.

And for our viewers on YouTube

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

and we'll make sure to get those sent over.

This webinar will be recorded

and archive for future reference on our webinars page

and on the Sono Site Institute.

So to get started, I'll introduce our

presenter, Daniel Shelton.

Daniel is the director of musculoskeletal market development

for Fujifilm SonoSite.

Daniel has spent 21 years

as a dedicated musculoskeletal sonographer

and 16 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.

And with that I'll hand it over to Daniel to get started.

- Okay Chris, thank you for that introduction.

We'll go ahead and get started.

I do want to say up front, this is going to come really fast.

This is the advanced ultrasound of the hand

and we're going to cover a lot of anatomy

and I'm assuming that you've been

through the other parts of the webinar.

So some of the content will just be briefly discussed

because we've already gone into it in other portions

and the live scan was prerecorded and cut

and diced to avoid any unnecessary

time, basically switching transducers

or long gaps between audio, things like that.

I've all been trimmed out to maximize content

because we have a lot to go through.

So I apologize for something that may seem fast,

but this is mostly a reference for you also.

And the full content will be put on the Sono Site

Learning Institute in the future.

Okay, we'll get started now.

We're going to cover the extensor hood nail bed collateral

ligaments in the police starting

with the extensor hood complex.

We'll get into the sagittal band, the extensor tendon,

and the lumbrical and inter oii

relationship to the lateral bands.

Looking at the side of the second digit,

we can see the extensor tendon going right over the joint,

the MCP joint.

So we have the M-C-P-P-I-P

and further down the line as the DIP.

We've already talked about the joint capsule,

so we won't go into a lot of detailed anatomy on

that like the arthritic webinar.

But I do want to show you the relationship

where the joint capsule's underneath the sagittal band.

So the joint capsule goes underneath sagittal band.

We can see the sagittal band coming up

to envelop the extensor tendons.

We can also see these other contributing structures

to the dorsal extensor hood complex,

which is this connective tissue umbrella that sets off

to the sides of the joint mostly at first.

And then it contributes fibers up

and across this entire extensor mechanism.

Dorsal aspect of the joint here, we've got it dissected

where we can see collaterals away from kind

of a window into the joint.

We can see that homolog

and the joint capsule folding back

proximally and redundantly.

We can see the lateral bands,

those are the contributing fibers between the lumbrical

and the dorsal interossei are, depending on the joint

that you're on, it could also be the Palmer Interosseous.

But on the on the second digit, that would be

strictly dorsal interosseous and lumbrical.

And then we have the extensor hood complex, which is a,

that band of fibers here it is just dorsally

and then we'll skip the Juntura tendinum.

But those are those little connections

between the extensor tendons back here on the top side

of the Palm Midsagittal slice through the MCP joint.

We covered in the arthritic hand webinar a little bit.

So we've got that joint capsule

starting at the metacarpal notch.

Good landmark folds back redundantly,

looks like a super patella recess in the knee.

Comes back and folds and then dives at the proximal phalanx.

Here's where we can see the sit the sagittal bands.

So we can see a superficial sagittal band

and a deep sagittal band.

You can flex and extend the tendon to

to see it all move together away from the joint capsule.

A little more distally at the PIP joint level.

We've got proximal phalanx, middle phalanx,

and then you're going to focus on the, the central slip

of the extensor tendon.

It's going to look really thin, mid shaft

of the proximal phalanx.

And then we're going to see it look really thick

because we have this whole host

of contributing fibers from the lumbrical area

and from the dorsal interosseous

where it contributes fibers very heavily right across here,

kind of forming a network of tendon.

Here's what that central slip looks like.

It does look thicker because

of all these contributing fibers coming in from the sides.

We'll go to the live demo quickly.

I, I tend to show people how to start this scan on when,

when there's a single tendon over the joint

and not these variations

with two tendons over the joints finger is hanging down

below so that I'm in control

of my pressure into the gel heap.

Slowly rest the transducer into the gel

to optimize this image.

I'll begin by decreasing my depth.

Am I on the distal metacarpal or the proximal phx?

There's a couple ways to tell that.

So I can see that metacarpal notch

that was discussed in the arthritic hand segment.

I can see these dips on the side which have a unique

footprint for collateral ligaments.

I can go distal and drop into the joint.

So there I'm between bones

and then go distal a little bit more.

And that shows me that I'm at the proximal phx.

So it's always good to get oriented with the bones.

So here's proximal phx joint as I go proximally

and then distal metacarpal head.

The distal metacarpal head also has this articular lene

cartilage, good bony landmark.

It's incompressible. So the layers on top of this,

we can see her skin,

we can see the extensor tendon as this oval.

And I can tilt and use an isotropic artifact to my advantage

to de to determine what's tendon and what's not.

But for the most part it's easy

to just scan proximal distal, proximal distal

and see the persistent oval that sits here.

And as I go proximal, you'll see these little shadows start

to form on each side right there.

So these are the shadow of the extensor,

or sorry, the sagittal band.

We have two parts of the sagittal band.

There's a superficial sagittal band

that goes over the extensor tendon

and there's a deep sagittal band that goes below

the extensor tendon and kind of act like another sling

or pulley on the dorsal part of the hand.

Now that that shadow on both sides does extend over the

proximal phalanx a bit.

But the sagittal band itself really stops at the joint.

It does wrap around if you chase

that shadow on the second digit.

'cause we can, we can curve all the way around.

You can chase that shadow down

to the intra metacarpal ligament level where it will start

to blend and taper in with the pulley mechanism on the voler

hand and the voler plate on either side of the joint.

We have neurovascular structures.

So we have the digital, the superficial digital

nerves and vessels.

We could confirm that with color.

So we'll hit the C button for color, go find a vessel nerve

vessel vessel over here.

And then same thing repeats in this

interdigital space here.

Let's go long axis.

I'm going to lay down a nice beta gel right across

where I know the, the dorsal hood

goes towards the middle portion of proximal phx.

And then you'll see me use this other thumb as kind

of a windshield wiper to, to elongate the structures

to get a maximum long axis distal metacarpal head.

Small pH again we have extensor tendon.

And in the arthritic hand webinar we went over the joint

capsule anatomy, how it dives into this metacarpal notch.

So we have metacarpal notch

and you follow that back, there's a redundant fold

of the joint recess where it folds here

and comes climbs up under the extensor tendon.

We have that fat pad or the homolog that sits in the joint,

that little triangular wedge.

And then the joint capsule terminates right here on the

proximal edge of the proximal phalanx.

Extensor tendon is not all of this thick structure here,

so I'm going to have our model just twitch her finger.

There we go. Or you can manually do it or passively do it

and you can see the stuff that's moving there.

So that's not all extensor tendon.

If we were to look really, really close, I could see

that I have long axis fibers here

and short axis fibers here.

But what might just look like a homogeneous structure like

any other fat pad can, can confirmed in the other plane.

Remember we went and saw a deep sagittal band

but the deep sagittal band was in long axis this

way, split the screen.

So I'm going to use the dual feature

and then I'm just going to rotate the probe.

Left side will be radial there

and we can see that long axis deep sagittal band

underneath the extensor tendon.

So extensor tendon, long axis,

deep sagittal band and metacarpal notch.

And you can see that reflected over here.

So here we have a long axis extensor tendon, short axis,

deep sagittal band and then the metacarpal notch.

So we're at the same level. So screen right is taking about

this slice here 'cause I can see the metacarpal

notch right here.

So just to clarify, these homogeneous structures on top

of the metacarpal notch are not related to the joint,

but the joint starts here right at the tip of the arrow.

The joint capsule can make the joint capsule move.

And all of SK ultrasound, make sure you're making it move

to distinguish these structures.

So you can see that deep sagittal band does try

to move with the extensor tendon.

That's another indicator it's not a part of that joint line.

I'll just switch over to the ultra high frequency.

This is the ultra high frequency 46 to 20.

So we have our metacarpal notch.

Here's the joint, here's that homolog.

Okay, so this is the cross-sectional deep sagittal band

and this is the long axis extensor tendon.

So I'm using a little bit of an atropic here

and we can see the angle artifact that's cast off

that superficial sagittal band right here.

Again, make it move. And I'm just going to drag the

skin back and forth.

I can start seeing the layers between the skin

and the extensor tendon complex that's happening here.

Show themselves a little bit.

So let's, let's trace that distally.

Now that we've kind of vetted out our superficial

and deep sagittal bands, our metacarpal notch

and joint capsule,

which is redundantly folding back here at 46 megahertz.

We can see a normal joint recess on an MCP joint,

which is not always the case with lower frequencies.

It will be averaged out.

So there we can see I'm just causing

that joint capsule to move.

Let's go short access to appreciate the

sagittal band anatomy.

Got extensor tendon here,

superficial sagittal band casting a really hard shadow

because of the fine, very thin nature

of this ultrasound beam being 46 megahertz

and isotropic is a little bit more

prevalent with this probe.

Tilt the transducer and aim down the side.

So we have extensor tendon, deep sagittal band shadow of

that extensor tendon coming in with the deep

and superficial sagittal band.

And then you can trace the,

the superficial sagittal band down here.

And then you can see this bump off the metacarpal head.

And we will segue into the collateral ligaments here later.

But it reminds me of a lateral epicondyle

of the elbow if you get it in the right plane.

And the the attachment

of the collateral ligament looks a lot like

the common extensor tendon when you get

it into its long axis.

But I do want you to know

where the collateral ligaments begin and end

because we're going to do a dynamic maneuver to show

where sagittal band begins

and ends sagittal band superficial and deep.

And then we can see collateral ligament anatomy starts

here, somewhere in between.

Here's the joint capsule.

It's really thin, it's normal

and it's just a potential space at this point.

But to delineate potential space,

just like in a subacromial bursa in the shoulder,

I'm going to spread her fingers a little bit.

You just want to make it move to delineate the space.

So I'm going to grab her finger and just wiggle back and forth.

And I can see the layers underneath

that deep sagittal band moving.

And that's revealing this layer right here is the joint

capsule right where my arrow is.

And if I were to go distal to that,

I could see joint capsule sitting on cartilage.

So here's cartilage

and I can see the joint capsule move this way.

So if I followed the extensor tendon distally

into the joint right here.

So the joint, you know I don't see any bones here.

I just see extensor tendon.

I'm going to go distal, distal distal.

Now I'm at the proximal phalanx.

The extensor tendon is starting to flatten out

and the central slip slip will attach right here on the

proximal edge of the middle phalanx.

And on each side you see vessels, neurovascular structures,

easy to compress.

But you can follow that extensor tendon, which is this oval.

It's still more shallow. There we go. Really, really nice.

Nice flat extensor tendon.

So distal proximal, distal proximal.

And then move into another zone.

Distal proximal, distal proximal and just pick one structure

and then just kind of vet it out with a beam.

'cause here you can even see the extensor tendon

as it reaches the central flip area.

The PIP, we're going to follow a few fibers where it splits.

So it'll divide like we saw in the anatomy diagram.

One part goes to central slip proximal of the middle phalanx

and then it divides into two pieces

and goes around the knuckle

and continues onto the sides of the DIP.

So we'll follow those with ultra frequency.

So here the tendon is more centralized,

I can see the tendon here.

And then watch on each side you'll see these round ovals

start to form that are more anti isotropic if you tilt the

probe back forth.

But that's what this oval is here.

So here's, we'll just keep following this oval.

This oval it will go around the PIP joins up

with lumbrical and a bit of the inner oii tendons

and eventually come all the way down to the DIP.

So if the layers are looking like they're just kind

of getting muddied together, pick one side of the joint,

not central or not joint,

but the finger don't scan in the middle of the finger,

pick a side, lean the probe into that side

'cause we have to stay perpendicular to it.

And then just find one echo on the screen

and go proximal distal, proximal distal before you move on.

And definitely don't hold the probe still for these exams.

You got to really move the transducer. So make it move.

But we're just following these teeny tiny tendons to their

eventual insertion on the DIP.

What we're seeing here is the beginning of the nail.

So we're at the nail bed joint of DIP

and that's where we get that triangular ligament

in the middle of the DIP area,

these two tendons come together

and we've got that triangular ligament,

which is just a little bit of a fascia between the

tendons that attach at the DIP level.

So this right here where my arrow is,

this triangular ligament, it's in cross-section

or it's traveling cross-sectionally across the joint

of the DIP or proximal to the DIP.

And then on each side are the tendons for that that go

to the eventual insertions.

So we'll just look at the insertion of the DIP really quick

and a bit of the nail bed since we're in the area.

So we'll just kind of combine those

scanning topics real quick.

So we've got the kind of central portion

of the common extensor tendon right here.

So extensor digitorum attaching here.

But remember on each side we've got those slips coming in

from the oblique side of the finger

so we can see a distinct tendon here

on the side tracking all the way down.

So that's lumbrical, that's dorsal, dorsal inter oii kind

of combined to create that pathway for the extensor tendon

to combine all those fibers.

So you'll see a really strong tendon appearance

and long axis here, even though I'm on the side

of the knuckle and you can confirm that it goes all the way

to the tip just by moving the DIP.

So I'm just pushing the DIP down

and I can trace which tendon I'm following

and you'll just have much better luck going down the side

walls of these fingers, not dorsally.

You can go extreme dorsal right there

and get some of those fibers to move but they're really thin

and a lot of them attach right here on the PIP.

So we're not catching all of the extensor fibers.

But if you go to the side of the PIP,

you'll catch those kind of traveler tendons that go down

and all, all work together to insert at the DIP level

getting right into

where we left off on the dorsal PIP joint basically.

So we're going to cover more anatomy of the dorsal PIP

and then combine that with the nail bed anatomy.

So they just, they go along so well together.

My favorite atlas for this is the surgical anatomy

of the hand if you want to know

where I got this particular illustration

and the following two illustrations coming up.

So you can see the extensor tendon is a little bit complex

as we approach the the DIP joint.

You can see that triangular ligament here going

between the two heads of those lateral bands,

those lateral bands come on to insert seemingly

what would be on the, the base of the distal phx right here.

But there are other fibers that keep going

that we can see at ultra high frequency

to come across the nail

plate here at the base of the cuticle.

And that's called the nail halter.

And so we can see that there's a nice group

of bands going all the way across the nail bed.

And that is something that's very well appreciated,

especially at alternative frequency.

We'll talk about the nail plate as well.

I apologize in advance.

These two illustrations are facing each other.

So left side of the left screen is proximal

and the right side

of the illustration over here is proximal on the right.

So distals in the middle

of the screen I guess you could say.

But we can really appreciate these layers of anatomy

where we can see the, the nail plate come down

to the nail root forming right at its dorsal matrix area

where, where everything kind of kind of granulates

and begins and starts growing our nail.

And then you can see the connective tissue fibers here from

that nail halter that we talked about.

So we can see the extensor tendon insert more,

more commonly easier to appreciate on most transducers.

But then on ultra high frequency,

which we're focusing on here, you can see that

that continuation of fibers

that do come up off the DIP extensor tendon to the nail bed

and not nail bed necessarily,

but to the base root of the nail plate.

Here's a cadaver cross section also out of the surgical

anatomy of the hand atlas here

where you can really appreciate that layer coming across

to the nail root.

And then it just does a good job at distinguishing

where the cuticle is, where the matrix is,

where the nail halter is and then the nail bed.

Alright, let's go look at it For the nail bed

exam we'll be using the 15

to four workhorse transducer again

because it's the transducer just about everybody has.

And then we'll switch over to the 46 to 20 large gel heap

right across the nail.

So let's do that really quick

so we can see the whole thing even to extend the nail,

the gel a little bit past the nail.

So we just kind of lay down a nice bead of gel there

hanging my finger underneath the transducer

and bracing that onto her finger first.

I've got two fingers here

and that's going to allow me to stay very,

very steady and level.

So two fingers kind of bracing down into that gel heap

that helps me descend my transducer into the gel.

So superficially I need to optimize this picture.

The image is kind of focusing to the middle of the screen.

So to make this image look better, I need

to decrease my depth so it goes as shallow

as possible since we're scanning a nail bed

and you'll see things sharpen up really nice.

Middle phalanx distally, distal phalanx,

approximately we've got the DIP joint

and then we ended the, the extensor tendon exam with

that extensor tendon climbing over the DIP.

So we see the joint and the recess here

and then I can see the tendon somewhat attaching here a bit,

but we know from the slides there's a bit more

of anatomy to look at here.

So there's fibers that jump from the extensor to the nail

root, which we'll be evaluating at 46 megahertz a little bit

better, but I want to see what I can see.

So it's important if you're looking at this nail bed

to make sure your, your fingernail image is

as reflective as possible.

What do I mean by that? If I tilt the probe

and I see these fuzzy echoes, I'm not 90 degrees to the nail

and if I don't see a sharp point right here

inside the nail matrix area

or the halter, which is a cross-sectional ligament

holding that nail in place.

So we're seeing what looked like homogeneous fibers

around the nail root.

And what it is is cross-sectional fibers going across the

whole distal phalanx, wrapping around to the collaterals,

basically acting like another pulley mechanism

or hood keeping the nail situated with this extensor tendon.

And then we have the nail matrix down here,

nail plate, nail bed.

And I do find that if you add even a little taller gel

standoff, you can control the focus

of the beam a little bit more with just the depth

that you let the transducer go into the gel.

Not to mention the more gel you have,

the more it enhances the sound wave.

So you're using a bit of posterior acoustic enhancement

to create a scanning window that highlights anatomy.

So the gel is enhancing the sound waves,

making it look really, really nice.

But that's your nail route right there, nice and sharp.

It is a highly vascularized area which we covered slightly

in the arthritic hand webinar.

But I'll hit color just to demonstrate that

and I'll probably have to drop my

scale a bit and turn the gain up.

So I'll drop the scale, turn the gain

and we should start seeing these

nice little vessels in the area.

You could switch over to power Doppler CPD

and what the difference is between the colorized doppler

and power doppler is the directional

or DCPD Doppler basically is,

is a using the computing power of the ultrasound machine

to assign velocity direction

and that takes a lot more computer processing.

But if you switch over to power,

it only uses the amplitudes of a signal.

It is a bit more sensitive to motion artifact but

because it's not using the information necessary

to assign velocity

and direction, it does allow the ultrasound machine

to process a bit more low flow areas since we're just

concerned with if there's blood flow there or not.

So there we can see her nail, we see a little bit

of mirror image artifact happening here.

So that's kind of fun to point out.

So there's, there's a vessel here

and it's climbing its way over to the nail root.

And then we have a hard specular reflector of the distal phx

or the middle phx distally.

And what what's happening here is the doppler effect is

catching these echoes

and we're catching reverberation under the bone.

And when we see that reverberation under the bone

with something that's moving with reverberation,

it also assigns it a doppler shift

but it will be in the exact location opposite to the bone.

So we're seeing a perfect reflection upside down of

that vessel underneath the cortex.

So we're not seeing flow under the cortex.

That's not real flow, that's mirror image artifact.

It's a pretty cool property of a doppler exam

to be aware of or a color exam.

You don't always get it. It's hard to reproduce

but one that it's really easy

to practice on if you get a chance to try

that artifact out is the dorsalis pettus

and your ankle is a very easy one

to create a mirror image artifact.

Switching over to another 46 megahertz transducer.

This is called the UHF 46

and it is a lot of fun to scan with.

So again I've got cord management, cable management here.

I have wrapped this cord right around my hand like this.

And what that does again is it allows me

to be a little bit more dexterous with my hands

and I'm not fighting the way to the cord off the end

of the table or something like that using that gel standoff.

Again, we'll start with a fresh bead of gel

and I've got my fingers under here like stilts.

So I'm going to use 'em to control

that descent into the gel on each side of the probes.

And here we can see a very clean image of that nail root

and the nail plate.

Again, you want to be 90 degrees to the surface

where you won't catch those echoes reflecting back really

nice but really, really nice nail root.

And then it's not so hypo coic anymore.

But we do have a set of fibers here

that we're looking at cross-sectionally that encompass

that nail root.

Okay And that's called the nail halter

and that's that section of ligaments that goes

around in wraps almost like an extensor hood

and attaches this set of fibers to the extensor tendon here.

So we've got this kind of really, really fine

ligament layer jumping from the extensor tendon over

to this nail root.

Let me go short axis. So left side

of the screen will be radial.

Here's the skin. So we have that nail root

following it down.

And then here's that DIP joint.

It'll put a beta gel just across the DIP level so we can see

that triangular ligament.

So DIP, there you go, there's that face I was talking about.

I find that in just about everybody.

But here's long axis fibers

of the triangular ligament right here.

And if we were long axis to the joint,

we'd be looking at kind of short axis fibers

and that the true extensor tendon terminates.

See these ovals on the side watch me squish the

subcutaneous fat a little bit.

You can see these ovals that show up on

each side of the joint.

That's a cross section of the extensor tendon complex from

the lumbricals and the dorsal inter oii of

what eventually terminates with those extensor tendons

after they pass the central slip

and come down to the distal phx.

So these ovals on the side are your real tendons

and this this guy in the middle is not necessarily extensor

tendon but the triangular ligament

that does jump across the joint gap

and inserts on the proximal end of the distal phalanx

the nail and make 'em move.

'cause this is ultrasound, we're going to make it move

then you can follow those fibers

right there, right where my arrow is.

But I was lucky. And you can see how far on the side

of the phalanx I am.

I'm not mid sagittal to the phx

and I'm seeing those fibers move real nice

And we'll look at the color

with the UHF and just see what we can see.

I've got Howard Doppler already selected.

I want to open my box just a bit tall,

got a little bit of noise at the top of the screen.

I'm going to bump my scale up a touch, clean that up.

And we start to see really nice flow

and even cross-sectionally left side of the screen.

I'll make radial. So I've got the nail going in. Here we go.

You can see what looks like two simul lunar echoes

got skin and cuticle nail going to root nail matrix.

We'll hit colored to what we see.

And it's also awesome to go compare to other joints too.

So if you're suspecting things to be systematic

or just in one area, you've got that option.

These are very tiny vessels.

I'll go through my scales just

to make sure we're seeing all the flow we need to see.

So it's the lowest scale, it's going to let in the most noise.

And then I've got a wall filter of medium.

So I'm going to go down to low wall filter,

turn my game down just a touch.

There we go. Earlier I had a medium wall filter

and I probably would've seen more vessels in long

axis like we're seeing here.

So there's that nail matrix just

around that route.

I'll get long access to that.

What I mean when I talk about color scale.

So color scale is a lot like shutter speed and photography

or cinema, cinema, photography where you can,

you can have your scale set improperly when you're looking

for something that's moving.

So imagine a wagon wheel turning in the picture frame like

an old classic western film.

And the shutter speed is clicking at, you know,

its standard rate, let's just say it's 60 hertz.

So it's taking a flash ev, you know, once every 60th.

And if the wheel

that's moving on the screen is moving at the same rate

as the flash from the shutter of the camera,

it'll look like the wheel is standing still.

And that's why you see those old films when the wagon

you know is chasing across the prairie

and it looks like the wheels are standing still.

That's because the revolution of the wheel is catching up

to the shutter frame of the camera.

And that same thing can happen here with color.

So that's when you want to go through your scales

because everybody has a different velocity.

Everybody has different blood pressure,

everybody has different just properties

to their to their blood.

So that can also affect temp things like temperature.

Temperature in the room can also make a big,

big difference when you're scanning things with low flow.

Okay, now time for the ligaments in the hand,

focusing on the side of that second MCP joint, just

'cause it's easier to see and study.

We're going to walk, we're going to walk through the primary

and the accessory.

Now primary and accessory think P over here.

Accessory and primary think anterior and posterior.

So if you're in an anatomical position,

this is the posterior side of the hand

and the palmer side is the anterior side of the hand.

So the primary ligament stays very posterior

and the accessory heads anterior.

So that's one way to remember it.

The accessory does eventually contribute to the fibers

of the palmer plate just as a, as a reference

for you in the pulley here it is in cross-section at the

distal part of the MCP joint.

This is the distal metacarpal head.

Here we've got the extensor tendon, we've got illustration

of the sagittal band here, superficial sagittal band,

deep sagittal band and their fibers that come out

between the interdigital spaces.

Below that we have a joint capsule.

Below that we have a primary collateral ligament

and then an accessory collateral ligament that contributes

to this network of the palmer plate.

Here it is on the first digit.

So this is the collateral ligaments to the thumb, again,

think anterior, posterior.

The anatomy repeats here.

Then we have the extensor lysis that's going to come into play

and attach to this APA neurosis

that comes from the palm of the hand.

Remember the adductor, the big landmark in the hand,

the transverse transversely oriented muscle

that eventually heads towards the thumb.

We're going to take its superficial fibers

and then see them drape out like an umbrella over the MCP

joint of the first digit.

And then what we're going to do is wiggle the thumb

and see it differentiate itself.

So why does that matter? So if you end up with a tear

of the ulnar collateral ligament of the thumb

and it protrudes through this network of fibers,

then surgical intervention is required.

You have what's called a thinners lesion if it stays,

if the tear, if this ligament ruptures

and the tear stays beneath these fibers,

then you've got an isolated ulnar collateral ligament

and probably a few more options of treatment.

Here's the dynamic maneuver and what you should see.

So we've got our distal metacarpal in our proximal phx

and then you can see the A neurosis moving here.

Here's what that looks like and we'll do more in the live

demo, but use this as a reference

and then also use this slide as a reference

for your future learning.

But I'll cruise through the anatomy pretty quickly here

again, proximal or distal metacarpal head.

Here's that kind of epicondyle looking origin

of the primary collateral ligament.

And then here we can see moving back

and forth the extensor lysis longest relationship to the

to the adductor, a APA neurosis that's moving here.

Let's go look at it. I'll start out

with collateral ligament anatomy here on just the second MCP

because we can, we can follow it around.

And I think that's just important in knowing

about the anatomy and where it is

and where it's going so that you can apply it

to the rest of the joints.

And then we'll go down to the PIP

with a smaller footprint transducer.

So this being the most common transducer people

have, I'll start with that.

This is our L 15 to four

and I'll start just dorsally transversely

and I switched hands versus the rest of the videos just

to give good camera window to the inside of the thumb.

This is a little bit backwards from the rest

of the shots just to remember

that radial is now screen right and ulnar is screen left.

So I'm at the metacarpal here

and I can just scan that distally, distally, distally.

Just to review, we've got the metacarpal, the

extensor tendon

and as I go distally you'll see the metacarpal change shape.

So this little drop off that we have houses, collateral,

ligament origins.

And so we start there by going, actually let's look at

that long axis too.

So I'll take this midsagittal, then I'll fall off radially.

So you can see that that really neat distinct shape,

remember dorsally, we had that, that nice metacarpal notch

and then that metacarpal notch

as we go more towards the thumb will will open up

and as it opens up it becomes

what looks like a lateral epicondyle of an elbow.

And if you just think of it that way,

then you can pivot the distal part of your probe

inferiorly towards the table a little bit

and down towards the proximal phalanx.

And we get this nice elongated primary collateral ligament.

There we go. So that's the primary,

or as you saw in the anatomy diagram on the slides, think

of it as the posterior of the two.

So it's a P for primary.

And then we have an accessory collateral ligament which

dives straight down all the way to the pulley system.

I'll open up the thumb here just

to gimme a little bit more scan angle.

And there you can see the shadow

of the accessory right here diving towards the table.

So primary on top accessory on the bottom.

And this is on the radial aspect,

but we have a nice long axis of an accessory

collateral ligament of the MCP joint

and it will not insert so much on the proximal phalanx

as it does wrap around to the pulley.

So we'll hold the hand up here in kind

of a karate chop position

and then we'll follow that accessory all the way around.

So we're just looking at these nice long access fibers here.

Long access fibers, long access fibers.

We see we're still on the metacarpal, start to see cartilage

articular lene cartilage on the voler surface.

But you can see how that accessory collateral ligament here

turns into a a bowler plate just like that.

So now we are looking at a voler plate.

So when you're on the palm

and you're kind of wondering where voler plates come from,

flexor tendon, superficial profundus

and on flexor tendon number two

underneath it we see palmer plate.

So let's follow that palmer plate radially.

And you can just see that relationship, same group

of fibers, wraps around

and becomes the accessory collateral.

Now from the rest of the polymer plate here,

if I go distally, distally distally to the proximal phx

where the polymer plate is also originating from just

that front lip or the proximal lip.

And it's better to practice on this knuckle

because it's the biggest to see this relationship.

When you get down to the PS and dips, I would more

or less just look for the same landmarks just

with fluid collections or koic gaps.

But you can see the same thing here.

So you can see primary collateral superficially

and then you can rotate your transducer.

I think it helps to just completely rotate the probe

to go find a palmer plate

and then work your way backwards on a PIP joint.

Don't waste a bunch of time on the, on the beginning of

that epicondyle looking surface,

it looks like an elbow there right where the arrow is.

So I'll go more shallow if it'll let me. Might even zoom in.

There's our primary right there in

that long axis ligament there.

And this is where I think it's a good opportunity

to switch over to our ultra high frequency.

46 to 20. Same thing here.

We're looking at that kind

of epicondyle looking surface on the lateral MCP joint

following those fibers windshield wiping the distal part

of the probe right there.

Now to tighten these ligaments up both sets really

making a fist actually helps.

Let's curl the fingers and make a fist.

And the reason that tightens it up is

because the distal metacarpal head is shaped like a cam

so it's not perfectly round the bottom

or palmer side is longer than the front side.

And so when we do that, this proximal phalanx wraps itself

around the longer side of

that distal metacarpal head tightening these ligaments.

So it is a way to put some stress on the footprint,

but here we can see a really, really nice primary collateral

and if I go a bit more volar,

we'll see the shadow show itself here of the accessory

and the accessories in short axis in this particular case.

So I would just rotate the transducer

and point it down towards the palm

and then we could follow the primary collateral shadow

basically at this point all the way down

to the palmer plate.

Now let's go down to PIP collateral. Take a look at it.

Same scanning technique, looking for that,

that drop off that.

There we go. Really nice. Maybe I just got lucky.

Popped it right on there too shallow. There we go.

Somewhere in the middle there. So we see the same thing.

We, we see actual fibers

because of the resolution of this transducer,

but we can see these ligament fibers of the primary

and we'll rotate the probe almost in a complete short axis

to see the accessory.

So left side of the screen would be dorsal there

and there I can see the shadow starting to form

of accessory right there.

But the accessory origin being here up top,

and this would be the primary going

cross-sectionally across the joint.

But we can follow these long axis fibers all the way

to the palm and extend the finger

and then trace those down to it's bowler plate

so we can see the bowler plate of the PIP there

and those fibers that reach around.

Okay, now let's go to the thumb UCL,

which I think most people are interested in.

Now a a few ways to to get at this is just to understand

how ulnar we're talking when we're

talking about ulnar collateral ligament.

We're not just talking about slightly ulnar two dorsal,

it's extremely coronal.

This slice that we're going to take.

And remember the APA neurosis is coming from the adductor

lysis from the palm coming right under my gel there

to the top of the knuckle

and seeing it drape across the top.

So to see that joint in the, in a true coronal,

you don't want to scan at this angle, you really need

to take the pro and lay it against the second MCP joint.

So I'm going to lay this whole transducer against the second

MCP joint and drop it straight onto the knuckle.

And that is the extreme coronal plane I want you

to take when you try this.

And then you end up seeing that nice ligament

come up more shallow here.

Same looking for the epicondyle looking surface,

kind of like we did on the elbow right up here

and seeing it bridge that gap.

Now it does help to kind of bolster the thumb.

So we're going to put this bottle of gel under here

and this, this provides us a better scanning window

and a more dynamic room for me

to fully stress this thumb.

So here I am again leaning this side

of the transducer against the knuckle

of the second MCP joint when I drop it on there

and then just set it right down in long axis to the rest

of the, the rest of the thumb really,

I can stress the joint itself here just

by putting my other finger behind it

and when my thumb is here.

And that provides a nice fulcrum.

So that tests the ligament itself.

And you always want to do a bilateral study on this

'cause you're always going to get the joint

to open a little bit more than you think it should open.

Okay? And then that ligament looks good.

And then the other thing that we're going to test is the APA

neurosis and the APA neurosis, which is harder

to see on conventional transducers,

is this one thin black line right here.

And anything in Ms K ultrasound, you should make it move.

So what we're going to do to make that move, we know

that the A neurosis is connected to the EPL,

the extensor lysis longest as well.

So we're going to twitch the thumb distally here

and you can see me pull on that

and you get, you get two if you put your fingers in.

In this position here, I've got the ability

to twitch the thumb here

and to stress the thumb this way, all in one scanning plane.

So here I've got stress on the thumb and then up

and down with the DIP

to check the integrity of the AP neurosis.

So stress check.

Now let's change to the ultra high frequency,

same scanning window here, extreme angle,

much smaller transducer.

So we're going to see a much bigger field of view,

but now we see that really, really nice joint.

Now we can see the fibers and really elongate them

and focus on getting a true cut on the joint instead

of just relying on horizontally based shadows.

But there I'm stressing the joint the same way I did before.

And then let's take a look at that API

neurosis that sits up top.

And it's going to be this distinct line here, right there.

I'm going to twitch the thumb, let's get it going.

And we want to make sure that that a neurosis that's gliding.

Drop my arrow down just a touch more

since it's just me in here.

There that API neurosis needs

to stay on top of the ligament.

If the ligament tears and protrudes through the A neurosis,

you've got yourself a real st thinner lesion.

If the ligament tears and stays underneath the aosis

and the ane rosas then hacked, then you're just dealing

with an isolated ulnar collateral ligament tear.

And that's how you would classify the two

to see the accessory in this case is very difficult.

It's not impossible. So there it is, the accessory is here

and it's going to look like a supraspinatus in the shoulder

and it's taking that extreme dive towards the, I would say,

normal volar plate of the first digit.

But you're going to, it's going to go up to the sesamoid.

So we should see the radial side,

or sorry, the ulnar side sesamoid right there.

And then that ces, that sesamoid gets encapsulated basically

by the same ligamentous structures.

And on the other side too, we have a, an ulnar sesamoid,

but that would be the, the accessory

collateral of the thumb.

And then we would windshield wiper the other side

of the probe over to the primary

collateral to do that assessment.

Now we've got the flexor tendons

and the pulleys of the fingers.

It's a very exciting and dynamic part of the hand exam,

but also very complex and complicated.

Let's talk about the deeper layers.

I'm assuming that you studied the, the palmer

or the volar hand webinar.

So I want to go over this relationship

after we leave the palm of the hand

and we head towards the fingers how complex

and complicated the anatomy can get for

something like the superficialis portion

of the flexor tendon.

So this is the flexor digitorum.

After the MCP joint level, it will bifurcate

and then it will come on to attach at the middle portion

of the middle phalanx down the sides here.

Now as it bifurcates as it splits, there is a web

that's very variable.

So don't, don't take the grid pattern that you see here

as all of them will show this representation.

You probably won't ever see these fibers

unless you're using ultra high frequency.

And then even then you're, you're,

you're never going to see a standard layer here.

There's about eight variations of this woven pattern,

but it's, it's important surgically, I guess if you need

to see where the cullum

and the little neurovascular structure is.

Basically the arteries that pierce

and feed the flexor tendons travel

through this network here.

And it's called campers chiasma.

And I think of campers, as you know, if you're going camping

this, this looks like a hammock

that sits across the two heads as they divide.

And we'll see that in the live scan.

They also hold the flexor digitorum profundus.

So you can see the deep part

or the, the profundus portion of

flexor digitorum comes out from between the split

of the flexor digitorum superficialis

and keeps headed over the PIP

and then over the DIP to insert at the base

of the pro of the distal phalanx.

And that that web here between the two heads holds

that profundus into place.

So we have the pulley system holding the tendons

to the fingers.

If you were to bend the fingers without this pulley system,

the tendons would just bow string across.

And we're not going to go into all the, all the pathologies,

we just don't have time in the

short amount of time that we have.

But I will cover the survey of the hand

and how to find these things and how to evaluate them.

So we have the A one, the A two

that's anatomically very consistent.

You can have anatomical variation from here on it.

It's not always going to look like this,

especially if you go check out the surgical anatomy atlases.

So if you get frustrated not finding the pulleys exactly

after a two, the way you see on this diagram, just know

that there's a lot of variation.

A pulley annular means little ring, it's easy to see,

it's thicker and it's more structural cruciate.

These are the C pulleys, C 1 23. That means cross.

And it's harder to see thinner and less structural.

Most people actually skip looking at these

and we probably skip looking at 'em in the,

in the live demo, but use this as a reference.

And then as we look at those in cross section, at the level

of a one, we see flexor digitorum superficialis about a 50

50 split over flexor digitorum profundus.

As you travel down to a two, you start

to see the superficialis will split.

And then as you get distally closer towards the PIP just

before the PIP, this flexor digitorum superficial

is split completely.

And you can see that over here. And the representation,

this over here, these images were taken with our L 19

transducer, the the small footprint linear 19 megahertz.

It's not the larger footprint L

that I'll be using in the live demo.

And it's not the ultra high frequency,

that's not the ultra high frequency 46 to 20.

So it's kind of our in-between

but a lower frequency than ultra high frequency.

But it image is very nice

and you can see the pulley's very nice here as we go.

More display at the level of A three,

we've got profundus now completely

between superficialis superficialis split on both sides.

And as we head down to a four where the insertion starts to

attach at middle phalanx here you can see the

superficialis now underneath profundus completely.

And then as you go distally between the A four

and the A five, the, the insertion completely taken place

and profundus is out there on its own distally

to a five just profundus.

And then at the enthesis at the base

of the distal phal anx is just profundus on the voler part

of the first MCP joint.

We have some varying anatomy here for pullies of the thumb.

The A one pulley is very similar to looking at the rest

of the hand except it's going to bridge a gap

between two sesamoids.

We have an ulnar sesamoid and a radial sesamoid.

And the ulnar side sesamoid is towards the palm,

the radial side sesamoids toward the outside of the thumb.

And you're going to bridge the gap between those two tilt.

Rock your probe until you get this big dark umbrella.

That whole web is basically a, a large network of pulley

combined with the collateral ligament

anatomy as you go distally.

This is where it varies a little bit.

We've got a Y or oblique ligament, it changes names.

It's not a two. So we had a one here,

this is a A two is up here.

This is the oblique or the Y shaped pulley

because it does come off the adductor epi neurosis as well.

Now distally at the level of the palmer plate,

we can see a two more traditional looks just like the other

pulley did, except we don't see a split

and a flexor tendon anymore.

It's just flexor flexor lysis long.

So it looks a little bit different than the flexor di the

the profundus layer of the flexor digitorum.

So we're going to isolate the second, third, fourth and fifth.

So I'll start with the A one pulley here.

On the MCP joint side of the hand, dry skin is full

of air cells and air is the enemy of ultrasound.

So if you've ever seen an abdominal ultrasound

where gaskets in the way or lung sliding, you see

what air can do to an ultrasound beam.

Keep that in mind at the skin level just like you're doing

the heel and the foot or plantar fascia.

You want this type of skin here to be as as moisturized

and debrided of any callous or anything

before you get started just

to give yourself the best shot you can.

First, let's identify the bones.

I like to stay in the third.

I'll tell you why When I'm, when I'm teaching this

or showing somebody if you stay on the third,

it keeps the bone relatively in a straight line.

Whereas if I'm on the second

or the fifth, the bones kind of take a curve this way

and the tendons definitely take a curve this way.

So on right side of the screen we've got the proximal phx

and we have the distal metacarpal.

Approximately on the left I'm going to bring my depth up more

shallow to optimize.

And we already covered a bit of flexor tendons in a

previous webinar.

So I'm going to ignore the hand part of the flexor tendons.

But we are going to go into the part of the finger

where the tendon kind of changes shape.

So let's focus on the tendon really quick

before we get into the pulleys.

On the long axis of the tendons, we've got

a superficial and a deep

or profundus layer.

And on some transducers it may be a little less obvious.

So what you can do is just isolate the DIP

and cause profundus to move

while superficial stays stationary.

Now what you'll notice is as I go distal profundus

becomes more superficial

and then you see the superficialis portion

of the flexor here dive on the sides

and that's more evident in a cross section.

But here you can see them almost switch places especially on

on the lateral edges of the tendon like this.

I'll go cross sectionally

and let's watch 'em kind

of switch places like we did in the PowerPoint slide.

So when I'm proximal,

I've got two layers of the tendon kind of a hemisphere

profundus superficialis superficialis at this point will

split vertically

and we start to see the two heads of superficialis

go on each side of profundus.

Profundus changes its echo texture here

because it's changing direction, it also changes its echo

unless I were to rock the transducer.

So if a rock the transducer to match it,

they start to look the same.

But if you let the anti isotropic property show you,

which is which, you can leave the profundus layer dark

and the superficialis layer will stay bright.

And the superficialis layer

or these triangles on the side

as we reach the PIP joint here.

So we have cartilage of the proximal and middle phalanx.

So this will be the distal head,

and then this will be the proximal

surface of the middle phalanx.

And we see up top what looks like three tendons.

But what we really have is superficialis,

superficialis and profundus.

What's not commonly on a lot of anatomy diagrams is

that there are two heads to the profundus.

You will see it on most of the surgical stuff,

but not just general drawings,

but there's a septum right there

and it stays there all the way to the enthesis here.

If you're looking to differentiate between superficialis

and profundus at the level of the PIP joint,

they've completely swapped places.

So superficialis are these little triangular corners

on each side of profundus

and profundus is in the middle and it has a septum.

Now let's go back to the pulley. So I'm at the MCP joint

level here because I see cartilage and palmer plate

and I'm in the palm here.

So we have metacarpal metacarpal head with cartilage,

proximal phalanx with no cartilage and no palmer plate.

So this is palmer plate here.

Then we have the flexor tendons

and then we have the shadows of the A one pulley.

So the shadows of the A one pulley look a lot like kind

of pigtails off the side of a head.

So you see what looks like a head here,

and then you see shadows, which looks like hair

and it's a very prominent broad ligamentous portion.

So if you wanted to get maximum echoes back to the probe,

you'd have to dig in the probe to one side of the palm here

and those fibers would echo back.

But when you just have the probe at a natural rest on the

skin, it will

just dive away causing those big shadows on the side.

So this is a tube pull

or a one pulley, which is thicker, more broad.

And as I jump the joint gap

and make my way to the proximal phalanx.

We've got a two,

so a two begins right here.

And if I go long axis on these, you can see

that they're pretty far apart from each

other and they're shadows.

So superficially I have a shadow of a one

and a two starts way down here.

This this broad kind of sock shape

of a, of a pulley down here.

So a one.

And if that shadow's not so distinct to you,

what you can do is just move the finger

to see the undersurface

and rock the subcutaneous fat with the probe

to see the superficial surface

of the pulley right there.

So we can see the fat rolling over the pulley.

And at the PIP level we have a three right

over the palmer plate.

So a three starts here.

So we have palmer plate and then we have the A three.

We're going to ignore, basically ignore C one

because it's really hard to see.

Most of the time you don't see it in a,

in a conventional frequency, you probably won't.

So you'll just jump from a two to a three.

A three is right over palmer plate of the PIP.

And then we'll keep on going over the shaft

of the middle phalanx.

And over the shaft of the middle phalanx we get a four.

So here we are over the shaft of the middle phalanx.

We should get a bright white hyper coic thin

band right on over the shaft.

That's your A four. And then up here we have a five,

another bright white connective tissue layer right there

between the arrow and the X.

And again, if you're confused as to what tissue is

what move the phx,

rock the fat under the skin and make it move.

Also easier to see in transverse.

So I'll switch over to the ultra

high frequency really quick.

The left side of the screen will be ulnar in this case.

I'll try to keep that conventional

and we'll go with bony landmarks here.

So I've got a deep bone turn the gain up,

just a touch there.

So I've got a deep bone and it has cartilage right there.

And that would be my distal metacarpal head.

And then that tells me that I'm at the level

where the flexor profundus on the bottom

and the superficialis haven't quite split yet.

And if I were to go distal to that, you would see

that split right there.

Looks a bit like a Mercedes-Benz sign.

So we have superficialis, superficialis and profundus.

I'll bring my depth up more shallow

so the machine focuses more clearly on that layer.

And now we can see the relationship of

the superficialis curling under the profundus

as we go distal to the, to the PIP level.

See it's already split apart from each other

and curled under and they almost join.

They join with the fibrous band

of connective tissue called campers, chiasma or chiasm.

And that's what is hanging onto a little bit

of arterial supply to feed the flexor tendons.

Okay, so now we're at the PIP level

'cause I can see cartilage, I can see palmer plate.

Okay, I see that septum be between profundus.

So this is all profundus. Keep that in mind.

And if you want to get a really good look at the

superficialis, you have

to go almost like you're in a

hemisphere like I talked about earlier.

So my arrow is on superficialis as it curls under profundus.

So this is Palmer plate,

this is Superficialis here, this is Profundus.

We can follow Profundus up

and over to the other superficialis,

which is this other little corner.

And then let's follow a superficialis to its

to its termination or in thesis right here.

There you can actually see it inserting right there.

There's this big long ridge on the middle phalanx

that goes down the shaft of the middle

part of the middle phalanx.

And that big ridge, which can often be mistaken

for a step off deformity

or a fracture, is just a long tubercle for the insertion

of the superficialis.

So let's watch that and then we'll spin on it

and go long axis here we go there

and I'll just spin the transducer long axis, see

how off to the side I am.

So if I were mid sagittal to the finger, I get profundus

and it's two layers and I can twitch the distal phx.

But if I go off to the side,

I can see this diving tendon very distinct away

from profundus.

And I can wiggle the tip of the finger and isolate that

and show that that's not the,

the profundus that we're looking at.

It's strictly superficialis right there.

So here I was over some profundus, look at that.

And then I go even more ulnar to separate the two.

So superficialis, profundus,

superficialis profundus.

So make it move. Use your dynamic maneuvers.

Then we will take this second

to talk about the palmer plate.

So the palmer plate is this fibrous connective tissue

that originates here at the base

of the proximal or middle phalanx.

We're looking at a cross-sectional plate of fibers.

So the fibers are coming at us in the picture.

And then they have a tail right here of fibers

that branches off and holds itself down to the

proximal phalanx right here.

And these are called check reign, like the reins of a horse

check rain ligaments.

And we can see one shadow here attaching to palmer plate.

And then that camper's chiasma

that we were talking about is the rest

of the connective tissue above that

and below the flexor tendons,

which acts like a hammock bridging the gap

between superficialis and profundus right here.

So cross-sectionally, here's the PIP cartilage Muer plate.

Palmer plate. I'm going to go proximal to that.

We can see the shadows of the check reins.

And then between the check reins, we have

this hammock shape right here that's not part

of the flexor tendons, doesn't move

with a flexor tendon, it's a hammock.

I think of campers chiasma as like a camping hammock.

So this is like a hammock bridging the gap

between superficialis superficialis.

And then there's this connective tissue like the dorsal part

of the hand at the DIP had that triangular ligament bridging

that gap over the joint.

And we have a lot of that kind of similar architecture here

and that's where we see camper chiasma.

And it does hold some arterial supply to the flexor tendons.

Going back to the pulleys though, check that out.

Long axis pulley, there's just no doubt that we're seeing

the undersurface of a one right there.

So arrow here, A one

A one really starts with that palmer fascia way back here.

But by ultrasound we're definitely seeing the beginning of

that structural A one pulley right here.

So dynamic maneuvers to do is to flex the tendon

here and then rock the transducer to get that subq fat

to roll over the pulley

to help you delineate the margins of the pulley.

So hopefully that helps you. So we'll go distal to that.

And we'll look for at the beginning of a two,

which is this big long fiber across the superficial margin

of that superficialis.

And it's shaped a bit like an airplane wing in that one.

One side's really, really broad.

And there's more of a connective tissue

thickening at the distal part of a two.

And that's why it looks much thicker

and it kind of teardrops on back approximately

to a thinner margin, which

I would say stops here because I can rock the subq fat

and that subq fat kind

of goes down in towards the tendon at that point.

So just use those methods when you're

identifying the pulleys.

Flex the tendon to see the undersurface, okay right there.

And then rock the subq fat to see the top surface.

And then you just keep following that.

So there's a three that hyper cook triangle here.

So flex rock, move on down the line. A four.

We're going to flex rock here.

And I'm not completely ignoring the the cruciate,

the the C one, two and threes,

but they're just less a part of the exam than

the annular pulleys.

So I have a little bit of an air under my transducer.

There we go. So you can see the, the A five really,

really nice right here.

So again, we can flex or we can rock.

Actually that was fat. So the pulleys under

that right there,

right?

And that does it for the live demo.

If you have any questions, go ahead

and ask them in the portal.

Chris, do we have any questions queued up?

- Not currently,

but just a reminder, if you're on the Zoom broadcast, the q

and a box is on the bottom or the side of your screen.

So go ahead and put your questions into there.

And then if you were on the LinkedIn

or YouTube stream, go ahead

and put your questions in the chat

and I'll make sure those get over to Daniel.

- Perfect, thank you Chris. And that was a lot of content,

so just know that

that was a trimmed down version of, of quite a bit

that was already previously filmed.

And that if you're a member

of the Sauna Site Learning Institute by being a customer,

you will have access to a more long form version of some

of the scanning techniques and the tips

and tricks that it takes to,

to catch some of these scanning windows.

And if you didn't catch our previous webinars on the hand,

we did cover the dorsal hand

and then we went to the volar hand

and then we had a guest speaker, Dr.

Dan Malone, rheumatologist over 20 years

musculoskeletal ultrasound expert who was our,

our guest here in the studio to do the arthritic hand

where we covered cps.

We covered some arthritic conditions that involve the,

the base of the thumb.

We talked a little bit about gout injection techniques

and then here to cap everything off,

the advanced hand was more

or less to finish off where the others ended.

But the, I would say the more advanced things are out here

in the fingers where the anatomy gets smaller

and a bit more involved.

So your sports injuries typically being on the thumb,

your climbing injuries for example, being on the fingers

and the pulley mechanisms, there's just a lot

of intricate anatomy there.

- We do have a question that just came in.

What is the orientation of the needle when doing thumb?

A one pulley injection.

- So a thumb, a one pulley.

So we will have a procedure series later next year

basically where we go over injections,

we'll have guest speakers, guest physicians in that case on

you know, how much of a medication to include volumes.

But if you were to do, which I don't believe our live scan,

we really got a chance to stick

with the, let's switch hands.

Let me go to the other hand here that way,

- Just an fyi, it looks like you're still on the video

and not on your live camera. Hmm,

- I see.

Good, good point Chris. There we go. There's the switch.

Okay, so in in general

that's typically done out a plane anyways,

but you're going to find your, your sesamoids as a landmark.

Everybody has the ulnar and a radial sesamoid there

and the pulley is bridging the gap on each side of that.

So if you don't have the bones on both sides,

you're probably not perpendicular to the pulley.

Let me see how this looks on zoom.

I'm going to turn my game up just a touch. There we go.

But you would start with your needle out a plane shallow,

avoiding the sides,

probably want to land a center mark down the middle

of the screen avoiding neurovascular structures.

So always wanting to put the color down first

before you go in with any procedures.

So you have nerves on each side. Arteries,

there we go.

So marking your vessels, going right down the middle,

parking your needle under the shadow right

where the arrow is and then you would rotate your transducer

confirming you're not bevel down in a tendon staying

above the tendon.

But here's our a a one pulley right here,

looks like a little airplane wing.

And just confirm dynamically your layers also

before you land your needle anywhere.

But yeah, stopping your needle anywhere underneath

that pulley where the arrow is and above the moving tendon.

A little test shot might get you into the sheath,

which is an isolated sheath.

It goes down into the carpal tunnel,

but out a plane right under there.

Center line, avoid your neurovascular structures,

whether you go proximal, distal

or distal to proximal, I would think going distal

to proximal would keep you out

of the neurovascular structures easier than going proximal

to distal or they have more room to to rest over the tendon.

Great question. We'll make a note

of it when we have our guest speaker line up.

- Is there anything that you could go over

that maybe you cut out of the

video that might be quick to show?

- You know, we did not get a chance

to go in depth on the nerves

and I do plan on having a follow-up session on nerves.

So I would say just the scanning technique involving small

tubular structures like nerves is

pretty much always the same.

So I'm, I'm down here on the radius, I'm going to scoot

or model the camera.

There we go. Here's our extensor tendon

compartment over two.

This is one. And we have that superficial radial nerve here.

So the, the nerve anatomy as

as you go distal from here is very, it,

it's extremely variable.

But right back here proximal to compartment one, it's,

it's usually pretty uniform.

So you just pick a branch

and you go proximal distal, proximal, distal

and then you go down a little further,

then you pick a branch, just the same scanning technique

back forth, back forth, back forth.

Pick a branch there, they just popped over

that compartment one

and now they're headed over on top of compartment two.

These are, these are useful structures to map out.

If you're doing something like a simple decar vein tenitis

injection, you might want to avoid hitting the superficial

sensory branches with the radial nerve right here.

So that's EPL right there sitting over the snuff box.

So we can have our model just twitch her thumb

and we can see EPL activate.

Nice little, too much gain on zoom now. There we go.

But yeah, that's her EPL

and you can see all those little nerve branches sitting on

top right there.

You could, you could easily land your needle on accident

into one of these little nerve branches

and just cause some unnecessary pain

and you know,

maybe artificially anesthetize an area on accident

for a period of time that you didn't mean to,

and then you got your radial artery here.

A lot of landmarks in the area to avoid.

But yeah, just scanning nerves, we'll have to have

some requests if anybody wants to send us a list of nerves

that they would like studied.

The plan was to do the dorsal ulnar

on the ulnar side to cover deep motor and superficial.

And on the radial side these radial

branches of the superficial sensory.

But we just ran out of time

and there's only so much

that we could fit in in about an hour,

but we plan on holding more of these webinars.

We'll take your suggestion, that'd be great.

But now that we've pretty much up most

of the body parts in MSK on the webinar series

behind the scan@ec.com, as Chris mentioned,

under education webinars

or if you're a learning institute member as a customer

and you have access to a lot more content, you'll see more

of, more of our, our learning modules be populated with

more thorough explanations of each of these structures.

- Yeah, Daniel's correct there.

Let me get the link up here on the screen here.

So if you go ahead and scan that QR code here,

you'll be able to go straight to our webinars page there.

But as Daniel said, I do believe that we are out

of time for today.

So Daniel, thank you so much

for this incredibly in-depth hand series.

I know it was a lot of work for for you

and I think it was, it was really amazing.

So thanks for taking the time

to get everything put together for us.

Thanks

- Again everybody for joining.

Thank you Chris.

- Yep. And we'll see you at the next one.

Learn advanced, practical techniques for diagnostic hand ultrasound in this final session of a four-part series from FUJIFILM Sonosite. The educaitonal webinar focuses on high-value anatomy and scanning approaches that help you confidently evaluate small, intricate structures in the fingers and thumb.

You will learn how to identify and assess the dorsal extensor hood complex, including the extensor tendon, superficial and deep sagittal bands, central slip, lateral bands, and the triangular ligament at the DIP. The webinar emphasizes using dynamic maneuvers—flexion/extension, gentle stress, and tissue “wiggle”—to distinguish tendons, ligaments, and joint capsule recesses, and to reduce common pitfalls such as anisotropy.

A dedicated segment walks through nail anatomy with both conventional and ultra-high-frequency imaging, showing how to optimize gel standoff, probe angle, and Doppler settings to visualize the nail root, matrix, and nail halter. You will also learn how to recognize Doppler artifacts to assist you with Doppler signal assessment.

Collateral ligament scanning is covered in detail at the MCP and PIP joints, including how to locate primary versus accessory collateral ligaments and how to follow their continuity toward the volar plate. The thumb UCL evaluation receives special attention, including dynamic stress testing and assessment of the adductor aponeurosis to support recognition of a Stener lesion pattern.

Finally, the webinar reviews flexor tendon anatomy and the pulley system (A1–A5), including practical tips to find pulleys reliably, understand normal variations, and visualize Camper’s chiasm and the superficialis/profundus relationship. This session helps you refine your scanning workflow, improve diagnostic confidence, and bring higher-resolution point-of-care ultrasound assessments to hand and finger injuries.

What You'll Learn

  • Dynamic maneuvers to help differentiate intricate layers of anatomy.
  • Advanced scanning techniques and transducer handling for complex exams.
  • Visualization of difficult ligament and tendon insertions
  • Discover the benefits of ultra-high frequency when imaging the dorsal and volar hand.
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.

Related

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.