Ultrasound of the Elbow, Wrist, and Hand

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Ultrasound of the Elbow, Disclosures: Wrist, and Hand • Consultant: Bioclinica • Advisory Board: Philips Jon A. Jacobson, M.D. • Book Royalties: Elsevier • Not relevant to this talk 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.

Biceps Brachii Tendon: tendinosis Pathology • Elbow – Biceps and triceps – Epicondylitis Radius – Ligament tears Ulna Medial Approach • Wrist and Hand – Inflammatory arthritis – Tendon and pulley pathology – Gamekeeper’s thumb Dorsal Flexion Pronation Position

Biceps Brachii Tendon: complete tear Biceps Brachii Tendon: complete tear

Proximal biceps stump Long Axis Distal biceps stump

Radial Radial Tuberosity Head Long Axis Short Axis

Normal

1 Biceps Brachii Tendon: Biceps Brachii Tendon: partial tear (short head) complete tear non-retracted

Radius Shadowing Longitudinal: Longitudinal: dynamic imaging Retracted superficial short head (yellow arrows) Kalume Brigido M. Eur Radiol 2009 ; 19:1817 Hypoechoic but intact deep long head (white arrows)

Biceps Tendon Tears: dynamic imaging Triceps Tear: • Muscle injury: contusion – Mixed echogenicity hemorrhage • Distal tendon injury – Usually partial-thickness tear – Superficial aspect of tendon – Avulsion fracture of olecranon Partial Tear Complete Tear

Hematoma: triceps Anatomy of the Distal Triceps Brachii

• Superficial (blue arrow): long + lateral heads • Deep (black arrow): medial head Longitudinal – Primarily muscular insertion *From Resnick, Skeletal Radiol 2009; 38:171

2 Triceps Tendon: Triceps Tear: partial thickness tear partial tear + avulsion • Superficial layer torn Intact deep fibers – Long and lateral heads • Intact deep layer (medial head) • Associated enthesophyte bone fragment Intact deep – 1 – 2 cm in size fibers – 2.5 – 4 cm retraction Humerus – No donor site J Ultrasound Med 2011; 30:1351

Triceps Tendon: partial tear + avulsion Muscle Injury: DOMS • Delayed onset muscle soreness • Type 1 muscle strain • Pain after intense physical activity: – Microtrauma: inflammation and edema Olecranon Intact – Onset: day 1, peak day 2-3, resolves day 7 Bone Medial – Possible increased creatine kinase Fragment Head • Upper extremity: triceps, biceps, brachialis • Muscle enlargement with Increased echogenicity

Longo V et al. J Ultrasound Med 2016; 35:2517 Long Axis (Sagittal Plane)

DOMS: delayed onset muscle soreness Pathology • Elbow – Biceps and triceps – Epicondylitis – Ligament tears • Wrist and Hand H – Inflammatory arthritis Triceps Brachii: Deltoid – Tendon and pulley tear medial head – Gamekeeper’s thumb

3 Epicondylitis: Common Extensor Tendon: elbow • Common flexor and extensor tendons • Often called “tennis elbow” or “lateral • Abnormal hypoechogenicity epicondylitis” or “epicondylosis” or …… • All terms are misnomers – Mucoid degeneration, tendinosis • Those inflicted usually do not play tennis • Anechoic: partial-thickness tear (professionally or correctly) • No inflammatory cells* • It is not inflammatory • It is not a primary problem of the epicondyle Potter, Radiology 1995; 196:43 Connell, AJR 2001; 176:777

Common Extensor Tendon: Common Extensor Tendon tendinosis

Lateral Radial Epicondyle Head Lateral Radial Epicondyle Head

Tendinosis Interstitial Tear

Common Extensor Tendon: epicondylitis Common Extensor Tendinosis + RCL Tear

Radial Head Long Axis Short Axis

Note: normal radial collateral ligament (white arrow)

4 Pathology Collateral Ligament Tear • Elbow – Biceps and triceps • Partial tear: hypoechoic, thickened – Epicondylitis • Complete tear: anechoic fluid tracking – Ligament tears through ligament defect • Wrist and Hand • Dynamic examination: stress – Inflammatory arthritis – Tendon and pulley tear Miller et al. Skeletal Radiol 2004; 33:386 – Gamekeeper’s thumb

Ulnar Collateral Ligament Tear Ulnar Collateral Ligament: partial tear

Long Axis

T1w Coronal T2w Coronal post-gadolinium post-gadolinium Normal

Ulnar Collateral Ligament Ulnar Collateral Ligament: valgus stress • >1 mm asymmetric gapping = 87% accuracy in • Valgus stress: 30 degrees elbow flexion diagnosis of UCL tear – Unlock the olecranon – MR arthrography accuracy = 88% – Stress the UCL anterior band – US + MR arthrography: accuracy = 98% • Gravity stress is adequate, equal to Telos1 • Asymmetric joint space widening with stress: • Ultrasound measurements: – Normal: 1.3 mm or less – Reliable and precise2 – Partial tear: 1.2 – 3.0 mm – Full thickness tear: 2.8 – 4.8 mm 1Harada M et al. J Sho Elb Surg 2014; 23:561 2Bica D et al. J Ultrasound Med 2015; 34:371 Roedl JB et al. Radiology 2016

5 Ulnar Collateral Ligament: laxity Radial Collateral Ligament Complex: injury

R H R Radial Collateral Ligament Annular Ligament

With valgus stress R U

T2w fat sat Lateral Ulnar Collateral Ligament

Pathology Inflammatory Arthritis: role • Elbow • Identify synovitis and erosions – Biceps and triceps – Prior to initiating treatment – Epicondylitis • Determine activity: hyperemia – Ligament tears • Aspirate or inject • Wrist and Hand • Follow-up after therapy – Inflammatory arthritis – Decreased hyperemia and synovial thickness – Lack of synovial thickness improvement at 3 – Tendon and pulley tear months predicts progression* – Gamekeeper’s thumb *Chen YC et al J Clin Rheum 2017; 23:73

Arthritis: synovitis Synovitis: dorsal wrist • Synovial locations: – Joint recess, bursa, tendon sheath • Hypoechoic compared to adjacent Radius subcutaneous fat Lunate Capitate – May be isoechoic or hyperechoic • Hyperemia: variable – Represents activity of inflammation – Decreased: treatment (even NSAIDS) Sagittal Plane: Radiocarpal and Mid-carpal Joints

Backhaus M, Arthritis and Rheum 1999; 42:1232

6 Rheumatoid Arthritis Erosions • US criteria: – Disrupted cortex, two planes – Adjacent synovitis increases specificity 5th PIP 5th PIP • US better than radiographs1 • 29% false-positive rate compared to CT2 • 40% sensivity3

1Lopez-Ben, et al. Skeletal Radiol 2004; 33: 80 2 2nd PIP Finzel S. et al. Arth Rheumatism 2011; 63:1231 3Dohn UF M, Arthritis Res Ther 2006; 8:1

Rheumatoid Arthritis Pseudoerosions

3rd MCP: sagittal Lunate

ECU

2nd MCP 3rd MCP: transverse Ulna

Tenosynovitis: rheumatoid arthritis Pathology • Elbow – Biceps and triceps ECU ECU – Epicondylitis – Ligament tears • Wrist and Hand – Inflammatory arthritis – Tendon and pulley pathology Short Axis Long Axis: color Doppler – Gamekeeper’s thumb

7 De Quervain’s Tenosynovitis de Quervain Tenosynovitis:

• Stenosing tenosynovitis AbPL – Overuse, primary care givers EPB EPB • 1st dorsal wrist compartment: Radius – Extensor pollicis brevis + abductor pollicis longus • Ultrasound findings: Long Axis Short Axis – Thick synovial sheath Axial PDw Axial T2w – Tendinosis – Cortical irregularity, hyperemia

J Ultrasound Med 1997; 16:685

Extensor Pollicis Longus: tear Flexor Carpi Radialis

• Courses volar to triscaphe EPL joint (scapho-trapezium- trapezoid compartment) ECRL • FCR tendinosis and tear ECRB Radius • Associated triscaphe osteoarthritis Long Axis Short Axis Scaphoid Radius Trapezium Parellada et al. Skeletal Radiol 2006; 35:572

Flexor Digitorum Longus Avulsion and Pulley A4 Tear Intersection Syndrome • Distal forearm – 1st wrist compartment tendons (APB/EPL) cross over 2nd wrist compartment tendons (ECRB/L) FDS Middle Phalanx – Swollen, possible edema • Snapping with supination and pronation Long Axis From: AJR 2003; 181:1245

8 Intersection Syndrome Pulley Tear • A2 and A4 pulleys: 1st compartment 2nd most important Long Axis Short Axis • Sagittal image – Bowstringing 1st compartment – Hypoechoic edema / 2nd hemorrhage

Radius • Dynamic evaluation*

*Radiology 2002; 222:755 Radiology 1998; 206:339 Abnormal Normal

A2 – 4 Pulley Injury A4 Pulley Injury: bowstringing

Middle Phalanx Middle Phalanx Proximal Phalanx From: Klauser A et al. Radiology A2 A3 2002;222:755-761 A4 A4

Normal Normal Normal Normal: < 1 mm; incomplete rupture: 1 – 3 mm; complete: 3 mm

Scapholunate Ligament Tear Extrinsic Dorsal Ligament Injury

Triquetrum Lunate Scaphoid

Scapholunate Scaphoid Ligament Lunate Normal

At Rest Clench Fist Dorsal Radiotriquetral Axial Ligament

Normal Diagram from: Theumann Radiology 2003; 226:171

9 Gamekeeper’s Thumb Pathology • Injury of the ulnar collateral ligament (UCL) of the thumb • Elbow – Historically, chronic injury in Scottish gamekeepers – Biceps and triceps – Frequently, due to acute MCP joint hyperabduction – Epicondylitis – Skier’s thumb: up to 86% of thumb base injuries – Ligament tears

• Wrist and Hand Rabbit – Inflammatory arthritis – Tendon and pulley tear

– Gamekeeper’s thumb Mandals Acute Mechanism Chronic Mechanism

Ulnar Collateral Ligament: thumb Ulnar Collateral Ligament: thumb

MC PP

Note: sliding of adductor aponeurosis with isolated NormalSprain Partial Nondisplaced Displaced interphalangeal joint flexion Tear Complete Complete Tear Tear (Stener Lesion) (+ fracture)

Radiographics 2006;26:1007

Stener Lesion: variations UCL: tears

Normal 12

Non-displaced tear 34 Partial-thickness tear Full-thickness tear

Displaced Full-thickness Tears Normal

10 Stener Lesion: dynamic Stener Lesion: • Displaced proximal stump of torn UCL – Hypoechoic & round – Proximal to MCP joint 1st Metacarpal Proximal – At proximal edge of adductor aponeurosis Phalanx • No tissue spanning MCP joint White arrows = adductor aponeurosis • “Yo-yo on a string” sign Yellow arrows = Stener lesion • Ultrasound: 100% accuracy

*Melville D. et al. Skeletal Radiology 2013; 42:667

Normal

Stener Lesion Stener Lesion

Long Axis Long Axis

Normal Normal From: Melville D. et al. Skeletal Radiology 2013; 42:667 From: Melville D. et al. Skeletal Radiology 2013; 42:667

Triangular Fibrocartilage Tear

ECU Triangular Fibrocartilage: Ulna Meniscus Homologue • Normal: hyperechoic, difficult to see

• Abnormal: Triquetrum – Abnormal thinning <2.5 mm*

– Complete absence Lunate – 68% sensitivity, 85% accuracy Radius *J Ultrasound Med 1998; 17:41 Coronal Arthrogram

11 Triangular Fibrocartilage Tear Take-home Points ECU • Epicondylitis: misnomer Ulna H • Inflammatory arthritis: focus on synovitis Triquetrum • Dynamic imaging –Biceps tear Radius –Ulnar collateral ligament –Gamekeeper’s thumb

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