Skeletal Radiology

, Volume 48, Issue 1, pp 57–74 | Cite as

Sonographic evaluation of uncommonly assessed upper extremity peripheral nerves: anatomy, technique, and clinical syndromes

  • Jonathan M. Youngner
  • Kulia Matsuo
  • Tom Grant
  • Ankur Garg
  • Jonathan Samet
  • Imran M. Omar
Review Article


Targeted ultrasound of the median, ulnar, and radial nerves is a well-established technique for suspected upper extremity peripheral neuropathy. However, sonographic imaging of the brachial plexus and smaller peripheral nerve branches is more technically difficult and the anatomy is less familiar to many radiologists. As imaging techniques improve, many clinicians refer patients for imaging of previously less-familiar structures. In addition, some patients may present with injuries that could involve local neurovascular structures. Finally, patients presenting with isolated peripheral neuropathies may be referred for perineural injections with local anesthetic for diagnostic purposes, or steroid for therapeutic reasons. This requires sonologists to have a firm understanding of the courses of these nerves and the surrounding anatomic landmarks that can be used to accurately identify and characterize them. We discuss clinical syndromes referable to specific peripheral nerve branches in the upper extremity, the relevant anatomy, and sonographic technique.


Ultrasound Peripheral nerve Perineural injection 


  1. 1.
    Klauser AS, Halpern EJ, De Zordo T, Feuchtner GM, Arora R, Gruber J, et al. Carpal tunnel syndrome assessment with US: value of additional cross-sectional area measurements of the median nerve in patients versus healthy volunteers. Radiology. 2009;250(1):171–7.CrossRefPubMedGoogle Scholar
  2. 2.
    Martinoli C, Bianchi S, Gandolfo N, Valle M, Simonetti S, Derchi LE. US of nerve entrapments in osteofibrous tunnels of the upper and lower limbs. Radiographics. 2000;20:S199–213.CrossRefPubMedGoogle Scholar
  3. 3.
    Brown JM, Yablon CM, Morag Y, Brandon CJ, Jacobson JA. US of the peripheral nerves of the upper extremity: a landmark approach. Radiographics. 2016;36(2):452–63.CrossRefPubMedGoogle Scholar
  4. 4.
    Yablon CM, Hammer MR, Morag Y, Brandon CJ, Fessell DP, Jacobson JA. US of the peripheral nerves of the lower extremity: a landmark approach. Radiographics. 2016;36(2):464–78.CrossRefPubMedGoogle Scholar
  5. 5.
    Tagliafico A, Martinoli C. Reliability of side-to-side sonographic cross-sectional area measurements of upper extremity nerves in healthy volunteers. J Ultrasound Med. 2013;32:457–62.CrossRefPubMedGoogle Scholar
  6. 6.
    Neal JM, Gerancher JC, Hebl JR, Ilfeld BM, McCartney CJ, Franco CD. Upper extremity regional anesthesia. Reg Anesth Pain Med. 2009;34(2):134–70.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Sehmbi H, Madjdpour C, Shah UJ, Chin KJ. Ultrasound-guided distal peripheral nerve block of the upper limb: a technical review. J Anasethesiol Clin Pharmacol. 2015;31(3):296–307.CrossRefGoogle Scholar
  8. 8.
    Capek A, Dolan J. Ultrasound-guided peripheral nerve blocks of the upper limb. Continuing education in anaesthesia. Critical care & Pain. 2015;15:160–5.Google Scholar
  9. 9.
    Nwawka OK, Miller TT. Ultrasound-guided peripheral nerve injection techniques. AJR Am J Roentgenol. 2016;207(3):507–16.CrossRefPubMedGoogle Scholar
  10. 10.
    Walter RW, Burke CJ, Adler RS. Ultrasound-guided therapeutic injections for neural pathology about the foot and ankle: a 4 year retrospective review. Skelet Radiol. 2017;46(6):795–803.CrossRefGoogle Scholar
  11. 11.
    Orebaugh SL, Williams BA. Brachial plexus anatomy: normal and variant. Sci World J. 2009;9:300–12.CrossRefGoogle Scholar
  12. 12.
    Uysal II, Seker M, Karabulut AK, Buyukmumcu M, Ziylan T. Brachial plexus variations in human fetuses. Neurosurg. 2003;53(3):676–84.CrossRefGoogle Scholar
  13. 13.
    Emamhadi M, Chabok SY, Samini F, Alijani B, Behzadnia H, et al. Anatomical variations of brachial plexus in adult cadavers; a descriptive study. Arch Bone Jt Surg. 2016;4(3):253–8.PubMedPubMedCentralGoogle Scholar
  14. 14.
    Khadilkar SV, Khade SS. Brachial plexopathy. Ann Indian Acad Neurol. 2013;16:12–8.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Lapegue F, Faruch-Bilfeld M, Demondion X, Apredoaei C, Bayol MA, Artico H, et al. Ultrasonography of the brachial plexus, normal appearance and practical applications. Diagn Interv Imaging. 2014;95:259–75.CrossRefPubMedGoogle Scholar
  16. 16.
    Canella C, Demondion X, Abreu E, et al. Anatomical study of spinal accessory nerve using ultrasonography. Eur J Radiol. 2013;82(1):56–61.CrossRefPubMedGoogle Scholar
  17. 17.
    Kennedy E, Albert M, Nicholson H. The fascicular anatomy and peak force capabilities of the sternocleidomastoid muscle. Surg Radiol Anat. 2017;39(6):629–45.CrossRefPubMedGoogle Scholar
  18. 18.
    Kelley MJ, Kane TE, Leggin BG. Spinal accessory nerve palsy: associated signs and symptoms. J Orthop Sports Phys Ther. 2008;38:78–86.CrossRefPubMedGoogle Scholar
  19. 19.
    Kakkar C, Shetty CM, Koteshwara P, Baijpai S. Telltale signs of peripheral neurogenic tumors on magnetic resonance imaging. Indian J Radiol Imaging. 2015;25(4):453–8.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Linda DD, Harish S, Stewart BG, Finlay K, Parusa N, Rebello RP. Multimodality imaging of the peripheral neuropathies of the upper limb and brachial plexus. Radiographics. 2010;30(5):1373–400.CrossRefPubMedGoogle Scholar
  21. 21.
    Stephens L, Kinderknecht JJ, Wen DY. Musculocutaneous nerve injury in a high school pitcher. Clin J Sport Med. 2014;24(6):e68–9.CrossRefPubMedGoogle Scholar
  22. 22.
    Chiavaras MM, Jacobson JA, Billone L, Lawton JM, Lawton J. Sonography of the lateral antebrachial cutaneous nerve with magnetic resonance imaging with anatomic correlation. J Ultrasound Med. 2014;33(8):1475–83.CrossRefPubMedGoogle Scholar
  23. 23.
    Miller TT, Reinus WR. Nerve entrapment syndromes of the elbow, forearm, and wrist. AJR Am J Roentgenol. 2010;195:585–94.CrossRefPubMedGoogle Scholar
  24. 24.
    Lee MJ, LaStayo PC. Pronator syndrome and other nerve compressions that mimic carpal tunnel syndrome. J Orthop Sports Phys Ther. 2004;34(10):601–9.CrossRefPubMedGoogle Scholar
  25. 25.
    Strakowski JA. Ultrasound-guided peripheral nerve procedures. Phys Med Rehabil Clin N Am. 2016 Aug;27(3):687–715.CrossRefPubMedGoogle Scholar
  26. 26.
    Sehmbi H, Madjdpour C, Shah UJ, Chin KJ. Ultrasound-guided distal peripheral nerve block of the upper limb: a technical review. J Anaesthesiol Clin Pharmacol. 2015;31(3):296–307.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Hide IG, Grainger AJ, Naisby GP, Campbell RS. Sonographic findings in anterior interosseous nerve syndrome. J Clin Ultrasound. 1999;27:459–64.CrossRefPubMedGoogle Scholar
  28. 28.
    Cheung JW, Shyu JF, Teng CC, Chen TH, Su CH, et al. The anatomical variations of the palmar cutaneous branch of the median nerve in Chinese adults. J Chin Med Assoc. 2004;67(1):27–31.PubMedGoogle Scholar
  29. 29.
    Nagle DJ, Santiago KJ. Anomalous palmar cutaneous branch of the median nerve in the distal forearm: a case report. Hand Surg Am. 2008;33(8):1329–30.CrossRefGoogle Scholar
  30. 30.
    Tagliafico A, Pugliese F, Bianchi S, Bodner G, Padua L, Rubino M, et al. High-resolution sonography of the palmar cutaneous branch of the median nerve. AJR Am J Roentgenol. 2008;191(1):107–14.CrossRefPubMedGoogle Scholar
  31. 31.
    Riegler G, Pivec C, Platzgummer H, Lieba-Samal D, Brugger P, Jengojan S, et al. High-resolution ultrasound visualization of the recurrent motor branch of the median nerve: normal and first pathological findings. Eur J Radiol. 2017;27(7):2941–9.CrossRefGoogle Scholar
  32. 32.
    Shams OE, Al-Ghanmdi SM. Isolated neuropathy of recurrent motor branch of median nerve. Neurosciences (Riyadh). 2006;11:326–8.Google Scholar
  33. 33.
    Duggal A, Anastakis DJ, Salonen D, Becker E. Compression of the deep palmar branch of the ulnar nerve by a ganglion. Hand. 2006;1:98–101.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Kim SS, Kim JH, Kand HI, Lee SJ. Ulnar nerve compression at Guyon’s canal by an arteriovenous malformation. J Korean Neurosurg Soc. 2009;45:57–9.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Le Corroller T, Bauones S, Acid S, Champsaur P. Anatomical study of the dorsal cutaneous branch of the ulnar nerve using ultrasound. Eur J Radiol. 2013;23:2246–51.CrossRefGoogle Scholar
  36. 36.
    Wajid H, LeBlanc J, Shapiro DB, Delzell PB. Bowler’s thumb: ultrasound diagnosis of a neuroma of the ulnar digital nerve of the thumb. Skelet Radiol. 2016;45:1589–92.CrossRefGoogle Scholar
  37. 37.
    Meng S, Tinhofer I, Weninger WJ, Grisold W. Anatomical and ultrasound correlation of the superficial branch of the radial nerve. Muscle Nerve. 2014;50(6):939–42.CrossRefPubMedGoogle Scholar
  38. 38.
    Andreisek G, Crook DW, Burg D, Marincek B, Weishaupt D. Peripheral neuropathies of the median, radial, and ulnar nerves: MR imaging features. Radiographics. 2006;26(5):1267–87.CrossRefPubMedGoogle Scholar
  39. 39.
    Choi S-J, Ahn JH, Ryu DS, Kang CH, Jung SM, Park MS. Ultrasonography for nerve compression syndromes of the upper extremity. Ultrasonography. 2015;34(4):275–91.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Chien AJ, Jamadar DA, Jacobson JA, Hayes CW, Louis D. Sonography and MR imaging of posterior interosseous nerve syndrome with surgical correlation. AJR Am J Roentgenol. 2003;181:219–21.CrossRefPubMedGoogle Scholar

Copyright information

© ISS 2018

Authors and Affiliations

  • Jonathan M. Youngner
    • 1
  • Kulia Matsuo
    • 1
  • Tom Grant
    • 1
  • Ankur Garg
    • 1
  • Jonathan Samet
    • 1
    • 2
  • Imran M. Omar
    • 1
  1. 1.Department of Radiology, Feinberg School of MedicineNorthwestern UniversityChicagoUSA
  2. 2.Department of RadiologyLurie Children’s HospitalChicagoUSA

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