Scanning Technique
The patients may lie down on a table to evaluate the elbow joint. It is helpful to divide the examination into four parts: anterior, lateral, medial, and posterior. Once skilled, it is possible to tailor the examination to assess the patient's specific site of complaints or targeted clinical questions. Different positions of the elbow joints are needed for each examination target.
Anterior evaluation
The patient is instructed to extend the elbow and supinate the forearm for the examination, which begins in the transverse plane with the transducer placed parallel to the elbow crease. The transducer is then moved proximally and distally. In the transverse images of the supracondylar region, both the superficial biceps and the deep brachialis muscles are visible. Medial to these muscles, the brachial artery and the median nerve are located, with the nerve positioned medially to the artery. For diagnosing arthritic effusion, locating the coronoid fossa and assessing the amount of fluid in the deep space is useful. The coronoid fossa appears as a concavity on the anterior surface of the humerus, typically filled with the anterior fat pad. Normally, a small amount of fluid may be observed between the fat pad and the humerus.
The distal biceps tendon is evaluated in both transverse and longitudinal planes, but it presents a challenge due to its deep and oblique course towards the radial tuberosity. The examination usually starts more proximally at the musculotendinous junction, following the tendon distally, while the patient's forearm remains in maximal supination. This positioning helps bring the tendon's insertion at the radial tuberosity into view. Correct ultrasound transducer orientation is vital to avoid anisotropy, requiring the distal half of the probe to be gently pressed against the patient's skin. This maneuver ensures parallel alignment of the ultrasound beam with the distal biceps tendon, allowing adequate visualization of its fibrillar pattern. The long-axis view is preferable for examining the distal biceps tendon. Short-axis planes are less effective for assessing the distal portion due to the potential for dramatic variations in tendon echogenicity with slight changes in probe orientation, which can cause confusion between the tendon and the adjacent artery. Both the radial tuberosity and the bicipitoradial bursa should also be examined.
Lateral evaluation
The lateral aspect of the elbow is examined with the elbow flexed and the forearm pronated. After evaluating the common extensor tendon on its long axis, the coronal planes are utilized by positioning the cranial edge of the probe on the lateral epicondyle. The attachment of the common extensor tendon typically presents a uniform, hyperechoic, triangular shape. It is important to assess the lateral epicondyle for any surface irregularities or signs of enthesopathy. Under normal conditions, the lateral collateral ligament complex cannot be distinguished from the overlying deep portion of the extensor tendon due to their similar fibrillar echotexture. It can only be estimated by the location of the structure.
I will focus on the detailed structure of the lateral tendon and ligament complex in a different lecture.
To evaluate the radial nerve, begin by locating the main trunk of the radial nerve in its short axis, positioned between the brachioradialis and the brachialis muscle. Trace the nerve down to where it bifurcates into the superficial sensory branch and the posterior interosseous nerve. Continue tracking these nerves in their short axis using meticulous scanning techniques. It is crucial to demonstrate the posterior interosseous nerve in short axis planes as it penetrates the supinator muscle, passing through the arcade of Fröhse, located between the superficial and deep parts of the muscle.
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26 авг 2024