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Faye Chiou Tan, MDProfessor PMR, Baylor COM
Chief PMR, Director EMG, HCHD
Torsional Anatomy
Disclosures
Royalties – EMG Secrets Textbook – Elsevier
Thanks to the Team
Dr. John CiancaDr. Joslyn JohnDr. Erin Furr-Stimming – NeurologyDr. Sindhu PanditDr. Katherine Taber
Background
Frequently we are asked to perform procedures on patients who cannot be positioned in “anatomic neutral”
Yet, anatomic references display the human body in anatomic neutral.
No anatomic references to examine where to inject in altered position
Anatomic neutral
Anatomy in motion
where do structures move to In sports? In movement disorders – dystonia?In spasticity?In contractures/ casting?
Anatomy in motion
The study of anatomy in the position of altered posture (ie other than anatomic neutral).
Torsional MSK Anatomy
Study of MSK anatomy in torsion - NEWDefinition of torsion (Merriam Webster):
1. the twisting or wrenching of a body by the exertion of forces tending to turn one end or part about a longitudinal axis while the other is held fast or turned in the opposite direction; also : the state of being twisted
2. the twisting of a bodily organ or part on its own axis
Other Torsion Examples
Testicular torsionIntestinal torsionLimb budding of the leg - embryology
Limb budding of the leg
“Anatomic neutral” is not free of torsionEmbryonic limb budding of the leg
Leg bud begins with great toe cephalad Leg twists internally so great toe is medial Similar to stripes on a candy cane
Limb budding of the leg
Eg: PlexusUpper anterior – obturator – medialUpper posterior – femoral – anteriorLower anterior – tibial – posteriorLower posterior – peroneal - anterior
Week 10 Gestation
Week 15 Gestation
Week 30 Gestation
Differentiate Torsional MSK Anatomy from Rotational
Torsional anatomy : origin and insertion turn at different rates (in the same direction)
Rotational anatomy : origin and insertion turn at the same rate (in the same direction)
Ref: Chiou-Tan FY, Cianca J, Pandit S, John J, Furr-Stimming E, Taber KH: Procedure oriented torsional anatomy of the proximal arm for spasticity injection, J Comput Assist Tomogr, 39(3): 449-452, 2015.
Topical Anatomy Challenges
EdemaSoft tissueAltered anatomy (trauma, surgery)ContracturesSpasticity
Overview
I. NeckII. ArmIII. Forearm
Part 1:Muscles in Torticollis
Anatomy of Neck Injection : SCM
*
Fig 1a: Sternocleidomastoid – anatomic neutral position
Fig 1b: Sternocleidomastoid – left torticollis position
Anatomy of Neck Injection: Upper trapezius
*
Fig 1d: Trapezius – left torticollis position
Take Home#1 inTorsional Anatomy
The anchored or tethered end of torsion does not move as much as the free end.
(Eg. The door hinge does not have as wide an excursion as the door knob.)
Injection sites near the tethered end will not move as much as the free end.
Anatomy of Neck Injection: Scalenes
**
Fig 1e: Scalenes – anatomic neutral position
Fig 1f: Scalenes – left torticollis position
Take Home#2
Structures which were viewed easily in cross section can be difficult to view or “disappear” after torsion (i.e. are oblique) due to anisotropy. Adjusting the probe may (or may not) assist in achieving the desired view.
Eg. Cannot find the honeycomb appearance of the brachial plexus
Eg. Muscles bunch up and are not in either longitudinal or cross-sectional view.
Summary Torticollis
NEUTRAL POSITION TORTICOLLIS POSITION
Sternocleidomastoid Trapezius, Levator scapula
Upper Trapezius Upper Trapezius
Scalenes Scalenes
(Brachial plexus visible) (Brachial plexus difficult to view)
Part 2: Upper Arm Torsional Changes with Internal Rotation
Anatomy of Upper Arm Injection:Proximal – Pectoralis Major
*
InternalRotation
Neutral
Fig 2a: Proximal 1/3 Upper Arm
Anatomy of Upper Arm Injection:Middle - Biceps and Brachialis
*
Fig 2b: Middle Upper Arm
Anatomy of Upper Arm Injection:Distal 1/3 and 1/6 – Biceps and Brachialis
**
Fig 2c:Distal 1/3 Upper Arm
Neutral
InternalRotation
Anatomy of Upper Arm Injection:Distal 1/6 – Radial Nerve
*
Fig 2d: Distal 1/6 Upper Arm
Neutral
InternalRotation
“Rising Sun Sign”
Supination – Radial nerve is lateralPronation – Radial nerve is anterior
Ref: Chiou-Tan FY, Cianca J, Pandit S, John J, Furr-Stimming E, Taber KH: Procedure oriented torsional anatomy of the proximal arm for spasticity injection, J Comput Assist Tomogr, 39(3): 449-452, 2015.
Summary Upper Arm
Part 3: Forearm Changes with Internal Torsion
Supination/Pronation
Study of supination/pronation dates to 1800’s
Broken forearm bones that healed had limited supination/pronation
“Functional alignment” of bonesBoth radius and ulna move, but not to
same degree.
Supination/Pronation Refs
Duchenne GB. Physiology of Motion, Demonstrated by Means of Electrical Stimulation and Clinical Observation and Applied Study of Paralysis and Deformities. Philadelphia: Lippincott, 1949
Heibern J. Movements of the ulna in rotation of the fore-arm. J Anat Physiol. 1855; 19:237-240.
Dwight T. The movement of the ulna in rotation of the fore-arm. J Anat Physiol. 1855; 19:186-189.
Weinberg AM, Pietsch IT, Helm MB, et al. A new kinematic model of pro- and supinaton of the forearm. J Biomech. 2000; 33:487-491.
Nakamura T, Yabe Y, Horiuchi Y et al. Three dimensional MRI of interosseous membrane of forearm: a new method using fuzzy reasoning. Magn Reson Imaging. 1999; 17:463-470.
Pronator Teres
*
Pronator Teres
MedialRotation
Neutral
Flexor Carpi Radialis
*
FCR
Neutral
MedialRotation
FCU/FDP
*
FCU and FDP
Neutral
MedialRotation
Brachioradialis
**
Brachioradialis (BR)
Neutral
MedialRotation
Flexor Digitorum Superficialis
*
Flexor Digitorum Superficialis
Neutral
InternalRotation
Take Home #3 in Torsional Anatomy
Missing the intended muscle could lead to:1. injecting too much total medication in
another muscle (i.e. Brachialis twice rather than Biceps once, Brachialis once)
2. injecting an extensor rather than flexor and worsening the imbalance of muscles.
3. injecting an unintended target (eg. nerve, artery, vein, tendon)
Biceps tendon
Hypovascular – at risk for injuryMechanical impingement in pronationBiceps tendon occupies 85% of
radioulnar position in pronated position
Ref: Miyamoto RG, et al. Distal biceps tendon injuries. J Bone Joint Surg Am. 2010;92:2128-2138.
Summary Distal Arm
MSKUS Probe centered over muscle listed in supinated anatomic neutral position and held immobile while subject turned to hemispastic pronated position.
NEUTRAL POSITION INTERNAL TORSION POSITION
Pronator Teres Brachialis, Biceps tendon, and
median nerve (more superficial)
Flexor Carpi Radialis Pronator Teres, median nerve
FCU, FDP FCR, PT, median nerve
Brachioradialis Extensor Carpi Radialis
Flexor Digitorum Superficialis Brachioradialis, ECR, radial nerve
Conclusions
Torsional MSK anatomy is NEW Torsional anatomy is provided to help
injectors localize targets precisely and avoid injecting other non intended structures.
Learn which structures move and which do not.
Torsional Anatomy References
Neck - Movement disorder society – Stockholm Sweden: Furr-Stimming, Cianca J, Pandit S, John J, Chiou-Tan FY, 2014
Upper arm – Movement disorder society – Stockholm Sweden: Chiou-Tan FY, Cianca J, Pandit S, John J, Furr-Stimming, 2014
Upper arm - AAPMR-San Diego: Chiou-Tan FY, Cianca J, Pandit S, John J, Furr-Stimming, Taber K, 2014
Distal arm – Association of Academic Physiatrists – San Antonio: Chiou-Tan FY, Cianca J, John J, Pandit S, Furr-Stimming, Taber K, 2015
Torsional Anatomy References
Chiou-Tan FY, Cianca J, Pandit S, John J, Furr-Stimming E, Taber KH: Procedure-Oriented Torsional Anatomy of the Proximal Arm for Spasticity Injection. J Comput Assist Tomogr 39(3): 449-452, 2015.
Chiou-Tan FY, Cianca J, John J, Furr-Stimming E, Pandit S, Taber KH: Procedure-Oriented Torsional Anatomy of the Forearm for Spasticity Injection. J Comput Assist Tomogr (in press), 2015.
Comments from Sweden
“ I have this (localization) problem all the time when I teach my students”
“I use ultrasound guidance. I bet my colleagues free lunch to whoever gets the right spot – I haven’t paid for lunch yet”
Thank You!
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