Disclosures: Biceps and Triceps Brachii • Consultant: BioClinica • Advisory Board: GE, Philips Jon A. Jacobson, M.D. • Book Royalties: Elsevier Ann Arbor, Michigan Note: all images from the textbook Fundamentals of Musculoskeletal Ultrasound are copyrighted by Elsevier Inc. Anatomy: biceps brachii Biceps Brachii: • Insertion: radial tuberosity – 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: elbow flexed Note: toggling the • Dorsal: flexed pronated view transducer, which creates anisotropy allows visualization of two tendon heads Courtesy of M. Chiavaras, Hamilton, Ontario Biceps Brachii Tendon: distal Biceps Brachii Tendon: technique Short head Long head Radial Tuberosity Medial Approach + Dynamic Imaging Long Axis Smith J et al. J Ultrasound 1 = long head Tagliafico A., et.al. Eur Radiol 2010 Med 2010; 29:861 2 = short head Biceps Brachii Tendon: lateral approach Tendon Abnormalities: • Tendinosis: hypoechoic, swollen • Partial-thickness tear: anechoic focus, no retraction • Full-thickness tear: discontinuity – Dynamic imaging: retraction Long Axis: dynamic imaging Kalume Brigido M. Eur Radiol 2009 ; 19:1817 2 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) 3 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: short head tear Brachii: tear of short short head head tear White arrows = intact long head Yellow arrows = tear of short head White arrows = intact long head 4 Biceps Brachii: short head tear Biceps Brachii Tendon: repaired RH Brachialis Anterior Lateral Pitfall: retracted short head tear is not in view from medial approach when viewing long head (white arrows) Bicipital Aponeurosis Injury Bicipitoradial Bursa: • Surrounds distal biceps BT BT Pronator – Does not communicate to elbow joint Teres – No distal biceps tendon sheath Brachialis • If distended: – Mechanical, inflammatory – Average: 1.8 – 2.5 cm in size Biceps: long axis Biceps: short axis – May displace deep branch of radial nerve Skaf AY, Radiology 1999; 212:111 Bicipitoradial Bursitis Bicipitoradial Bursitis BT Long Axis to Sagittal T2w Short Axis to Axial T2w Biceps Biceps 5 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 Anatomy of the Distal Triceps Tendon Anatomy of the Distal Triceps Brachii TRICEPS TENDON TRICEPS MUSCLE OLECRANON OLECRANON FOSSA • Superficial (blue arrow): long + lateral heads • Deep (black arrow): medial head • 3 heads: long, lateral, medial – Primarily muscular insertion • Inserts as common tendon on olecranon *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 6 Triceps Tendon: partial tear + avulsion Triceps Tendon: partial tear + avulsion Olecranon Intact Bone Medial Fragment Head Long Axis (Sagittal Plane) Long Axis (Sagittal Plane) Ankylosing Spondylitis Muscle Injury: DOMS • Delayed onset muscle soreness • Type 1 muscle strain • Pain after intense physical activity: – Microtrauma: inflammation and edema Medial Epicondyle – Onset: day 1, peak day 2-3, resolves day 7 – Possible increased creatine kinase • Upper extremity: triceps, biceps, brachialis Long Axis • Muscle enlargement with Increased echogenicity Longo V et al. J Ultrasound Med 2016; 35:2517 DOMS: delayed onset muscle soreness DOMS: delayed onset muscle soreness Short Axis Contralateral H Triceps Brachii: Deltoid medial head Long Axis Contralateral 7 Take-home Points: Thank you! • Biceps brachii: – Anatomy explains partial-thickness tears See www.jacobsonmskus.com for – Multiple scanning techniques my syllabus material and other educational musculoskeletal – Dynamic imaging ultrasound material • Triceps brachii: – Anatomy explains partial-thickness tears Follow on twitter: – Avulsed enthesophyte pitfall @jjacobsn 8.