Download Biceps Brachii

The Elbow
Chane Price PGY-3
Anthony Esposito PGY-4
Course Objectives
 Review function and anatomy of the elbow
 Brief discussion on U/S techniques for the elbow
 Brief discussion of potential pathology of elbow
 Hands on Ultrasound
Elbow Anatomy
 The elbow is a simple, hinge joint that allows flexion,
extension, supination, and pronation of the arm. The joint
is comprised of:
 3 bones (humerus, ulna, and radius)
 3 articulations (trochlea of humerus with the ulna, capitulum
of the humerus with the head of the radius, and pivot-joint
between the head of the radius and the radial notch of the
ulna)
 3 Ligaments (ulnar & radial collateral ligaments, annular
ligament)
 Several muscles that cross the elbow
 Nerves , Veins, Arteries
Muscles of Elbow
 Biceps Brachii: O-Coracoid process and Supragleniod tubercle, I- radial
tuberosity. A: flexion and supination.
 Triceps Brachii: O- Scapula and back surface of the Humerus , IOlecranon process. A: main extensor of the elbow.
 Brachialis: O- lower half of the front of the Humerus, I- coronoid process.
A: strongest elbow flexor when palm is pronated.
 Brachioradialis: O- outer edge of the lower third of the Humerus, I: lower
end of the Radius. A: elbow flexion and aid pronation and supination.
 Pronator Teres: O- above medial epicondyle, I- outer surface of Radius.
A: aid flexion of elbow and pronate the forearm.
 Extensor Carpi Radialis Brevis: O- lateral epicondyle of the humerus, Ithird metacarpal of hand. A: extend wrist and aid extension of elbow.
 Anconeus: O- posterior surface of lateral epicondyle, I- on ulna lateral to
the olecranon. A- controversial, assists in extension of elbow.
Elbow Articulations
Main Ligaments of Elbow
Ligamentous Functions
 Ulnar Collateral Ligament: extends from medial
epicondyle of the humerus to the proximal portion of the
ulna. Prevents excessive abduction of the elbow joint
 Radial Collateral Ligament: extends from lateral
epicondyle of the humerus to the head of the radius.
Prevents excessive adduction of the elbow joint.
 Annular Ligament: encircles the head of the radius, and
retains it in contact with the radial notch of the ulna
Elbow Flexors
Biceps Brachii
Brachialis
Brachioradialis
Pronator Teres
Elbow Extensors
Triceps Brachii
Extensor Carpi
Radialis Brevis
Anconeus
Biceps Brachii
 Origin: Coracoid process
and Supraglenoid
Tubercle
 Insertion: radial
tuberosity
 Action: flexion and
supination of elbow
Biceps Tendon
Brachialis
Origin- lower half of the
front of the humerus
Insertion- coronoid
process.
Action: strongest elbow
flexor when palm is
pronated.
Anterior Joint Recess
Radial Nerve and PIN
Radial Tunnel Syndrome
• Compression of PIN
• Refractory lateral elbow and
forearm pain
• Radial tunnel runs from
radiocapitellar joint to distal edge of
supinator. Bordered medially by
brachialis muscle and biceps
tendon distally. Lateral border is
comprised of ECRL and ECRB
Anterior view of the course of the radial nerve. Note the
position of the deep branch of the radial nerve (posterior
interosseous nerve) as it passes through the arcade of
Frohse at the proximal margin of the superficial head of the
supinator muscle.
Radial Tunnel Syndrome
C. Short axis sonogram of the right posterior interosseous nerve (arrow) just
proximal to the supinator muscle (S) demonstrates swelling, with short axis
dimension 2mm. R = radius.
D. Short axis sonogram of the left posterior interosseous nmuscle (S) performed
for comparison demonstrates normal caliber of the nerve, with erve (arrow) just
proximal to the supinator short axis dimension 1mm. R = radius.
ECRB
 Origin- lateral
epicondyle of the
Humerus,
 Insertion- third
metacarpal of hand.
 Action- extend wrist
and aid extension of
elbow.
Lateral Elbow: common extensor tendon
Lateral Epicondylitis
 “Tennis Elbow”
 Common Extensor
Tendon (ECRB)
 Overuse injury
Lateral epicondylitis with thick hypoechoic tendon insertion on the left
compared to normal longitudinal plane on the right.
 Place the patient in a comfortable, supine position. This aids relaxation and guards
against possible fainting.[1]
 Have the patient flex the affected elbow to 90° with the hand tucked under the buttock.
 Mark the lateral epicondyle and radial head
 Inject the corticosteroid and local anesthetic into the common extensor tendon origin at
the lateral humeral epicondyle.
 Infiltrate the corticosteroid deeply at the tenoperiosteal junction.
 A painful reaction to injection or firm resistance during injection suggests that the needle
is too deep and is within the body of the tendon; withdraw the needle 1/8 inch if this
occurs.
 The needle should move freely with skin traction if the tip is above the tendon; conversely,
the needle sticks in place if the tip is within the body of the tendon.
 Inject the corticosteroid at the tissue plane between the subcutaneous fat and the tendon.
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Common Flexor Tendon
 Pronator Teres
 Flexor Carpi Radialis
 Palmaris Longus
 Flexor Digitorum Superficialis
 Flexor Carpi Ulnaris
Ulnar Collateral Ligament
 extends from medial
epicondyle of the humerus
to the proximal portion of
the ulna.
 Prevents excessive
abduction of the elbow joint
 composed of three bands:
anterior, posterior, and
transverse bands.
Medial Elbow: Common Flexor Tendon and Ulnar
Collateral Ligament
Medial Epicondylitis
Medial epicondylitis with a thickened
hypoechoic common flexor tendon
insertion and intratendinous rupture
Normal tendon longitudinal
Triceps
Origin- Scapula
and back surface
of the humerus
InsertionOlecranon process
Action: main
extensor of the
elbow
Posterior Elbow: Triceps tendon
Triceps Tendonitis/Rupture
• Most commonly occurs due to
repetitive activities placing strain on
the triceps tendon such as pushing
activities or straightening the elbow
against resistance (Weight lifting).
May occur suddenly due to a high
force going through the triceps
tendon beyond what it can withstand
(Fist pump).
Triceps Tendonitis/Rupture
Old triceps rupture with extensive
calcifications
Intact tendon longitudinal
Cubital Tunnel/Ulnar Nerve
Ulnar Nerve Compression
 “Cubital Tunnel
Syndrome”
 Causes: ulnar nerve
instability, direct
pressure, trauma
 second most common
focal peripheral
neuropathy
Ulnar Nerve Compression
Symptomatic focal enlargement of the ulnar nerve (large arrows) compared
with the more normal caliber nerve (small arrows) in the longitudinal plane. If
there is compression, the nerve is generally narrowed at the level of
compression and swollen proximally typically with loss of the normal
fascicular pattern.
Summary
 A complete examination of the elbow will cover
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Biceps tendon
Anterior Joint Recess (Brachialis Tendon)
Radial Nerve/PIN
Lateral Elbow (Lateral Epicondylitis)
Medial Elbow (Medial Epicondylitis)
Triceps
Ulnar nerve/Cubital Tunnel
 Always correlate your U/S findings to the clinical H&P and
tailor your exam accordingly!