The Elias University Hospital Approach: A Visual Guide to Ultrasound-Guided Botulinum Toxin Injection in Spasticity: Part II-Proximal Upper Limb Muscles

Abstract

Ultrasound-guided botulinum toxin type A (BoNT-A) injections play a critical role in the management of upper limb spasticity. This is the second part of 'The Elias University Hospital Approach: A Visual Guide to Ultrasound-Guided Botulinum Toxin Injection in Spasticity' and it focuses on the proximal upper limb muscles, complementing the first part, which addressed the distal upper limb muscles. This guide provides a detailed analysis of ultrasound anatomy, clinical relevance, and injection strategies for the latissimus dorsi, teres major, subscapularis, pectoralis major, pectoralis minor, deltoid, triceps brachii, biceps brachii, brachialis, and brachioradialis. Using the Elias University Hospital (EUH) model, it presents a structured approach to BoNT-A administration, ensuring precision, safety, and optimal outcomes in spasticity management. To enhance clinical application, this guide incorporates a wide array of high-quality ultrasound images and dynamic videos, offering a comprehensive and practical understanding of scanning techniques, anatomical structures, and injection procedures. This second part of the series serves as an essential reference for clinicians, aligning with the first installment to provide a complete and systematic approach to ultrasound-guided BoNT-A therapy for upper limb spasticity.

Keywords: botulinum toxin-A injections; musculoskeletal ultrasound; post-stroke spasticity; proximal upper limb muscles; ultrasound-guided therapy.

Figure 1

Ultrasound anatomy of the latissimus dorsi (LD) with key landmarks: LD—latissimus dorsi; ICM—intercostal muscle; and P—pleura.

Figure 2

Ultrasound anatomy of the latissimus dorsi (LD) and serratus anterior (SA) with key landmarks: LD—latissimus dorsi; SA—serratus anterior; ICM—intercostal muscle; Rb—rib; and P—pleura.

Figure 3

Ultrasound anatomy of the teres major (TM) with key landmarks: TM—teres major; Tm—teres minor; SSC—subscapularis; and Scap—scapula.

Figure 4

Ultrasound anatomy of the subscapularis (SSC) posterior view with key landmarks: SSC—subscapularis; TM—teres major; Tm—teres minor; Scap—scapula; and IMFS—intramuscular fascial septum.

Figure 5

Ultrasound anatomy of the subscapularis (SSC) anterior view with key landmarks: AD—anterior deltoid; SSC—subscapularis; SSC-T—subscapularis tendon; H—humerus; LHBT—long head bicep tendon; and CHL—coracohumeral ligament.

Figure 6

Ultrasound anatomy of the pectoralis major (Pmaj) with key landmarks: PMC—pectoralis major clavicular head; PMS—pectoralis major sternocostal head; IMF—intramuscular fascia; Pmin—pectoralis minor; n—nerve; A—artery; and V—vein.

Figure 7

Ultrasound anatomy of the pectoralis minor (Pmin) with key landmarks: Pmaj—pectoralis major; Pmin—pectoralis minor; ICM—intercostal muscle; Rb—rib; n—nerve; A—artery; and V—vein.

Figure 8

Ultrasound anatomy of the anterior deltoid (AD) with key landmarks: AD—anterior deltoid; LD—lateral deltoid; H—humerus; LHBT—long head bicep tendon; and CHL—coracohumeral ligament.

Figure 9

Ultrasound anatomy of the lateral deltoid (LD) with key landmarks: PD—posterior deltoid; LD—lateral deltoid; AD—anterior deltoid; and H—humerus.

Figure 10

Ultrasound anatomy of the posterior deltoid (PD) with key landmarks: PD—posterior deltoid; IS—infraspinatus; GL—glenoid labrum; and H—humerus.

Figure 11

Ultrasound anatomy of the triceps brachii (TB) with key landmarks: LHTB—long head triceps brachii; IMF—intramuscular fascia; LatHTB—lateral head triceps brachii; MHTB—medial head triceps brachii; UN—ulnar nerve; RN—radial nerve; MN—median nerve; BA—brachial artery; and H—humerus.

Figure 12

Ultrasound anatomy of the biceps brachii (BB) with key landmarks: SHBB—short head biceps brachii; LHBB—long head biceps brachii; IMF—intramuscular fascia; MCB—musculocutaneous branch; MN—median nerve; BA—brachial artery; Brach—brachialis; and H—humerus.

Figure 13

Ultrasound anatomy of the long head biceps brachii (LHBB) with key landmarks: LHBB—long head biceps brachii; IF—intermuscular fascia; MCN—musculocutaneous nerve; CB—coracobrachialis; MN—median nerve; BA—brachial artery; LatHTB—lateral head triceps brachii; H—humerus; and LHTB—long head triceps brachii.

Figure 14

Ultrasound anatomy of the brachialis (Brach) with key landmarks: Brach—brachialis; H—humerus; MCB—musculocutaneous branch; and BB—bicep brachii.

Figure 15

Ultrasound anatomy of the brachioradialis (BR) in the arm compartment with key landmarks: H—humerus; BR—brachioradialis; RN—radial nerve; IF—intermuscular fascia; and Brach—brachialis.

Figure 16

Ultrasound anatomy of the brachioradialis (BR) in the forearm compartment with key landmarks: BR—brachioradialis; IF—intermuscular fascia; ECRL—extensor carpi radialis longus; ECRB—extensor carpi radialis brevis; Sup—supinator; R—radius; and pin—posterior interosseous nerve.