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Tutorial Article Ultrasonographic Examination of the Proximal Tendon of the Biceps Brachii: Technique and Reference Images H

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Tutorial Article Ultrasonographic Examination of the Proximal Tendon of the Biceps Brachii: Technique and Reference Images H EQUINE VETERINARY EDUCATION / AE / June 2008 331 Tutorial Article Ultrasonographic examination of the proximal tendon of the biceps brachii: Technique and reference images H. PASQUET*, V. COUDRY AND J.-M. DENOIX CIRALE – Ecole Nationale Vétérinaire de Maisons-Alfort, 14430 Goustranville, France. Keywords: horse; ultrasonography; biceps brachii; reference images Summary The purpose of this paper is to describe the ultrasonographic technique to image the PTBB completely and Ultrasonography of the shoulder is of interest in the the normal ultrasonographic appearance of this tendon in diagnosis of proximal forelimb lameness. The proximal order to improve the practitioner’s ability to detect lesions and tendon of the biceps brachii (PTBB) and its associated avoid misinterpretation of some anatomic features. structures are frequently injured and should be included in the routine ultrasonographic examination Indications of the shoulder. This paper describes a complete ultrasonographic Ultrasonography of the PTBB is indicated whenever an injury procedure for examining the bicipital apparatus, on of the cranial aspect of the shoulder is suspected because of: transverse and longitudinal scans, from the insertion of the PTBB on the supraglenoid tubercle to the muscle • trauma of the cranial aspect of the shoulder; body below the intertubercular sulcus. • local physical deformation: soft tissue swelling, asymmetry of the point of the shoulders, muscle atrophy; Introduction • forelimb lameness associated with an abnormal response to the mobilisation tests of the shoulder without any Shoulder lameness is often difficult to diagnose and document abnormal findings in the middle and distal parts of the in field practice. Soft tissue injuries have been considered as limb; the most frequent cause of shoulder lameness (Dyson 1986). • negative response to antebrachial and distal nerves Radiographs and diagnostic analgesia are often difficult to diagnostic analgesia; interpret and sometimes do not permit a precise diagnosis. • negative response to intra-articular analgesia performed in Ultrasonography was proven an adequate noninvasive the elbow, carpus and distal limb; technique to examine equine soft tissues in the field (Denoix • positive intra-articular analgesia of the scapulohumeral joint or bicipital bursa; and 1996). Traumatic injuries of the proximal tendon of the biceps • abnormal radiographic and/or scintigraphic findings on the brachii (PTBB) have been described (Dyson 1985; McDiarmid shoulder. 1999) and the use of ultrasonography to diagnose bicipital apparatus injuries has been presented (Hamelin et al. 1994; Anatomical review of the area Denoix et al. 2001). More recently congenital hypoplasia of the minor tubercle of the humerus with medial luxation of the The equine bicipital apparatus is composed of the biceps PTBB has been reported in 4 adult horses (Coudry et al. 2005). brachii muscle, the supraglenoid tubercle of the scapula, the Because of its anatomic location, the PTBB cannot be imaged intertubercular sulcus of the humerus, the bicipital bursa and with the current magnetic resonance imaging equipment. The the proximal tuberosity of the radius (distal attachment of the normal ultrasonographic appearance of the PTBB has been biceps brachii). It contributes to the forelimb passive stay published previously (Crabill et al. 1995; Tnibar et al. 1999) apparatus and assists in forelimb protraction coupling the but little detail on the tendon architecture and echogenicity shoulder and elbow angles (Gyuru and Zajer 1982; was given and the technique to image the tendon on Hermanson and Hurley 1990; Barone 2000). In the horse, the longitudinal scans was not described in detail. biceps brachii is a simple, spindle-shaped muscle with 2 tendonous extremities. The proximal tendon originates on *Author to whom correspondence should be addressed. the supraglenoid tubercle of the scapula. It is very thick and 332 EQUINE VETERINARY EDUCATION / AE / June 2008 fits tightly the intertubercular groove of the humerus, which is and receives the attachment of the most proximal fibres of the covered with fibrocartilage and the bicipital bursa (Fig 1). The ascending pectoral muscle. The muscular body of the biceps cranial aspect of this tendon is covered by the distal brachii contains a high amount of fibrous lamellae from which aponeurosis of the supraspinatus muscle. This structure emanates distally the lacertus fibrosus that attaches over the extends between the medial and lateral supraspinatus tendons radial carpal extensor muscle (Barone 2000). The distal tendon of the biceps brachii is shorter than the proximal and inserts on the radial tuberosity; some fibres end on the medial collateral ligament of the elbow joint. Equipment Ultrasonographic examination of the proximal tendon of the biceps brachii is ideally performed with a 5–7.5 MHz convex probe. However, a 7.5 MHz linear probe can provide adequate diagnostic ultrasonographic images. To improve contact, a stand-off pad can be used. The cranial aspect of the shoulder is clipped, washed with warm water and a coupling gel is applied over the entire point of the shoulder. Technique and reference images The complete ultrasonographic evaluation of the bicipital apparatus is performed on the fully loaded limb in transverse and longitudinal (sagittal and parasagittal) sections. Reference transverse ultrasound scans are presented in the following 4 sites (Fig 1): Site 1 – at the level of the supraglenoid tubercle; Site 2 – between the supraglenoid tubercle and the intertubercular sulcus; Site 3 – at the level of the intertubercular sulcus; and Site 4 – just below the intertubercular sulcus. Transverse sections Fig 1: Lateral view of a left dissected shoulder. S1 = site 1; S2 = site 2; S3 = site 3; S4 = site 4. 1 = neck of scapula; 2 = glenoid cavity; 3 = supraglenoid tubercle; 4 = major humeral tubercle: Site 1 (Fig 2) 4a = convexity (caudal portion), 4b = top (cranial portion), 4c = crest; 5 = humeral body; 6 = biceps brachii: 6a = proximal tendon, The surface of the supraglenoid tubercle appears as a regular, 6b = cranial muscle fibres, 6c = body; 7 = bicipital bursa (open). convex and hyperechogenic line. The PTBB is visualised as a Fig 2: Transverse ultrasound scan (Site 1 on Fig 1) of the Fig 3: Transverse ultrasound scan (Site 2 on Fig 1) of the proximal proximal tendon of the biceps brachii at the level of the tendon of the biceps brachii (see Fig 1 and 6) (cranial is to the top supraglenoid tubercle (see Fig 1) (cranial is to the top and medial and medial is to the left). 1 = scapulohumeral fat pad; is to the left). 1 = supraglenoid tubercle; 2 = proximal tendon of 2 = proximal tendon of the biceps brachii: 2a = medial lobe, the biceps brachii; 3 = supraspinatus muscle: 3a = medial 2b = lateral lobe, 2c = cranial muscle fibres; 3 = supraspinatus tendon, 3b = lateral tendon; 4 = brachiocephalicus muscle; 5 = muscle: 3a = medial tendon, 3b = lateral tendon, skin. Arrows = cranial limit of the supraspinatus muscle. 3c = aponeurosis; 4 = brachiocephalicus muscle; 5 = skin. EQUINE VETERINARY EDUCATION / AE / June 2008 333 crescent-shaped homogeneously echogenic structure. It is body and tendons. The medial supraspinatus tendon is covered by the supraspinatus muscle, which has 2 echogenic echogenic and flat, medially to the PTBB; the lateral intramuscular tendonous branches laterally and medially. supraspinatus tendon is bigger than the medial tendon, echogenic and presents a triangular cross section. Between the Site 2 (Fig 3) PTBB and the shoulder joint lies the scapulohumeral fat pad, which is less echogenic than the tendon. The PTBB is irregularly elliptic in shape. At this level, it contains areas of fat connective tissue inducing a heterogeneous Site 3 (Fig 4) echogenicity. The PTBB divides progressively in 2 homogeneously echogenic lobes. The lateral lobe is thicker The 2 lobes of the PTBB are visualised over the intertubercular and oval; the medial lobe has a C shape. The cranial layer of the sulcus. The bone surface of this sulcus appears as a smooth, PTBB is made of hypoechogenic striated muscle fibres (Fig 1). hyperechogenic and W-shaped line. The PTBB is not The PTBB is completely surrounded by the supraspinatus muscle homogenously echogenic because of the different radii of curvature of the superficial and deep fibre layers over the intertubercular sulcus. Between the tendon and the intertubercular sulcus bone surface, the fibrocartilage appears as a thin interface with little echogenicity. Site 4 (Fig 5) The PTBB merges progressively with the hypoechogenic striated fibres of the muscle body. On transverse sections this junction has an oval shape and a heterogeneous echogenicity. It is separated from the humerus by a poorly echogenic space made of the distal recess of the bicipital bursa and fat. A small amount of fluid can be seen at the caudal and lateral aspect of the PTBB. In normal horses this distal recess never extends to the cranial aspect of the tendon and its width does not exceed 10 mm. Fig 4: Transverse ultrasound scan (Site 3 on Fig 1) of the proximal tendon of the biceps brachii at the level of the intertubercular sulcus (see Fig 1) (cranial is to the top and medial is to the left). 1 = humerus (intertubercular sulcus): 1a = minor tubercle, 1b = intermediate tubercle, 1c = major tubercle, 1d = grooves of the intertubercular sulcus; 2 = proximal tendon of the biceps brachii: 2a = medial lobe, 2b = lateral lobe; 3 = supraspinatus muscle: 3a = supraspinatus aponeurosis;
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