High-resolution ultrasound of the elbow - didactic approach.

High-resolution ultrasound of the elbow - didactic approach. Poster No.: C-2358 Congress: ECR 2014 Type: Educational Exhibit Authors: C. M. Olchowy, M. Lasecki, U. Zaleska-Dorobisz; Wroclaw/PL Keywords: Musculoskeletal soft tissue, Musculoskeletal joint, Anatomy, Ultrasound, Education, Technical aspects, Education and training DOI: 10.1594/ecr2014/C-2358 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. www.myesr.org Page 1 of 33

Learning objectives The purpose of our educational exhibit is to: 1. illustrate the normal anatomy and normal ultrasound appearance of elbow; 2. describe a systematic technique (easy to follow check-list protocol) for evaluation of anatomical structures; 3. introduce practical "tips and hints" that will make highly diagnostic images easier to obtain. Background Musculoskeletal ultrasound shows many advantages over other imaging modalities: capability to perform a dynamic assessment of musculoskeletal elements, ultrasonography is safe, cost effective, highly accepted by patients, available, and has excellent and multiplanar capability to visualize superficial soft tissue structures. Wellperformed elbow ultrasound provides detailed informations about joint effusions, medial and lateral epicondylitis, tears of the distal biceps and triceps tendons, radial and ulnar collateral ligament tears, ulnar nerve entrapment, cubital or olecranon bursitis and intraarticular loose bodies. But the first step should always be a proper scanning technique and understanding of anatomy. Images for this section: Page 2 of 33

Fig. 4: Elbow area, Transverse view. During standard ultrasound examination of the wrist four aspects of elbow should be evaluated: anterior, lateral, medial and posterior. In each aspect od the elbow number of anatomical structures should be identified. Page 3 of 33

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Fig. 1: insertion regions of upper limb muscles. Radius and ulna, anterior view. Page 5 of 33

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Fig. 2: insertion regions of upper limb muscles. Radius and ulna, posterior view. Fig. 3: Insertion regions of upper limb muscles. Humerus. Page 7 of 33

Findings and procedure details To make the scanning technique of the elbow joint easier to remember it is devided into 4 main parts: 1. assessment of anterior aspect of the elbow 2. assessment of medial aspect of the elbow 3. assessment of lateral aspect of the elbow 4. assessment of posterior aspect of the elbow. Fig. 4: Elbow area, Transverse view. During standard ultrasound examination of the wrist four aspects of elbow should be evaluated: anterior, lateral, medial and posterior. In each aspect od the elbow number of anatomical structures should be identified. References: Cyprian Olchowy, Wroclaw Medical University, Poland 1. assessment of anterior aspect of the elbow Following anatomical structures should be identified and evaluated: Page 8 of 33

Distal biceps tendon Anterior coronoid recess (with anterior fat pad) Radial nerve (and its deep branch) Median nerve Page 9 of 33

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Fig. 5: Anterior elbow. Transverse view. Probe position. (hand supinated) References: Cyprian Olchowy, Wroclaw Medical University, Poland Identify and follow median nerve proximally and distally in short-axis view. Fig. 6: Anterior elbow. Transverse view. A - brachial artery, V - veins. Note that the most "massive" muscle in anterior elbow is the brachialis muscle. References: Cyprian Olchowy, Wroclaw Medical University, Poland Page 11 of 33

Fig. 7: Anterior elbow. anatomy review. References: Department of Radiology, Wroclaw Medical University, University Hospital - Wroclaw/PL Distal biceps tendon To obtain the best image place the probe in the longitudinal position, then move its distal end a little to the radial side (as common distal biceps tendon inserts into tuberosity of the radial bone). Page 12 of 33

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Fig. 8: Distal biceps tendon. Probe position. To obtain longitudinal image of distal biceps tendon move distal end of the probe a bit to the radial side (as the distal biceps tendon inserts into tuberosity of the radial bone) References: Cyprian Olchowy, Wroclaw Medical University, Poland In this probe position following image should be obtained Fig. 9: Distal biceps tendon. References: Cyprian Olchowy, Wroclaw Medical University, Poland Anterior joint recess Page 14 of 33

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Fig. 10: Anterior joint recess. Probe position. (elbow extended, hand supinated) References: Cyprian Olchowy, Wroclaw Medical University, Poland Fig. 11: Anterior joint recess. Longitudinal view. As you identify all the stuctures rotate the probe 90 degrees and evaluate this area also in transverse view. References: Cyprian Olchowy, Wroclaw Medical University, Poland Radial nerve (and its deep branch - posterior interosseous nerve) Page 16 of 33

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Fig. 12: Radial and posterior interosseous nerves. Probe position, transverse view. Probe is placed on the radial side of anterior aspect of the elbow (few cm above elbow joint). Main trunk of radial nerve is identified in its short-axis and then probe is moved distally (From position A to D). Radial nerve divides into two branches : posterior interosseous nerve and cutaneous sensory branch. References: Cyprian Olchowy, Wroclaw Medical University, Poland Fig. 13: Radial and posterior interosseous nerves. Transverse view. Probe is placed on the radial side of anterior aspect of the elbow (few cm above elbow joint). Main trunk of radial nerve is identified in its short-axis and then probe is moved distally (From position A to D). Radial nerve divides into two branches : posterior interosseous nerve and cutaneous sensory branch. Compare the image to the videoloop (fig. 14) References: Cyprian Olchowy, Wroclaw Medical University, Poland Page 18 of 33

Fig. 14: Radial and posterior interosseous nerves. Transverse view. Probe is placed on the radial side of anterior aspect of the elbow (few cm above elbow joint). Main trunk of radial nerve is identified in its short-axis and then probe is moved distally (From position A to D). Radial nerve divides into two branches : posterior interosseous nerve and cutaneous sensory branch. Compare the image to the Fig.13 where all the anatomical structures seen on the videoloop are identified. References: Cyprian Olchowy, Wroclaw Medical University, Poland 2. assessment of medial aspect of the elbow Following anatomical structures should be identified and evaluated: Page 19 of 33

Common flexor tendon Medial collateral ligament Fig. 15: Medial elbow. Probe position. Longitudinal view. References: Cyprian Olchowy, Wroclaw Medical University, Poland Fig. 20: Medial elbow. Longitudinal view. (Common flexor tendon that origins from medial epicondyle of humerus) References: Cyprian Olchowy, Wroclaw Medical University, Poland Page 20 of 33

3. assessment of lateral aspect of the elbow Following anatomical structures should be identified and evaluated: Common extensor tendon Radiocapitellar joint Radial head, neck + annular ligament Fig. 16: Lateral Elbow. Probe position. Longitudinal view References: Cyprian Olchowy, Wroclaw Medical University, Poland Page 21 of 33

Fig. 18: Lateral elbow. Longitudinal view. (Common extensor tendon) References: Cyprian Olchowy, Wroclaw Medical University, Poland 4. assessment of posterior aspect of the elbow. Following anatomical structures should be identified and evaluated: Triceps tendon Cubital tunnel + ulnar nerve Page 22 of 33

Fig. 17: Posterior elbow. Probe and patient position. Longitudinal view of triceps tendon and posterior fat pad are supposed to be identified and evaluated. Page 23 of 33

References: Cyprian Olchowy, Wroclaw Medical University, Poland Fig. 19: Posterior elbow. Longitudinal view. Note the location of posterior fat pad and echogenicity of normal triceps tendon References: Cyprian Olchowy, Wroclaw Medical University, Poland In most cases ultrasound examination of the elbow is focused to one quadrant of the joint only, where the clinical symptoms are present. In this educational exhibit authors presented the protocol for full elbow ultrasound examination. All the images were obtained on high-performance Toshiba Aplio 500 ultrasound machine using high frequency linear probes (7.2-18 MHz). Images for this section: Page 24 of 33

Fig. 4: Elbow area, Transverse view. During standard ultrasound examination of the wrist four aspects of elbow should be evaluated: anterior, lateral, medial and posterior. In each aspect od the elbow number of anatomical structures should be identified. Page 25 of 33

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Fig. 8: Distal biceps tendon. Probe position. To obtain longitudinal image of distal biceps tendon move distal end of the probe a bit to the radial side (as the distal biceps tendon inserts into tuberosity of the radial bone) Fig. 9: Distal biceps tendon. Page 27 of 33

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Fig. 10: Anterior joint recess. Probe position. (elbow extended, hand supinated) Fig. 11: Anterior joint recess. Longitudinal view. As you identify all the stuctures rotate the probe 90 degrees and evaluate this area also in transverse view. Page 29 of 33

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Fig. 12: Radial and posterior interosseous nerves. Probe position, transverse view. Probe is placed on the radial side of anterior aspect of the elbow (few cm above elbow joint). Main trunk of radial nerve is identified in its short-axis and then probe is moved distally (From position A to D). Radial nerve divides into two branches : posterior interosseous nerve and cutaneous sensory branch. Fig. 13: Radial and posterior interosseous nerves. Transverse view. Probe is placed on the radial side of anterior aspect of the elbow (few cm above elbow joint). Main trunk of radial nerve is identified in its short-axis and then probe is moved distally (From position A to D). Radial nerve divides into two branches : posterior interosseous nerve and cutaneous sensory branch. Compare the image to the videoloop (fig. 14) Page 31 of 33

Fig. 14: Radial and posterior interosseous nerves. Transverse view. Probe is placed on the radial side of anterior aspect of the elbow (few cm above elbow joint). Main trunk of radial nerve is identified in its short-axis and then probe is moved distally (From position A to D). Radial nerve divides into two branches : posterior interosseous nerve and cutaneous sensory branch. Compare the image to the Fig.13 where all the anatomical structures seen on the videoloop are identified. Page 32 of 33

Conclusion 1. Knowledge and understanding of anatomy is essential for scanning the elbow accurately and efficiently. 2. Easy to follow check-list protocol with highly detailed anatomical schemes can be a useful tool in everyday practice of radiologists. Personal information References 1. Beggs I, Bianchi S, Bueno A, Cohen M, Court-Payen M, Grainger A, Kainberger F, Klauser A, Martinoli C, McNally E, O'Connor PJ, Peetrons P, Reijnierse M, Remplik P, Silvestri E. Musculoskeletal Ultrasound Technical Guidelines. European Society of Musculoskeletal Radiology. 2. Bianchi S, Martinoli C. Ultrasound of the musculoskeletal system. Springer 2007. 3. Van Holsbeeck M, Introcaso J. Musculoskeletal Ultrasound 2nd ed. Mosby, 2000. 4. McNally E. Practical Musculoskeletal Ultrasound. Elsevier, 2004. 5. Bradley M, O'Donnell P. Atlas of Musculoskeletal Ultrasound Anatomy. Cambridge University Press, 2002. Page 33 of 33