US of the

peripheral
nerves of the
upper limb

Basic concepts
 Professor of radiology-Ain shams university
Scientific rapporteur of the Egyptian society of skeletal radiology (EGSSR)
Member of the international skeletal society (ISS)
Content
01 Structure of peripheral nerves.

02 Anatomy of the peripheral nerves of the UL.

03 Normal US appearance of peripheral nerves.

04 US appearance of peripheral nerves in different pathological entities.

05 Take home message.

3
 Structure of the peripheral nerves
01
➢ Each peripheral nerve is
formed of several fascicles
with adipose & connective
tissue in between &
surrounded by epineurium.

➢ Each fascicle is formed of

several nerve fibers
surrounded by perineurium.
4
 Structure of the peripheral nerves

01
➢ Each nerve fiber is formed of an axon covered
by myelin sheath (fatty acids encloses the
nerve fiber) that is covered by neurilemma
(cytoplasm of Schwan cell) & surrounded by
endoneurium.

➢ The nodes of Ranvier are short (1um)

Axon
specialized regions in the axonal membrane
that are not insulated by myelin. 5
 Structure of the peripheral nerves

01
➢ Myelin sheath allows electrical impulses to transmit quickly and
efficiently along the nerve axons

➢ Neurilemma serves a protective function for peripheral nerve fibers

& forms a regeneration tube through which the growing axon re-
establishes its original connection.

➢ The nodes of Ranvier facilitate the rapid conduction of nerve

impulses 6
 Anatomy of the peripheral nerves of the UL
01
02
The major nerves of the upper limb are:

➢ The median nerve.

➢ The ulnar nerve.

➢ The radial nerve.

 Anatomy of the peripheral nerves of the UL

01
02
the median nerve

➢ After originating from the brachial plexus in the

axilla, the median nerve descends down the arm,
initially lateral to the brachial artery. Halfway
down the upper arm, the nerve crosses over the
brachial artery, and becomes situated medially.

➢ The median nerve enters the anterior compartment

of the forearm via the cubital fossa.
 Anatomy of the peripheral nerves of the UL

01
02
the median nerve
➢ the median nerve enters the forearm under
the bicipital aponeurosis then it passes
between the two heads of pronator teres
muscle.

➢ In the forearm, the nerve travels between

the flexor digitorum profundus and flexor
digitorum superficialis muscles.
 Anatomy of the peripheral nerves of the UL

01
02
the median nerve

the median nerve enters the

hand via the carpal

tunnel where it terminates by

dividing into two common

palmar digital nerves

 Anatomy of the peripheral nerves of the UL

01
02
the ulnar nerve

➢ After arising from the brachial plexus, the ulnar

nerve descends in between the axillary artery and
the axillary vein.
➢ It proceeds down the medial aspect of the upper arm
with the brachial artery located lateral.
➢ At the mid-point of the upper arm, it penetrates the
medial fascial septum to enter the posterior
compartment of the arm.
 Anatomy of the peripheral nerves of the UL

01
02
the ulnar nerve

➢ It passes posterior to the elbow through

the cubital tunnel

➢ It enters the forearm deep to the flexor

carpi ulnaris aponeurosis.

➢ In the forearm, the ulnar nerve passes

deep to the flexor carpi ulnaris
muscle, alongside the ulna.
 Anatomy of the peripheral nerves of the UL

01
02
the ulnar nerve

➢ At the wrist, the ulnar nerve

travels superficial to the flexor
retinaculum, and is medial to the
ulnar artery.

➢ It enters the hand via the ulnar

canal (Guyon’s canal).
 Anatomy of the peripheral nerves of the UL

01
02
the radial nerve

➢ The radial nerve lies posterior to the axillary artery

in the axilla and enters the posterior compartment
of the arm under teres major muscle.

➢ The radial nerve then descends down the

arm, travelling in a shallow depression within the
surface of the humerus, known as the spiral groove.
 Anatomy of the peripheral nerves of the UL

01
02
the radial nerve

➢ It pierces the lateral intermuscular septum at

the midpoint of the humerus to enter the

anterior compartment of the arm.

➢ It lies deep to the brachialis and then between

it & the brachioradialis.

 Anatomy of the peripheral nerves of the UL

01
02
the radial nerve

➢ To enter the forearm, the radial nerve travels

anterior to the lateral epicondyle of the
humerus, through the cubital fossa.

➢ The nerve then terminates by dividing into a

superficial & a deep branch.

➢ Its deep branch pass deep to the supinator arch

 Anatomy of the peripheral nerves of the UL

01
02
the radial nerve

➢ The superficial branch of

the radial nerve passes deep
to the brachioradialis
muscle then it crosses over
the anatomical snuff box.
 Anatomy of the peripheral nerves of the UL

01
02
the radial nerve

➢ The deep branch of the

radial nerve passes through
the supinator muscle then
lies between the superficial
& deep extensor muscles of
the forearm.
 Normal US appearance of the peripheral nerves
01
03
➢ Nerves are cable-like structures consisting of fascicles and
surrounding epineurium.

➢ In the transverse plane, the echo pattern is described as

“honeycomb” appearance because of the dark punctuate areas
(fascicles) distributed throughout a hyperechoic background
(perineurium)
 Normal US appearance of the peripheral nerves
01
03
➢ In the longitudinal plane, nerves present as long, slim structures
with a mixture of parallel hypoechoic and hyperechoic lines.
US appearance of a normal nerve in LS & TS images
 Nerves Vs Tendons
01
03
➢ Tendons are more hyperechoic than nerves

➢ Tendons move actively with joint movement

➢ Tendons if followed proximally or distally will lead to muscles.

➢ Tendons have greater anisotropy than nerves so subtle change in the

angle of the probe will change the appearance of tendons more than
nerves.
 Doppler examination of nerves
01
03
➢ No color Doppler signal should be observed in a normal nerve.

➢ Color flow in a nerve indicates hypervascularity which is usually

due to compression or inflammation.

➢ Intraneural edema results in reduced echogenicity and loss of the

fascicular pattern.
Intra neural vascularity in two different cases of CTS
 Dynamic examination of nerves
01
03
➢ Median nerve mobility decreases in CTS

➢ Normally the median nerve moves during finger and wrist

flexion/extension.

➢ Mobility is reduced or absent in median nerve entrapment

Healthy volunteer

26
27
Patient with CTS

28
29
 Dynamic examination of nerves
01
03
➢ Ulnar nerve normally lies lateral to the medial epicondyle between
it & the medial head of triceps muscle.

➢ Subluxation is defined as movement of the ulnar nerve to the tip of

the medial epicondyle

➢ Dislocation is defined as complete relocation of the ulnar nerve

over the medial epicondyle.
Dynamic US
of ulnar nerve
in normal,
subluxation &
dislocation
 Nerve measurements
01
03
➢ Nerve cross sectional area should be measured just inside the
echogenic rim of the nerve (Epineurium)

➢ The swelling ratio is the ratio between the cross-sectional area of

the nerve at the site of maximal enlargement and that at an
unaffected site (normal less than 1.3).

➢ The flattening ratio is defined as the ratio between the largest and
smallest diameter of the nerve in cross section (normal less than 3).
 US appearance of nerves in different pathological entities

01
compressive neuropathy
04
➢ Enlargement of the nerve proximal to the site of compression.

➢ Decreased echogenicity.

➢ Increased vascularity.

➢ Reduced mobility.

➢ +/- cause of compression: osteophyte, cyst, tumour, tenosynovitis.

Ulnar nerve entrapment at Guyon’s canal Vs the
normal nerve at the forearm
Ulnar nerve entrapment at the right cubital tunnel Vs the
normal nerve at the left side
Ulnar nerve entrapment at Guyon’s canal by ulnar artery
thrombosis
 US appearance of nerves in different pathological entities

01
compressive neuropathy
04
Specific findings in CTS:

➢ Increased flattening ratio.

➢ Abrupt tapering in longitudinal images.

➢ Thickening & volar bowing of the flexor retinaculum

➢ +/- cause e.g. tenosynovitis, synovial cyst, Bifid median nerve,

Persistent medial artery +/- acute thrombosis or dilatation.
Median nerve in a healthy volunteer & in a patient with CTS
Median nerve in a patient with CTS
LS image of Median nerve in a patient with CTS
Median nerve entrapment at the carpal tunnel by
tenosynovitis in patient with RA
Post operative median nerve with nerve enlargement &
scarring Vs the normal contra lateral one
US appearance of nerves in different pathological entities

01
Traumatic nerve injury
04
Seddon type Sunderland grade Structures injured Appearance Management
neuropraxia 1 Demyelination Normal Conservative
2 Axon loss Diffuse swelling
Surgery may be
Intact edematous
3 Endoneurium needed
fascicles
axonotmesis Fascicular
discontinuity
4 Perineurium Surgery
(neuroma in
continuity)

Nerve transection +/-

neurotmesis 5 Epineurium ???
end-bulb neuroma

6 (Mackinnon & Variable combination

Variable ???
Dellon) of injury types
 US appearance of nerves in different pathological entities

01
Traumatic nerve injury
04
➢ Focal or diffuse nerve enlargement & hypoechogenicity are the
most common finding
➢ Loss of fascicular appearance, fascicular discontinuity ,
heterogenicity or thickening.
➢ Discontinuity of the nerve (transection)
➢ Neuroma (in continuity or end bulb)
➢ Increased intra neural vascularity (acute phase).
 US appearance of nerves in different pathological entities

01
Traumatic nerve injury
04
➢ Bone callus or bone fragments
➢ Foreign bodies
➢ Scar tissue.
➢ Secondary signs in the muscles:
❑ Muscle heterogenicity in acute denervation.
❑ Muscle hyperechogenicity (fatty infiltration) in chronic denervation.
Post traumatic focal nerve swelling with intact nerve
fascicles (grade 2)
Post traumatic partial interruption of nerve fascicles
with intact epineurium (grade 4)
Post cut wound partial interruption of the epineurium
of the median nerve
Traumatic ulnar nerve
complete transection with
discontinuous epineurium
(grade 5)
Post traumatic complete interruption of nerve fascicles with
intact epineurium (grade 4)
Post traumatic neuroma in continuity
Post traumatic end bulb neuroma (grade 5)
Right thenar
muscles fatty
infiltration in
case of median
nerve injury
Vs the normal
contralateral
ones
 Clinical data

20-year-old male from Gaza, his home has been bombed

& he has been injured by shrapnel 1 month ago, now he

is complaining of right foot drop

 NCS & EMG report
❑ Sever axonal neuropathy (nerve injury) affecting the

right CPN with neuropathic pattern of tibialis anterior

muscle.

❑ Proximal radiculopathy affecting the right tibial nerve.

Neuromuscular US
Neuromuscular US
Neuromuscular US
 Neuromuscular US report

❑ Complete transection of the sciatic nerve (grade 5

Sunderland classification)
❑ Axonotmesis of the CPN (grade 3 Sunderland
classification)
❑ Mild fatty infiltration of the related muscles (grade II
Heckmatt classification).
 US findings in peripheral neuropathy

04
❑ The over all size of the nerve: enlarged or reduced

❑ Nerve echopattern: hypoechoic or hyperechoic.

❑ Fascicular pattern: intact or lost.

❑ Fascicular size: enlarged or not, symmetrical or not

 US findings in peripheral neuropathy

Non-symmetrically enlarged, Interruption of the fascicular

structure in multifocal
hypoechoic fascicles in acquired demyelinating
Charcot Marie Tooth disease sensory and motor
neuropathy
 US findings in peripheral neuropathy

Enlarged CSA, with

reasonably normal fascicular Normal CSA with lost
architecture, due to
increased perineurial fascicular pattern in amyloid
connective tissue in
hypertrophic neuropathy neuropathy
01
05
 01
05
❑ Nerve US is a powerful tool in assessment of different peripheral

nerve pathologies.

❑ It needs good knowledge of anatomy & histopathology.

❑ It should be correlated with clinical data & neurophysiological

studies
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