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Upper Extremity Dynamic Imaging • Consultant: Bioclinica • Advisory Board: GE, Philips Jon A

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Upper Extremity Dynamic Imaging • Consultant: Bioclinica • Advisory Board: GE, Philips Jon A Musculoskeletal Ultrasound: Disclosures: Upper Extremity Dynamic Imaging • Consultant: Bioclinica • Advisory Board: GE, Philips Jon A. Jacobson, M.D. • Book Royalties: Elsevier 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. Shoulder: Dynamic Imaging: • Biceps brachii tendon dislocation • Shoulder • Impingement • Elbow • Wrist and Hand • Adhesive capsulitis • Acromioclavicular joint subluxation • Paralabral cyst assessment • Intra-articular bone fragment Biceps Tendon Biceps Brachii Tendon: • Subluxation: – Partially perched on lesser tuberosity • Dislocation: * * Lesser – Empty bicipital groove Lesser Tuberosity Tuberosity – Simulates biceps tendon tear – Associated subscapularis tears Farin et al. Radiology 1995; 195:845 Subluxation Dislocation 1 Biceps Tendon: dislocation Biceps Tendon: dislocation * * Humerus Humerus Transverse Axial Obl T2w Longitudinal Sagittal Obl T2w Biceps Tendon: Dislocation into Biceps Tendon: dislocation subscapularis tendon Deltoid Lesser Tuberosity Longitudinal Sagittal Obl PDw Biceps Tendon Dislocation Biceps Tendon Dislocation 2 Rotator Interval Tear • Abnormal hypoechogenicity, SST Impingement Syndrome non-visualization B • Cuff impingement • Abnormal supraspinatus, superior glenohumeral ligament, “Chondral Print Sign” • Subacromial enthesophyte subscapularis or acromioclavicular • Biceps instability joint osteophyte – “Chondral Print Sign”* SST • Associated tendon Supraspinatus – Intracapsular instability B degeneration and tear Case #2: instability Case #3: remote tear Yellow Arrow = coracohumeral ligament *Zappia M et al. Skel Radiol 2016: 45:35 Subacromial-subdeltoid Bursa (blue) Impingement: bursal fluid Supraspinatus Supraspinatus • Abnormal pooling of subacromial-subdeltoid bursal fluid • Lateral acromion1: Subscapularis Infraspinatus – Coronal plane, active arm elevation – Not visible in neutral position, no cuff tear Teres Minor • At coracoid2: – Axial plane, active elevation internal rotation Biceps Long Head 1Farin et al. Radiology 1990; 176:845 2Stallenberg et al. AJR 2006; 187:894 Impingement Test Impingement Syndrome A A 3 Impingement: supraspinatus Subacromial Impingement • Thickened tendon or bursa – Possible snapping of thickened bursa – “Gathering” of bursa: may be asymptomatic1 • Superior movement of humeral head – Possible contact between humerus and acromion2 1Daghir A et al. Skeletal Radiol 2012; 41:1047 2Bureau N et al. AJR 2006; 187:216 Subacromial Impingement: anterior Impingement: supraspinatus Impingement: osseous Joint Effusion: subscapularis recess 4 Adhesive Capsulitis: Adhesive Capsulitis: • Frozen shoulder • Gradual limitation in motion • Supraspinatus tendon does not • Incidence 2 – 5% slide beneath acromion with lateral • Diabetic (insulin dependent): 30% elevation of arm • Associations: female, trauma, >40 years old, • Sensitivity 91%, specificity 100%, diabetes, immobilization, thyroid disease, accuracy 92% stroke, MI, autoimmune disease Ryu et al. J Ultrasound Med 1993; 12:445 Griesser, et al, JBJS 2011; 93:1727 Adhesive Capsulitis Adhesive Capsulitis A Humerus A Humerus Longitudinal Arm Elevation Acromioclavicular Joint: Acromioclavicular Joint: abnormal • Dynamic evaluation: • Dynamic: – Clinical sign “cross-arm” – ACJ narrows > 1 mm – Ipsilateral hand to opposite shoulder: pain – Extruded capsule and disc • Normal: – Osteoarthritis – Maneuver: ACJ narrows <1 mm, no pain • Rest: – Rest: widens back to normal (up to 5 mm) – ACJ widens > 5 mm: trauma 5 AC joint: subluxation Acromioclavicular Joint Clavicle Acromion Axial T2w Osteoarthrosis Prior Trauma Sagittal T2w Posterior Labral Tear and Cyst Paralabral Cysts: • Periarticular shoulder cyst • May cause pain simulating rotator cuff tear L Humerus • Associated with labral tears Tung et al. AJR 2000; 174:1707 Glenoid Axial Axial T1w post-gado Posterior Labral Tear and Cyst Labral Tear and Labral Cyst L Humerus Glenoid Axial Axial T1w post-gado 6 Pitfall: suprascapular vein dilation Snapping Lesser Tuberosity Fragment Elbow: Dynamic Imaging: • Ulnar nerve dislocation • Shoulder • Elbow • Snapping triceps syndrome • Wrist and Hand • Ulnar collateral ligament tear • Posterolateral rotary subluxation • Distal biceps brachii tear Ulnar Nerve Cubital Tunnel Ulnar Nerve Dislocation Anatomy: Medial • Occurs in elbow flexion Olecranon Epicondyle • Space between medial Apex • Reduces in extension epicondyle and • Nerve irritation, predisposes to injury olecranon process • Contains ulnar nerve • Found in 20% asymptomatic volunteers Flexor Tendons Okamoto, J Hand Surg 2000; 25B:85 Axial 7 Technique: ulnar nerve subluxation Ulnar Nerve Dislocation FF Humerus O E O E T Extension Partial Flexion Flexion Transverse Isolated Ulnar Nerve Dislocation Ulnar Nerve Translocation Ulnar Nerve Pronator Medial Teres Epicondyle Medial Epicondyle Apex Medial Epicondyle Pronator Pronator Teres Teres Normal Location Subcutaneous Submuscular Short Axis 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 8 Anconeus Epitrochlearis: Subluxation Snapping Triceps Syndrome • Ulnar nerve and medial triceps dislocate over apex of medial epicondyle • Ulnar nerve and medial triceps remain in contact with each other • Palpable snap felt through transducer Short axis to ulnar nerve (white arrow) Radiology 2001; 220:601 Snapping Triceps Syndrome: dynamic imaging Ligament Evaluation: Anterior Posterior • Abnormal ligament: – Hypoechoic, anechoic • Complete tear (dynamic imaging) – Discontinuity – Joint space widening Transverse Ulnar Collateral Ligament: complete tear Ulnar Collateral Ligament: partial tear Med Epic Ulna Longitudinal Coronal T2w Normal 9 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 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% Symptomatic • Asymmetric joint space widening with stress: 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 10 Biceps Brachii Tendon: complete tear Biceps Brachii: • Tear: – Tendon fiber disruption: hypoechoic – Tendon retraction – Interposed fluid Proximal biceps stump Distal biceps stump • Pitfall: – Partial-thickness vs. full-thickness Longitudinal Miller, AJR 2000; 175:1081 Biceps Brachii Tendon: Biceps Brachii Tendon: complete tear normal Radial Radial Tuberosity Head Longitudinal Transverse Longitudinal: dynamic imaging Eur Radiol Feb 2009 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) 11 Biceps Tendon Tears: dynamic imaging Radial Head: posterolateral rotatory subluxation Partial Tear Complete Tear Lateral Ulnar Collateral Radiocapitellar Joint Ligament Radial Collateral Ligament Complex: injury Dynamic Imaging: R R • Shoulder H • Elbow Radial Collateral Ligament Annular Ligament • Wrist and Hand R U Varus Stress Lateral Ulnar Collateral Ligament Wrist and Hand: Extensor Carpi Ulnaris: • Tendon abnormalities: • 6th extensor wrist compartment –ECU dislocation • Asymptomatic subluxation –Boxer knuckle – Supination –Pulley tear – Up to 50% out of groove – No tear or tenosynovitis –Trigger finger • Ganglion cyst Lee KS et al. AJR 2009; 193:651 • Gamekeeper’s thumb 12 Dislocation: extensor carpi ulnaris Boxer Knuckle: • Damage to the sagittal bands of extensor hood –Transverse orientation • Extensor tendon subluxation or dislocation with finger flexion Lopez-Ben et al. Radiology 2003; 228:642 Short Axis Boxer Knuckle Boxer Knuckle Short Axis Short Axis A2 – 4 Pulley Injury Pulley Tear • A2 and A4 pulleys: most important Middle Phalanx • Sagittal image Proximal Phalanx – Bowstringing A2 A3 A4 – Hypoechoic edema / hemorrhage • Dynamic evaluation* *Radiology 2002; 222:755 Radiology 1998; 206:339 Normal Normal 13 A4 Pulley Injury: bowstringing Trigger Finger: • Stenosing tenosynovitis: A1 pulley • Thick and hypoechoic pulley Middle Phalanx From: Klauser A et al. Radiology • Hyperemia: 91% 2002;222:755-761 A4 • Tendinosis: 48% • Tenosynovitis: 55% Guerini et al. J Ultrasound Med 2008; 27:1407 Normal Trigger Finger Trigger Finger: A1 pulley PP MC MC PP Case #1 Case #2 Long Axis Trigger Finger: thumb Ganglion Cyst: dorsal • 70% are located dorsal • Superficial to scapholunate ligament • Differentiate from dorsal joint recess – ganglion: noncompressible Case #1 Case #2 *Radiology 1994; 193:259 14 Ganglion
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