USG Cross Sectional Anatomy & US Pathology of Elbow & Wrist

Don-Kyu Kim M.D.

Chung-Ang University Hospital

Radiologic anatomy of elbow

Medial epicondyle

Coronoid process

Radial tuberosity

Lateral epicondyle

Head of radius

Olecranon

C RTR

O

AP Lateral

Anterior fat pad

Supinator fat line

Ligament of Elbow Lateral & Medial

Ultrasound anatomy and scanning technique of the elbow

1. Anterior aspect

1) Elbow joint

a. Transverse scan (capitellum, trochlea)

b. Longitudinal scan (lateral radiocapital joint, medial trochlea ulnar joint)

2) Distal biceps tendon - longitudinal and transverse scan

2. Lateral aspect

1) Lateral epicondyle - longitudinal and transverse scan

2) Common extensor tendon - longitudinal and transverse scan

3. Medial aspect

1) Medial epicondyle - longitudinal and transverse scan

2) Common flexor tendon - longitudinal and transverse scan

3) Ulnar collateral ligament - longitudinal and transverse scan

4) Ulnar nerve - longitudinal and transverse scan

4. Posterior aspect

1) Triceps tendon and olecranon fossa - longitudinal and transverse scan

Transverse Scan of Anterior Elbow

Median N

Brachial a. & v.

Brachialis

Radial N

Brachioradialis

B: BrachialisC: capitellumT: Trochlear

B

C

T

Biceps tendon

Transverse Scan of Anterior Elbow

Median N

Brachial a. & v.

Brachialis

Radial N

Brachioradialis

ECR

Biceps Brachii & tendon

Longitudinal Scan of Anterior Elbow: lateral side

RH: Radial head, C: Capitellum

Radial N Brachioradial m Brachialis

B

Longitudinal Scan of Anterior Elbow: Medial

Median N Brachial a. & v.

Brachialis

B

T CP

Anterior recess

B: BrachialisCP: Coronoid processT: Trochlear

Longitudinal Scan of Anterior Elbow: Biceps Brachii

Position: maximum supination

RH: Radial head

RT: Radial tuberosity

RHRT RT

RH

Biceps tendon

Joint effusionM/53

(C.C) 팔꿈치 앞쪽 통증, 1년 전에 아령하고 난후

- 원위 이두근힘줄 부위의 통증

case

B

T

B: BrachialisT: Trochlear

Transverse image in the olecranon recess

Joint effusion

• F/75

• Pain ,elbow and wrist

• 5~6 month ago

• Fall down

Loose body in the joint

• M/50

• Pain on ROM in the elbow

case

Lateral elbow :Longitudinal & Transverse Scan of Common

Extensor Tendon

LE: Lateral Epicondyle

RH: Radial head

LERH

LE

Radial collateral ligament

-Teixeira et al, Eur radiol 2011 -

Lateral ligament complex-Radial collateral ligament-

Radial collateral ligament injury

• 팔꿈치가 잘 구부러지지 않는다

• 2년 전에 헬스클럽에서 운동하고 난 후 통증이 발생했다

case

Lateral epicondylitis

- Tendinitis - Tendinosis

- partial tear - Complete tear

- Significant relationship between clinical symptoms and ultrasound findings

- Sensitivity: 72–88% - Specificity: 36–48.5%

-Levin et al, 2005-

Sonographic findings of the degenerative tendon (tendinosis)

Tendinosis and hypervascularity

• Abnormally thickened tendons with altered echotexture (focal hypoechoic areas) and hypervascular pattern at color and power Doppler imaging (angiofibroblastic infiltration)

• Painful tendinosis : more hypervascular than of asymptomatic tendinosis,

• hypervascular pattern is not an unfavorable sign

• Part of reparative process ?

Tendinosis with hypervascularityor Tendinitis

• Swelling of tendon

• Power doppler : hyperemia

Tear with hypervascularity

F/47- 3 개월전 부터 심한 통증- 6 개월전 부터 골프를배우고 나서 발생함

- VAS: 8

Partial tear

• Macroscopically, produce discontinuities in individual portions of complex tendons

• loss of longitudinal fibrillar pattern

• Lack of retraction( DDX with complete tear)

Partial tear-linear intrasubstance tear-

• Focal anechoic area

• Absence of fibrillar pattern

Tear with retraction

- Walz et al, radiographics, 2010 -

Complete tear

• Acute complete rupture: – focal defect created by a variable degree of retraction of the

torn tendon edges

– defect created by the tear is usually filled with anechoic or hypoechoic fluid from local hematoma.

• Subacute to chronic tearing: – the absence of fresh hemorrhagic fluid

– the organized hematoma which fills the defect with echogenic material can be misleading, mimicking tendon integrity

– gentle passive assisted movements can be helpful to enhance the separation of the tendon ends during stretching

Near full thickness tear

-Walz et al, radiographics, 2010 -

Medial Elbow:Longitudinal Scan of Common Flexor Tendon

ME: Medial Epicondyle

C: Coronoid Process

Position: Elbow extension, forearm E/R

C

ME

Medial epicondylitis

• Similar to other degenerative tendinopathies

case

Medial Collateral Ligament

• Thickness: 2.6~4 mm

ME

UT

90o

Full flexion

Medial Elbow :Transverse Scan of Cubital Tunnel

ME: Medial Epicondyle FCU: Flexor carpi ulnaris

O: Olecranon

U: Ulnar nerve

FCU

FCU

Ulnar nerve

Ulnar nerve

ME

O

Arcuate ligament

Medial Elbow:Longitudinal Scan of Cubital Tunnel

ME: Medial Epicondyle

UN: Ulnar nerve

Ulnar nerve

Ulnar neuropathy at the Elbow

Latency (ms) Amplitude NCV (m/sec)

Motor Left Ulnar 2.70 14.3 mV 66.1

Right Ulnar 2.85 14.4 mV 59.1

Sensory Left Ulnar 2.30 8.2 uV

Right Ulnar 2.40 37.5 uV

0

10

20

30

40

50

60

70

80

5 cm

above

2.5 cm

above

E 2.5 cm

below

5 cm

below

NCV (m/sec)

case

Ulnar neropathy at the elbow

- Beekman, Muscle & Nerve, 2011-

Posterior Elbow: Longitudinal Scan

H: Humerus

T: Triceps Brachii (arrow)

O: Olecranon

Olecranon fossa

O

TrochleaH

Posterior Elbow: Transverse Scan

Fat pad in the olecranon fossa

T: Triceps tendon (arrow)

O: Olecranon

O

Olecranon bursitis

case

Cystic lesion in the Olecranon

• Cystic lesion in the olecranon, from 2 years ago

• No trauma history

• Pain, swelling, redness

• 2*2 cm

Bx: Epidermal cyst

case

USG Cross Sectional Anatomy & US Pathology of Elbow & Wrist

Part II

Wrist

Radiologic anatomy

• 8 carpal bones

• Joint and its capsule

- Distal radio-ulnar joint

- Radio-carpal joint

- Midcarpal joint

- CMC joint

- MCP joint

- Distal & Proximal lP joint

L

SCP

HTm

Tq

TFCC

Tz

TFCC: stabilizing DRUJ & support compressive load

1) ulnar collateral ligament 2) ECU tendon sheath

3) articular disc 4) joint capsule

5) RU ligament, UL & Utq ligament

Wrist: volar aspect, transverse view

• Carpal tunnel: proximal (inlet)

- Scaphoid tubercle to pisiform

Median NerveUlnar a & nerve

FCR

FPL

Wrist: volar aspect, transverse view

• Distal carpal tunnel

– Tubercle of trapezium ~ hook of hamate

Hook of Hamate

Median Nerve

Ulnar a & nerve

Tubercle of trapezium

Wrist: volar, longitudinal view

Median NerveFDS

RadiusPQ

Radial a.

Median Nerve

• CSA measurement: the median nerve at the wrist (pisiform) and mid-forearm (approximately half the distance between the ulnar styloid and the elbow crease)

• Median nerve CSA at the carpal tunnel inlet (≥ 11 mm2) and wrist–forearm CSA difference (≥ 6 mm2) provides the best discrimination between patients with CTS and controls

- Muscle & Nerve, 2011-

Carpal tunnel syndrome

Latency Amplitude NCV (m/sec)

Motor Left Median 4.45 10.5 mV 53.1

Right Median 3.60 16.4 mV 55.1

Sensory Left Median 3.80 13.8 uV

Right Median 2.40 30.3 uV

case

Carpal tunnel syndrome

Latency Amplitude NCV (m/sec)

Motor Left Median 5.05 5.6 mV 46.9

Right Median 3.75 10.8mV 55.9

Sensory Left Median 4.55 5.1 uV

Right Median 2.95 16.8 uV

case

Female / 45

EMG : carpal tunnel syndrome

case

1 month later : wrist swelling at volar side

with LOM, 2nd ~ 4th fingers(extension)

Wrist pain & Tingling sensationonset : 2 months ago

Ultrasonography: Transverse

right left

trans long

Ultrasonography: Transverse & Longtudinal

MRI T2

M

M: median nerve

Wrist: volar aspect, transverse view- Guyon’s canal -

Ulnar artery

Ulnar nerve

Ulnar nerve

Ulnar artery

Hook of Hamate

Wrist dorsal aspect

Lister’s tubercle & 2nd compartment

ECRBECRL

Lister’s tubercle

1st compartment APL EPBRadial a.

Variant: central septum

Wrist: dorsal aspect3,4,5th compartment

EPL EIP, EDC EDQ

Wrist: dorsal aspect6th compartment

UlnarTriquetrum

de Quervain’s diseasecase

EPL tendon rupture

• (C.C) 우측 엄지손가락 신전젗한

• F/62

• 한달 전에 의자에서 넘어지면서우측 손등으로 땅에 집으면서부종이 있었음

• 동네 정형외과에서는 엑스레이상 이상은 없었다고 들음.

• 실금이 의심되어 부목을 약 1주일 했고 부목 젗거 후에 우측 엄지손가락이 뒤로 젖혀지지 않아신경검사 및 재활치료 위하여내원함

case

Ganglion cyst

case

Triangular Fibrocartilage Complex

• Triangular homogeneously hyperechoic area thicker than 2.5 mm

• Sonography correlated – 7/8 (87.5%) with arthroscopy

– 11/13 (84.6%) with MRI

• patient’s hand prone in mild radial deviation using the extensor carpi ulnaris tendon as an acoustic window

Triangular Fibrocartilage Complex(TFCC) tear

case

Triangular Fibrocartilage Complex(TFCC) tear

case

Thank you for listening !!