Sonography of the Elbow Evan Peck MD Section of Sports Health Department of Orthopaedic Surgery Cleveland Clinic Florida Disclosures Financial disclosures Neither I Evan Peck nor any family members have any relevant financial relationships to be discussed directly or indirectly referred ID: 772399
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Sonography of the Elbow Evan Peck, MDSection of Sports HealthDepartment of Orthopaedic SurgeryCleveland Clinic Florida
DisclosuresFinancial disclosures: Neither I, Evan Peck, nor any family member(s), have any relevant financial relationships to be discussed, directly or indirectly, referred to or illustrated with or without recognition within the presentation. Off-label use disclosures: None.
ObjectivesUnderstand the proper technique for performance of the diagnostic elbow ultrasound (US) examination. Be familiar with the structures required for complete diagnostic US evaluation of each region of the elbow.Recognize the sonographic appearance of normal elbow structures and common pathology.
Workshop Logistics 6 stations: One ultrasound machine at each station.You should have been given a number (1-6) upon your entry to the workshop today, which corresponds to your ultrasound station number. If you were not given a number, please raise your hand now.6 resident volunteer models.7 faculty: One for each station; one will “roam.”You will stay at the same station and split scanning time among attendees at that station.
Workshop Faculty and Models(with Station Number) Jerod Cottrill (1)Troy Henning (2)Ellie Jelsing (3)Paul Lento (4)Jeff Payne (5)Mike Schaefer (6) Evan Peck (roam)Tony Cuneo (1) Kristin Garlanger (2)Julia Iafrate (3)Ryan Kruse (4) Katie Nanos (5) Lindsay Ramey (6)
General ApproachPatient seated or supine. High-frequency (>10 MHz), linear-array transducer.May conduct regional examination based on clinical findings (anterior, lateral, medial, or posterior).
Anterior Elbow: ChecklistAnterior humeroradial and humeroulnar joints. Radial and coronoid fossae.Annular recess of the radial neck (including dynamic imaging).Distal biceps tendon (including dynamic imaging).Brachialis muscle, radial and brachial vessels, and median and radial nerves as clinically indicated.AIUM.org
Anterior Elbow Joint: Short Axis
Brachial Artery and Median Nerve: Short Axis
Radial Fossa and Capitulum: Long Axis
Humeroradial Joint: Long Axis
Annular Recess of the Radial Neck: Long Axis (Supination)
Annular Recess of the Radial Neck: Long Axis (Pronation)
Coronoid Fossa and Trochlea: Long Axis
Humeroulnar Joint: Long Axis
Distal Biceps Tendon: Long Axis (Pronator Window) US has 95% sensitivity, 71% specificity, and 91% accuracy for DX of complete vs partial distal biceps tendon tears. Lobo Lda 2013
Radial Nerve: Short Axis Position 1
Radial Nerve: Short Axis Position 2
Lateral Elbow: Checklist Lateral epicondyle.Common extensor tendon.Extensor carpi radialis longus tendon.Brachioradialis tendon.Radial collateral ligament.Radiocapitellar joint (see prior section). Stress/dynamic views as indicated.AIUM.org
Common Extensor Tendon: Long Axis The radial collateral ligament (RCL) occupies, on average, 54% of the total proximal footprint of the common extensor tendon and RCL combined. Jacobson 2014
Brachioradialis and Extensor Carpi Radialis Longus: Long Axis
Medial Elbow: Checklist Medial epicondyle.Common flexor tendon.Ulnar collateral ligament.Ulnar nerve in the cubital tunnel.Stress/dynamic views as indicated.AIUM.org
Common Flexor/Pronator Tendon: Long Axis
Dynamic Ulnar Collateral Ligament (Anterior Band) Evaluation Flex elbow to 30o.Measure humeroulnar joint space at rest and with valgus stress.Compare contralaterally.>1 mm difference at rest and >2 mm difference with stress are abnormal.Nazarian 2003
Ulnar Nerve: Short Axis
Ulnar Nerve: Dynamic Evaluation Patient actively flexes elbow while visualizing ulnar nerve in short axis.Avoid excessive transducer pressure.Dislocation rate up to 20% in asymptomatic patients.Medial head of triceps may also dislocate.Okamoto 2000
Posterior Elbow: Checklist Posterior elbow joint space.Triceps tendon.Olecranon process.Olecranon bursa.AIUM.org
Posterior Elbow Joint: Long Axis
Distal Triceps Tendon: Long Axis
SummaryUse a systematic approach. Bony landmarks often helpful for localization of other structures.Utilize dynamic imaging as indicated.Contralateral comparison often useful.Modulate transducer pressure appropriately.
References AIUM.org. AIUM Practice Guideline for the Performance of a Musculoskeletal Ultrasound Examination.AIUM.org. Diagnostic Musculoskeletal Case Submission Requirements.Lobo Lda G et al. The role of sonography in differentiating full versus partial distal biceps tendon tears: correlation with surgical findings. AJR Am J Roentgenol. 2013 Jan;200(1):158-62.Jacobson JA et al. Radial collateral ligament of the elbow: sonographic characterization with cadaveric dissection correlation and magnetic resonance arthrography. J Ultrasound Med. 2014 Jun;33(6):1041-8. Nazarian LN et al. Dynamic US of the anterior band of the ulnar collateral ligament of the elbow in asymptomatic major league baseball pitchers. Radiology. 2003;227:149-154. Okamoto M et al. Morphology and dynamics of the ulnar nerve in the cubital tunnel: observation by ultrasonography . J Hand Surg Br. 2000;25:85-89.
Thank You pecke@ccf.org