Pictorial review of bicipitoradial bursa pathology: our center's experience.

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1 Pictorial review of bicipitoradial bursa pathology: our center's experience. Poster No.: C-2169 Congress: ECR 2014 Type: Educational Exhibit Authors: N. LAUNAY, C. Bourdet, N. Zee, R. Campagna, H. Guerini, E. Pluot, A. Feydy, J.-L. Drapé ; Paris/FR, MONTROUGE/FR, 3 Paris Cedex 14/FR Keywords: Neoplasia, Inflammation, Education, MR-Diffusion/Perfusion, MR, Musculoskeletal soft tissue, Tissue characterisation DOI: /ecr2014/C-2169 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 76

2 Learning objectives To review the bicipitoradial bursa's anatomy. To describe the typical and atypical imaging features of bicipitoradial bursitis from mechanical origin. To discuss and describe the differential diagnosis including non-neoplastic pathologies, benign and malignant tumors. Background The bicipitoradial bursa (BBR) is a rare site of bursitis, which most frequent causes are recurrent microtraumas and overuse. An accurate knowledge of the bicipitoradial bursa's anatomy would help radiologists avoiding interpretative errors. Magnetic resonance imaging plays a key role for differential diagnosis. Findings and procedure details Anatomy: The antecubital fossa contains two bursae, which may occasionnally communicate: the bicipitoradial bursa (BBR) and the interosseous bursa. (figure 1) Page 2 of 76

3 Fig. 1: Normal anatomy of the antecubital fossa in coronal plane References: Skaf AY et al (1999) Bicipito radial bursitis: MR imaging findings in eight patients and anatomic data from contrast material opacification of bursae followed by routine radiography and MR imaging in cadavers.radiology 1999;212: The bicipitoradial bursa, which is located between the distal insertion of the biceps tendon and the radial tuberosity, lies at the anterior aspect of the elbow joint. The biceps tendon at the level of the bursa does not have a tendon sheath. In supination, the BBR wraps around the biceps tendon. In pronation the radial tuberosity rotates posteriorly and the BBR is compressed between the biceps tendon and the radial cortex. (figure 2) Page 3 of 76

4 Fig. 2: Bicipitoradial bursa anatomy in supination and pronation References: Skaf AY et al.(1999) Bicipito radial bursitis: MR imaging findings in eight patients and anatomic data from contrast material opacification of bursae followed by routine radiography and MR imaging in cadavers. Radiology 1999;212: Histology: The BBR contains a synovial lining. The synovial membrane lines the internal face of diarthrodial joints as well as tendon sheath and bursae. (Figure 3) Page 4 of 76

5 Fig. 3: Synovial membrane. References: Cumming B. Pearson Education The synovium has usually two layers (Figure 4) : Page 5 of 76

6 the outer layer mainly composed of adipocytic tissue, fibrous tissue and blood vessels. the inner layer consisting of sheets of synoviocytes. There are two types of synoviocytes: macrophagic synoviocytes (type A synoviocytes) fibroblast-like synoviocytes (type B cells) Fig. 4: Synovial membrane histology. S: synoviocytes T conj: fibrous tissue C: blood vessels References: Ea HK et al. Histologie et physiologie de la membrane synoviale. Appareil locomoteur. Traité EMC Pathologies: Page 6 of 76

7 Fig. 5: Bicipitoradial bursa pathologies. References: PARIS, Cochin hospital - Paris/FR Mecanical bicipitoradial bursitis: Inflammation of the bicipitoradial bursa is a rare condition. Clinically, bicipitoradial bursitis (Figures 6, 7, 8, 9 and 10) often presents as a painful palpable mass of the proximal forearm and can impair elbow motion. With pronation, the radial tuberosity rotates posteriorly and compresses the BBR between the biceps tendon and the radial tuberosity. The bicipitoradial bursitis may lead to compression of the adjacent nerves, rarely of the medial nerve and more frequently of the radial nerve, including the superficial branch, with sensory symptoms and the deep branch (interosseous posterior nerve), with motor symptoms. The first cause of bicipitoradial bursitis is from mechanical origin. Several etiologies of mechanical bursitis are suggested: Repetitive microtrauma or overuse. Partial or complete tear of biceps tendon. Osseous proliferation : Paget's disease (Figure 11). Osteochondroma Extrinsic compression (Figures 12 and 13) : Page 7 of 76

8 Traumatic cause (hematoma) Tumoral origin Plain radiographs are generally normal. In rare cases, calcifications in the biceps tendon and roughening of the radial tuberosity may be detected.(figure 6) Page 8 of 76

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10 Fig. 6: Roughening of the radial tuberosity with adjacent calcifications. References: PARIS, Cochin hospital - Paris/FR Plain CT demonstrates the bursitis as a fusiform lesion with thin or thick walls and low uniform density compared to the muscles. (Figure 7) Fig. 7: Axial view unenhanced CT: hypodense homogeneous fusiform formation of the bicipitoradial bursa. References: Yamamoto T et al. (2001) Bicipital radial bursitis: CT and MR appearance. Computerized medical imaging and graphics ;25: On MR imaging, bursitis usually appears hypointense to muscles on T1-weighted images, and in a variable signal on T2-weighted images, with a peripheric rim enhancement after gadolinium injection. Hypointense septal structures may be observed. In rare cases, bursitis may contain multiple rice bodies iso intense with muscles (Figure 8, Page 10 of 76

11 9 and 10). Coronal and sagittal planes T2-weighted sequences with the elbow maintained in a 90 flexion position may be useful to analyze in detail the biceps tendon's insertion. Fig. 8: Bicipitoradial bursitis: axial STIR image showing a hyperintense enlarged bicipitoradial bursa. Green arrow: biceps tendon. References: PARIS, Cochin hospital - Paris/FR Page 11 of 76

12 Fig. 9: Bicipitoradial bursitis: axial T1-weighted image showing a isointense enlarged bicipitoradial bursa. Green arrow: biceps tendon. References: PARIS, Cochin hospital - Paris/FR Page 12 of 76

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14 Fig. 10: Bicipitoradial bursitis associated with biceps tendinopathy. Green arrow: thickened biceps tendon. Yellow arrow: bicipitoradial bursitis References: PARIS, Cochin hospital - Paris/FR Fig. 11: Paget's disease of the proximal ulna and bicipitoradial bursitis. Yellow arrow: osseous hypertrophy and deformation associated with cortical thickening of the ulna. References: PARIS, Cochin hospital - Paris/FR Page 14 of 76

15 Fig. 12: Bicipitoradial bursitis secondary to a nodular fasciitis: axial STIR image showing the biceps tendon and the bicipitoradial bursa compressed by a homogeneous hyperintense mass. Green arrow: tissular mass. Red arrow: biceps tendon. Yellow arrow: bicipitoradial bursitis. References: PARIS, Cochin hospital - Paris/FR Page 15 of 76

16 Fig. 13: Bicipitoradial bursitis secondary to a nodular fasciitis: axial T1-weighted fatsaturated contrast-enhanced sequence demonstrating the biceps tendon and the bicipitoradial bursa compressed by a homogeneous moderatedly hyperintense mass showing no significant enhancement. Green arrow: tissular mass. Red arrow: biceps tendon. Yellow arrow: bicipitoradial bursitis. References: PARIS, Cochin hospital - Paris/FR Treatment: Conservative treatment of the bicipitoradial bursitis consists of aspiration of the bursa and injection of corticosteroid medication. Surgical resection may be required if failure of conservative treatment occurs, or if there are neurologic symptoms. Non neoplastic pathologies of the BBR: Page 16 of 76

17 Non neoplastic pathologies of the bicipitoradial bursa include: Infection Common germs Tuberculosis,... Inflammation Rheumatoid arthritis Psoriatic arthropathy,... Metaplasia Synovial chondromatosis,... Septic bicipitoradial bursitis: Septic bicipitoradial bursitis are uncommon. To our knowledge, only two cases of septic bicipitoradial bursitis, which were tuberculous bursitis, have been reported in the English literature. In one of them, CT demonstrated an irregular-shaped, low-density multicystic lesion around the biceps brachii tendon (Figure 14). Page 17 of 76

18 Fig. 14: Tuberculous bicipitoradial bursitis: irregular-shaped, low-density multicystic lesion around the biceps tendon, with peripheral enhancement. References: Nishida et al. (2007) Tuberculous bicipitoradial bursitis: a case report. Skeletal radiol. 36: The lesion had heterogeneous relatively high signal intensity with scattered low and high signal intensity areas on T2-weighted sequence and a homogeneous low signal intensity on T1-weighted sequence (Figures 15 and 16). Page 18 of 76

19 Fig. 16: Tuberculous bicipitoradial bursitis: homogeneous hypointense lesion on T1weighted sequence. References: Nishida et al. (2007) Tuberculous bicipitoradial bursitis: a case report. Skeletal radiol. 36: Page 19 of 76

20 Fig. 15: Tuberculous bicipitoradial bursitis: heterogeneous relatively high signal intensity lesion with scattered low and high signal intensity areas on T2-weighted sequence. References: Nishida et al. (2007) Tuberculous bicipitoradial bursitis: a case report. Skeletal radiol. 36: Histologically, the lesion contained epithelioid cell granuloma with necrotic change. Bicipitoradial bursitis secondary to inflammatory polyarthritis: Bicipitoradial bursitis secondary to rheumatoid arthritis or psoriatic arthritis is rare. Only one patient with rheumatoid arthritis presenting with bicipitoradial bursitis extended around the radial neck has been reported in the English literature. Page 20 of 76

21 Primary synovial chondromatosis of the bicipitoradial bursa: Primary synovial chondromatosis is a benign uncommon process, characterized by synovial membrane proliferation and metaplasia, which typically affects young adults. Men are more frequently affected than women for intraarticular disease, however extraarticular disease usually affects older patients with a female predominance. Typical finding is of multiple, regular, oval-shaped cartilaginous bodies within the bursa. Plain radiographs reveal multiple intrabursal calcifications, which distribution reflects the anatomy of the bursa. Radiographs may be normal if the cartilaginous bodies are not calcified. Arthrography and CT-arthrography reveal the multifocal intrabursal cartilaginous bodies seen as multiple circular filling defects (Figure 17). Page 21 of 76

22 Fig. 17: Arthrography of the elbow revealing multiple intraarticular circular filling defects: primary synovial chondromatosis of the elbow. References: PARIS, Cochin hospital - Paris/FR MRI usually demonstrates multiple unmineralized nodules appearing hypo or isointense on T1-weighted sequences and hyperintense on T2-weighted sequences. They may show focal areas of signal void consistant with areas of mineralization.(figures 18, 19, 20, 21 and 22). Fig. 18: Primary synovial chondromatosis: axial STIR image showing an enlarged bicipitoradial bursa in hypersignal (green arrow), containing multiple chondromas (red arrow). Yellow arrow: biceps tendon. References: PARIS, Cochin hospital - Paris/FR Page 22 of 76

23 Fig. 19: Primary synovial chondromatosis: coronal STIR image showing an enlarged bicipitoradial bursa in hypersignal (green arrow), containing multiple chondromas (red arrow). Yellow arrow: biceps tendon. References: PARIS, Cochin hospital - Paris/FR Page 23 of 76

24 Fig. 20: Primary synovial chondromatosis: axial T1 image showing an enlarged bicipitoradial bursa in isosignal. References: PARIS, Cochin hospital - Paris/FR Page 24 of 76

25 Fig. 21: Primary synovial chondromatosis: axial T1-weighted fat-saturated contrastenhanced sequence showing an enlarged bicipitoradial bursa in isosignal with rim enhancement, containing multiple chondromas. References: PARIS, Cochin hospital - Paris/FR Page 25 of 76

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27 Fig. 22: Primary synovial chondromatosis: coronal T1-weighted fat-saturated contrastenhanced sequence showing an enlarged bicipitoradial bursa in isosignal with rim enhancement, containing multiple chondromas. References: PARIS, Cochin hospital - Paris/FR Lipoma arborescens of the bicipitoradial bursa: Lipoma arborescens is a rare synovial process, characterized by a hyperplastic proliferation of fatty tissue replacing the subsynovial connective layer and forming villous proliferations. The exact etiology of lipoma arborescens remains unknown, but it is likely to be a non specific reaction to joint injury and chronic synovitis. It may be associatied with osteoarthritis, diabetis mellitus, gout, rheumatoid arthritis and psoriatic arthritis. Lipoma arborescens usually affects men between the age of forty and sixty years old. The most common site of involvement is the knee, but other sites such as the shoulder, the hip, the elbow or the wrist have been reported. Plain radiographs occasionally demonstrate fatty lucencies within a soft tissue lesion. Ultrasonography reveals effusion in the bicipitoradial bursa associated with hyperechoic irregular villous synovial proliferations. MRI is the modality of choice for diagnosis and demonstrates villous tree-like architecture synovial mass, hyperintense on both T1 and T2-weighted sequences, without enhancement.(unless if associated with bursitis)(figures 23, 24, 25 and 26). Page 27 of 76

28 Fig. 23: Lipoma arborescents of the bicipitoradial bursa: axial STIR image showing a heterogeneous mass of the bicipitoradial bursa, with hyper and hypo intense components associated with a bursitis. Green arrow: lipoma arborescens. Red arrow: bursitis. Yellow arrow: biceps tendon. References: PARIS, Cochin hospital - Paris/FR Page 28 of 76

29 Fig. 24: Lipoma arborescents of the bicipitoradial bursa: axial T1-weighted image showing a heterogeneous hyperintense mass of the bicipitoradial bursa, associated with a bursitis. Green arrow: lipoma arborescens. Red arrow: bursitis. Yellow arrow: biceps tendon. References: PARIS, Cochin hospital - Paris/FR Page 29 of 76

30 Fig. 25: Lipoma arborescents of the bicipitoradial bursa: axial T1-weighted fatsaturated gadolinium-enhanced image showing a heterogeneous mass of the bicipitoradial bursa with hypo and hyperintense components, associated with a bursitis. References: PARIS, Cochin hospital - Paris/FR Page 30 of 76

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32 Fig. 26: Lipoma arborescents of the bicipitoradial bursa: coronal T1-weighted fat-saturated gadolinium-enhanced image showing a heterogeneous mass of the bicipitoradial bursa with hypo and hyperintense components, associated with a bursitis. References: PARIS, Cochin hospital - Paris/FR Treatment: Lipoma arborescens is treated by open or arthroscopic synovectomy. Recurrence is uncommon. Benign and malignant tumors of the bicipitoradial bursa: Both benign and malignant tumors of the bicipitoradial bursa are very rare. Benign tumors include: Lipoma Hemangioma Fibroma Villonodular synovitis Malignant primtive tumors of the bicipitoradial bursa are exceptional and metastasis are rare. Synovial cell sarcoma of the bicipitoradial bursa: Synovial cell sarcoma accounts for 5 to 10% of all soft tissue sarcomas. Mean age of patients at diagnosis is approximately thirty years. Approximately 90% of synovial cell sarcomas occur in the extremities, mostly in the lower limbs. It is often found to be in close association with joint capsules, tendon sheaths or bursae. Plain radiographs show calcifications in 25% of patients. CT scan demonstrates a heterogeneous soft tissue mass with calcifications deep within the tumor. MRI is the modality of choice for the staging of synovial cell sarcomas, demonstrating a heterogeneous multilocular soft tissue mass, hypointense on T1-weighted sequence, hyperintense on T2-weighted sequence and enhancing after gadolinium injection. (Figures 27, 28, 29 and 30) Page 32 of 76

33 Fig. 27: Synovial cell sarcoma of the bicipitoradial bursa: axial STIR image showing a heterogeneous hyperintense mass of the bicipitoradial bursa. References: PARIS, Cochin hospital - Paris/FR Page 33 of 76

34 Fig. 28: Synovial cell sarcoma of the bicipitoradial bursa: coronal STIR image showing a heterogeneous hyperintense mass of the bicipitoradial bursa. References: PARIS, Cochin hospital - Paris/FR Page 34 of 76

35 Fig. 29: Synovial cell sarcoma of the bicipitoradial bursa: axial T1-weighted image showing a isointense mass of the bicipitoradial bursa. References: PARIS, Cochin hospital - Paris/FR Page 35 of 76

36 Fig. 30: Synovial cell sarcoma of the bicipitoradial bursa: axial T1-weighted fatsaturated gadolinium enhanced image showing a heterogeneous enhancement bicipitoradial bursa's mass. References: PARIS, Cochin hospital - Paris/FR Treatment: The primary treatment for synovial cell sarcoma is surgery with a large resection of the tumor. Local radiotherapy is often required for the local control of the disease. The role of adjuvant chemotherapy remains controversial. The frequency of recurrence is approximately 25%. The lung is the most frequent site of metastasis. Images for this section: Page 36 of 76

37 Fig. 1: Normal anatomy of the antecubital fossa in coronal plane Page 37 of 76

38 Fig. 2: Bicipitoradial bursa anatomy in supination and pronation Page 38 of 76

39 Fig. 3: Synovial membrane. Page 39 of 76

40 Fig. 4: Synovial membrane histology. S: synoviocytes T conj: fibrous tissue C: blood vessels Page 40 of 76

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42 Fig. 31: Roughening of the radial tuberosity with adjacent calcifications. Fig. 32: Bicipitoradial bursitis Green arrow: biceps tendon. Yellow arrow: enlarged bicipitoradial bursa hyperintense on STIR (left image) and hypointense on T1-weighted sequence. Page 42 of 76

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44 Fig. 10: Bicipitoradial bursitis associated with biceps tendinopathy. Green arrow: thickened biceps tendon. Yellow arrow: bicipitoradial bursitis Fig. 11: Paget's disease of the proximal ulna and bicipitoradial bursitis. Yellow arrow: osseous hypertrophy and deformation associated with cortical thickening of the ulna. Page 44 of 76

45 Fig. 33: Bicipitoradial bursa pathologies Page 45 of 76

46 Fig. 14: Tuberculous bicipitoradial bursitis: irregular-shaped, low-density multicystic lesion around the biceps tendon, with peripheral enhancement. Page 46 of 76

47 Fig. 15: Tuberculous bicipitoradial bursitis: heterogeneous relatively high signal intensity lesion with scattered low and high signal intensity areas on T2-weighted sequence. Page 47 of 76

48 Fig. 5: Bicipitoradial bursa pathologies. Page 48 of 76

49 Fig. 17: Arthrography of the elbow revealing multiple intraarticular circular filling defects: primary synovial chondromatosis of the elbow. Page 49 of 76

50 Fig. 35: Lipoma arborescents of the bicipitoradial bursa: axial T1-weighted image showing a heterogeneous hyperintense mass of the bicipitoradial bursa, associated with a bursitis. Green arrow: lipoma arborescens. Red arrow: bursitis. Yellow arrow: biceps tendon. Page 50 of 76

51 Fig. 34: Lipoma arborescents of the bicipitoradial bursa: axial STIR image showing a heterogeneous mass of the bicipitoradial bursa, with hyper and hypo intense components associated with a bursitis. Green arrow: lipoma arborescens. Red arrow: bursitis. Yellow arrow: biceps tendon. Page 51 of 76

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53 Fig. 37: Lipoma arborescents of the bicipitoradial bursa: coronal T1-weighted fat-saturated gadolinium-enhanced image showing a heterogeneous mass of the bicipitoradial bursa with hypo and hyperintense components, associated with a bursitis. Fig. 36: Lipoma arborescents of the bicipitoradial bursa: axial T1-weighted fat-saturated gadolinium-enhanced image showing a heterogeneous mass of the bicipitoradial bursa with hypo and hyperintense components, associated with a bursitis. Page 53 of 76

54 Fig. 24: Lipoma arborescents of the bicipitoradial bursa: axial T1-weighted image showing a heterogeneous hyperintense mass of the bicipitoradial bursa, associated with a bursitis. Green arrow: lipoma arborescens. Red arrow: bursitis. Yellow arrow: biceps tendon. Page 54 of 76

55 Fig. 25: Lipoma arborescents of the bicipitoradial bursa: axial T1-weighted fat-saturated gadolinium-enhanced image showing a heterogeneous mass of the bicipitoradial bursa with hypo and hyperintense components, associated with a bursitis. Page 55 of 76

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57 Fig. 26: Lipoma arborescents of the bicipitoradial bursa: coronal T1-weighted fat-saturated gadolinium-enhanced image showing a heterogeneous mass of the bicipitoradial bursa with hypo and hyperintense components, associated with a bursitis. Fig. 23: Lipoma arborescents of the bicipitoradial bursa: axial STIR image showing a heterogeneous mass of the bicipitoradial bursa, with hyper and hypo intense components associated with a bursitis. Green arrow: lipoma arborescens. Red arrow: bursitis. Yellow arrow: biceps tendon. Page 57 of 76

58 Fig. 27: Synovial cell sarcoma of the bicipitoradial bursa: axial STIR image showing a heterogeneous hyperintense mass of the bicipitoradial bursa. Page 58 of 76

59 Fig. 28: Synovial cell sarcoma of the bicipitoradial bursa: coronal STIR image showing a heterogeneous hyperintense mass of the bicipitoradial bursa. Page 59 of 76

60 Fig. 29: Synovial cell sarcoma of the bicipitoradial bursa: axial T1-weighted image showing a isointense mass of the bicipitoradial bursa. Page 60 of 76

61 Fig. 30: Synovial cell sarcoma of the bicipitoradial bursa: axial T1-weighted fat-saturated gadolinium enhanced image showing a heterogeneous enhancement bicipitoradial bursa's mass. Page 61 of 76

62 Fig. 38 Page 62 of 76

63 Fig. 39 Page 63 of 76

64 Fig. 20: Primary synovial chondromatosis: axial T1 image showing an enlarged bicipitoradial bursa in isosignal. Page 64 of 76

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67 Fig. 22: Primary synovial chondromatosis: coronal T1-weighted fat-saturated contrastenhanced sequence showing an enlarged bicipitoradial bursa in isosignal with rim enhancement, containing multiple chondromas. Page 67 of 76

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69 Fig. 6: Roughening of the radial tuberosity with adjacent calcifications. Fig. 7: Axial view unenhanced CT: hypodense homogeneous fusiform formation of the bicipitoradial bursa. Page 69 of 76

70 Fig. 8: Bicipitoradial bursitis: axial STIR image showing a hyperintense enlarged bicipitoradial bursa. Green arrow: biceps tendon. Page 70 of 76

71 Fig. 9: Bicipitoradial bursitis: axial T1-weighted image showing a isointense enlarged bicipitoradial bursa. Green arrow: biceps tendon. Page 71 of 76

72 Fig. 13: Bicipitoradial bursitis secondary to a nodular fasciitis: axial T1-weighted fat-saturated contrast-enhanced sequence demonstrating the biceps tendon and the bicipitoradial bursa compressed by a homogeneous moderatedly hyperintense mass showing no significant enhancement. Green arrow: tissular mass. Red arrow: biceps tendon. Yellow arrow: bicipitoradial bursitis. Page 72 of 76

73 Fig. 12: Bicipitoradial bursitis secondary to a nodular fasciitis: axial STIR image showing the biceps tendon and the bicipitoradial bursa compressed by a homogeneous hyperintense mass. Green arrow: tissular mass. Red arrow: biceps tendon. Yellow arrow: bicipitoradial bursitis. Page 73 of 76

74 Fig. 16: Tuberculous bicipitoradial bursitis: homogeneous hypointense lesion on T1weighted sequence. Page 74 of 76

75 Conclusion Bicipitoradial bursitis should be taken into consideration in the differential diagnosis of an antecubital fossa mass. The first cause of bicipitoradial bursitis is from mechanical origin, secondary to repetitive microtraumas. Personal information References Yamamoto T, Mizuno K, Soejima T, Fujii M Bicipital radial bursitis: CT and MR appearance. Computerized medical imaging and graphics.2001;25: Skaf AY, Boutin RD, Dantas RWM et al. Bicipito radial bursitis: MR imaging findings in eight patients and anatomic data from contrast material opacification of bursae followed by routine radiography and MR imaging in cadavers. Radiology 1999;212: Spence LD, Adams J, Gibbons D, Mason MD, Eustace S. Rice body formation in bicipito radial bursitis: ultrasound, CT, and MRI findings. Skeletal Radiol. 1998;27: Dinauer P, Bojescul JA, Kaplan KJ, Litts C. Bilateral lipoma arborescens of the bicipitoradial bursa. Skeletal Radiol. 2002;31: Doyle AJ, Miller MV, French JG. Lipoma arborescens in the bicipital bursa of the elbow:mri findings in two cases. Skeletal Radiol. 2002;31: Levadoux M, Gadea J, Flandrin P, Carlos E, Aswad R, Panuel M. Lipoma arborescens of the elbow: a case report. J Hand Surg Am. 2000;25: Satge D, Pusel J, Rodier D, Moyses B, Linster L, Janser JC. Arborescent lipoma of the elbow. Acta Orthop Belg. 1987;53(4): O'Connell JX Pathology of the synovium. Anatomic pathology. Pathology of the synovium. Am J Clin Pathol 2000;114: Ea H-K, Bazille C, Lioté F. Histologie et physiologie de la membrane synoviale. Appareil locomoteur. Traité EMC. Legré V, Boyer T, Dorfmann H, Lafforgue P. Tumeurs et dystrophie de la synoviale. Appareil locomoteur. Traité EMC Murphey MD, Vidal JA, Fanburg-Smith JC,Gajewski DA. Imaging of synovial chondromatosis with radiologic-pathologic correlation, Radiographics 2007;27: Page 75 of 76

76 Soler T, Rodriguez E, Bargiela A, Da Riba M. Lipoma arborescens of the knee: MR characteristics in 13 joints. J Comput Assist Tomogr.1998;22:605-9 Page 76 of 76