Ultrasound of Common Disclosures: Elbow 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 • Tendon abnormalities • Displaced hyperechoic fat pad by anechoic / hypoechoic fluid • Ligament abnormalities • Best place to look with US* • Nerve abnormalities • More sensitive than radiographs* • Soft tissue 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 Triceps 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 Synovitis: seronegative arthritis Complex Fluid: septic Septic Joint: Coccidiomycosis Synovial Hypertrophy and Erosions RH Capitellum Radial Head Capitellum Longitudinal Sagittal T1w + gado Humerus 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 Bursitis: – 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 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 Biceps 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 Bicipital Aponeurosis 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: Common Extensor Tendon: elbow • Common flexor and extensor tendons • Often called “tennis elbow” 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 Common Flexor Tendon: 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 fascia • Tendon abnormalities – Cubital tunnel 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