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Home , Common extensor tendon, Common flexor tendon, Enthesophyte

Ultrasound of Common Disclosures: Pathology • Consultant: Bioclinica • Advisory Board: GE, 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.

Pathology: Joint Effusion: • Joint effusion and bursa • Olecranon recess • abnormalities • Displaced hyperechoic fat pad by anechoic / hypoechoic fluid • abnormalities • Best place to look with US* • Nerve abnormalities • More sensitive than radiographs* • masses De Maeseneer, Invest Radiology 1998; 33:117

Olecranon Recess: joint effusion Joint Effusion: anterior elbow

Radial Recess Coronoid Recess

Triceps O

Fat Pad Capitellum Radius Trochlea Trochlea Ulna

Sagittal: lateralTransverse Sagittal: medial Sagittal Sagittal T1w

1 Olecranon Recess Complicated Fluid vs. Synovium • Both may appear hypo- or isoechoic Findings that suggest effusion: Fat Pad O • Displacement with transducer pressure Fat Pad O • Joint recess collapse w/ joint movement Trochlea • Negative flow on color Doppler imaging Trochlea • Swirling with transducer pressure : seronegative arthritis Complex Fluid: septic

Septic Joint: Coccidiomycosis Synovial Hypertrophy and Erosions

RH Capitellum

Radial Head

Capitellum

Longitudinal Sagittal T1w + gado

Synovial Chondromatosis Annular Recess

Triceps

Ulna Sagittal T2w Radial Head

Humerus Synovitis Intraarticular Body Sagittal Post-IV gado

2 Intra-articular Body: elbow joint Intraarticular body • Olecranon, coronoid, annular recess • Calcified & ossified bodies:

hyperechoic with shadowing O • Surrounded by joint fluid: intraarticular • Movement during real-time US H H excludes osteophyte

Frankel, Radiology 1998; 206:41

Synovial Fold Syndrome • Normal capsular tissue Olecranon : – Hyperechoic, triangular C R • Abnormal: • Over olecranon – Thickened > 3 mm • Anechoic or hypoechoic – Heterogeneous • Well-defined – Adjacent synovitis • Heterogeneous: Olecranon complicated fluid

Cerezal et al. AJR 2013; 201:W88

Olecranon Bursitis : Gout

Infection Traumatic Transverse

3 Olecranon Bursitis: Gout Olecranon Bursitis: rheumatoid arthritis

T

Sagittal

Sagittal Transverse Note erosion (white arrow) O

Transverse

Olecranon Bursitis: dynamic imaging Pathology: • Joint effusion and bursa • Tendon abnormalities • Ligament abnormalities • Nerve abnormalities • Soft tissue masses

Biceps Brachii Tendon: tendinosis Tendon Abnormalities: • Tendinosis: hypoechoic, swollen • Partial-thickness tear: anechoic focus, no retraction • Full-thickness tear: discontinuity – Dynamic imaging: retraction Anterior Approach Medial Approach

4 Brachii Tendon: tendinosis Biceps Brachii Tendon: complete tear

Radius Ulna Medial Approach Proximal biceps stump Long Axis Distal biceps stump

Dorsal Flexion Pronation Normal Position

Biceps Brachii Tendon: Biceps Brachii Tendon: complete tear complete tear non-retracted

Radial Radial Tuberosity Head Long Axis Short Axis Longitudinal: dynamic imaging Kalume Brigido M. Eur Radiol 2009 ; 19:1817

Biceps Brachii Tendon: non-retracted tear Biceps Brachii Tears: • Diagnosis of full-thickness tear versus Lateral Pronator Medial partial-thickness tear: Teres – 95% sensitivity Biceps Tear – 71% specificity – 91% accuracy • Shadowing: important indirect sign of tendon retraction Transverse Intact or da Gama Lobo et al., Am J Roentgenol 2013; 200:158 Lacertus Fibrosus (white arrows)

5 Biceps Brachii Tendon: partial tear (short head) Biceps Tendon Tears: dynamic imaging

Radius Shadowing Longitudinal: Partial Tear Complete Tear Retracted superficial short head (yellow arrows) Hypoechoic but intact deep long head (white arrows)

Biceps Brachii: short head tear Biceps Brachii: short head tear

Yellow arrows = short head Yellow arrows = tear of short head White arrows = fluid around long head White arrows = intact long head

Biceps Yellow arrows = Biceps Brachii Tendon: repaired Brachii: tear of short short head head tear White arrows = intact long RH head

Brachialis

Anterior Lateral

6 Bicipitoradial Bursa Bicipitoradial Bursitis

• Surrounds distal biceps – Does not communicate to elbow joint – No distal biceps tendon sheath • If distended: – Mechanical, inflammatory – Characteristic “U” shape – Average: 1.8 – 2.5 cm in size – May displace deep branch of radial nerve Long Axis to Sagittal T2w Skaf AY, Radiology 1999; 212:111 Biceps

Bicipitoradial Bursitis Bicipitoradial Bursitis

BT

Long Axis to Biceps: Lateral Approach Short Axis to Axial T2w Biceps

Hematoma: triceps Triceps Tear: • Muscle injury: contusion – Mixed echogenicity hemorrhage • Distal tendon injury – Usually partial-thickness tear – Superficial aspect of tendon – Avulsion fracture of olecranon

Longitudinal

7 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 Ankylosing Spondylitis

Medial Olecranon Intact Epicondyle Bone Medial Fragment Head

Long Axis

Long Axis (Sagittal Plane)

Muscle Injury: DOMS DOMS: delayed onset muscle soreness • Delayed onset muscle soreness • Type 1 muscle strain • Pain after intense physical activity: – Microtrauma: inflammation and edema – Onset: day 1, peak day 2-3, resolves day 7 – Possible increased creatine kinase H • Upper extremity: triceps, biceps, brachialis • Muscle enlargement with Increased echogenicity Triceps Brachii: Deltoid medial head Longo V et al. J Ultrasound Med 2016; 35:2517

8 Epicondylitis: : elbow • Common flexor and extensor • Often called “” 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: epicondylitis Common Extensor Tendon: epicondylitis

Long Axis Short Axis Lateral Radial Epicondyle Head

Patient #1 Patient #2

Note: normal radial collateral ligament (white arrow)

Common Extensor Tendinosis + RCL Tear : tendinosis

Radial Head Medial Epicondyle

Patient #1 Patient #2

9 Pathology: Collateral Ligament Tear • Joint effusion and bursa • Partial tear: hypoechoic, thickened • Tendon abnormalities • Complete tear: anechoic fluid tracking • Ligament abnormalities through ligament defect • Nerve abnormalities • Dynamic examination: stress • Soft tissue masses Miller et al. Skeletal Radiol 2004; 33:386

Ulnar Collateral Ligament Tear Ulnar Collateral

E Ligament: partial tear U

Long Axis

T1w Coronal T2w Coronal post-gadolinium post-gadolinium

Normal

Ulnar Collateral Ligament: partial tear Ulnar Collateral Ligament • Valgus stress: 30 degrees elbow flexion – Unlock the olecranon – Stress the UCL anterior band • Gravity stress is adequate, equal to Telos1 • Ultrasound measurements: – Reliable and precise2

1Harada M et al. J Sho Elb Surg 2014; 23:561 2Bica D et al. J Ultrasound Med 2015; 34:371

10 Ulnar Collateral Ligament: laxity Ulnar Collateral Ligament: valgus stress 2.1 mm 2.0 mm • >1 mm asymmetric gapping = 87% accuracy in diagnosis of UCL tear – MR arthrography accuracy = 88% – US + MR arthrography: accuracy = 98% • Asymmetric joint space widening with stress: Symptomatic Contralateral – Normal: 1.3 mm or less 4.7 mm 3.0 mm – Partial tear: 1.2 – 3.0 mm – Full thickness tear: 2.8 – 4.8 mm

Roedl JB et al. Radiology 2016 With valgus stress With valgus stress

Ulnar Collateral Ligament: laxity Ulnar Collateral Ligament: complete tear

With valgus stress

T2w fat sat

Radial Collateral Ligament Complex: injury Radial Collateral Ligament Tear:

• Abnormal hypoechogenicity R H • Can be difficult to demonstrate R • Lateral ulnar collateral ligament tear or Radial Collateral Ligament Annular Ligament thickening: – Associated with lateral epicondylitis

R Bredella et al. AJR 1999; 173:1379 U Lateral Ulnar Collateral Ligament

11 Pathology: Ulnar Nerve: anatomy • Behind medial epicondyle Ulnar Nerve • Joint effusion and bursa of humerus: Osborn’s • Tendon abnormalities – retinaculum or Arcuate ligament Osborn’s fascia • Ligament abnormalities • Distal to epicondyle: • Nerve abnormalities – True cubital tunnel – Between ulnar and humeral • Soft tissue masses heads: flexor carpi ulnaris – Under arcuate ligament

Martinoli, C. et al. Radiographics 2000;20:S199-S217

Ulnar Nerve: cubital tunnel syndrome Cubital Tunnel Syndrome

• Hypoechoic and enlarged Arcuate Ligament – > 9 mm2 area1 – Ratio greater than 2.8 compared to proximal2 FCUh • Mild hypoechogenicity alone: may be normal FCUu • Causes: – Idiopathic, overuse, joint process – Anconeus epitrochlearis: compression • Normal variant accessory muscle Short Axis Long Axis 1Thoirs K et al. J Ultrasound Med 2008; 27:737 2Yoon JS et al. Muscle Nerve 2008; 38:1231

Anconeus Epitrochlearis Anconeus Epitrochlearis Ulnar Nerve • Normal variant: 34% of population • Roof of cubital tunnel: Olecr – Residual muscle Med Epicond – In absence of normal attrition forming Osborn Short Axis fascia • Secondary ulnar nerve entrapment • Diagnose in elbow extension!

Sem Musculoskel Radiol 2000; 14:814:473 Transverse

12 Technique: ulnar nerve subluxation Ulnar Nerve: dislocation • 20% of asymptomatic volunteers • Dynamic imaging: – Dislocates in anterior to medial epicondyle of humerus in elbow flexion – Reduces in extension (normal MRI) E E O • Transducer pressure may inhibit movement T

Okamoto, J Surg Br 2000; 25:499

Short Axis

Isolated Ulnar Nerve Dislocation Ulnar Nerve Transposition

Ulnar Nerve

Pronator Medial Teres Epicondyle Medial Epicondyle Apex Medial Epicondyle Pronator Pronator Teres Teres Normal Location Subcutaneous Submuscular Short Axis

Snapping Triceps Syndrome: dynamic imaging Snapping Triceps Syndrome • Abnormal condition: Anterior Posterior – Medial head of triceps – Snaps over medial epicondyle of elbow with elbow flexion – Associated with ulnar nerve dislocation

Radiology 2001; 220:601 Transverse

13 Radial Nerve: deep branch Radial tunnel • Supinator syndrome: • Radial nerve: deep branch – Motor deficits (wrist, finger extension) – Originates from radial nerve – Abnormal electrodiagnostic studies between and brachialis – Nerve enlargement: entrapment – Passes between deep and • Radial tunnel syndrome: superficial layers of – Pain, no motor deficits, normal EMG supinator muscle – Muscle denervation on MRI – Exits as posterior – No nerve enlargement interosseous nerve

Ferdinand BD et al. Radiology 2006; 240:161 Jacobson JA. et al. Sem Musculoskel Rad 2010; 14:473

Supinator Syndrome Supinator Syndrome: deep br. radial nv.

Brachioradialis RH Superficial Br. Deep Br. Supinator Abnormal

Radius Humerus

Radial Head Abnormal Normal Transverse Normal

Nerve Transection: radial nerve • Neuroma formation: – Disorganized and tangled nerve end – Normal response to nerve transection – US important to determine if symptomatic

Provost, J Clin Ultrasound 1997; 25:85

14 Humerus Fracture: intact radial nerve Humerus Fracture: radial nerve neuroma

Humerus Humerus Humerus Humerus Transverse Longitudinal Longitudinal Transverse

Ganglion Cyst (elbow): aspiration Pathology: • Joint effusion and bursa • Tendon abnormalities • Ligament abnormalities Lavage • Nerve abnormalities • Soft tissue masses

18-gauge needle Post-aspiration

Epitrochlear Lymph Nodes: hyperplastic Cat scratch disease = infection • Animal scratch: usually a cat – Bartonella henselae • Child or adolescent: T2w – Most common • Elbow: – Lymphadenopathy – Epitrochlear lymph node (medial)

Gado

15 Cat scratch fever = rock album Take-home Points: • Joint: aspirate if concern for infection • Biceps and triceps: – Anatomy explains partial-thickness tears • Nerves: don’t forget to look • Dynamic imaging – Ulnar nerve dislocation, snapping triceps – Ulnar collateral ligament evaluation

Syllabus on line and other educational material: www.jacobsonmskus.com Twitter handle: @jjacobsn

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