Elbow Scanning Technique
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1 Elbow Scanning Technique Jon A. Jacobson, M.D. Disclosures: Book Royalties: Elsevier Professor of Radiology Director, Division of Musculoskeletal Radiology University of Michigan Note: all images from the textbook Fundamentals of Musculoskeletal Ultrasound are copyrighted by Elsevier Inc. Anatomy: anterior Anatomy: posterior From: Netter s Atlas of Human Anatomy From: Netter s Atlas of Human Anatomy Sonographic Technique: Standardized sequence Anterior Medial Lateral Posterior Focused examination Transducers: MHz linear Technique: anterior elbow extended Biceps brachii Coronoid and radial recesses 1
2 Brachioradialis Anterior Elbow: transverse Biceps A Median Nerve Pronator Teres Biceps,, and Anterior Recess Radial Nerve Branches Lateral Medial Fat Pad Long Axis Biceps Brachii Tendon: distal Radial Tuberosity Biceps Brachii: Insertion: radial tuberosity Short head: superficial, distal Long head; deep, proximal No synovial sheath Bicipitoradial bursa Long Axis From: Eames M. et.al. J Bone Joint Surg 2007:89:1044 Biceps Brachii: long (1), short (2) heads Biceps Brachii: terminal bifurcation A A Trochlea Transverse Lateral Transverse Medial Lateral Medial Note: long head (1) courses lateral to medial, deep to short head (2) From: Tagliafico A., et.al. Eur Radiol 2010; 20:202 Note: toggling the transducer, which creates anisotropy allows visualization of two tendon heads Courtesy of M. Chiavaras, Hamilton, Ontario 2
3 Biceps Brachii: Terminal Bifurcation Biceps Brachii Tendon: technique Medial Approach + Dynamic Imaging Note: endotenon septum (asterisk and arrows) From: Blasi M., et.al. Surg Radiol Anat 2014; 36:17 Smith J et al. J Ultrasound Med 2010; 29:861 Biceps Brachii Tendon: lateral approach Biceps Tendon: Radial insertion Elbow flexed, wrist pronated Radial tuberosity rotated into view Dynamic imaging: Partial vs. full-thickness tear Long Axis: dynamic imaging Kalume Brigido M. Eur Radiol 2009 ; 19:1817 Biceps Brachii Tendon: dorsal Technique: medial Ulna Radial Tuberosity Supination Radial Tuberosity Pronation Ulna elbow partially flexed Ulnar collateral ligament Anterior bundle Common flexor tendon Cubital tunnel Ulnar nerve 3
4 Ulnar Collateral Ligament Anterior, Posterior, and Transverse Bundles UCL and Common Flexor Tendon Flexors Ulna From: AJR 2003; 180:389 Coronal Technique: cubital tunnel Med Epicond Olecranon Technique: cubital tunnel Post Bundle UCL Arcuate Ligament FCUh FCUu Longitudinal Distal E Technique: ulnar nerve subluxation E O T Technique: lateral elbow partially flexed Common extensor tendon Radial collateral ligament Radial head & annular recess Capitellum Transverse 4
5 Lateral Collateral Ligament Complex Radial collateral ligament (arrows) Common extensor tendon (E) Annular ligament (arrowhead) Lateral ulnar collateral ligament (curved arrow) Jacobson J. et al. J Ultrasound Medicine 2013; 33:1041 E Lateral Collateral Ligament Complex Common extensor tendon (curved arrows) Radial collateral ligament (arrowheads) Annular ligament (a) Jacobson J. et al. J Ultrasound Medicine 2013; 33:1041 Note: footprints Common Extensor Tendon Removed Radial Nerve: deep branch As it enters into supinator under Arcade of Frohse Normally flattens in AP dimension: 50% Cross-sectional area does not change Technique: posterior elbow flexed Olecranon recess Triceps brachii Olecranon bursa Dong Q. et al. J Ultrasound Med 2010; 29:691 Anatomy of the Distal Triceps Brachii Olecranon Recess and Triceps Triceps Olec Superficial (blue arrow): long + lateral heads Deep (black arrow): medial head Primarily muscular insertion *From Resnick, Skeletal Radiol 2009; 38:171 Sagittal Fat Pad 5
6 Olecranon Recess and Triceps Axial Capitellum Triceps Fat Pad Trochlea Take Home Points Biceps brachii: Anterior and medial approach Lateral approach: dynamic Cobra: intervention Medial: UCL and ulnar nerve, dynamic Lateral: RCL and extensor tendon footprints Posterior: flexion, effusion evaluation 6
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