**3.10 Flexor carpi ulnaris (FCU)**

The child should lie supine or sitting with the dorsal forearm resting on the table in full supination. In the middle of the medial forearm, try to hold the muscle with fingers near/anterior to the ulnar border. Gentle wrist extension -flexion and radial-ulnar deviation should result in good needle movement. While finger

#### **Figure 18.**

*Flexor digitorum Profundus (FDP): L1- line from olecranon medial wrist crease. US- line at ulnar shaft. Plus denotes needle entry point through the midpoint between the ulnar shaft and L 1 in proximal one-third to the distal two-thirds junction of the forearm.*

*Anatomical Surface Guided Techniques for Botulinum Toxin Injection in Spastic Cerebral… DOI: http://dx.doi.org/10.5772/intechopen.107200*

#### **Figure 19.**

*Flexor carpi Ulnaris (FCU): line represents ulnar border. Plus denotes an injection entry point for FCU in the middle of the medial forearm. Arrow showing the direction of the needle.*

flexion-extension should not show needle movement. Adjust the needle if one has gone anteriorly into FDS or deep into FDP (**Figure 19**).

### **3.11 Flexor pollicis longus (FPL)**

Position supine or sitting. Forearm in full supination. Draw a line from the middle of the elbow flexor crease to the lateral wrist flexor crease. The middle point of this line is the area of interest. Also, start palpating the radial artery from distal to proximal. In the midpoint of this line, just lateral to radial artery pulse (almost lost at this point) is the needle entry point straight vertically downwards in mid-depth (skin to radius bone). Do not forget to aspirate, as the radial artery is very close. Passive extension-flexion of the thumb distally will help in the localization of FPL and movement of the needle confirms its placement in FPL (**Figure 20**).

#### **3.12 Opponens pollicis**

Supinated forearm means Palm facing up. Thumb adducted or thumb in the palm. Mark the midpoint of the thumb metacarpal. Gently aside the abductor pollicis brevis medially and insert the needle just medial to the bone from this midpoint and remain close to the bone. Gently move the thumb laterally (opposite action of opponens) to confirm needle movement and injection placement (**Figure 21**).

#### **3.13 Adductor pollicis (AP)**

Forearm pronated, palm facing down, thumb as much laterally as possible to make the dorsal first web as prominent as possible. Place one finger from the palm side and

#### **Figure 20.**

*Flexor pollicis longus (FPL): L1- line joining medial & lateral elbow flexor crease. L2 a line from MID PINT OF L1 to lat wrist flexor crease. Small plus (on line L2) denotes the absence of a palpable radial pulse. Larger plus lateral to it is a vertical needle entry point for FPL.*
