Diagnostics 13 01928

diagnostics
Review
Ultrasound Imaging and Guidance for Distal Peripheral Nerve
Pathologies at the Wrist/Hand
Wei-Ting Wu 1,2 , Ke-Vin Chang 1,2,3, * , Yu-Chun Hsu 1 , Yuan-Yuan Tsai 1 , Kamal Mezian 4 ,
Vincenzo Ricci 5 and Levent Özçakar 6
1 Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch,
Taipei 10845, Taiwan; [email protected] (W.-T.W.); [email protected] (Y.-C.H.);
[email protected] (Y.-Y.T.)
2 Department of Physical Medicine and Rehabilitation, National Taiwan University College of Medicine,
Taipei 10048, Taiwan
3 Center for Regional Anesthesia and Pain Medicine, Wang-Fang Hospital, Taipei Medical University,
Taipei 11600, Taiwan
4 Department of Rehabilitation Medicine, First Faculty of Medicine and General University Hospital,
Charles University, 12800 Prague, Czech Republic; [email protected]
5 Physical and Rehabilitation Medicine Unit, Luigi Sacco University Hospital, ASST Fatebenefratelli-Sacco,
20157 Milan, Italy; [email protected]
6 Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School,
Ankara 20157, Turkey; [email protected]
* Correspondence: [email protected]
Abstract: Ultrasound has emerged as a highly valuable tool in imaging peripheral nerve lesions
in the wrist region, particularly for common pathologies such as carpal tunnel and Guyon’s canal
syndromes. Extensive research has demonstrated nerve swelling proximal to the entrapment site,
an unclear border, and flattening as features of nerve entrapments. However, there is a dearth of
information regarding small or terminal nerves in the wrist and hand. This article aims to bridge this
knowledge gap by providing a comprehensive overview concerning scanning techniques, pathology,
and guided-injection methods for those nerve entrapments. The median nerve (main trunk, palmar
cutaneous branch, and recurrent motor branch), ulnar nerve (main trunk, superficial branch, deep
Citation: Wu, W.-T.; Chang, K.-V.;
branch, palmar ulnar cutaneous branch, and dorsal ulnar cutaneous branch), superficial radial nerve,
Hsu, Y.-C.; Tsai, Y.-Y.; Mezian, K.;
posterior interosseous nerve, palmar common/proper digital nerves, and dorsal common/proper
Ricci, V.; Özçakar, L. Ultrasound
Imaging and Guidance for Distal
digital nerves are elaborated in this review. A series of ultrasound images are used to illustrate these
Peripheral Nerve Pathologies at the techniques in detail. Finally, sonographic findings complement electrodiagnostic studies, providing
Wrist/Hand. Diagnostics 2023, 13, better insight into understanding the whole clinical scenario, while ultrasound-guided interventions
1928. https://doi.org/10.3390/ are safe and effective for treating relevant nerve pathologies.
diagnostics13111928
Keywords: ultrasonography; neuropathy; entrapment; diagnosis; finger
Academic Editor: Christoph Trumm
Received: 10 May 2023

Revised: 27 May 2023
Accepted: 29 May 2023 1. Introduction
Published: 31 May 2023
While magnetic resonance imaging (MRI) can be used to assess peripheral nerve
pathologies, high cost and lack of portability limit its widespread use in clinical settings.
Additionally, MRI cannot be used to guide injections for entrapped nerves. In recent years,
Copyright: © 2023 by the authors.
high-resolution ultrasound (US) has increasingly been used to investigate peripheral nerve
Licensee MDPI, Basel, Switzerland. lesions, with its diagnostic performance comparable to MRI [1,2]. Although numerous
This article is an open access article clinical guidelines have addressed scanning techniques for peripheral nerves [1,3–6], they
distributed under the terms and mainly focused on the proximal/main nerve trunks [2,7,8]. There are few pictorial reviews
conditions of the Creative Commons targeting terminal nerves in the wrist and hand. Furthermore, most existing literature
Attribution (CC BY) license (https:// emphasizes carpal tunnel [9] and Guyon’s canal syndromes [10], while other nerve entrap-
creativecommons.org/licenses/by/ ment syndromes, such as compression of the recurrent motor branch of the median nerve,
4.0/). are rarely mentioned. Herein, this pictorial essay aims to provide a detailed overview of
Diagnostics 2023, 13, 1928. https://doi.org/10.3390/diagnostics13111928 https://www.mdpi.com/journal/diagnostics

Diagnostics 2023, 13, x FOR PEER REVIEW 2 of 32
Diagnostics 2023, 13, 1928 2 of 30
nerve, are rarely mentioned. Herein, this pictorial essay aims to provide a detailed over-
regional
view neuralneural
of regional anatomy (Figure
anatomy 1), scanning
(Figure skills,
1), scanning and and
skills, sonographic pathologies
sonographic for the
pathologies
formain nerves
the main and their
nerves distaldistal
and their branches at theatwrist
branches and hand.
the wrist Of note,
and hand. several
Of note, US images
several US
and videos
images are illustrated
and videos for prompt
are illustrated for promptdiagnosis andand
diagnosis guided injections
guided of pertinent
injections nerve
of pertinent
entrapment
nerve syndromes
entrapment syndromes[11,12].
[11,12].
Figure 1. Schematic
Figure drawing
1. Schematic of the
drawing innervation
of the of the
innervation wrist
of the andand
wrist hand.
hand.
Diagnostics 2023, 13, 1928 3 of 30
2. General Considerations
2.1. Ultrasound Setting and Scanning Plane
In the present pictorial review, high-frequency linear transducers (5–18 MHz; HI
VISION, Ascendus, Hitachi, Japan, and Aplio 500, Canon, Tokyo, Japan) were used for
scanning the nerves. The transducer was placed in the nerve’s short axis to delineate its
epineurium during quantification of its cross-sectional area (CSA) [13–15]. Herewith, the
transducer was positioned along the nerve’s long axis for prompt identification of the
entrapped segment. Additionally, Doppler imaging was used to detect accompanying
vessels or peri/intraneural hypervascularity due to inflammatory pathologies.
2.2. Common Ultrasonographic Features of Peripheral Nerve Pathologies

Common causes of peripheral nerve lesions are entrapment [11,12], tumors, and
trauma. Nerve compression can obstruct microvasculature, leading to Schwann cell necrosis
and subsequent demyelination. Severe cases can result in arterial flow obstruction, axonal
injury, and degeneration, which can be detected in electrophysiological examinations as
well. Duration and magnitude of nerve compression are directly related to the severity
of symptoms. US can identify swollen nerve fascicles proximal and distal to the site of
compression [16]. It is also useful in identifying the underlying cause of entrapment, e.g.,
hypertrophic scar.
Primary peripheral nerve tumors are mostly benign, such as schwannoma and neu-
rofibroma. The former originates from Schwann cells within the neural sheath and appears
as an encapsulated hypoechoic mass (with a round, fusiform, or oval shape), which can
cause compression and lateral displacement of the nerve trunk [17,18]. On the other hand,
neurofibromas are commonly associated with neurofibromatosis type 1 and display a mixed
origin, including Schwann cells, fibroblasts, mast cells, and axons [19,20]. Neurofibromas
usually have a hypoechoic, fusiform, and lobulated shape on US, with significantly larger
diameters than that of schwannomas [21]. In contrast, a malignant peripheral nerve tumor
tends to be larger in size, with ill-defined margins, central necrosis, and infiltration of the
surrounding tissues [22].
The mechanisms of traumatic nerve injuries include compression, traction, crush, and
transection. Traction and compression injuries are usually associated with neurapraxia,
presenting as focal demyelination without damage to the axons or connective tissues. A
crush injury often results from contusion by a blunt object (e.g., bat or surgical clamp) and
can cause varying degrees of neural damage [23]. On the other hand, a transection injury
caused by a glass shard, knife, or gunshot typically leads to neurotmesis, which involves
complete discontinuation of the nerve [23]. US features of traumatic nerve injuries may
include nerve swelling (i.e., enlarged CSA), loss of normal architecture, disruption of the
fascicular pattern, and loss of nerve continuity [24].
To establish a definitive diagnosis of a peripheral nerve pathology, it is crucial to
conduct a comparative analysis of US findings in the affected vs. contralateral side. It
is noteworthy that sono-Tinel sign, which involves using the transducer to compress the
target nerve and elicit symptoms, can aid in precisely locating the lesion. Moreover, the
related muscles become atrophied/hyperechoic as a result of denervation [25].
2.3. Ultrasound-Guided Hydrodissection

A diagnostic US-guided nerve block with local anesthetics can be performed to con-
firm the clinical scenario. Hydrodissection (using regimens such as 5% dextrose or cor-
ticosteroid) is suggested to first target the nerve’s short axis for better delineating the
epineurium [9,26,27]. The needle tip can be placed with its bevel up for the upper half of
the epineurium and bevel down for the lower half of the epineurium, to fully separate
the epineurium from the surrounding connective tissues. In the case of a long-segment
entrapment, an alternative approach would be to align the transducer with the target
nerve’s long axis for hydrodissecting the upper half of the epineurium.
3. Sonoanatomy and Pathology

Diagnostics 2023, 13, 1928 4 of 30
3.1. Median Nerve
3.1.1. Main Trunk
3. Sonoanatomy and Pathology
Anatomy
3.1. Median Nerve
The Main
3.1.1. median nerve originates from the lateral and medial cords of the brachial plexus
Trunk
which are
Anatomy formed by the ventral roots from C5 to T1. Apart from the flexor carpi ulnaris
and the The
ulnar half of
median the originates
nerve flexor digitorum profundus,
from the lateral the median
and medial nerve
cords of the provides
brachial plexus,innerva
tionwhich
to theareanterior
formed bycompartment offrom
the ventral roots the C5
forearm muscles.
to T1. Apart from At
the the palmar
flexor wrist,and
carpi ulnaris the nerve
the ulnar half of the flexor digitorum profundus, the median nerve provides innervation
innervates the first and second lumbrical muscles and thenar muscles. In terms of sensory to
the anterioritcompartment
innervation, supplies theofpalmar
the forearm muscles.
surface At the
of the palmar
thumb wrist,
and thethe nerve innervates
second, third, and radia
the first and second lumbrical muscles and thenar muscles. In terms of sensory innervation,
half of the fourth fingers.
it supplies the palmar surface of the thumb and the second, third, and radial half of the
fourth fingers.
Scanning Technique
Scanning Technique
The transducer can be placed in the axial plane on the distal one-third of the forearm
with theThe transducer can be placed in the axial plane on the distal one-third of the forearm
forearm supinated. The median nerve travels between the flexor digitorum su-
with the forearm supinated. The median nerve travels between the flexor digitorum
perficialis and flexor digitorum profundus muscles. It gradually runs superficially to enter
superficialis and flexor digitorum profundus muscles. It gradually runs superficially to
the carpal
enter thetunnel. The carpal
carpal tunnel. tunnel
The carpal inletinlet
tunnel is defined
is definedasasthe
theplane crossing
plane crossing the
the scaphoid and
scaphoid
pisiform (Figure 2A), whereas the plane linking the trapezium and hook
and pisiform (Figure 2A), whereas the plane linking the trapezium and hook of the hamate of the hamate
serves as the
serves carpal
as the carpaltunnel
tunnel outlet (Figure
outlet (Figure 2B).
2B).
Figure 2. Sonographic/normal
Figure 2. Sonographic/normalimaging
imagingof of the mediannerve
the median nervefrom
fromthethe inlet
inlet (A)(A) to outlet
to the the outlet
(B) of(B) of the
carpal tunnel. Hypertrophy of the flexor retinaculum at both the inlet (C) and outlet
the carpal tunnel. Hypertrophy of the flexor retinaculum at both the inlet (C) and outlet (D) (D) ofofthe carpa
tunnel.
the carpal tunnel. Asterisk: median nerve; small white arrowheads: normal flexor retinaculum; arrow
Asterisk: median nerve; small white arrowheads: normal flexor retinaculum; large
heads: hypertrophy
large arrowheads: of the flexorofretinaculum.
hypertrophy FCR: flexor
the flexor retinaculum. carpi
FCR: radialis;
flexor S: scaphoid;
carpi radialis; P: pisiform;
S: scaphoid; P: T
trapezium;
pisiform;H:T: hook of the
trapezium; H:hamate.
hook of the hamate.
Clinical Implication
Carpal tunnel syndrome is the most common entrapment neuropathy whereby the
Carpalnerve
median tunnel syndrome
is entrapped by is the most
various common
causes, entrapment
like hypertrophy of theneuropathy whereby the
flexor retinaculum
median nerve
(Figure 2C,D)is and
entrapped by various
compression from thecauses,
accessory like hypertrophy
muscles, swollen of the flexor
tendons, retinaculum
ganglions,
and bony
(Figure 2C,D)fractures within the tunnel.
and compression from theUltrasonographic
accessory muscles,changes encompass
swollen swelling
tendons, ganglions
proximal to the entrapment site (Figure 3A), flattening over the entrapment
and bony fractures within the tunnel. Ultrasonographic changes encompass swelling site (Figure 3B),
intraneural hypervascularity (Figure 3C), and focal loss of the trimline pattern (Figure 3D).
proximal to the entrapment site (Figure 3A), flattening over the entrapment site (Figure
3B), intraneural hypervascularity (Figure 3C), and focal loss of the trimline pattern (Figure
3D).
The nerve’s CSA (a cutoff value of 9–10.5 mm2) arises as the most useful parameter
for the diagnosis [28], whereas its diameter, gliding resistance [29], stiffness (evaluated by
sonoelastography), and intraneural vascularity (assessed by power Doppler imaging)
may serve as adjuvant indicators. A bifid median nerve (Figure 4A), the presence of a per
sistent median artery (Figure 4B) with or without thrombosis, accessory flexor digitorum
Diagnostics 2023, 13, 1928 5 of 30

superficialis muscle (Figure 4C), laceration of the palmaris longus tendon (Figure 4D), and
schwannoma (Figure 5) can be associated findings for carpal tunnel syndrome [9].
superficialis muscle (Figure 4C), laceration of the palmaris longus tendon (Figure 4D), and
schwannoma (Figure 5) can be associated findings for carpal tunnel syndrome [9].
Figure 3. Sonographic
Figure 3. Sonographic images
imagesof of
patients
patientswith
withcarpal
carpaltunnel
tunnel syndrome, showingfocal
syndrome, showing focal swelling prox-
swelling
imalproximal
to the compression site (A),
to the compression siteflattening at the
(A), flattening at compression
the compression site (B),
site (B),intraneural hypervascularity
intraneural hypervas-
(C), cularity
and loss(C),of and
the loss
trimline
of thepattern
trimline(D). White
pattern (D). arrowhead: focal focal
White arrowhead: swelling of the
swelling median
of the median nerve; as-
terisk:
nerve; asterisk: flattening of the median nerve; black arrowheads: intraneural hypervascularity of the median
flattening of the median nerve; black arrowheads: intraneural hypervascularity of the
nerve; whitenerve;
median arrows:
whiteloss of the
arrows: losstrimline pattern
of the trimline of the
pattern of median
the mediannerve;
nerve;black
black arrow: thickened flexor
arrow: thickened
retinaculum
flexor retinaculum.
The nerve’s CSA (a cutoff value of 9–10.5 mm2 ) arises as the most useful parameter
Figure 3.
for theSonographic images
diagnosis [28], of patients
whereas with carpal
its diameter, tunnel
gliding syndrome,
resistance [29],showing
stiffnessfocal swelling prox-
(evaluated
imalbyto sonoelastography),
the compression site and(A), flattening vascularity
intraneural at the compression
(assessedsite
by (B),
powerintraneural hypervascularity
Doppler imaging)
(C), and
may loss ofas
serve theadjuvant
trimlineindicators.
pattern (D). A White arrowhead:
bifid median nervefocal swelling
(Figure of the
4A), the median
presence of nerve;
a as-
terisk: flattening
persistent of theartery
median median nerve;
(Figure 4B)black
with arrowheads: intraneural
or without thrombosis, hypervascularity
accessory of the median
flexor digitorum
superficialis
nerve; muscle
white arrows: (Figure
loss of the4C), laceration
trimline patternof the palmaris
of the median longus tendon
nerve; black(Figure
arrow: 4D), and flexor
thickened
schwannoma
retinaculum (Figure 5) can be associated findings for carpal tunnel syndrome [9].
Figure 4. Sonographic images show a bifid median nerve (A), a persistent median artery with a bifid
median nerve (B), accessory flexor digitorum superficialis muscle (C), and laceration of the palmaris
longus (PL) tendon with the compression of the median nerve (D). White arrowheads: median
nerve; white arrow: persistent median artery; asterisk: accessory flexor digitorum superficialis mus-
cle. FCR: flexor carpi radialis tendon; S: scaphoid.
Figure 4. Sonographic images
imagesshow
show aa bifid
bifidmedian
median nerve
nerve (A),(A), a persistent
a persistent median
median artery
artery with with a bifid
a bifid
median
median nerve (B), accessory flexor digitorum superficialis muscle (C), and laceration of the palmarispalmaris
nerve (B), accessory flexor digitorum superficialis muscle (C), and laceration of the
longus (PL)(PL)
longus tendon
tendonwith thecompression
with the compression ofmedian
of the the median nerve
nerve (D). White(D). White arrowheads:
arrowheads: median nerve; median
nerve; white
white arrow:
arrow: persistent
persistent medianmedian artery; accessory
artery; asterisk: asterisk: flexor
accessory flexor
digitorum digitorum
superficialis superficialis
muscle. FCR: mus-
cle. FCR:
flexorflexor carpi radialis
carpi radialis tendon; S:tendon;
scaphoid.S: scaphoid.
Figure 5. Comparative ultrasonography (long-axis view) between healthy (A) vs. affected (B) sides
shows a schwannoma (black arrowhead) with increased intraneural vascularity.
Regarding US-guided injections for carpal tunnel syndrome, a network meta-analy-

sis, including ten studies with 497 patients, reported that 5% dextrose (D5W) injection was
Figure 4. Sonographic images show a bifid median nerve (A), a persistent median artery with a bifid
median nerve (B), accessory flexor digitorum superficialis muscle (C), and laceration of the palmaris
longus (PL) tendon with the compression of the median nerve (D). White arrowheads: median
Diagnostics 2023, 13, 1928 6 of 30
nerve; white arrow: persistent median artery; asterisk: accessory flexor digitorum superficialis mus
cle. FCR: flexor carpi radialis tendon; S: scaphoid.
Figure 5. Comparative
Figure 5. Comparativeultrasonography (long-axis
ultrasonography (long-axis view)
view) between
between healthy
healthy (A) vs.(A) vs. affected
affected (B) sides(B) sides
RegardingUS-guided
Regarding US-guided injections
injections forfor
carpal tunnel
carpal syndrome,
tunnel a network
syndrome, meta-analysis,
a network meta-analy-
including ten studies with 497 patients, reported that 5% dextrose (D5W) injection was likely
sis, including ten studies with 497 patients, reported that 5% dextrose (D5W) injection was
to be the best treatment for symptom relief, followed by platelet-rich plasma injection [30].
likely to be
injection
During the
[30]. best hydrodissection
During
hydrodissection treatment for nerve,
of the median symptom
of thethe
medianrelief,
needle canfollowed
nerve, by using
the needle
be introduced platelet-rich
can be the plasma
introduced
either
using eitherapproach
in-plane the in-plane approach
targeting targeting
the short-axis the short-axis
(Figure 6A, Video (Figure 6A, Video
S1) or long-axis S1) or
(Figure 6B,long-
axis (Figure
Video 6B, Video
S2) views of theS2) views
nerve. If of the nerve.
symptoms If symptoms
persist persist despite
despite non-operative non-operative
management,
management,
considerationconsideration
should be givenshould
to minimalbe given
invasiveto carpal
minimal invasive
tunnel release,carpal tunnel release,
with confirmation
of complete
with release
confirmation of using dynamic
complete US [31].
release using dynamic US [31].
Figure 6. Ultrasound-guided
Figure 6. Ultrasound-guidedhydrodissection
hydrodissection ofofthe
themedian
median nerve
nerve under
under short-axis
short-axis (A) or(A) or long-axis
long-axis
(B) (B)
imaging.
imaging.Asterisk:
Asterisk:median
mediannerve; arrows:needle.
nerve; arrows: needle.S:S:scaphoid;
scaphoid; P: pisiform.
P: pisiform.
3.1.2.
3.1.2. Palmar
Palmar CutaneousBranch
Cutaneous Branch of
of the
theMedian
MedianNerve
Nerve
Anatomy
Anatomy
The palmar cutaneous branch of the median nerve is responsible for sensory innerva-
The
tion to palmar
the skin cutaneous
of the thenar branch of the median
and proximal nerve isItresponsible
palmar regions. for sensory
originates from the radialinner-
vation
side to
of the skin of nerve
the median the thenar
in theand proximal
distal forearm, palmar
perforatesregions. It originates
the antebrachial from
fascia the radial
between
side
theofflexor
the median nerveand
carpi radialis in the distallongus
palmaris forearm, perforates
tendons, and does thenot
antebrachial fascia
enter the carpal between
tunnel.
The nerve then divides into the medial and lateral branches distal to the flexor
the flexor carpi radialis and palmaris longus tendons, and does not enter the carpal tunnel.retinaculum,
Theproviding
nerve then cutaneous
divides sensation
into thetomedial
the palmandand the ball
lateral of the thumb.
branches distal to the flexor retinacu-
lum, providing
Scanning cutaneous sensation to the palm and the ball of the thumb.
Technique
The transducer is first placed in the axial plane over the distal forearm with the
Scanning Technique
forearm supinated to locate the median nerve between the flexor digitorum superficialis
The
and transducer
profundus is first
muscles placed
(Figure 7A).inMoving
the axial
theplane over distally,
transducer the distal
theforearm with the fore-
palmar cutaneous
branch of the median nerve, shown as a single hypoechoic fascicle, emerges
arm supinated to locate the median nerve between the flexor digitorum superficialis from the radial and
aspect of muscles
profundus the median nerve (Figure
(Figure 7B) [32].
7A). Moving theThe nerve thendistally,
transducer penetratesthethepalmar
antebrachial
cutaneous
fascia and runs on the ulnar aspect of the flexor carpi radialis tendon (Figure
branch of the median nerve, shown as a single hypoechoic fascicle, emerges from the ra- 7C). Eventually,
the nerve can be identified superficial to the abductor pollicis brevis muscle (Figure 7D).
dial aspect of the median nerve (Figure 7B) [32]. The nerve then penetrates the an-
tebrachial fascia and runs on the ulnar aspect of the flexor carpi radialis tendon (Figure
7C). Eventually, the nerve can be identified superficial to the abductor pollicis brevis mus-
cle (Figure 7D).
profundus muscles (Figure 7A). Moving the transducer distally, the palmar cutaneous
branch of the median nerve, shown as a single hypoechoic fascicle, emerges from the ra-
dial aspect of the median nerve (Figure 7B) [32]. The nerve then penetrates the an-
tebrachial fascia and runs on the ulnar aspect of the flexor carpi radialis tendon (Figure
Diagnostics 2023, 13, 1928 7 of 30
7C). Eventually, the nerve can be identified superficial to the abductor pollicis brevis mus-
cle (Figure 7D).
Figure
Figure7. 7.
Sonographic
Sonographicimaging
imagingofofthe
thepalmar
palmar cutaneous branchofofthe
cutaneous branch themedian
median nerve
nerve (A)(A) shows its
shows
emerging
its emerging from the radial aspect of the median nerve (B), penetrating the antebrachial fascia (C),
from the radial aspect of the median nerve (B), penetrating the antebrachial fascia
and(C),
arriving at the at
and arriving superficial site of
the superficial the
site ofabductor pollicis
the abductor brevis
pollicis muscle
brevis muscle(D). Asterisk:
(D). Asterisk:median
mediannerve;
arrowhead:
nerve; arrowhead: palmar cutaneous branch of the median nerve; dashed line, antebrachial fascia;
palmar cutaneous branch of the median nerve; dashed line, antebrachial fascia; FCR:
FCR: flexor carpi radialis tendon; T: trapezium; PL: palmaris longus tendon; AbP: abductor pollicis
brevis muscle.
The palmar cutaneous branch of the median nerve can be injured due to cuts, result-
ing in neuroma formation (Figure 8A–C) [9]. During an intervention for carpal tunnel
syndrome, it is essential to identify the palmar cutaneous branch of the median nerve to
prevent accidental injury. Recurrent pain and paresthesia over the palmar region following
carpal tunnel release can also be subsequent to entrapment by post-operative scar tissues.
For hydrodissection of this nerve, the preferred approach is an in-plane approach targeting
its short axis from the ulnar aspect (Figure 9).
3.1.3. Recurrent Motor Branch of the Median Nerve

Anatomy
The recurrent motor branch of the median nerve innervates the thenar muscles, i.e.,
abductor pollicis brevis, opponens pollicis, and the superficial head of the flexor pollicis
brevis. There are four main types of reciprocal anatomy between this branch and the
transverse carpal ligament. The mean diameter of the recurrent motor branch has been
reported as 0.7 mm—with a standard deviation of 0.1 mm in healthy volunteers [33]. The
extraligamentous type is the most common [34,35], where the nerve emerges from the main
trunk distal to the carpal tunnel outlet, ascends vertically to the palmar surface through
the distal edge of the transverse carpal ligament [36], and then curves back to innervate
the thenar muscles. However, if the recurrent motor branch exits the main trunk in other
locations, the nerve is classified as preligamentous, subligamentous, or transligamentous,
depending on whether it exits proximal to the flexor retinaculum, within the carpal tunnel,
or by piercing the transverse carpal ligament, respectively [35].
Scanning Technique
To assess the median nerve and its branches, the transducer is initially placed over
the carpal tunnel inlet and then moved distally/radially. In the extraligamentous type, the
recurrent motor branch emerges from the radial aspect of the median nerve as it travels
distally to the carpal tunnel outlet. However, at this point, identifying the precise site of
branching may be challenging due to anisotropy and the nerve’s reversed course. To aid
visualization, the physician can pivot the radial end of the transducer back and forth to
identify the recurrent motor branch. It appears as a hypoechoic monofascicle that pierces
muscle.
The palmar cutaneous branch of the median nerve can be injured due to cuts, result-
Diagnostics 2023, 13, 1928 ing in neuroma formation (Figure 8A–C) [9]. During an intervention for carpal tunnel syn- 8 of 30
drome, it is essential to identify the palmar cutaneous branch of the median nerve to pre-
vent accidental injury. Recurrent pain and paresthesia over the palmar region following
carpal tunnel release can also be subsequent to entrapment by post-operative scar tissues.
the
Forpalmar aponeurosis,
hydrodissection reaching
of this nerve,the
thesurface of the
preferred thenar is
approach muscle (Figureapproach
an in-plane 10). Occasionally,
target-
other anatomic variants can also be visualized (Figure
ing its short axis from the ulnar aspect (Figure 9). 11) [37].
Figure 8. Compared with the normal proximal segment (A), a neuroma originating from the palmar
Figure 8. Compared with the normal proximal segment (A), a neuroma originating from the palmar
cutaneous branch of the median nerve is seen in short-axis (B) and long-axis (C) imaging. Asterisk:
cutaneous branch of the median nerve is seen in short-axis (B) and long-axis (C) imaging. Asterisk:
median nerve; white arrowheads: palmar cutaneous branch of the median nerve; black arrowhead:
neuroma. FCR: flexor carpi radialis tendon; PL: palmaris longus tendon.
Diagnostics 2023, 13, 1928 9 of 30

median nerve; white arrowheads: palmar cutaneous branch of the median nerve; black arrowhead:
neuroma. FCR: flexor carpi radialis tendon; PL: palmaris longus tendon.
Figure 9. Ultrasound-guided hydrodissection (short-axis view) for the palmar cutaneous branch of
Figure 9. Ultrasound-guided hydrodissection (short-axis view) for the palmar cutaneous branch of
the median nerve. Asterisk: median nerve; arrowhead: palmar cutaneous branch of the median
border
the median nerve. ofAsterisk:
the injured nerve,nerve;
median with poor visualization of the epineurium (Figure 12; median
Video
nerve; arrow: needle. FCR: flexor arrowhead: palmar
carpi radialis tendon. cutaneous branch of the
S3). US-guided hydrodissection in short-axis
nerve; arrow: needle. FCR: flexor carpi radialis tendon. view has been reported helpful for reducing
thenar3.1.3.
painRecurrent
in a case with
Motorrecurrent
Branch of motor branch Nerve
the Median entrapment [36].
Anatomy
The recurrent motor branch of the median nerve innervates the thenar muscles, i.e.,
abductor pollicis brevis, opponens pollicis, and the superficial head of the flexor pollicis
brevis. There are four main types of reciprocal anatomy between this branch and the trans-
verse carpal ligament. The mean diameter of the recurrent motor branch has been reported
as 0.7 mm—with a standard deviation of 0.1 mm in healthy volunteers [33]. The extralig-
amentous type is the most common [34,35], where the nerve emerges from the main trunk
distal to the carpal tunnel outlet, ascends vertically to the palmar surface through the dis-
tal edge of the transverse carpal ligament [36], and then curves back to innervate the the-
nar muscles. However, if the recurrent motor branch exits the main trunk in other loca-
tions, the nerve is classified as preligamentous, subligamentous, or transligamentous, de-
pending on whether it exits proximal to the flexor retinaculum, within the carpal tunnel,
or by piercing the transverse carpal ligament, respectively [35].
Scanning Technique
To assess the median nerve and its branches, the transducer is initially placed over
the carpal tunnel inlet and then moved distally/radially. In the extraligamentous type, the
recurrent motor branch emerges from the radial aspect of the median nerve as it travels
distally to the carpal tunnel outlet. However, at this point, identifying the precise site of
branching may be challenging due to anisotropy and the nerve’s reversed course. To aid
visualization, the physician can pivot the radial end of the transducer back and forth to
identify the recurrent motor branch. It appears as a hypoechoic monofascicle that pierces
the palmar aponeurosis, reaching the surface of the thenar muscle (Figure 10). Occasion-
ally, other anatomic variants can also be visualized (Figure 11) [37].
The recurrent motor branch may be injured during carpal tunnel release, trigger
point injection of the thenar muscle, and repetitive impact of the thenar eminence [34]. In
the case of nerve injury, the thenar muscle is likely to undergo atrophy, leading to a sub-
sequent reduction in pinch and grasp forces. US reveals a swollen fascicle and an indistinct

Figure 10. Sonographic imagingimaging
for the for the recurrent
recurrent motor motor branch
branch of the
of the mediannerve.
median nerve. Tracking
Trackingback
back
from the surface of the thenar muscle (A) toward the division site from the main trunk in short-axis
from the surface of the thenar muscle (A) toward the division site from the main trunk in
(B) and long-axis (C) imaging. Asterisk: median nerve; white arrowheads: recurrent motor branch
short-axis
(B) and long-axis (C) imaging.
of the median nerve; a:Asterisk: median
artery; FPL: nerve; white
flexor pollicis longus arrowheads: recurrent
tendon; FPB: flexor motor
pollicis brevisbranch
muscle.of
the median nerve; a: artery; FPL: flexor pollicis longus tendon; FPB: flexor pollicis brevis muscle.
Diagnostics
Diagnostics 2023,
2023, 13, 13, PEER
x FOR 1928 REVIEW 10 of 32 10 of 30
Figure 11. Sonographic imaging of the preligamentous type of recurrent motor branch of the median
Figure 11. Sonographic imaging of the preligamentous type of recurrent motor branch of the median
nerve. It divides from the median nerve proximal to the carpal tunnel as seen in the long-axis view
(A), andnerve.
residesIt superficial
divides from theflexor
to the median nerve proximal
retinaculum, as seento
inthe
the carpal tunnel
short-axis viewas(B),
seen in the the
whereas long-axis view
transligamentous type of recurrent motor branch accompanies the median nerve into the carpal(B), whereas
(A), and resides superficial to the flexor retinaculum, as seen in the short-axis view
the transligamentous
tunnel (C), type of recurrent
penetrating the retinaculum motor
at the outlet branch
of the carpalaccompanies the median
tunnel (D). Asterisk: nerve
median into the carpal
nerve;
arrowheads: recurrent motor branch of the median nerve; arrows: flexor retinaculum. FCR: flexor
tunnel (C), penetrating the retinaculum at the outlet of the carpal tunnel (D). Asterisk: median nerve;
carpi radialis tendon.recurrent motor branch of the median nerve; arrows: flexor retinaculum. FCR: flexor
arrowheads:
carpi radialis tendon.
The recurrent motor branch may be injured during carpal tunnel release, trigger point
injection of the thenar muscle, and repetitive impact of the thenar eminence [34]. In the
case of nerve injury, the thenar muscle is likely to undergo atrophy, leading to a subsequent
reduction in pinch and grasp forces. US reveals a swollen fascicle and an indistinct border
of the injured nerve, with poor visualization of the epineurium (Figure 12; Video S3). US-
guided hydrodissection in short-axis view has been reported helpful for reducing thenar
pain in a case with recurrent motor branch entrapment [36].
3.2. Ulnar Nerve

3.2.1. Main Trunk, Superficial, and Deep Branches
Anatomy
The ulnar nerve originates from the medial cord of the brachial plexus, specifically
from the C8 and T1 nerve roots. As it approaches the wrist region, it courses below the
flexor carpi ulnaris (FCU) tendon alongside the ulnar artery. It then enters the Guyon’s
canal, bordered by the palmar carpal ligament, transverse carpal ligament, and pisiform.
Beyond the canal, a concave fibrous arch connects the two attachments of the flexor digiti
minimi brevis muscle on the flexor retinaculum and the hamate hook [38]. The fibrous arch
constitutes the roof of the narrow pisohamate hiatus, whereby its floor is formed by the
pisohamate ligament [39].
The ulnar nerve gives rise to two terminal (i.e., superficial and deep) branches, which
are divided from the main trunk prior to the hook of hamate. The superficial branch
provides sensory innervation to the volar and dorsal regions of the little finger and the
ulnar half of the ring finger, and motor innervation to the palmaris brevis muscle. The deep
branch, accompanied by an artery, passes through the pisohamate hiatus and courses be-
tween the flexor digiti minimi brevis and opponens digiti minimi muscles. It subsequently
enters the deep palm alongside the deep palmar branch of the ulnar artery, supplying the
abductor digiti minimi, flexor digiti minimi brevis, opponens digiti minimi, deep head of
flexor pollicis brevis, adductor pollicis, and the two lumbrical muscles located on the ulnar
aspect and the palmar/dorsal interossei muscles.
Diagnostics 2023, 13, 1928 11 of 30
Figure 12. Sonographic imaging (short-axis view) shows the segment (A) distal to the neuroma of
Figure 12. Sonographic imaging (short-axis view) shows the segment (A) distal to the neuroma of
the recurrent motor branch of the median nerve (B) and the proximal segment (C). Asterisk: median
the recurrent motor branch
nerve; of arrowhead:
white the medianrecurrent
nerve (B) and branch
motor the proximal segment
of the median (C).black
nerve; Asterisk: medianneuroma.
arrowheads:
nerve; white arrowhead: recurrent
FPB: flexor motormuscle;
pollicis brevis branchAbP:
of the median
abductor nerve;
pollicis blackmuscle.
brevis arrowheads: neuroma.
FPB: flexor pollicis brevis muscle; AbP: abductor pollicis brevis muscle.
Scanning Technique
To locate the Guyon’s canal, the transducer is placed along the axial plane on the volar
wrist with the forearm supinated. This will reveal the ulnar nerve and artery within the
canal (Figure 13A). To investigate the nerve’s long axis, the transducer is rotated 90 degrees.
By moving the transducer toward the finger, the superficial and deep branches can be seen.
Between the pisiform and hamate, the superficial and deep branches (along with their
accompanying vessels) can be visualized as separated by the fibrous arch of hypothenar
muscles, respectively (Figure 13B) [39].
To locate the Guyon’s canal, the transducer is placed along the axial plane on the
volar wrist with the forearm supinated. This will reveal the ulnar nerve and artery within
the canal (Figure 13A). To investigate the nerve’s long axis, the transducer is rotated 90
degrees. By moving the transducer toward the finger, the superficial and deep branches
can be seen. Between the pisiform and hamate, the superficial and deep branches (along
Diagnostics 2023, 13, 1928 12 of 30
with their accompanying vessels) can be visualized as separated by the fibrous arch of
hypothenar muscles, respectively (Figure 13B) [39].
Figure 13. Sonographic imaging (short-axis view) shows the ulnar nerve within the Guyon’s canal
Figure 13. Sonographic imaging (short-axis view) shows the ulnar nerve within the Guyon’s canal
(A), separation of branches beside the pisohamate hiatus (B), deep branch of the ulnar nerve located
(A), separation of branches beside the pisohamate hiatus (B), deep branch of the ulnar nerve located
between the hypothenar muscles distal to the hook of the hamate (C). Long-axis view (through piv-
between
oting the the hypothenar
transducer) muscles
shows distal toofthe
the segment thehook
deepofbranch
the hamate
within(C).
the Long-axis view (through
adductor pollicis muscle
pivoting the transducer) shows the segment of the deep branch within the adductor pollicis
(D). Arrowhead: ulnar nerve; white arrows: superficial branch of the ulnar nerve; black arrows: muscle
deep
(D). Arrowhead: ulnar nerve; white arrows: superficial branch of the ulnar nerve; black arrows:
branch of the ulnar nerve; orange arrow: branch of the ulnar nerve to the abductor digiti minimi; deep*:
branch of the ulnar nerve; orange arrow: branch of the ulnar nerve to the abductor digiti minimi; *:
pisohamate ligment MN: median nerve; UA: ulnar artery; P: pisiform; H: hook of hamate; A: artery;
L: lumbrical muscle; FDM: flexor digiti minimi brevis muscle; Opp DM: opponens digiti minimi
muscle; AbDM: abductor digiti minimi muscle; AdP: adductor pollicis muscle.
The superficial branch divides into two palmar digital nerves. They run superficially
along the little finger and half of the ring finger. The deep branch, on the other hand, can
be observed between the flexor digiti minimi brevis and opponens digiti minimi muscles
before it penetrates the deep aspect of the palm (Figure 13C). By pivoting the transducer,
the physician can display the long axis of the deep branch, extending all the way to the
segment within the adductor pollicis muscle (Figure 13D).
Injuries to the ulnar nerve beyond the elbow can cause claw hand, which manifests as
hyperextension at the metacarpophalangeal joints and flexion at the proximal and distal
interphalangeal joints of the fourth and fifth fingers—due to the unopposed action of the
ulnar side of the flexor digitorum profundus muscle against the paralyzed fourth and fifth
lumbrical muscles. If the nerve injury is distal to the wrist crest, it can lead to Guyon’s
canal syndrome or ulnar tunnel syndrome. To investigate such cases, the mean pooled
cross-sectional area (CSA) of the ulnar nerve at the Guyon’s canal in healthy volunteers (4.1
mm2 with a 95% CI between 3.6 and 4.6 mm2 ) can be used as a reference [40].
Repeat contusions to the hypothenar region and space-occupying lesions such as gan-
glion cysts, fracture segments, spurs of the pisiform, schwannoma, ulnar artery thrombosis,
or aneurysms and fibrolipomatus hamatoma (Figure 14) can cause Guyon’s canal syndrome.
Compression at the inlet of the Guyon’s canal, which is located proximal to the bifurcation
of the ulnar nerve into the superficial and deep branches, can result in both sensory and
motor deficits. However, if the injury is located more distally (Figure 15A), e.g., due to a
fracture of the hamate or pisohamate ligament sprain (Figure 15B,C), only motor deficits
may be observed [38].
ganglion cysts, fracture segments, spurs of the pisiform, schwannoma, ulnar artery throm-
bosis, or aneurysms and fibrolipomatus hamatoma (Figure 14) can cause Guyon’s canal
syndrome. Compression at the inlet of the Guyon’s canal, which is located proximal to the
bifurcation of the ulnar nerve into the superficial and deep branches, can result in both
sensory and motor deficits. However, if the injury is located more distally (Figure 15A),
Diagnostics 2023, 13, 1928 13 of 30
e.g., due to a fracture of the hamate or pisohamate ligament sprain (Figure 15B,C), only
motor deficits may be observed [38].
It enters the Guyon’s canal and perforates the palmar carpal ligament. It then courses be-
tween the palmaris longus and FCU tendons, and in some cases, communicates with the
Figure
Figure 14.
14. Sonographic
superficial and images
deep branches
Sonographic ofdepict
images aa fibrolipomatous
the ulnar
depict nerve, and evenhamartoma
fibrolipomatous (arrowheads)
with the palmar
hamartoma in
cutaneous
(arrowheads) in the
the short-
short- (A)
(A)
and long-axis
branch (B) views.
of the median nerve [41]. The nerve is responsible for supplying sensation to the
and long-axis (B) views.
hypothenar eminence and carries a vascular branch to the ulnar artery.
Handlebar neuropathy is a similar scenario that occurs due to continuous compres-
sion of the ulnar nerve at the ulnar wrist in cyclists. Focal swelling of the deep branch can
be seen at the hamate level. An associated finding would be atrophy/weakness of the dor-
sal interossei muscles (Figure 16). For treatment, injection over the short axis of the ulnar
nerve can be performed using the in-plane approach from the radial aspect in the Guyon’s
canal (Figure 17). For certainty, identifying the ulnar artery is essential to prevent iatro-
genic injury.
3.2.2. Palmar Ulnar Cutaneous Nerve

Anatomy
The palmar ulnar cutaneous nerve is a distal branch of the ulnar nerve and it origi-
nates from the main trunk approximately 5 to 10 cm proximal to the wrist crease. A ca-
daveric study revealed that the nerve has a mean diameter of 0.8 mm [41]. Together with
the ulnar nerve and vessels, the nerve courses below the flexor carpi ulnaris (FCU) tendon.
Figure
Figure15. 15.Illustration of the
Illustration ofpisohamate hiatus formed
the pisohamate hiatusby the archby
formed ofthe
hypothenar
arch of muscles and the
hypothenar muscles and the
pisohamate ligament (A). Compared with the normal ligament (B), long-axis imaging displays
sprain and swelling of the pisohamate ligament (C). Blue area: pisohamate ligament; green area: displays sprain
pisohamate ligament (A). Compared with the normal ligament (B), long-axis imaging
and swelling
fibrous arch of theof flexor
the pisohamate
digiti minimiligament (C). white
brevis muscle; Blue area:
arrows:pisohamate ligament;
normal pisohamate green area: fibrous
ligament;
black
arch arrows:
of the swollen pisohamate
flexor digiti minimiligament;
brevisH:muscle;
hamate; P: pisiform;
white T: triquetrum;
arrows: normalL:pisohamate
lunate; C: cap-ligament; black
itate; Tro: trapezoid; Tra: trapezium; S: scaphoid.
arrows: swollen pisohamate ligament; H: hamate; P: pisiform; T: triquetrum; L: lunate; C: capitate;
Tro: trapezoid; Tra: trapezium; S: scaphoid.
Diagnostics 2023, 13, 1928 14 of 30
Handlebar neuropathy is a similar scenario that occurs due to continuous compression

of the ulnar nerve at the ulnar wrist in cyclists. Focal swelling of the deep branch can be
seen at the hamate level. An associated finding would be atrophy/weakness of the dorsal
interossei muscles (Figure 16). For treatment, injection over the short axis of the ulnar nerve
can be performed using the in-plane approach from the radial aspect in the Guyon’s canal
(Figure 17). For certainty, identifying the ulnar artery is essential to prevent iatrogenic
Diagnostics 2023, 13, x FOR PEER REVIEW
injury. 15 of 32
Figure 16.
Figure 16. As
As opposed
opposed toto the
the normal
normal third
third dorsal
dorsal interossei (DIO) muscle,
interossei (DIO) muscle, atrophy
atrophy in
in the
the fourth
fourth DIO
DIO
Figure
muscle16. As opposed
indicates injurytotothe normal
the third
terminal dorsalofinterossei
branch the deep(DIO) muscle,
branch of the atrophy in theBlue
ulnar nerve. fourth DIO
double
muscle indicates injury to the terminal branch of the deep branch of the ulnar nerve. Blue double
muscle
dashed indicates injury thickness.
arrows: muscle to the terminal branch of the deep branch of the ulnar nerve. Blue double
dashed
dashed arrows:
arrows: muscle
muscle thickness.
thickness.
Figure 17. Ultrasound-guided injection of the ulnar nerve in short-axis view. Arrowhead: ulnar
Figure 17. Ultrasound-guided
nerve; arrow: needle. UA: ulnarinjection
artery; C:ofcapitate.
the ulnar nerve in short-axis view. Arrowhead: ulnar
Figure 17. Ultrasound-guided injection of the ulnar nerve in short-axis view. Arrowhead: ulnar
nerve; arrow: needle. UA: ulnar artery; C: capitate.
nerve; arrow: needle. UA: ulnar artery; C: capitate.
Scanning Technique
Scanning Technique
During scanning, the forearm is supinated with the transducer placed along the axial
planeDuring
of the scanning, the forearm
distal forearm. Moving is the
supinated withmore
transducer the transducer placed
distally, the along
palmar the cuta-
ulnar axial
plane
neous of the distal
nerve can beforearm.
seen as aMoving the transducer
single hypoechoic moredeparting
fascicle distally, the
frompalmar ulnarside
the radial cuta-
of
neous nerve can be seen as a single hypoechoic fascicle departing from the radial
the main trunk near the bifurcating point for the dorsal ulnar cutaneous nerve (Figure side of
Diagnostics 2023, 13, 1928 15 of 30
3.2.2. Palmar Ulnar Cutaneous Nerve

Anatomy
The palmar ulnar cutaneous nerve is a distal branch of the ulnar nerve and it originates
from the main trunk approximately 5 to 10 cm proximal to the wrist crease. A cadaveric
study revealed that the nerve has a mean diameter of 0.8 mm [41]. Together with the ulnar
nerve and vessels, the nerve courses below the flexor carpi ulnaris (FCU) tendon. It enters
the Guyon’s canal and perforates the palmar carpal ligament. It then courses between the
palmaris longus and FCU tendons, and in some cases, communicates with the superficial
and deep branches of the ulnar nerve, and even with the palmar cutaneous branch of the
median nerve [41]. The nerve is responsible for supplying sensation to the hypothenar
eminence and carries a vascular branch to the ulnar artery.
Scanning Technique
During scanning, the forearm is supinated with the transducer placed along the
axial plane of the distal forearm. Moving the transducer more distally, the palmar ulnar
cutaneous nerve can be seen as a single hypoechoic fascicle departing from the radial side of
the main trunk near the bifurcating point for the dorsal ulnar cutaneous nerve (Figure 18A).
Diagnostics 2023, 13, x FOR PEER REVIEW
It is crucial to apply light touch without compressing the adjacent vein, which can16beofused
32
to highlight the nerve’s border.
Figure 18. Sonographic imaging (short-axis view) of the palmar ulnar cutaneous nerve (A) and its
Figure 18. Sonographic imaging (short-axis view) of the palmar ulnar cutaneous nerve (A) and its
entrapment in the presence of an accessory abductor digiti minimi muscle (B). Arrowhead: palmar
entrapment in thenerve;
ulnar cutaneous presence of anaccessory
asterisk: accessoryabductor
abductor digiti
digiti minimi
minimi muscle
muscle. (B).ulnar
UN: Arrowhead: palmar
nerve; UA: ul-
ulnar cutaneous nerve; asterisk: accessory abductor digiti
nar artery; UV: ulnar vein; FCU: flexor carpi ulnaris tendon. minimi muscle. UN: ulnar nerve; UA:
ulnar artery; UV: ulnar vein; FCU: flexor carpi ulnaris tendon.
The palmar ulnar cutaneous nerve has been associated with certain peripheral vas-
The palmar ulnar cutaneous nerve has been associated with certain peripheral vas-
cular disorders that can lead to arterial constriction and erythema over the hypothenar
cular disorders that can lead to arterial constriction and erythema over the hypothenar
eminence [42]. The nerve may be persistently entrapped due to the presence of an acces-
eminence [42]. The nerve may be persistently entrapped due to the presence of an accessory
sory abductor digiti minimi muscle (Figure 18B) [42].
abductor digiti minimi muscle (Figure 18B) [42].
3.2.3.Dorsal
3.2.3. Dorsal Ulnar
Ulnar Cutaneous
Cutaneous Nerve
Nerve
Anatomy
Anatomy
Thedorsal
The dorsal ulnar
ulnar cutaneous
cutaneous nerve
nerve branches
branchesfrom fromthe
themain
maintrunk
trunkatatthe
thedistal
distalulnar
ulnar
aspect of the forearm, coursing initially beneath the FCU tendon. After piercingan-
aspect of the forearm, coursing initially beneath the FCU tendon. After piercing the the
tebrachial fascia,
antebrachial fascia,it itreaches
reachesthe
thedorsal
dorsalaspect
aspectofofthe
thewrist,
wrist,and
andthen
thendivides
dividesintointocommon
common
digitalbranches
digital branches to
to provide
provide innervation
innervation to tothe
thelittle
littlefinger
fingerand
andulnar
ulnarside
sideofof
the
thering
ringfinger.
finger.
ScanningTechnique
Scanning Technique
With the
With the forearm
forearm inin supination,
supination, the
the transducer
transducerisisplaced
placedononthe
thedistal
distalthird
thirdofofthe
the
ventralforearm
ventral forearmtotolocate
locatethe
themyotendinous
myotendinousjunction
junctionofofthe
theFCU.
FCU.The
Thedorsal
dorsalulnar
ulnarcutaneous
cutane-
ous nerve
nerve branches
branches fromfrom
the the ulnar
ulnar aspect
aspect ofof theulnar
the ulnarnerve
nerveunderneath
underneath the
theFCU,
FCU,and andthen
then
wraps around the distal
wraps around the distal ulna ulna to reach the dorsal wrist. Moving the transducer to
dorsal wrist. Moving the transducer to the the dorsal
dorsal
wrist, the nerve can be seen coursing above the extensor carpi ulnaris tendon (Figure 19),
toward the dorsal ulnar wrist and hand region.
aspect of the forearm, coursing initially beneath the FCU tendon. After piercing the an-
tebrachial fascia, it reaches the dorsal aspect of the wrist, and then divides into common
digital branches to provide innervation to the little finger and ulnar side of the ring finger.
Scanning Technique
Diagnostics 2023, 13, 1928 With the forearm in supination, the transducer is placed on the distal third of the 16 of 30
ventral forearm to locate the myotendinous junction of the FCU. The dorsal ulnar cutane-
ous nerve branches from the ulnar aspect of the ulnar nerve underneath the FCU, and then
wraps around the distal ulna to reach the dorsal wrist. Moving the transducer to the dorsal
Figure 19. Sonographic imaging of the dorsal ulnar cutaneous nerve as it branches from the ulnar
Figure 19. Sonographic imaging of the dorsal ulnar cutaneous nerve as it branches from the ulnar
aspect of the ulnar nerve underneath the flexor carpi ulnaris (FCU) muscle (A). The nerve wraps
aspect of the
around thedistal
ulnarulna
nerve underneath
to reach thewrist
the dorsal flexor
(B).carpi ulnaris dorsal
Arrowhead: (FCU)ulnar
muscle (A). The
cutaneous nerve
nerve. UN:wraps
around
ulnar the distal
nerve; UA: ulna toartery;
ulnar reach the dorsal
FDS: flexorwrist (B). Arrowhead:
digitorum superficialis dorsal ulnar
muscle; FDP: cutaneous
flexor nerve. UN:
digitorum
profundus
ulnar nerve;muscle; PQ; pronator
UA: ulnar quadratus
artery; FDS: flexormuscle;
digitorumECU:superficialis
extensor carpi ulnaris FDP:
muscle; tendon.
flexor digitorum
profundus muscle; PQ; pronator quadratus muscle; ECU: extensor carpi ulnaris tendon.
The causes of damage/entrapment
damage/entrapmentof ofthe
thedorsal
dorsalulnar
ulnarcutaneous
cutaneousnerve
nerveinclude
includecom-
com-
pression over the distal forearm by a bracelet or a metal implant, extensor carpi
pression over the distal forearm by a bracelet or a metal implant, extensor carpi ulnaris ulnaris
tenosynovitis, or
tenosynovitis, or triangular
triangular fibrocartilage
fibrocartilage complex
complex injury
injury [43].
[43]. For
For hydrodissection
hydrodissection of of the
the
entrapped nerve
entrapped nerve (Figure
(Figure 20A–C),
20A–C), the
the in-plane
in-plane approach
approach targeting
targeting its
its short
short axis
axis is
is preferred
preferred
(Figure 20D).
(Figure 20D).
Figure 20. Sonographic tracking (short-axis view) of the dorsal ulnar cutaneous nerve from its nor-
Figure 20. Sonographic tracking (short-axis view) of the dorsal ulnar cutaneous nerve from its normal
mal (A) to the swollen segment (B) proximal to the entrapment. The normal, swollen, and entrapped
(A) to the swollen segment (B) proximal to the entrapment. The normal, swollen, and entrapped
segments of the dorsal ulnar cutaneous nerve are seen in long-axis imaging (C). Ultrasound-guided
segments of the dorsal
hydrodissection of the ulnar
nerve cutaneous
(D). Whitenerve are seen normal
arrowheads: in long-axis imaging
segment; black(C). Ultrasound-guided
arrowheads: swollen
hydrodissection
segment; orange of the nerve (D).
arrowhead: White arrowheads:
entrapped normal
segment; white segment;
arrows: needle.black
FCU:arrowheads:
flexor carpiswollen
ulnaris
segment;UN:
muscle; orange
ulnararrowhead:
nerve; UA: entrapped segment; white arrows: needle. FCU: flexor carpi ulnaris
ulnar artery.
muscle; UN: ulnar nerve; UA: ulnar artery.
3.3. Radial Nerve
3.3.1. Superficial Radial Nerve
Anatomy
The superficial radial nerve is a branch of the radial nerve, originating from the pos-
terior cord of the brachial plexus. It descends underneath the brachioradialis muscle and
courses lateral to the radial artery. Upon reaching the radial aspect of the distal forearm,
it perforates the antebrachial fascia, and travels between the brachioradialis and extensor
Diagnostics 2023, 13, 1928 17 of 30
3.3. Radial Nerve

3.3.1. Superficial Radial Nerve
Anatomy
The superficial radial nerve is a branch of the radial nerve, originating from the
posterior cord of the brachial plexus. It descends underneath the brachioradialis muscle
and courses lateral to the radial artery. Upon reaching the radial aspect of the distal forearm,
it perforates the antebrachial fascia, and travels between the brachioradialis and extensor
carpi radialis longus tendons. It then courses to the dorsal wrist between the first and
second dorsal extensor compartments, where it divides into two branches. The dorsolateral
branch supplies the sensation of the dorsal radial region of the thumb proximal to the
interphalangeal joint. The dorsomedial branch innervates the dorsoulnar aspect of the
thumb proximal to the interphalangeal joint, dorsoradial half of the hand and the index,
middle, and radial half of the ring fingers, proximal to the distal interphalangeal joint.
Scanning Technique
With the forearm supinated, the transducer is positioned in the axial plane at the
lateral aspect of the antecubital fossa. The superficial and deep radial nerves are situated
between the brachioradialis and brachialis muscles. The superficial radial nerve initially
courses next to the radial artery below the brachioradialis muscle, and then departs from
the radial artery in the distal third of the forearm (Figure 21A). Distally, it pierces the
antebrachial fascia between the extensor carpi radialis longus and brachioradialis tendons.
When tracking the terminal portion of the superficial radial nerve, the forearm can be
antebrachial fascia between the extensor carpi radialis longus and brachioradialis ten-
pronated, as it courses
dons. When toward
tracking the theportion
terminal dorsalofradial aspect of
the superficial thenerve,
radial wrist/hand.
the forearm Thecansuperficial
radial nerve travels above the proximal intersection junction between the first
be pronated, as it courses toward the dorsal radial aspect of the wrist/hand. The superficial and second
dorsal extensor
radial compartments
nerve travels (Figure
above the proximal 21B). Later,
intersection it divides
junction between into theand
the first dorsomedial
second and
dorsal extensor
dorsolateral compartments
branches. The former(Figure 21B). Later,
courses above it divides into the
the distal dorsomedial
intersection and
junction of the
dorsolateral
second and thirdbranches. The former(Figure
compartments courses above
21C).the
Thedistal intersection
latter junction
runs beside theofextensor
the sec- pollicis
ond and third compartments (Figure 21C). The latter runs beside the extensor pollicis lon-
longus tendon (Figure 21D).
gus tendon (Figure 21D).
Figure 21. Sonographic imaging (short-axis view) of the superficial radial nerve from the distal third
Figure Sonographic
21.supinated
of the forearmimaging
(A). With (short-axis view) ofthethe
the pronated forearm, superficial
nerve radial
is seen to travel nerve
above from the distal
the prox-
third imal
of the supinated
intersection forearm
junction (A). With
(B), divide into the pronated forearm,
the dorsomedial the nerve
branch coursing aboveis the
seen to travel
distal inter- above the
section
proximal junction (C), and
intersection the dorsolateral
junction branch
(B), divide running
into beside the extensor
the dorsomedial pollicis
branch longus tendon
coursing above the distal
(D). Arrowheads: superficial radial nerve; white arrow: dorsomedial branch; black arrow: dorsolat-
intersection junction (C), and the dorsolateral branch running beside the extensor
eral branch. RA: radial artery; APL: abductor pollicis longus tendon; EPB: extensor pollicis brevis pollicis longus
tendon (D). ECRL:
tendon; Arrowheads: superficial
extensor carpi radialtendon;
radialis longus nerve; ECRB:
whiteextensor
arrow: carpi
dorsomedial branch;
radialis brevis black arrow:
tendon;
EPL: extensor
dorsolateral pollicis
branch. RA:longus
radial tendon; C: APL:
artery; cephalic vein.
abductor pollicis longus tendon; EPB: extensor pollicis
brevis tendon; ECRL: extensor carpi radialis longus tendon; ECRB: extensor carpi radialis brevis
tendon; EPL: extensor pollicis longus tendon; C: cephalic vein.
Cheiralgia paresthetica, also known as Wartenberg’s syndrome, is the compressive
neuropathy of the superficial radial nerve. Symptoms such as tenderness, numbness, and
allodynia can be exacerbated by wrist flexion and ulnar deviation. The nerve can be com-
pressed by a handcuff, watch, bracelet, metal implant, ganglion cyst, or distal radius frac-
ture. Nerve entrapment commonly takes place at the proximal intersection zone pertain-
ing to the first and second extensor compartments (Figure 22).
Additionally, acupuncture and cannulation of the cephalic vein over the distal fore-
Diagnostics 2023, 13, 1928 18 of 30
Cheiralgia paresthetica, also known as Wartenberg’s syndrome, is the compressive
neuropathy of the superficial radial nerve. Symptoms such as tenderness, numbness,
and allodynia can be exacerbated by wrist flexion and ulnar deviation. The nerve can
be compressed by a handcuff, watch, bracelet, metal implant, ganglion cyst, or distal
radius
Diagnostics 2023, fracture.
13, x FOR Nerve entrapment commonly takes place at the proximal intersection zone
PEER REVIEW 19 of 32
pertaining to the first and second extensor compartments (Figure 22).
Figure 22. Sonographic imaging (short-axis view) of the dorsolateral branch of the superficial radial
Figure 22. Sonographic imaging (short-axis view) of the dorsolateral branch of the superficial ra-
nerve at normal (A), swollen (B), and compressed (C) segments. White arrowhead: normal segment;
dial nerve at normal
black(A), swollenswollen
arrowhead: (B), and compressed
segment; (C) segments.
orange arrowhead: White
entrapped arrowhead:
segment. normal
ECRL: extensor carpi
segment; black arrowhead: swollen
radialis longus tendon;segment; orange
ECRB: extensor arrowhead:
carpi entrapped
radialis brevis segment.
tendon; EPL: extensor ECRL: ex-
pollicis longus
tendon.
tensor carpi radialis longus tendon; ECRB: extensor carpi radialis brevis tendon; EPL: extensor
pollicis longus tendon.
Diagnostics 2023, 13, 1928 19 of 30
Additionally, acupuncture and cannulation of the cephalic vein over the distal fore-
arm can lead to nerve injury. To prevent iatrogenic injury, the superficial radial nerve
before injection should also be recognized for de Quervain’s syndrome (Figure 23A) [44],
ganglion cyst aspiration (Figure 23B), and catheterization (Figure 24A–C). For injection
of the superficial radial nerve, an in-plane approach in the nerve’s short axis is preferred
(Figure 24D).
Figure 23. Sonographic imaging of the superficial radial nerve beside the first extensor compartment
Figure 23. Sonographic imaging of the superficial radial nerve beside the first extensor compartment
of the wrist
Figure (A), and a ganglion
23. Sonographic cyst
imaging of theover the second
superficial extensor
radial compartment
nerve beside of the wrist
the first extensor (B). White
compartment
of the wrist (A), and a ganglion cyst over the second extensor compartment of the wrist (B). White
arrowheads:
of superficial
the wrist (A), radial
and a ganglion nerve; white
cyst over arrow:
thearrow: needle.
secondneedle. APL:
extensorAPL: abductor
compartment pollicis longus
of the wrist (B).tendon;
White
arrowheads: superficial
EPB: extensorsuperficial radial
pollicis brevis nerve;
tendon; white abductor pollicis longus tendon;
arrowheads: radial nerve; ECRL:
white extensor carpi radialis
arrow: needle. longus tendon;
APL: abductor pollicis ECRB:
longusextensor
tendon;
EPB: extensor
carpi pollicis
radialis brevis brevis tendon; ECRL: extensor carpi radialis longus tendon; ECRB: extensor
tendon.
EPB: extensor pollicis brevis tendon; ECRL: extensor carpi radialis longus tendon; ECRB: extensor
carpi radialis brevis tendon.
carpi radialis brevis tendon.
Figure 24. Sonographic imaging of the superficial radial nerve entrapment due to a post-surgical
scar. Short-axis
Figure imaging imaging
24. Sonographic at the normal
of the(A) and the swollen
superficial (B) segment
radial nerve proximal
entrapment due to
tothe entrapment.
a post-surgical
Figure
The 24. Sonographic
normal, swollen, imaging
and of thesegments
entrapped superficialofradial
the nerveare
nerve entrapment
seen in due to a post-surgical
long-axis view scar.
(C). Ultra-
scar. Short-axis imaging at the normal (A) and the swollen (B) segment proximal to the entrapment.
Short-axis imaging
sound-guided at the normal
hydrodissection of(A)
theand thefrom
nerve swollen (B) segment proximal to arrowheads:
the entrapment. The
The normal, swollen, and entrapped segments of the
the ulnar
nerveaspect (D).inWhite
are seen long-axis view (C).normal
Ultra-
normal,
segment; swollen,
black and entrapped
arrowheads: segments
swollen of
segment; the nerve
orange are seen
arrowhead: in long-axis
entrapped
sound-guided hydrodissection of the nerve from the ulnar aspect (D). White arrowheads: normalview (C).
segment; Ultrasound-
white ar-
rows:
guided needle; black arrow:
hydrodissection of scars
the on
nerve the skin;
from theasterisk:
ulnar scars
aspect in
(D).the subcutaneous
White arrowheads:
segment; black arrowheads: swollen segment; orange arrowhead: entrapped segment; white ar- tissue; APL:
normal abduc-
segment;
tor pollicis
black
rows: longus
needle; blacktendon;
arrowheads: arrow: EPB:
swollen extensor
segment;
scars on the pollicis
orange
skin; brevisscars
arrowhead:
asterisk: tendon; ECRL:
entrapped
in the extensorwhite
segment;
subcutaneous carpi radialis
arrows:
tissue; longus
needle;
APL: abduc-
tendon;
black ECRB:
arrow: extensor
scars on carpi
the radialis
skin; brevis
asterisk: tendon.
scars in the subcutaneous tissue; APL: abductor
tor pollicis longus tendon; EPB: extensor pollicis brevis tendon; ECRL: extensor carpi radialis longus pollicis
tendon; ECRB: extensor
longus tendon; carpi radialis
EPB: extensor pollicisbrevis
brevistendon.
tendon; ECRL: extensor carpi radialis longus tendon;
ECRB: extensor carpi radialis brevis tendon.
For those receiving surgery such as fixation or debridement of the radial wrist, the
nerve can be occasionally injured, resulting in residual numbness, allodynia, dysesthesia,
or hypoesthesia (Figure 25).
Diagnostics 2023,
2023, 13,
13, 1928
x FOR PEER REVIEW 20of
21 of 30
32
Figure 25. Sonographic images depict the location of a neuroma of the superficial radial nerve. The
Figure 25. Sonographic images depict the location of a neuroma of the superficial radial nerve. The
normal/proximal segment (A) and the neuroma in short-axis (B) and long-axis (C) views are seen.
normal/proximal segment (A) and the neuroma in short-axis (B) and long-axis (C) views are seen.
White arrowhead: superficial radial nerve; black arrowheads: neuroma; APL: abductor pollicis lon-
White arrowhead:
gus tendon; superficial
EPB: extensor radial
pollicis nerve;
brevis blackECRL:
tendon; arrowheads:
extensorneuroma; APL:longus
carpi radialis abductor pollicis
tendon; C:
longus tendon;
cephalic vein. EPB: extensor pollicis brevis tendon; ECRL: extensor carpi radialis longus tendon;
C: cephalic vein.
3.3.2. Posterior Interosseous Nerve
3.3.2.
AnatomyPosterior Interosseous Nerve
Anatomy
The posterior interosseus nerve is initially located at the radial aspect of the proximal
The posterior
forearm, interosseus
situated between the nerve is initiallyand
brachioradialis located at the radial
brachialis musclesaspect
withofthe
thesuperficial
proximal
forearm, situated between the brachioradialis and brachialis muscles with the superficial
radial nerve. It then passes under the arcade of Frohse, which is the superficial layer of the
Diagnostics 2023, 13, 1928 21 of 30
radial nerve. It then passes under the arcade of Frohse, which is the superficial layer of the
supinator muscle. Later, it courses through the radial tunnel formed by the humeral and
ulnar head of the supinator muscle and continues between the extensor digitorum longus
and abductor pollicis longus (or extensor pollicis brevis) muscles before diving to run on
top of the interosseous membrane, a fibrous tissue that connects the radius to the ulna [45].
The posterior interosseus nerve provides motor innervation to all dorsal forearm muscles
except the brachioradialis, anconeus, and extensor carpi radialis longus. It also provides
proprioception to the dorsal radioulnar joint.
Scanning Technique
With the forearm supinated, the transducer is placed at the radial side of the upper
third of the forearm in short-axis view. The posterior interosseus nerve is situated between
the extensor digitorum longus and abductor pollicis longus (or extensor pollicis brevis)
muscles. The transducer is moved distally along the dorsal forearm. The nerve courses
radial to the extensor pollicis longus muscle and then dives toward the surface of the
dorsal interosseous membrane. At the wrist level, the nerve appears as a small hypoechoic
monofascicle with an average diameter about 1–3 mm [46] and then it travels onto the
carpus with the dorsal interosseous artery (Figure 26A).
Figure 26. Sonographic imaging (short-axis view) of the dorsal interosseus nerve from the normal
(A) to theimaging
swollen (B) (short-axis
segment proximalview)
to the of the dorsal
entrapment interosseus
site. Normal, nerve
swollen, and from the normal
compressed
(A) to the swollensegments of the nerve are seen in long-axis view (C). White arrowhead: normal segment; black ar-
(B) segment proximal to the entrapment site. Normal, swollen, and compressed
rowhead: swollen segment; yellow arrowhead: entrapped segment; EPL: extensor pollicis longus
segments of the nerve areextensor
tendon; ED: seen in long-axis
digitorum tendon.view (C). White arrowhead: normal segment; black
arrowhead: swollen segment; yellow arrowhead: entrapped segment; EPL: extensor pollicis longus
tendon; ED: extensor digitorum tendon.
Diagnostics 2023, 13, 1928 22 of 30
Nerve entrapment can occur from repetitive and forceful use of extensor digitorum
longus and extensor pollicis longus muscles. Contusion to the wrist can traumatize the
posterior interosseus nerve, leading to neuroma formation (Figure 26B,C). The nerve can
also be irritated by hypertrophic synovium secondary to extensor digitorum communis
tenosynovitis (Figure 27A) [47]. When injecting the scapho-lunate joint, the nerve should
Figure 26. Sonographic imaging (short-axis view) of the dorsal interosseus nerve from the normal
be identified first to avoid iatrogenic injury. In cases suffering from pain or allodynia over
(A) to the swollen (B) segment proximal to the entrapment site. Normal, swollen, and compressed
the dorsal
segments radioulnar
of the nerve arejoint,
seen hydrodissection
in long-axis viewof theWhite
(C). nervearrowhead:
can be performed. The in-plane
normal segment; black ar-
approach
rowhead: duringsegment;
swollen the nerve’s short-axis
yellow view is
arrowhead: the preferred
entrapped method
segment; EPL:(Figure 27B)
extensor whereby
pollicis longus
iatrogenic
tendon; injury ofdigitorum
ED: extensor the vessels and extensor tendons can be prevented.
tendon.
Figure 27. Sonographic imaging (short-axis view) is performed to assess the posterior interosseus
nerve entrapment due to synovitis in rheumatoid arthritis (A). Ultrasound-guided injection (B).
Arrowheads: posterior interosseus nerve; arrow: needle; EPL: extensor pollicis longus tendon; ED:
extensor digitorum communis tendon; S: scaphoid; L: lunate.
3.4. Digital Nerves

3.4.1. Palmar Common Digital and Proper Digital Nerves
Anatomy
The palmar common digital nerves arise from two sources; the median nerve, which
supplies sensation to the palmar aspect of all phalanges of the first, second, third, and radial
aspect of the fourth digit, and the superficial branch of the ulnar nerve, which supplies the
remaining palmar aspect of the phalanges. The palmar common digital nerves then give
rise to the proper digital nerves that course along the bilateral palmar sides of the digits.
Furthermore, the palmar proper digital nerves—which receive fibers from the median
nerve—provide sensory innervation to the dorsal aspect of the middle and distal phalanges
of the second, third, and radial aspect of the fourth finger.
Scanning Technique
The transducer is placed on the mid-palm in the axial plane (Figure 28A). The palmar
common digital nerves course beside the flexor digitorum profundus/superficialis tendons
with the palmar common digital artery, and they are superficial to the palmar interosseous
muscles (Figure 28B). Moving the transducer more distally, the palmar proper digital nerves
can be identified alongside all phalanges (Figure 28C,D).
Direct injury of the palmar common digital nerve can occur due to various reasons
such as trauma, contusion, or iatrogenically during tendon injection. Nerve entrapment
caused by space-occupying lesions such as fractures, ganglia (Figure 29A–C), annular
ligament tears (Figure 29D), tenosynovitis, foreign bodies, fibroma (Figure 30A,B), or
hemangioma (Figure 30C–E) is also likely.
Scanning Technique
The transducer is placed on the mid-palm in the axial plane (Figure 28A). The palmar
common digital nerves course beside the flexor digitorum profundus/superficialis ten-
dons with the palmar common digital artery, and they are superficial to the palmar inter-
Diagnostics 2023, 13, 1928 23 of 30
osseous muscles (Figure 28B). Moving the transducer more distally, the palmar proper
digital nerves can be identified alongside all phalanges (Figure 28C,D).
Figure
Figure 28. Sonographic imaging
28. Sonographic imagingof ofthe
thepalmar
palmarcommon
common digital
digital nerves
nerves in in short-axis
short-axis (A)(A)
andand long-
long-axis
axis (B) views. Palmar proper digital nerves from the base (C) to the head of the proximal phalanx
(B) views. Palmar proper digital nerves from the base (C) to the head of the proximal phalanx (D).
(D). White arrowheads: palmar common digital nerves; black arrowheads: palmar proper digital
White arrowheads: palmar common digital nerves; black arrowheads: palmar proper digital nerves.
nerves. T: flexor tendon; L: lumbricalis muscle; PIO: palmar interosseous muscle; FDS: flexor digi-
T: flexor
torum tendon; L:tendon;
superficialis lumbricalis
FDP: muscle; PIO: palmar
flexor digitorum interosseous
profundus tendon;muscle; FDS:
A: artery; VP:flexor
volardigitorum
plate; PP:
superficialis tendon; FDP: flexor digitorum profundus
proximal phalanx; PPh: head of the proximal phalanx.
Diagnostics 2023, 13, x FOR PEER REVIEW tendon; A: artery; VP: volar plate; PP:
25 ofproximal
32
phalanx; PPh: head of the proximal phalanx.
Direct injury of the palmar common digital nerve can occur due to various reasons
such as trauma, contusion, or iatrogenically during tendon injection. Nerve entrapment
caused by space-occupying lesions such as fractures, ganglia (Figure 29A–C), annular lig-
ament tears (Figure 29D), tenosynovitis, foreign bodies, fibroma (Figure 30A,B), or he-
mangioma (Figure 30C–E) is also likely.
Figure 29. Ultrasound images demonstrate the entrapment of the palmar common digital nerve due
Figure 29. Ultrasound images demonstrate the entrapment of the palmar common digital nerve due
to a ganglion seen in short-axis (A) and long-axis (B) views. Ultrasound-guided aspiration (C).
to aNerve
ganglion seen indue
entrapment short-axis (A)ligament
to annular and long-axis (B) views.
tear (asterisk) Ultrasound-guided
following aspiration
an iatrogenic injury (C). Nerve
(D). Arrow-
entrapment due to annular ligament tear (asterisk) following an iatrogenic injury (D).
heads: palmar common digital nerve; Arrow: needle; T: flexor tendon; FDS: flexor digitorum super- Arrowheads:
ficialiscommon
palmar tendon; FDP: flexor
digital digitorum
nerve; Arrow:profundus
needle; T: tendon.
flexor tendon; FDS: flexor digitorum superficialis
tendon; FDP: flexor digitorum profundus tendon.
Chronic irritation may lead to the formation of a neuroma, which can occasionally be
detected through US imaging (Figure 31). Using the in-plane approach in short-axis view
(Figure 32, Video S4), hydrodissection of the entrapped nerves can be performed after
identifying the palmar common digital artery and flexor digitorum superficialis/profun-
dus tendons.
3.4.2. Dorsal Common Digital Nerve and Proper Digital Nerve

Diagnostics 2023, 13,
Diagnostics 2023, 13, 1928
x FOR PEER REVIEW 24 of
26 of 30
32
Figure 30. In comparison to the healthy side (A), short-axis imaging (B) shows irritation of both the
palmar and dorsal proper digital nerves due to a fibroma (asterisk). Short-axis (C) and long-axis (D)
palmar and dorsal proper digital nerves due to a fibroma (asterisk). Short-axis (C) and long-axis (D)
imaging demonstrates irritation of the palmar proper digital nerve due to a hemangioma. Spectral
imaging
Doppler demonstrates irritation
mode (E) confirms of the palmarWhite
the hemangioma. properarrowhead:
digital nerve due to
palmar a hemangioma.
proper Spectral
digital nerve; black
Doppler mode
arrowhead: (E) confirms
dorsal the hemangioma.
proper digital White
nerve; double arrowhead:
asterisk: palmarPP:
hemangioma; proper digital
proximal nerve; black
phalanx.
arrowhead: dorsal proper digital nerve; double asterisk: hemangioma; PP: proximal phalanx.
Chronic irritation may lead to the formation of a neuroma, which can occasionally
be detected
palmar through
and dorsal USdigital
proper imaging (Figure
nerves due to 31). Using
a fibroma the in-plane
(asterisk). approach
Short-axis (C) andin short-axis
long-axis (D)
view (Figure 32, Video S4), hydrodissection of the entrapped nerves can be performed
imaging demonstrates irritation of the palmar proper digital nerve due to a hemangioma. Spectral after
identifying
Doppler mode the(E)
palmar common
confirms digital artery
the hemangioma. Whiteand flexor digitorum
arrowhead: superficialis/profundus
palmar proper digital nerve; black
tendons. dorsal proper digital nerve; double asterisk: hemangioma; PP: proximal phalanx.
arrowhead:
Figure 31. Sonographic imaging of the neuroma of the palmar proper digital nerve in short-axis (A)
and long-axis (B) views. White arrowheads: normal segments of the palmar proper digital nerve;
black arrowhead: neuroma. FPL: flexor pollicis longus tendon.
Figure
Figure 31.
31. Sonographic
Sonographic imaging
imaging of
of the
the neuroma
neuroma of
of the
the palmar
palmar proper
proper digital
digital nerve
nerve in
in short-axis
short-axis (A)
(A)
Diagnostics 2023, 13, 1928
x FOR PEER REVIEW 2725of
of 32
30
Figure 32. In-plane ulnar to radial approach is used for injecting the palmar common digital nerve
Figure 32. In-plane ulnar to radial approach is used for injecting the palmar common digital nerve
in short-axis view. White arrowheads: palmar common digital nerve; black arrowhead: common
in short-axis view. White arrowheads: palmar common digital nerve; black arrowhead: common
palmar digital artery; arrow: needle; T: flexor tendons; 2nd MCP: second metacarpal.
palmar digital artery; arrow: needle; T: flexor tendons; 2nd MCP: second metacarpal.
Scanning Technique
3.4.2. Dorsal Common Digital Nerve and Proper Digital Nerve
Anatomy
The transducer is positioned on the axial plane of the dorsal metacarpal joint in the
targetThe
digit. Thecommon
dorsal dorsal proper digital arise
digital nerves nerves cantwo
from be primary
found on eitherthe
nerves; side of the sagittal
superficial radial
band
nerve(Figure
and the33A).
dorsalThe transducer
ulnar cutaneous is moved
nerve. Theproximally and the dorsal
former provides sensory common digital
innervation to
nerves can be observed
the dorsolateral aspect ofsuperficial
the wrist, to thethe extensor
dorsal thumb(usually the to
proximal extensor digitorum
the distal phalanx,pro-
the
prius)
proximaltendons (Figure
phalanx of the33B).
second By returning
digit, and tothethe levelaspect
radial of theofsagittal
the thirdband andAdditionally,
digit. moving the
transducer distally, the dorsal proper digital nerves can be seen superficial
the dorsal ulnar cutaneous nerve supplies sensory innervation to the dorsomedial to and along-
aspect of
side the central slip of the finger extensor tendon (Figure 33C). Alternatively,
the wrist, the dorsal little finger, the ulnar aspect of the fourth digit, the proximal phalanx moving the
transducer
of the radialdistally toward
aspect of the proximal
the fourth digit, andphalanx
the ulnarofaspect
the first to third
of the the radial
digit. aspect of the
At the digital
fourth phalanx
level, the dorsalallows
common observation of thedivide
digital nerves nerve into
fascicles of the proper
the dorsal palmardigital
propernerves,
digital which
nerve
originating fromtothe
run superficial themedian
extensor nerve (Figure that
expansion 33D).originates from the dorsal interossei and
lumbricalis muscles.
Scanning Technique
The transducer is positioned on the axial plane of the dorsal metacarpal joint in the
target digit. The dorsal proper digital nerves can be found on either side of the sagittal band
(Figure 33A). The transducer is moved proximally and the dorsal common digital nerves can
be observed superficial to the extensor (usually the extensor digitorum proprius) tendons
(Figure 33B). By returning to the level of the sagittal band and moving the transducer
distally, the dorsal proper digital nerves can be seen superficial to and alongside the central
slip of the finger extensor tendon (Figure 33C). Alternatively, moving the transducer distally
toward the proximal phalanx of the first to the radial aspect of the fourth phalanx allows
observation of the nerve fascicles of the palmar proper digital nerve originating from the
median nerve (Figure 33D).
Figure 33. Sonographic imaging of the dorsal common digital nerve on the metacarpal bone (A),
toward the metacarpal head (B). Dorsal proper digital nerves on the proximal phalanx (C), and the
terminal nerve originating from the palmar proper digital nerve on the distal phalanx of third finger
(D). Arrowheads: dorsal common digital nerve; arrows: palmar proper digital nerve. MCP: meta-
carpal bone; SB: sagittal band; E: extensor tendon; Cs: central slip; PP: proximal phalanx; T: terminal
band; DP: distal phalanx; DIO, dorsal interosseous muscle.
nerves can be observed superficial to the extensor (usually the extensor digitorum pro-
prius) tendons (Figure 33B). By returning to the level of the sagittal band and moving the
transducer distally, the dorsal proper digital nerves can be seen superficial to and along-
side the central slip of the finger extensor tendon (Figure 33C). Alternatively, moving the
transducer distally toward the proximal phalanx of the first to the radial aspect of the
Diagnostics 2023, 13, 1928 26 of 30
fourth phalanx allows observation of the nerve fascicles of the palmar proper digital nerve
originating from the median nerve (Figure 33D).
Figure
Figure 33.
33. Sonographic
Sonographic imaging
imaging of of the
the dorsal
dorsal common
common digital
digital nerve
nerve on
on the
the metacarpal
metacarpalbone
bone (A),
(A),
toward the metacarpal head (B). Dorsal proper digital nerves on the proximal phalanx (C), and the
toward the metacarpal head (B). Dorsal proper digital nerves on the proximal phalanx (C), and
terminal nerve originating from the palmar proper digital nerve on the distal phalanx of third finger
the terminal nerve originating from the palmar proper digital nerve on the distal phalanx of third
(D). Arrowheads: dorsal common digital nerve; arrows: palmar proper digital nerve. MCP: meta-
finger bone;
carpal (D). Arrowheads: dorsal
SB: sagittal band; E: common digital nerve;
extensor tendon; arrows:
Cs: central slip;palmar properphalanx;
PP: proximal digital nerve. MCP:
T: terminal
metacarpal bone; SB: sagittal band; E: extensor tendon;
band; DP: distal phalanx; DIO, dorsal interosseous muscle. Cs: central slip; PP: proximal phalanx; T:
terminal band; DP: distal phalanx; DIO, dorsal interosseous muscle.
Clinical
Implication
Injuries
Injuries to
to the
thedorsal
dorsalcommon
commondigital
digitalnerve
nervetypically occur
typically occurin in
thethe
workplace
workplace as aasresult
a re-
of cutting or crushing. However, the nerve can also sustain damage due
sult of cutting or crushing. However, the nerve can also sustain damage due to various to various other
factors such assuch
other factors fracture, ganglia,
as fracture, tenosynovitis,
ganglia, tumor (Figure
tenosynovitis, 34), foreign
tumor (Figure objects, objects,
34), foreign or boxing,or
which may cause contusion over the first knuckles (Figure 35).
boxing, which may cause contusion over the first knuckles (Figure 35).
Figure 34. In the short-axis view, the proper digital nerve is seen as irritated by a giant cell tumor
Figure 34. In the short-axis view, the proper digital nerve is seen as irritated by a giant cell tumor (A)
(A) with increased vascular signals (B). The association between the proper digital nerve and the
with increased vascular signals (B). The association between the proper digital nerve and the tumor
tumor is delineated in the long-axis view (C). Black arrowheads: proper digital nerve; PP: proximal
is delineated
phalanx; in the
*: giant long-axis
cell tumor. view (C). Black arrowheads: proper digital nerve; PP: proximal phalanx;
*: giant cell tumor.
Figure 34. In the short-axis view, the proper digital nerve is seen as irritated by a giant cell tumor
Diagnostics 2023, 13, 1928 (A) with increased vascular signals (B). The association between the proper digital nerve and 27 ofthe
30
tumor is delineated in the long-axis view (C). Black arrowheads: proper digital nerve; PP: proximal
phalanx; *: giant cell tumor.
Figure 35. Sonographic imaging reveals irritation of the ulnar aspect of the dorsal common digital
Figure 35. Sonographic imaging reveals irritation of the ulnar aspect of the dorsal common digital
nerve due to extensor tendon subluxation resulting from a tear in the sagittal band. Arrowheads:
nerve due to extensor tendon subluxation resulting from a tear in the sagittal band. Arrowheads:
dorsal common digital nerve; asterisk: tear of the sagittal band. SB: sagittal band; E: extensor 29
Diagnostics 2023, 13, x FOR PEER REVIEW tendon;
of 32
dorsalmetacarpal
MCP: common digital
bone.nerve; asterisk: tear of the sagittal band. SB: sagittal band; E: extensor tendon;
MCP: metacarpal bone.
US imaging
US imaging may
may reveal
reveal aa neuroma
neuroma in in cases
cases where
where patients report chronic
patients report chronic allodynia
allodynia
and/or tingling sensation in the affected digit (Figure 36). To perform hydrodissection,
and/or tingling sensation in the affected digit (Figure 36). To perform hydrodissection, thethe
in-plane approach can be utilized in the nerve’s short axis after identifying the extensor
in-plane approach can be utilized in the nerve’s short axis after identifying the extensor
digitorum tendons
digitorum tendons and
and the
the dorsal
dorsal metacarpal
metacarpal arteries
arteries (Figure
(Figure 37).
37).
Figure 36. Sonographic imaging (short-axis view) for a neuroma of the dorsal common digital nerve,
proximal site (A) and the site of the lesion (B). Long-axis imaging of the nerve/neuroma (C). White
proximal site (A) and the site of the lesion (B). Long-axis imaging of the nerve/neuroma (C). White
arrowhead: normal dorsal common digital nerve; black arrowheads: neuroma. SB: sagittal band; E:
arrowhead:
extensor normal
tendon; dorsal
MCP: commonbone;
metacarpal digital nerve;
DIO: black
dorsal arrowheads:
interosseous neuroma.
muscle; SB: sagittal band; E:
A: artery.
extensor tendon; MCP: metacarpal bone; DIO: dorsal interosseous muscle; A: artery.
Diagnostics 2023, 13, 1928 proximal site (A) and the site of the lesion (B). Long-axis imaging of the nerve/neuroma (C).28
White
of 30
arrowhead: normal dorsal common digital nerve; black arrowheads: neuroma. SB: sagittal band; E:
extensor tendon; MCP: metacarpal bone; DIO: dorsal interosseous muscle; A: artery.
Figure 37. Ultrasound-guided injection to the dorsal proper digital nerve in its short axis with the
Figure 37. Ultrasound-guided injection to the dorsal proper digital nerve in its short axis with the
dual imaging mode (Doppler vs. B mode). White arrowhead: dorsal proper digital nerve; black ar-
dual imaging mode (Doppler vs. B mode). White arrowhead: dorsal proper digital nerve; black
rowhead: dorsal proper digital artery; arrow: needle. T: flexor tendons.
arrowhead: dorsal proper digital artery; arrow: needle. T: flexor tendons.
4. Conclusions
4. Conclusions
This pictorial essay
This pictorial essay outlines
outlines a a systematic
systematic USUS scanning
scanning approach
approach for for examining
examining the the
distal nerves
distal nerves inin the
the wrist/hand
wrist/handregion.
region.USUSexamination
examination cancan
assist to identify/describe
assist to identify/describe the
affected
the nerves
affected andand
nerves theirtheir
morphological
morphologicalchanges. Sonographic
changes. Sonographic findings can can
findings alsoalso
comple-
com-
ment electrodiagnostic
plement electrodiagnostic studies to to
studies provide
providebetter
betterinsight
insightinto
intounderstanding
understanding the whole
the whole
clinical scenario.
scenario. Needless
Needlesstotosay,
say,US-guided
US-guided interventions (as appropriate) can be safe safe
interventions (as appropriate) can be and
and effective for treating relevant nerve pathologies.
effective for treating relevant nerve pathologies. Lastly, Lastly, further
further research
research can becan be con-
conducted
ducted
to to compare
compare the diagnostic
the diagnostic performance
performance of US imaging
of US imaging with other with other
tools suchtools suchand
as MRI as
MRI and electrophysiological
electrophysiological testing. testing.
Supplementary Materials: The following supporting information can be downloaded at: https:
//www.mdpi.com/article/10.3390/diagnostics13111928/s1, Video S1: Hydrodissection with the
in-plane approach targeting the short axis of the median nerve. Video S2: Hydrodissection with the
in-plane approach targeting the long axis of the median nerve. Video S3: Dynamic tracking of the
neuroma of recurrent motor branch of the median nerve. Video S4: Hydrodissection using in-plane
approach targeting the short axis of the palmar common digital nerve of the thumb.
Author Contributions: Conceptualization, W.-T.W. and K.-V.C.; methodology, W.-T.W., Y.-C.H. and
K.-V.C.; validation, Y.-Y.T., K.M., V.R. and L.Ö.; writing—original draft preparation, W.-T.W.; writing—
review and editing, W.-T.W., K.-V.C. and L.Ö.; funding acquisition, K.-V.C. All authors have read and
agreed to the published version of the manuscript.
Funding: This study was made possible by (1) research funding from the Community and Geriatric
Medicine Research Center, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan; (2)
Ministry of Science and Technology (MOST 106-2314-B-002-180-MY3, 109-2314-B-002-114-MY3, and
109-2314-B-002-127), and (3) the Taiwan Society of Ultrasound in Medicine.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Informed consent was obtained from all subjects involved in
the study.
Data Availability Statement: Data are contained within the main text of the manuscript.
Conflicts of Interest: The authors declare no conflict of interest.
Diagnostics 2023, 13, 1928 29 of 30
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diagnostics

Received: 10 May 2023

Diagnostics 2023, 13, 1928. https://doi.org/10.3390/diagnostics13111928 https://www.mdpi.com/journal/diagnostics

2.2. Common Ultrasonographic Features of Peripheral Nerve Pathologies

2.3. Ultrasound-Guided Hydrodissection

3. Sonoanatomy and Pathology

Diagnostics 2023, 13, 1928 5 of 30

Diagnostics 2023, 13, x FOR PEER REVIEW 5 of 32

Regarding US-guided injections for carpal tunnel syndrome, a network meta-analy-

3.1.3. Recurrent Motor Branch of the Median Nerve

Diagnostics 2023, 13, 1928 9 of 30

Diagnostics 2023, 13, x FOR PEER REVIEW 9 of 32

Figure 10. Sonographic

3.2. Ulnar Nerve

Diagnostics 2023, 13, x FOR PEER REVIEW 14 of 32

3.2.2. Palmar Ulnar Cutaneous Nerve

Handlebar neuropathy is a similar scenario that occurs due to continuous compression

3.2.2. Palmar Ulnar Cutaneous Nerve

3.3. Radial Nerve

3.4. Digital Nerves

3.4.2. Dorsal Common Digital Nerve and Proper Digital Nerve

Diagnostics 2023, 13, x FOR PEER REVIEW 26 of 32

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