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The extensor carpi radialis longus tendon and the extensor carpi radialis brevis tendon are important landmarks for the dorsoradial approach to the wrist. This case report presents an anatomic variant: both tendons are divided into two different reins. Knowledge about this anatomic variant is of importance in order to avoid misinterpretations.

Background: Aim of the study was to work out a reliable method for the ultrasonographic evaluation of the pectoral region., Methods: The study was performed in 20 cadaver specimens and 20 healthy volunteers as well as in 10 patients with disorders of the pectoral region., Results: For examination of the pectoralis major muscle, the landmark for the positioning of the ultrasound transducer was found to be the lateral border of the anterior axillary fold in the direction of the tip of the coracoid process. Tilting the probe medially, the fibres of the pectoralis major muscle become visible in longitudinal alignment. The main part of the clavicular portion of the pectoralis major muscle can be visualised by moving the probe parallel to this position. Tilting the probe downwards, both the internal part of the clavicular portion, the sterno-costal and the abdominal portion are evaluated. For examination of the pectoralis minor muscle, the probe is positioned between the tip of the coracoid process and the sternal angle. Thus the whole muscle can be examined with a single sweep of the transducer. In all the specimens, probands and patients of our group, both muscle, fascias and pathological lesions could be clearly depicted., Summary: Based on the introduction of standard examination planes, the pectoral region can be evaluated in detail using ultrasonography. Lesions and pathologic changes can be reliably appointed to individual anatomical structures.

This paper reports on the sonographic localisation of a metallic foreign body in the upper arm region and its topographic anatomic position as well as the sonographic diagnosis of an AV fistula due to a lesion of the brachial blood vessels. Ultrasonography is the method of choice for the evaluation and diagnosis of foreign body injuries and possible subsequent complications.

Background: Chronic ulnar nerve subluxation out of the sulcus in the elbow region may be a rare reason for undefined chronic disorders in the medial elbow aspect., Methods: We report two cases: A 38 years old male patient reports recurrent painful disorders including paresthesia of the 4th and 5th fingers. A 12 years old boy shows a palpable band in the medial elbow region without pain., Results: In both patients, the ulnar nerve was completely identified, both in transverse and longitudinal planes. Sonomorphology and echogeneity were the same as in the controlateral limb. Ulnar nerve subluxation could be diagnosed in elbow joint flexion, in both cases., Conclusion: Dynamic ultrasonographic examination is able to diagnose and document ulnar nerve subluxation and determine further (surgical) treatment.

In case of penetrating injuries near to the knee joint showing only a small skin lesion and no damage to tendons and neuro-vascular structures, opening of the joint cavity has to be taken into consideration. Besides surgical revision of the penetration canal, radiological depiction of free intraarticular air may be useful. We report the cases of two patients, who suffered from intraarticular effusion and pain two, respectively three days after a penetrating injury. In both of them, free intraarticular air in the suprapatellar region could be depicted by ultrasonographic assessment. Subsequent evaluation of radiographs showed intraarticular air already being there at the day of admittance. Performing an experimental study in fifteen cadaver knee joint specimens, the reliability of this technique was evaluated and documented. Using an injection needle, air was insufflated into the knee joints with or without previous instillation of fluid. Afterwards sonographic assessment was performed using 7,5 - 13 MHz linear probes and Siemens (Elegra) equipment. Ultrasonographic detection of pneumarthrosis of the knee joint was possible early and reliably in both of the patients reported. With sufficient experience of the clinician and adequate equipment, even singular intraarticular air blisters are detectable, especially in cases of concomitant intraarticular effusion. By ultrasound it was possible to detect pneumarthrosis with at least 0,5 ml, by X-ray with at least 2 ml. Ultrasonography proved to be a reliable diagnostic tool for the detection of free intraarticular air within the knee joint. This fact should be considered in the differential diagnosis of unclear knee joint disorders after penetrating injuries.

Ultrasound examinations of the sciatic nerve were performed using high-resolution transducers (7.5, 10 to 20 MHz) both in anatomical specimens and in healthy volunteers. The ultrasonographic anatomy (sono-anatomy) of the nerve, its course along the thigh and its echogenicity in comparison with muscles, tendons and adipose tissue were investigated in 10 isolated muscle/nerve preparations. In addition, the influence of the angle of the applied transducer on the various different tissues was evaluated. In the clinical part of the study, the sciatic nerve was identified ultrasonographically in both thighs of 50 sex-matched healthy volunteers aged between 2 and 76 years. The normal sciatic nerve presents as a tubular echogenic structure with parallel linear internal echoes in the longitudinal section, and as a punctiform moderately echoic structure in cross-section, with the perineurium producing bright boundary echoes. Varying the insonating angle of the transducer reduced echogenicity, but to a smaller degree than in muscles and tendons. Unequivocal identified of the sciatic nerve from the level of the gluteal fold to its bifurcation in the distal thigh was possible in all but one case. We conclude that the course of the sciatic nerve along the thigh can be reliably identified and imaged with high-resolution ultrasound.

Atypical neuroleptic drugs have enriched our treatment programs, especially in childhood and adolescent schizophrenia. Reviewed here is the use of atypical neuroleptics in children and adolescents with a schizophrenic disorder. The receptor binding profile and pharmacological properties, indications, side effects, clinical application, and trials of atypical neuroleptic drugs are compared to the classical neuroleptic drug haloperidol in the treatment of adolescent schizophrenia. Special attention is paid to the most common atypical neuroleptics clozapine, olanzapine and risperidone since most studies are carried out with these compounds, most often with clozapine. More clinically controlled trials have to be conducted since only one has been performed to date. The place of atypical neuroleptic drugs is discussed and further studies are necessary in order to differentiate, and eventually broaden the spectrum of the indications tested thus far.

Since the palmaris longus tendon is subject to a wide range of anatomical variations (in 10% of the cases, aplasia is observed), the identification and determination of its length and thickness is of importance for the pre-operative planning of ligament reconstructive surgery. Thirty healthy volunteers aged between 6 and 50 years were examined using high-resolution 10-12 MHz US probes. We determined the length and thickness of the tendon, and its relationship to the median nerve in the distal region of the forearm. Thanks to the dynamic nature of the examination and the typical tendinous echo structure, the palmaris longus tendon was accurately identified by US in both children and adults. Ultrasonography is highly suitable for the identification of the palmaris longus tendon and aids the pre-operative planning of ligament reconstructions.

To show the possibilities of imaging diagnostic procedures using high and extremely high resolution ultrasonic probes we investigated the anatomic structures of the foot. We examined 10 cadaver feet of the anatomic institute and in a clinical trial 20 healthy patients with 10 to 20-MHz-probes and could identify correctly single tendons and ligaments even in the toe region. Especially the possibility of dynamic examination had to be mentioned beside the other advantages of ultrasound diagnostic (saving of expenses, lack of radiation, side-to-side comparison).

Thanks to the increasing use of ultrasonography in the diagnostic evaluation of the musculoskeletal system, and the development of high-resolution ultrasonic transducers with ever better image quality, as well as the greater general trend towards non-invasive techniques, the use of ultrasonography in the diagnosis and follow-up of fractures would appear to make good sense. The aim of the present experimental study was, therefore, to identify the typical acoustic pattern of fractures and areas of bone impression and defects, while taking account of possible sources of error due to artefacts. Experiments were carried out on cadaver bones immersed in a water bath, using 7.5 and 10 MHz linear transducers. Depending on its size, the bony defect is represented by an interruption of the cortical echo, or a dorsal band of echoes limited to the fracture zone. Of interest is the fact that fractures and bony defects are not represented as such when the transducer is directed parallel to the line of the fracture or the impression area. Particular attention needs to be paid to the numerous artefacts occurring at the margins of the fracture. In summary, it may be noted that using resolution transducers under standardised experimental examination conditions, cortical interruptions of not less than 1 mm can be identified.

In recent years, ultrasonic assessment of the locomotory system has become established both as a screening method in patients with chronic disorders and for evaluating acute injuries. Thanks to technical improvements to the equipment (use of high-frequency probes up to 20 MHz), ever smaller structures can be visualized. Ultrasonography can be carried out immediately following the clinical- and possibly radiological-assessment, by one and the same investigator, and requires little extra time. A bilateral examination in particular permits good evaluation of the extent of an injury and, with appropriate experience and good-quality equipment, an accurate assessment of the anatomical topography. Ultrasonography should now be used as the primary imaging method in the diagnosis of injuries to the following parts of the locomotory system, thus helping to minimize the number of expensive, and more invasive, diagnostic procedures: muscles and tendons, peri-articular soft tissue (in particular shoulder, knee and elbow joints), detection of intra-articular effusions, collections of fluid and, where applicable, ultrasonically guided puncture. In numerous other problems, too (postoperative complications, foreign bodies, fractures, osteomyelitis, soft tissue inflammation, etc.), ultrasound can deliver the first information. In this way, expensive diagnostic techniques can be reserved for special cases only, thus reducing costs. Furthermore, used as an adjunctive method, ultrasonography can reduce the number of diagnostic and follow-up X-rays in the case of injuries to the AC joint, shoulder dislocations, Hill-Sachs lesions, fractures in children, and for the detection of foreign bodies, again reducing radiation exposure and overall costs.

Method: In an experimental study on ten isolated human cadaver tendons, the ultrasound anatomy and the reproducibility of artefacts was determined using 10- and 13-MHz probes. With these in vitro data, the form and diameter of a non-injured tendon were documented in a series of 30 patients between 3 and 60 years old. In a second series of 32 patients with acute, traumatic ruptures of the Achilles tendon and 40 patients with chronic disorders, we distinguished the pathological anatomy., Results: Injuries to a tendon with chronic disorders, reruptures and complications in the postoperative period after tendon repair can be made more difficult by calcification, scars, oedema, haematoma and suture materials. It is necessary to check the changing ultrasound patterns owing to an haematoma or oedema with tendon carpulence, the missing linear signals in a fresh rupture and the different signals after operative or nonoperative treatment., Conclusion: Using high-frequency probes with 10 or more MHz, it is possible to examine even the insertion area of the tendon or the pathology of a subachilleal bursa by tilting the probe. The dynamic examination and the comparison with the contralateral side in two planes should be included in a standardized examination procedure and are of great importance in some cases of fresh tendon ruptures. Knowledge of the physical principles and the possibility of misleading artefacts is crucial.

In an experimental study, the US pattern of foreign materials such as are often found in wounds, was investigated. The exploration was carried out with the aid of high-resolution, mechanical US probes (10-12 MHz) used to examine foreign bodies placed in a gelatine bath and in the shoulder of a pig. The study showed that all foreign bodies that measured at least 1-2 mm in diameter were reliably detected. The intensity of the interface echoes was identical with all the materials employed, irrespective of the nature of the surface. However, the artefacts caused by the foreign bodies used revealed considerable differences. Complete acoustic shadow, acoustic attenuation, reverberation echoes and even "comet-tail" artefacts were observed. In clinical practice, familiarity with the artefacts that may be expected during sonographic exploration and localization of foreign bodies in wounds would seem to make good sense.

Heterotopic ossification is a non-neoplastic deposit of bone within soft tissue (myositis ossificans). The most common localized form is post-traumatic myositis ossificans. The ultrasonographic appearance of heterotopic ossification is characterized by highly echogenic areas with attenuation or complete disappearance of the acoustic signal distal to these areas. The size and extent of para-articular ossifications can also be evaluated, and the choice of the surgical approach is facilitated and damage to soft tissue minimized by the ultrasonographic examination.

In a first experimental study we investigated the visualisation of metal implants in reference to dimension, shape, material (titanium, steel, biodegradable screws) and surface structures and an eventual change of the echo pattern in correlation to the surrounding structures, the vicinity to bone and the change of the sound angle. For this purpose ultrasound investigation was performed in artificial and cadaver bones and in cadaver limbs after implantation of screws, plates, K-wires and cerclage wires. We found that metal implants of a certain dimension can be localised by typical artefacts (resonance artefact, comet tile artefact). In the following clinical study we investigated the value of ultrasound in finding and localisation of implants after osteosynthesis. In patients with 25 locking femur nailing, 30 locking tibia nailing, 30 osteosynthesis done by screws and plating, metal was easily localised by typical artefacts. Ultrasound examination gave the possibility to define the number of screws, the localisation to surrounding tissue, loosening of screws and eventual as sociated inflammatory tissue swelling (bursitis, tendovaginitis).

The aim of the present study was to establish the typical ultrasound (US) patterns of metal implants used for internal fracture fixation, and consequently to use US for the identification and localisation of such implants. We investigated both the visualization of the implants in term of size and shape, material (titanium, steel, biodegradable screws) and surface structures, and possible changes in the echo pattern in relationship to surrounding structures (muscles, body fluid), proximity to bone, and changes in the angle of insonation. For this purpose ultrasonography was performed on artificial and isolated cadaver bones in a water bath, as well as on cadaver limbs following prior implantation of screws, plates, K-wires and cerclage wires. We found that, from a certain size upwards, metal implants can be easily localised on the basis of typical artefacts (resonance artefact, comet-tail artefact). US is thus most suitable for localisation of metal implants. The spatial and anatomical relationship to bony structures, joints, tendons, muscles and blood vessels can be determined with a high degree of accuracy.