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Normal and injured elbow: A pictorial review of MRI findings
Poster No.:
C-2227
Congress:
ECR 2010
Type:
Educational Exhibit
Topic:
Musculoskeletal
Authors:
C. H. Kim, M. H. Lee, E. C. Chung; Seoul/KR
Keywords:
elbow joint, MR imaging, anatomy and injury
DOI:
10.1594/ecr2010/C-2227
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Learning objectives
To review the MR imaging of the elbow which includes the complex anatomy, normal
variants of this joint with schematic illustrations, as well as commonly encountered
traumatic and overuse injuries.
Background
The elbow joint has complex constituents which are three components of the
humeroradial, humeroulnar and proximal radioulnar articulations with surrounding soft
tissue structures. It is one of the commonly injured joints. Injuries of the elbow can occur
from acute trauma or chronic overuse of the joint. MR imaging is the best diagnostic
modality for evaluation of this complex joint, particularly of soft tissue constraints.
Imaging findings OR Procedure details
ANATOMY
Osseous structures
The elbow is composed of the ulnohumeral, radiocapitellar, and proximal radioulnar joints
(Fig. 1). This allows the elbow two degrees of freedom: flexion-extension and pronationsupination. The most important bony stabilizer in extension is the articulation between
the trochlea and the sigmoid notch of the olecranon. Osseous stability is enhanced in
extension when the tip of the olecranon rotates into the olecranon fossa, and in flexion
when the coronoid process locks into the coronoid fossa of the distal humerus and the
radial head is contained in the radial fossa of the distal humerus.
There are several commonly encountered ''pseudolesions'' on MR imaging of the elbow
by normal anatomic variants. The olecranon and the coracoid process form the trochlear
groove which is divided by a nonarticulated ridge. These groove and ridge may cause
a misinterpretation on MR imaging of the elbow: pseudodefect of the trochlear groove,
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transverse trochlear ridge, pseudodefect of the capitellum (Fig. 2 A-D). A prominent
synovial fold also may simulate intraarticular disease (Fig. 2 E).
Ligamentous structures
- Medial (Ulnar) Collateral Ligament Complex
The medial collateral ligament (MCL) complex consists of three parts: the anterior,
posterior, and transverse or oblique bundles (Fig. 3). The anterior bundle (A-MCL) is the
most discrete and strong structure accounting for the largest component of the medial
collateral ligament complex and is best seen on coronal MR images. The posterior bundle
of the MCL is more a thickening of the posterior capsule rather than a distinct ligament.
The posterior bundle is a secondary stabilizer of the elbow joint against valgus and
internal rotatory stress. The oblique (transverse) ligament runs between the coronoid and
the tip of the olecranon. Because it is believed that the transverse ligament does not
contribute significantly to joint, this one is not routinely evaluated on MR imaging.
- Lateral (Radial) Collateral Ligament Complex
The lateral collateral ligament (LCL) complex consists of four components, including the
lateral ulnar collateral, annular, and radial collateral ligaments (Fig. 4). The lateral ulnar
collateral ligament (LUCL) is one of the primary elbow constraints against varus and
rotatory stress. The annular ligament encircles the radial head and stabilizes the proximal
radioulnar joint. The radial collateral ligament (RCL) inserts into the annular ligament and
stabilizes the radial head.
Although the role of the RCL, LUCL, and annular ligaments in varus stability
remains contentious, the more functionally important part is the proximal section, so
demonstration of the humeral attachment is important in lateral ligament imaging.
Muscular and Tendinous Structures
The musculature of the elbow is divided into medial, lateral, anterior, and posterior
compartments. The common flexor and extensor tendons are responsible for most
musculotendinous pathology of the elbow and are best assessed on coronal MR images.
The medial muscle group includes the pronator teres and the four superficial flexors: the
flexor carpi radialis, palmaris longus, flexor carpi ulnaris, and flexor digitorum superficialis.
These muscles function to flex the wrist and pronate the forearm (Fig. 5 B, C-E).
The lateral muscle group consists of three components: the superficial group, the
common extensors, and the supinator muscle. The common extensor group is composed
of the extensor carpi radialis brevis, extensor carpi ulnaris, extensor digitorum and
extensor digiti minimi. These muscles arise from the lateral epicondyle by way of the
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common extensor tendon (Fig. 5 A, C-E). The extensor carpi radialis brevis is the most
frequently involved tendon in common extensor pathology.
The anterior compartment is comprised of the brachialis and biceps muscles, which flex
the elbow (Fig. 6 A, C-E). The bicipitoradial bursa separates the distal biceps tendon from
the anterior aspect of the radial tuberosity. The distal biceps tendon and the brachialis
tendon is best evaluated on axial images or on the flexed abducted supinated (FABS)
view.
The posterior compartment is composed of the triceps, anconeus, and variably present
anconeus epitrochlearis muscles (Fig. 6 B, C-E). The medial, lateral, and long heads
of triceps blend to form a single musculotendinous unit that inserts into the tip of the
olecranon and is separated from the olecranon by the deep olecranon bursa. The triceps
tendon is best assessed on sagittal MR images.
Nerves Around the Elbow
At the elbow, the ulnar nerve runs within the cubital tunnel, where it lies in the posterior
aspect of the medial epicondyle, then passes between the humeral and ulnar heads of
flexor carpi ulnaris to enter the anterior compartment of the forearm.
The radial nerve travels along the lateral aspect of the elbow joint, and divides into
its motor branch, the posterior interosseous nerve (PIN), and its sensory branch, the
superficial radial nerve at the level of the radiocapitellar joint. The PIN passes inferiorly
within the radial tunnel between the two heads of supinator to the posterior forearm.
The median nerve passes anterior to the elbow joint and lies medial to the biceps tendon
and brachial artery. It enters the forearm between the two heads of pronator teres.
OSTEOCHONDRAL INJURIES
Osteochondritis Dissecans of the Capitellum
Osteochondral abnormalities most commonly occur at the capitellum impacts on the
radius, which are Osteochondrosis (Panner's disease) and osteochondritis dissecans.
Osteochondrosis (Panner's disease) is characterized by irregularity and fragmentation
of the capitellar epiphysis in adolescents, with subsequent remodeling with conservative
management.
Osteochondritis dissecans is a more focal abnormality, classically involves the anterior
aspect of the capitellum, consisting of a separated osteochondral articular fragment that
may separate from the native bone. Both are probably represent different stages of the
same process, seen in different age groups. These entities usually occur in men between
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the ages of 12 and 15 years when the capitellar epiphysis is almost completely ossified.
Most patients have a history of repetitive overuse of the elbow, such as baseball players
or gymnasts. Initially, excessive valgus stresses to the elbow cause a subchondral
bony infarction with preservation of articular cartilage. Continued microtrauma cause
bony necrosis and softening, resulting in separation of articular cartilage and secondary
chondral injury. More progressive and severe conditions show osteoarthritis, intraarticular
loose bodies, and locking.
Sagittal MR images tend to show flattening of the anterior capitellum or irregularities of
the radial head and T2-weighted or STIR images may show the extent of subchondral
necrosis (Fig. 7). This pattern of injury should not be confused with the ''pseudodefect''
of the capitellum.
LIGAMENTOUS INJURIES AND INSTABILITY
Medial Collateral Ligament Injury and Medial Elbow Instability
The MCL is the primary stabilizer against valgus stress and the most commonly injured
ligament in the elbow. MCL tears may occur after acute valgus stress or dislocation.
More commonly, however, MCL injury is due to repetitive valgus overload that results
in microtrauma to the ligament by the act of throwing in baseball or tennis players.
Continued overuse may lead to weakening and laxity of the ligament and eventually to
complete ligamentous detachment or rupture. The anterior bundle and the humeral and
ulnar insertions of the MCL are poorly visualized at arthroscopy, further emphasizing the
important role of MR imaging in diagnosing ligament injury.
Acute injury to the A-MCL most commonly involves the humeral insertion with an avulsion
fracture of the medial epicondyle. An acute tear is seen as high-signal intensity and
discontinuity of ligamentous fibers. In the case of complete rupture, total discontinuity
of fibers with or without ligamentous retraction occurs (Fig. 8). A partial-thickness
undersurface tear of the A-MCL with avulsion of the ulnar attachment of the deep fibers
has been described as a T sign on MR or CT arthrography, because of tracking of fluid
beneath the deep portion of the A-MCL.
In chronic injury, diffuse increase in signal intensity and thickening of the ligament may
occur from micro tears and remodeling. Concomitant flexor tendinopathy is common.
Lateral Collateral Ligament Injury and Posterolateral Rotatory Instability
LCL is the primary stabilizer of the elbow against varus stress. LCL injury is important
in the development of posterolateral rotatory instability (PLRI) (Fig. 9). This condition
usually follows an elbow dislocation in young patients, but in older patients the LUCL can
be torn by a varus hyperextension stress without dislocation, such as after a fall upon
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an outstretched hand with the forearm supinated, with a resultant axial and valgus load
causing injury to the LUCL.
TENDON INJURIES
Lateral Epicondylitis
Lateral epicondylitis is a tendinosis of the common extensor origin, associated with
repetitive and excessive use of the wrist extensor muscles. Although commonly known
as "tennis elbow" because of the high prevalence in tennis players, lateral epicondylitis
also is commonly seen in golfers, carpenters, and in other workers whose job require
repetitive rotatory motions of the forearm.
The role of MRI is to exclude other causes of lateral elbow pain and to establish the
therapeutic plan. On T2 weighted images, the common extensor tendon is thickened and
showed high signal intensity at its insertion on the lateral epicondyle (Fig. 10). These
changes involve the extensor carpi radialis brevis (ECRB) tendon in nearly all cases.
Dystrophic calcifications may arise adjacent to the lateral epicondyle. Most patients who
have moderate to severe lateral epicondylitis show partial- or fullthickness tears of the
LUCL. Although osseous changes are rare, avulsion injury may occur.
Medial Epicondylitis
Medial epicondylitis is a tendinosis of the common flexor tendon origin. It is much less
common than lateral epicondylitis. It is almost exclusively seen in athletes, such as
golfers, tennis players, swimmers, pitchers, and javelin throwers who perform repetitive
activities causing valgus and flexion forces to the elbow. MR imaging may diagnose
the medial epicondylitis and assess for associated MCL injury. MRI shows thickening
and increased signal intensity at the origin of the common flexor tendon (Fig. 11). The
origins of the flexor carpi radialis and pronator teres are most commonly involved. Ulnar
neuropathy is commonly associated.
Biceps Tendinopathy and Biceps Tendon Injuries
The distal biceps tendinopathy is usually caused by forced muscular flexion against
strong resistance, such as weightlifting. The tendon shows increased signal intensity
with or without tendon tear. Associated bicipitoradial bursa distension may compress the
radial nerve.
Rupture of the distal biceps tendon is rare and it is the result of a sudden extension force to
the arm with the elbow in mid flexion. The findings of an empty distal tendon sheath filled
with high-signal-intensity fluid, of tendon retraction are suggestive of complete tendon
rupture (Fig. 12). Partial tears show hypersignal intensity within an abnormally thick or
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thin biceps tendon, but no tendinous discontinuity. Secondary findings of tendon rupture
including bone marrow edema of the radial tuberosity, soft tissue edema in the antecubital
fossa and fluid in the bicipitoradial bursa may be present.
Triceps Tendinopathy and Triceps Rupture
Triceps tendinosis is an uncommon, but may be seen in sports that involve rapid or
forceful extension of the triceps, such as javelin throwing, baseball, bench pressing, and
gymnastics. Abnormal signal intensity presents at the insertion of the triceps tendon,
with or without thickening of the tendon. Other chronic posterior elbow disorders, such
as stress reaction of the olecranon process, olecranon osteophytes, loose bodies, and
olecranon bursitis may be recognized.
Triceps tendon rupture is a rare, but usually occurs at the insertion site. Partial ruptures
are characterized by a small fluid-filled defect within the distal triceps tendon. Complete
rupture shows a large fluid-filled gap between the distal triceps tendon and the olecranon
process, with variable tendon retraction (Fig. 13).
NEUROPATHIES
Ulnar Nerve and Cubital Tunnel Syndrome
The ulnar nerve may be injured by fibrous entrapment, compression, or subluxation of
the nerve. Ulnar neuropathy can occur as an isolated problem or as the result of other
medial elbow disorder including MCL injury, medial epicondylitis, and flexor-pronator
strain. Cubital tunnel syndrome which is defined as compression of the ulnar nerve at the
elbow is due to various casuses, such as cubitus valgus deformity, synovitis, osteophytes,
hematoma results from MCL rupture, ganglia, loose bodies, muscle hypertrophy, or
thickened retinaculum (Fig. 14).
Radial Nerve and Radial Tunnel Syndrome
Compression of the radial nerve has been referred to as radial tunnel syndrome (Fig. 15).
Because this condition frequently has been misdiagnosed and unsuccessfully treated
for lateral epicondylitis, it is also called as "resistant tennis elbow". It is mostly seen in
activities requiring repetitive rotation of the forearm. Radial tunnel syndrome may be
caused by radial head subluxation or a Monteggia fracture, synovitis, or thickening of the
anterior capsule, and compression by the branches of the radial recurrent artery, or by
space occupying lesions such as ganglia.
Compression of the posterior interosseous nerve (PIN) a different clinical entity from
radial tunnel syndrome in that muscle weakness accompanies the former (Fig. 16). The
posterior interosseous nerve is compressed under a fibrous band known as the arcade
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of Frohse at the proximal edge of the supinator muscle. It is referred to as deep radial
nerve syndrome or supinator syndrome.
Median Nerve and Pronator Syndrome
Pronator syndrome is caused by entrapment of the median nerve at the elbow. It is usually
associated with sports that involve repetitive pronation and supination of the forearm.
Compression of the median nerve can occur at multiple sites by one of several different
anatomic structures. Most commonly median nerve compressed by a fibrous band which
runs between the superficial and deep heads of the pronator teres muscle.
SYNOVIAL INFLAMMATION
Bursa is a small fluid filled sac lined by synovial membrane.
The bicipitoradial bursa is placed at the distal insertion of the biceps tendon in the cubital
fossa. The bursa reduces friction between the biceps tendon and the tuberosity of the
radius. When inflamed, bicipitoradial bursa shows distension and produces symptoms,
such as mass in the cubital fossa, and neurologic symptoms by nerve compression. It is
a rare condition, but mostly results from repetitive mechanical trauma (Fig. 17).
The olecranon bursa is located superficial to the olecranon process between the ulna
and the overlying skin. The olecranon bursa helps that the skin can slide over the
olecranon process without friction. Because it is located superficially, the olecranon bursa
is vulnerable to inflammation. It is presented as demarcated painful swelling over the
olecranon process (Fig. 18).
Images for this section:
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Fig. 1: Schema of normal elbow joint The elbow joint consists of the ulnohemeral joint
(arrow), the radiocapitellar (dashed arrow) joint and the proximal radioulnar joint (dashed
circle).
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Fig. 2: Normal variations of the elbow mimicking a disease. A. On T2-weighted sagittal
MR image, pseudodefect of the trochlear groove (arrow) is seen as small, midline, cortical
interruptions of the surface of the trochlear groove, simulating a cartilage defect. B.
T2-weighted sagittal MR image shows transverse trochlear ridge (arrow) dividing the
trochlear groove into the olecranon and coronoid process. This can mimic intraarticular
osteophyte or healed ulnar fracture. C, D. T2-weighted coronal, sagittal MR images
demonstrate pseudodefect of the capitellum (arrow). The junction between the smooth
capitellum and the rough, nonarticular surface of the lateral epicondyle is abrupt and
is accentuated with a trough-like undermining. The lateral capitellar margins overhang
this trough. Thus, the capitellar overhanging edge with its groove beneath appears as a
defect or notch. E. STIR coronal MR image shows lateral synovial fringe (arrow), which
is a particular plica located between the capitellium and radial head.
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Fig. 3: Normal anatomy of medial collateral ligament complex A. 3- dimensional schema
demonstrates medial collateral ligament complex, composed of anterior (dashed arrow),
posterior (arrow), and oblique (transverse, arrow head) bands. B. On T1-weighted coronal
MR image, anterior band of medial collateral ligament is identified.
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Fig. 4: Normal anatomy of lateral collateral ligament complex A-D. 3- dimensional
schema (A) and T1-weighted coronal (B, C), axial (D) MR images demonstrate four
components of lateral collateral ligament (LCL) complex, which are the lateral ulnar
collateral (arrow heads), annular (dotted arrow), and radial collateral ligaments (arrow).
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Fig. 5: 3- dimensional schema and T1-weighted coronal and axial MR images of
normal elbow. A, C-E. The lateral muscle compartment includes four superficial extensor
muscles in the forearm (extensor carpi ulnaris, extensor digiti minimi, extensor digitorum,
and extensor carpi radialis brevis) which share a common tendinous attachment to the
lateral epicondyle of the humerus. Extension of all joints crossed by the tendons. Extensor
carpi radialis longus (ECRL), Extensor carpi radialis brevis (ECRB), Extensor digitorum
(ED), Extensor carpi ulnaris (ECU). B, C-E. The medial muscle compartment includes the
pronator teres and the four superficial flexors: the flexor carpi radialis, palmaris longus,
flexor carpi ulnaris, and flexor digitorum superficialis. Flexor digitorum superficialis (FDS),
Flexor carpi ulnaris (FCU), Pronator teres (PT), Flexor carpi radialis (FCR).
Page 13 of 29
Fig. 6: Normal anatomy of the elbow A. 3- dimensional schema demonstrates the
anterior muscle compartment, comprised of the brachialis (asterisk) and biceps muscles
(tendon, arrow), which flex the elbow. B. 3-dimensional schema shows the posterior
muscle compartment, composed of the triceps, anconeus, and variably present anconeus
epitrochlearis muscles. Tendon of triceps brachii is a powerful extensor of the elbow.
The olecranon bursa lies between the olecranon and skin. C-E. T1-weighted sagittal and
axial images show brachialis (asterisk), tendon of biceps muscles (arrow) and tendon of
triceps brachii (arrowhead).
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Fig. 7: Osteochondritis dissecans in a 14-year-old girl. She is an elite table tennis
player with pain of the right elbow. Coronal T1-weighted images show an irregular
subchondral bony lesion (A, arrow) with thin sclerotic rim in the anterolateral aspect of
the capitellium. On fat suppressed T2-weighted images, thin hypersignal rim is seen
between the seperated osteochondral fragment and parent bone. Mild bone marrow
edema around the lesion is accompanied (B). Gd-enhanced fat suppressed T1 coronal
and sagittal images show enhancement of the lesion (C, D).
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Fig. 8: Medial collateral ligament tear. STIR coronal MR images revealed discontinuity
with focal hypersignal intensity at the humeral attachment site of medial collateral
ligament (arrow). Lateral collateral ligament (arrowheads) are intact.
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Fig. 9: A 40-year-old man complained the elbow instability on hyperextension and varus
stress after trauma. A, B. Proton density-weighted coronal MR images of right elbow
show non-visualization of radial collateral ligament with widening of radio-capitellar joint
space, indicating a complete tear. A small intraarticular body is seen. Medial collateral
ligament (arrowheads) are intact. C. On STIR coronal MR image, bone marrow edema
is prominent in the radial head and lateral epicondyle of the humerus.
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Fig. 10: Lateral epicondylitis. A 52-year-old woman who had a chronic left elbow pain. Fat
suppressed proton density-weighted coronal images revealed focal irregular hypersignal
intensity lesion in the humeral attachment site of common extensor tendon (arrow).
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Fig. 11: Medial epicondylitis in a 55-year-old woman with chronic left elbow pain.
Gd-enhanced axial and coronal images show ill-defined enhancement at the humeral
epicondyle insertion site of common flexor tendon (arrow) .
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Fig. 12: Rupture of distal biceps tendon. Non-visualization of distal tendon with tendon
retraction on T1-weighted sagittal and axial images (between the two pink lines in A),
suggesting complete rupture of the distal biceps tendon.
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Fig. 13: Triceps tendon rupture in a 52-year-old man presented posterior elbow pain. Gdenhanced fat saturated T1 sagittal images demonstrate discontinuity of triceps tendon at
the olecranon insertion site and bone marrow edema with a possible small bony avulsion
of the olecranon.
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Fig. 14: Ulnar neuropathy in a 38-year-old man presented numbness on the left 4th
and 5th fingers. Coronal T2-weighted images show mild swelling and increased signal of
the ulnar nerve (A, arrow). Gd-enhanced coronal and axial T1-weighted images (B, C)
show enhancement of the ulnar nerve is seen. On electromyogram and nerve conduction
studies, ulnar neuropathy at the elbow level was confirmed.
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Fig. 15: Radial neuropathy in a 38-year-old woman who had right wrist weakness.
Axial T2-weighted images show high signal intensity at the brachialis (B), extensor carpi
radialis (ECR), and extensor (Ex) muscles. Images by courtesy of Hong SH, MD.
Fig. 16: Posterior interosseous neuropathy in a 29-year-old man presented right forearm
weakness. T2 and contrast enhanced fat suppressed T1-weighted axial images reveal
abnormal high signal intensity and mild enhancement of supinator (S), and extensor (Ex)
muscles. Accompanied muscle atrophy is also noted. Images by courtesy of Hong SH,
MD.
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Fig. 17: Bicipitoradial bursitis in a 76-year-old woman presented a painful soft tissue
mass in the anterior aspect of the right forearm during 1 month. T2-weighted axial (A) and
Gd-enhanced T1-weighted axial and sagittal images (B, C) show fluid collection (arrow
head) around the biceps tendon (arrow) with rim enhancement. Mild swelling of the biceps
tendon is also noted.
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Fig. 18: Olecranon bursitis in a 37-year-old man with painful swelling of the posterior
elbow. He had a history of soft tissue scratch in the posterior aspect of the elbow 10 days
ago. On T2-weighted axial images and contrast enhanced T1-weighted axial and sagittal
images a loculated fluid collection in the overlying soft tissue of the ulnar olecranon is
seen with rim enhancement. Adjacent soft tissue swelling is associated.
Page 25 of 29
Conclusion
MR imaging of the elbow is a useful and superior modality in evaluation of the elbow
injuries. The accurate diagnosis of the injured elbow is based on a general consideration
of the anatomy and biomechanics of this complex joint. A comprehensive knowledge of
the normal and injured elbow can facilitate an accurate MR imaging diagnosis.
Personal Information
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