Wrist ultrasound examination – scanning technique and ultrasound anatomy. Part 2: Ventral wrist

Abstract

Ultrasound imaging of the musculoskeletal system is an important element of the diagnostic and therapeutic protocol. Clinical decisions, including those regarding surgical procedures, are often based solely on ultrasound imaging. However, detailed knowledge on the anatomy and a correct scanning technique are crucial for an accurate diagnosis. Modern ultrasonographic equipment allows obtaining detailed anatomical images of muscle tendons, ligaments, nerves and vessels of the carpal area. Ventral wrist ultrasound is one of the most common diagnostic procedures in patients with suspected carpal tunnel syndrome. Ventral wrist evaluation is also often performed in patients with wrist pain of unclear etiology, rheumatic diseases, wrist injuries or symptoms of ulnar neuropathy. The aim of this paper is to present ultrasound images with corresponding anatomical schemes. The technique of ultrasound examination of the ventral wrist along with practical guidance to help obtain highly diagnostic images is also discussed. The present paper is the second part of an article devoted to ultrasound anatomy and wrist ultrasound technique – the part discussing the dorsal side of the wrist was published in the Journal of Ultrasonography, Vol. 15, No 61. The following anatomical structures should be visualized during an ultrasound examination of the ventral wrist, both in the carpal tunnel as well as proximally and distally to it: four flexor digitorum superficialis tendons, four flexor digitorum profundus tendons, flexor pollicis longus, flexor carpi radialis tendon, median nerve and flexor retinaculum; in the carpal tunnel as well as proximally and distally to it: the ulnar nerve, ulnar artery and veins; the tendon of the flexor carpi ulnaris muscle; carpal joints.

Ultrasound-Guided Treatment of Peripheral Nerve Pathology

“…32,43,44 At the level of the hand, the median nerve enters the carpal tunnel superficial to the flexor tendons and deep to the transverse carpal ligament. 32,[43][44][45] The median nerve supplies motor innervation to the flexor muscles in the anterior compartment of the forearm with the exception of the flexor carpi ulnaris and the ulnar aspects of the flexor digitorum profundus muscles. In the distal forearm, the median nerve gives off the palmar cutaneous branch, supplying sensory innervation to the radial aspect of the palm.…”

“…After entering the carpal tunnel, the median nerve provides sensory innervation to the palmar aspect of the first three fingers and radial half of the fourth finger, as well as motor function to the first and second lumbricales and also the thenar muscles. 32,[43][44][45] The median nerve is commonly entrapped at the transverse carpal ligament producing the common symptoms of carpal tunnel syndrome; however, the nerve may also become entrapped more proximally by the ligament of Struthers, the bicipital aponeurosis, or from hypertrophied muscles along its course. 46 Ulnar Nerve at the Elbow The ulnar nerve arises from the medial cord of the brachial plexus and receives fibers from the C8 and T1 nerve roots.…”

“…The cubital tunnel is formed by the arcuate ligament above the nerve and the ulnar and radial heads of the flexor carpi ulnaris muscle on either side. 32,[43][44][45]47 The cubital tunnel is a common location of ulnar nerve entrapment (►Fig. 10), and patients with cubital tunnel syndrome frequently present with medial elbow pain, sensory disturbances in the fourth and fifth digits, and muscle weakness in the hand.…”

Feasibility of Ultrasound in Infant Wrist and Thumb Imaging

“…Ultrasound (US) is increasingly being used to characterize bone and cartilage abnormalities in children . Although US cannot penetrate cortical bone, it does offer better visualization of growth cartilage than radiographs, can show cortical breaks and erosions, and can detect periosteal abnormalities . Although magnetic resonance imaging (MRI) is also capable of defining cartilaginous and soft tissue structures, sedation is required in infants, and it comes with considerable expense.…”

“…1 Although US cannot penetrate cortical bone, it does offer better visualization of growth cartilage than radiographs, can show cortical breaks and erosions, and can detect periosteal abnormalities. [2][3][4][5] Although magnetic resonance imaging (MRI) is also capable of defining cartilaginous and soft tissue structures, sedation is required in infants, and it comes with considerable expense. We hypothesized that US would be a practical imaging modality for visualizing the unossified structures of the base of the thumb and lateral carpus in infants.…”