Download The Elbow

3/5/2015
The Elbow
The Elbow
Scanning Sequence
* Anterior Joint
(The anterior “Pyramid”)
* Lateral Epicondyle
* Medial Epicondyle
* Posterior Joint
The Elbow
The Elbow
Anterior Elbow “Pyramid”
The Surrounding Musculature
Anterior Elbow “Pyramid”
Courtesy of Jay Smith, MD . Vice chair PMR Mayo Clinic Rochester, MN
Short axis probe placement at the antecubital fossa
Biceps
Brachialis
Radial
Head
Ulnar
2
Notch
The Elbow
The Elbow
Anterior Compartment Effusion
Fat Pad Displacement
Anterior Elbow “Pyramid”
Brachial
Artery
Supine patient
Bolus under hand
to limit extension
= Brachialis
Cap
Troch
= Brachioradialis
= Pronator Teres
= Radial Nerve
= Artery w MN
Troch
Short axis scan through the Humeral Coronoid Fossa
may reveal fat pad displacement
as seen with occult fracture.
90 degree flexion with light probe pressure is helpful.
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3/5/2015
The Elbow
Anterior Transverse: Distal Biceps Tendon
Distal Biceps Tendon
Anterior Approach
Transverse probe
at the crease
Antecubital Fossa.
The two heads of Biceps
Brachii unite forming a thick
tendon, attaching at the
Radial Tuberosity.
The Elbow
The Elbow
Distal Biceps Tendon
Distal Biceps Tendon
Transverse Orientation
Anterior Longitudinal Orientation
Lateral
Biceps
Brachialis
Brachialis
Medial
Slight proximal beam
angulation helps
visualize the hyperechoic
tendon in cross-section
Biceps tendon is
centrally positioned on
TOP of the Brachialis
LAX probe
angled Radially
Tracking the Biceps tendon
to it’s Radial attachment
requires firm probe contact, and can
be difficult due to anisotropy
The Elbow
The Elbow
Distal Biceps Tendon
Distal Biceps Tendon
Longitudinal Orientation
Panoramic Image
Bic
Cap
Long Axis
Radial Beam
Anisotropy presents due to oblique,
deeper course to the attachment
on the Radial Tuberosity.
Radial
Head
Slight lateral probe translation reveals
Capitulum & Radial Head.
Tracing Radial cortex to the tuberosity
may visualize tendon attachment.
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3/5/2015
The Elbow
Anterior Longitudinal
(Medial Probe Angle = Brachialis tendon )
Distal Biceps Tendon
Brachialis
3
1
Brachialis
attachment
Probe
Angled medially
Lateral Approach
2
1 = Humeral Trochlea
2 = Coronoid Process of Ulna
Arrow: Brachialis attachment
3 = Pronator Teres Muscle
The Elbow
Lateral Approach to the Distal Biceps Tendon
The Elbow
Lateral Approach : Image Orientation
Superficial
Diagram
Courtesy
Jon Jacobson, MD
Supinator
Extensors
Radius
T = Probe
Lateral
becomes top of
image
90 degree elbow flexion
Sufficient hand supination to expose tendon
Longitudinal/Coronal Probe
Slightly distal from Radial Head
Bic Ten
Deep
Orientation of image can be difficult due to a 90 ⁰
rotation of the anatomy on the ultrasound monitor.
The Elbow
Lateral Approach Distal Biceps Tendon
Injection Setup
Supinator
Distal Biceps Tendon
Radius
Medial Approach
Extensors
Bic Ten
Probe Position and Needle Advancement
The probe is in short axis /coronal orientation along the
lateral elbow compartment. The needle is advanced
in plane with the radius and tendon well visualized.
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3/5/2015
The Elbow
Medial Approach to the Distal Biceps Tendon
Through the Pronator “window”
FCU
Pronator
Ulna
Bic Ten
Distal Biceps Tendon
Dorsal Approach
Radius
Unchanged patient position.
Medial to lateral beam angle
Probe at radial tuberosity
Hyperechoic fibers
seen from left side
of image.
The Elbow
Dorsal Approach to the Distal Biceps Tendon
Ulna
Radius
The most direct approach to view the attachment
and perform guided injection.
The Elbow
Dorsal Approach Distal Biceps : Pronation
Radius
The Elbow
Dorsal Approach Distal Biceps : Supination
Ulna
Radius
Biceps attachment on Radial Tuberosity NOT visible
with supinated arm in 90⁰ flexion
The Elbow
Dorsal Approach Distal Biceps : Dynamic Image
Ulna
Radius
Ulna
Pronation of arm exposes the tendon attachment
on Radial tuberosity
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3/5/2015
The Elbow
Anterior Lateral Longitudinal
Anterior Joint space and Annular Ligament
(Not the lateral epicondyle view.)
Lateral Elbow
Annular
Lig
LAX Probe
Lateral margin of
Antecubital Fossa
The Elbow
Lateral Epicondyle Longitudinal
Common Extensor Tendon and Radial Collateral Ligament
Fig. 1
H
RH
Anechoic hyaline cartilage lines
Humerus (H) and the Radial Head (RH)
Annular ligament contours Radial head
Anterior joint is “V” shaped
Synovial fringe extends from
synovial membrane.
The Elbow
Radial Nerve…Cutaneous Sensory …and
Posterior Inter-osseous branches
BrRad
Br
LAX Probe
Span the
joint space
Visualize the
Epicondyle !
Hyperechoic Common Extensor
is fibrillar & superficial to the…
darker/hypoechoic RCL
SAX Probe
At the
joint space
The hyperechoic RADIAL NERVE is identified
between the Brachioradialis and the Brachialis
The Elbow
The Cutaneous Sensory …and
Posterior Interosseous ( PIN )
Radial Nerve
The Cutaneous Sensory …and
Posterior Interosseous (PIN)
BrRad
Br
Slight
Distal/Lateral
Probe
Translation
from RN
RH
Radial Head becomes the only boney landmark.
The PIN splits laterally
The Cutaneous Sensory nerve splits medially
Both are HYPOECHOIC due to anisotropy
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3/5/2015
The Elbow
Posterior Interosseous ( PIN )
s1
Medial Elbow
s2
RH
Meticulous
Distal Probe
Translation
along radial
margin
Radius remains the only boney landmark.
The PIN is quite small and found between
the superficial (s1) and deep (s2)
heads of the Supinator muscle
The Elbow
The Elbow
Medial Epicondyle: Common Forearm Flexor
and Ulnar Collateral Ligament
Medial Epicondyle
MED
EPI
*
*
ULNA
= Pronator Teres
Supine patient
external rotation
= FDS
Probe Anterior to Epicondyle
Dynamic UCL Evaluation
Valgus stress by
depressing the wrist
Normal = < 2mm
Abnormal = > 2mm
ULNA
The Elbow
Posterior Midline Longitudinal
Landmarks are Humeral Trochlea.
and distal Ulnar Olecranon.
Posterior Elbow
Hyperechoic tendon fibers superficial
to deeper Triceps muscle..
Medial
Condyle
The flex
tendon
blend
with
attachm
t of the
more
superfic
Pronato
and th
Deepe
Flexo
Digitoru
Superfic
s
Olec
Process
Med Tr
HUM
“Crab “ position
for scanning the
posterior elbow
in midline
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3/5/2015
The Elbow
The Elbow
Ulnar Nerve Short Axis
Posterior Midline Transverse
Tip !
To see Olecranon
Bursa move distal
on flexed elbow
Triceps muscle seen in x-section
The Sub-Q nerve is typically
Deep concavity
is Olecranon
a hypoechoic
oval … Fossa
SAX probe proximal
to Olecranon
Tri
Muscle
Tri Ten
SAX
“starry night” internal echoes
adjacent to medial epicondyle
Probe position is SAX
Adjacent
Muscle: Medial
Triceps (MT)
Tri
Tri Ten
Bridging
Muscle
the Ulnar groove.
Capsule
Black Star = Olecranon process
Red Star = Medial Epicondyle
Fat & Synovium
LAT
MED
Hum
Hum
The Elbow
The Elbow
Ulnar Nerve Dynamic Imaging
Ulnar Nerve Short Axis
Subluxing Nerve
MT
Ulnar
Nerve
Med
Epi
Probe position is SAX
Bridging the Ulnar groove.
Olec
The Sub-Q nerve is typically
a hypoechoic oval …
“starry night” internal echoes
adjacent to medial epicondyle
The hypo echoic Ulnar nerve will slide up
and over the adjacent Medial Epicondyle
Adjacent Muscle: Medial Triceps (MT)
The Elbow
The Elbow
Ulnar Nerve Imaging : Longitudinal
Ulnar Nerve X-sectional Area
Proximal to the nerve entering Cubital Tunnel
Radial
Aspect
Ulnar
Nerve
Med
Epi
Accepted “abnormal” x-sectional value is
> 10 mm² proximal to the groove .
Some variability based on individual patient BMI.
Contralateral imaging recommended
Probe position
on posterior aspect of
humerus in LAX
Ulnar
Groove
Ulnar nerve dips between the
Flexor Carpi Ulnaris , and
Flexor Digitorum Profundus
as it goes distally.
Typically, NOT as efficient
as SAX image.
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3/5/2015
Pre-stenotic dilatation of
ulnar nerve using LAX
Thank You !
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