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

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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

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

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

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

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

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 Cyst: dorsal Ganglion Cyst vs Dorsal Recess

* Radius * Capitate Lunate SL ligament Sagittal Transverse Recess Ganglion: not compressible Recess: compressible = Dorsal Intercarpal Ligament * Sagittal with Wrist Flexion

Ulnar Collateral Ligament: thumb Gamekeeper’s Thumb: • Injury to ulnar collateral ligament of 1st MCP joint MC PP • Abnormally hypoechoic & thickened • Differentiate partial-thickness or non- Note: sliding of adductor displaced full-thickness tears from aponeurosis with isolated displaced tear (Stener lesion) interphalangeal joint flexion

Gamekeeper’s Thumb Adductor Aponeurosis Stener Lesion:

• Displaced proximal stump of torn UCL – Hypoechoic & round Proximal 1st Metacarpal Phalanx – Proximal to MCP joint – At proximal edge of adductor aponeurosis • No tissue spanning MCP joint Partial tear Non-displaced full-thickness tear + • “Yo-yo on a string” sign fracture *Radiology 1995; 194:65

Normal

15 Stener Lesion: variations Stener Lesion 12 Normal

1st 34 Non-displaced tear Metacarpal Proximal Phalanx

Coronal Coronal T1w Displaced Full-thickness Tears

Stener Lesion: dynamic Stener Lesion: dynamic

Proximal Phalanx 1st Metacarpal 1st Proximal Metacarpal Phalanx

White arrows = adductor aponeurosis Yellow arrows = Stener lesion White arrows = abductor aponeurosis Yellow arrows = Stener lesion Normal Normal

Extensor Digitorum Brevis Manus Extensor Digitorum Brevis Manus • Anatomic variant: 2-3% of population – Bilateral: 54%; males > females • Clinical: painful dorsal wrist mass MC2 MC3 – Those who perform repetitive movements MC2 • Ultrasound: – Muscle: dorsal wrist to extensor hood 2nd or 3rd digits Transverse Longitudinal – Dynamic: changes shape with finger extension

AJR 2003; 181:1224

16 Dynamic Imaging: summary • Dynamic pathologic conditions – Limited number – Involve specific structures • Consider ultrasound for any snapping or painful dynamic situation

See www.jacobsonmskus.com for syllabus and other educational material