Disclosures: and Pathology • 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.

Anatomy: biceps brachii Biceps Brachii: • Insertion: – Short head: superficial, distal – Long head; deep, proximal • No synovial sheath • Bicipitoradial bursa

From: Eames M. et.al. J Bone Joint Surg 2007:89:1044

From: University of Minnesota WebAnatomy

Biceps Brachii: long (1), short (2) heads Biceps Brachii: Terminal Bifurcation

Note: long head (1) courses lateral to medial, deep to short head (2)

From: Tagliafico A., et.al. Note: endotenon septum (asterisk and arrows) Eur Radiol 2010; 20:202 From: Blasi M., et.al. Surg Radiol Anat 2014; 36:17

1 Biceps Brachii: terminal bifurcation

A A Ultrasound Examination: Brachialis

Brachialis • Anterior: sagittal plane Trochlea • Medial: oblique coronal plane

Transverse Lateral Transverse Medial Lateral Medial • Lateral: flexed

Note: toggling the • Dorsal: flexion pronation transducer, which creates anisotropy allows visualization of two heads

Courtesy of M. Chiavaras, Hamilton, Ontario

Biceps Brachii Tendon: distal Biceps Tendon Short head • Medial approach • “Pronator window” • Transducer: – Distal aspect over Long medial epicondyle Pronator Teres head Radial Tuberosity – Parallel to – Slide transducer anterior Long Axis Rad Smith J. et al. J Ultrasound Med 1 = long head Tagliafico A., et.al. Eur Radiol 2010 2010; 29:861 2 = short head

Biceps Brachii Tendon: Biceps Tendon Supination lateral approach • Flexion, pronation view • Transverse: between radius and ulna • Radial tuberosity rotated Radius Radial into view Tuberosity • Limited diagnostic value Pronation • Ideal biceps tendon injection Ulna

Long Axis: dynamic imaging Kalume Brigido M. Eur Radiol 2009 ; 19:1817

2 Biceps Brachii Tendon: tendinosis Tendon Abnormalities: • Tendinosis: hypoechoic, swollen • Partial-thickness tear: anechoic focus, no retraction • Full-thickness tear: – Discontinuity: within1 -2 cm from tuberosity – Variable retraction – Dynamic imaging: retraction Anterior Approach Medial Approach

Belli, J Ultrasound Med 2001; 20:587

Biceps Brachii Tendon: tendinosis Biceps Brachii Tendon: tendinosis

Radius Ulna Medial Approach

Medial Approach Dorsal Flexion Pronation Position

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

Long Axis Short Axis Proximal biceps stump Long Axis Distal biceps stump

Normal Extended Field of View RT

3 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

Lacertus Fibrosus: normal Biceps Brachii Tendon: non-retracted tear

Lateral Medial

Lateral Pronator Medial Teres Biceps Tear Transverse

Transverse Pronator Teres Intact Bicipital or Long Axis Lacertus Fibrosus (white arrows)

Biceps Brachii Tendon: partial tear (short head) Biceps Brachii Tears: • Diagnosis of full-thickness tear versus partial-thickness tear: – 95% sensitivity – 71% specificity

– 91% accuracy Radius • Shadowing: important indirect sign of Shadowing tendon retraction Longitudinal: Retracted superficial short head (yellow arrows) da Gama Lobo et al., Am J Roentgenol 2013; 200:158 Hypoechoic but intact deep long head (white arrows)

4 Biceps Tendon Tears: dynamic imaging Biceps Brachii: short head tear

Partial Tear Complete Tear Yellow arrows = short head White arrows = fluid around long head

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

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

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

Pitfall: retracted short head tear is not in view Yellow arrows = tear of short head from medial approach when viewing long White arrows = intact long head head (white arrows)

5 Biceps Brachii Tendon: repaired Injury

BT BT Pronator RH Teres

Brachialis Brachialis

Anterior Lateral Biceps: long axis Biceps: short axis

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 Long Axis to Sagittal T2w Skaf AY, Radiology 1999; 212:111 Biceps

Bicipitoradial Bursitis Bicipitoradial Bursitis

BT

BT

Short Axis to Axial T2w Biceps

6 Bicipitoradial Bursitis: Triceps Tear: Compression BT • Muscle injury: contusion Axial T2w – Mixed echogenicity hemorrhage Transverse • Distal tendon injury – Usually partial-thickness tear – Superficial aspect of tendon – Avulsion fracture of

Sagittal

Triceps: long head tear Anatomy of the Distal Triceps Brachii

• Superficial (blue arrow): long + lateral heads • Deep (black arrow): medial head – Primarily muscular insertion

Longitudinal *From Resnick, Skeletal Radiol 2009; 38:171

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

7 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

DOMS: delayed onset muscle soreness Injury: Pronator Teres

Short Axis Contralateral

Short Axis Long Axis

Long Axis Contralateral

8 Take-home Points: • Biceps brachii: – 4 different scanning techniques – Anatomy explains partial tears – Dynamic: partial versus full-thickness tear • Triceps brachii: – Anatomy explains partial-thickness tears Syllabus on line and other educational material: – Don’t forget about medial head attachment www.jacobsonmskus.com Twitter handle: @jjacobsn

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