This document provides an ultrasound summary of the normal elbow anatomy and various pathologies that can be assessed using ultrasound. It describes the lateral, anterior, medial and posterior aspects of the elbow and identifies structures like tendons, ligaments, nerves and bursae. Common pathologies discussed include tendinosis, tears, bursitis, synovitis and effusions. The role of ultrasound in evaluating muscular, tendinous and ligamentous injuries is outlined. Proper scanning technique and ultrasound equipment selection are also reviewed.

1. ULTRASOUND OF THE ELBOW - Normal

2. Lateral Elbow
Common Extensor tendon.
Radial collateral ligament
Radial Nerve (Posterior Inter osseous nerve - 'PIN')
Annular ligament
Common extensor tendon insertion
to the lateral humeral epicondyle. Normal Common Extensor Tendon.

3. Radial Nerve scan plane. Radial Nerve - normal.

4. Anterior Elbow
Elbow joint
Biceps tendon
Median Nerve
Common extensor tendon insertion
to the lateral humeral epicondyle. Longitudinal anterior elbow joint.

5. Biceps insertion onto radial
tubercle- Longitudinal. Normal Biceps tendon insertion.

6. Biceps tendon and median
nerve at elbow crease-Transverse.
Median nerve and biceps
tendon in antecubital fossa.

7. Medial Elbow
Common Flexor Tendon
Ulna nerve
Ulna Collateral Ligament
Common Flexor tendon insertion.
Normal Common Flexor Tendon.

8. Ulna collateral ligament. Normal ulna collateral ligament.

9. Scan Plane for Transverse Ulnar nerve. Normal Ulnar Nerve in the ulna groove.

10. Posterior Elbow
Triceps tendon
Olecranon Bursa
Olecranon Fossa
Longitudinal triceps insertion. Normal longitudinal triceps insertion.

11. Olecranon fossa Transverse scan plane. Transverse Olecranon Fossa.

12. Distal biceps tendon.
Anterior joint recess.

13. Radial and posterior interosseous nerves. Transverse view.

14. Medial elbow.
Lateral elbow.

15. Posterior elbow.

16. ROLE OF ULTRASOUND
Ultrasound is essentially used for the external structures of the elbow.
Ultrasound is a valuable diagnostic tool in assessing the following indications;
Muscular, tendinous and ligamentous damage (chronic and acute)
Bursitis
Joint effusion
Vascular pathology
Haematomas
Masses such as ganglia or lipomas
Classification of a mass e.g. solid, cystic, mixed
Post surgical complications e.g. abscess, edema
Relationship of normal anatomy and pathology to each other
Some bony pathology
EQUIPMENT SELECTION AND TECHNIQUE
Use of a high resolution probe (7-15MHZ) is essential when assessing the elbow.
Careful scanning technique to avoid anisotropy (and possible misdiagnosis). Beam
steering or compounding can help to overcome anisotropy in linear structures such
as tendons. Good colour / power / Doppler capabilities when assessing vessels or
vascularity of a structure. Be prepared to change frequency output of probe (or
probes) to adequately assess both superficial and deeper structures.

18. Intraarticular effusions appear as anechoic (a, star) or hypo-anechoic (b, white arrow)
areas filling the anterior and posterior recesses and displacing the fat pad (b, star).

19. Rupture of the distal biceps tendon
is uncommon and it is usually due to attempting to lift
a heavy weight. Complete ruptures usually cause pain
and a clinically palpable defect so it is not difficult to
diagnose. In complete tears without muscle retraction,
when there is an important soft-tissue swelling with
difficult clinical examination or in partial ruptures,
imaging may be required. The complete rupture of the
tendon produces a defect at the expected location of
the tendon. The gap is filled with hematoma, and the
retracted tendon edge may be visible. Anomalies of
the median nerve can also be demonstrated. We show
a case of iatrogenic neuropathy after venopuncture.

21. Biceps tendon rupture with a retracted proximal biceps tendon.

22. Biceps tendon rupture with hypoechoic
mass distal to the biceps tendon.

23. (a, b) Longitudinal (a) and transverse (b) US images show a moderate
partial tear of the distal biceps tendon (arrows in a, arrowheads in b).

25. Lateral epicondylitis, also known as “tennis elbow” is an
overuse syndrome of the common extensor tendon. It is thought to
be due to repetitive micro trauma during supination of the forearm
and dorsiflexion of the wrist, that results in the breakdown of fibers
with tissue necrosis and fibrosis. Typically occurs in the 4th and 5th
decades, with equal prevalence in women and men. Patients
complain of poorly defined pain located over the lateral elbow that
is exacerbated with activities requiring wrist extension. Imaging is
reserved for cases which are refractory to conservative treatment,
to exclude other abnormalities and to assess the amount of
damaged tendon before surgery. US findings are: tendon thickening,
diffuse heterogeneity of the tendon with loss of the normal fibrillar
architecture, focal hypoechoic regions, intratendinous calcifications,
adjacent bone irregularity, enthesophytes at the tendon insertion
site, linear intrasubstance tears, peritendinous fluid and thickening
of peritendinous tissues and neovascularity in Colour Doppler

30. Medial epicondylitis also known as “golfer elbow” is
an overuse syndrome of the common flexor tendon. It is
thought to be due to repetitive micro trauma and results
in fibrosis. The ultrasound findings are comparable with
those of lateral epicondylitis.
The medial collateral ligament is injured in cases of
repeated valgus stress. It can be injured without damage
of the overlying common flexor tendon. Ultrasound may
demonstrate hypoechoic areas with fibrillar pattern
disruption, thickening or calcification of the ligament.
In the proximal elbow and adjacent to the epitrochlea,
the small lymph nodes can increase because of
inflammation or infection. Epitrochlear adenopathy can
be caused by cat scratch disease.

34. Epicondylitis. Longitudinal US image of the common extensor tendon old
woman depicts a linear hypoechoic region indicative of a partial-thickness
tear at the under-surface of the ECRB (arrowhead), with surrounding
heterogeneous echogenicity indicative of associated tendinosis (arrow).

35. Olecranon bursitis is due to repetitive trauma
although it also can be associated with calcifying
enthesopathy of the distal triceps tendon and in
patients with systemic diseases (gout, rheumatoid
arthritis). It produces a subcutaneous fluid-filled
mass superficial to olecranon process. Colour
Doppler may show peripheral hyperemia. Care
should be taken not to apply excessive pressure
with the probe, because small effusions may be
squeezed away. Echogenic fluid may be due to
infection, inflammation, hematoma or in
hydroxyapatite deposition disease.

38. Olecranon bursitis.

39. Olecranon bursitis with a fluid filled bursa with a vascularized wall.

40. Olecranon
synovitis.

42. The rupture of the triceps tendon usually results
from a fall with an outstretched hand. A bone
fragment may remain attached to the tendon
(avulsion). Ultrasound shows a retracted tendon
surrounded by fluid. Partial ruptures produce a
small fluid-filled or an hypoechoic area in the
tendon .
Dynamic sonography of the elbow is very useful in
diagnosing ulnar nerve dislocation and snapping of
the medial triceps muscle, confirming either medial
dislocation of the nerve or the medial triceps
muscle over the medial epicondyle, or even both
of them.

46. Ultrasound right elbow. Arrow denotes 7 mm
avulsion gap and triceps avulsion fracture.
Plain film radiography right elbow. Arrow
denotes ‘sail sign’ or hemoarthrosis.

47. Partial rupture of triceps muscle.

48. Partial thickness tear of the triceps tendon.

49. Many tumours can occur around the elbow. Lipomatous
tumours as lipoma or liposarcoma, are usually found in the
subcutaneous tissue or inside a muscle. Neural tumours:
benign and malignant nerve sheath tumours , muscular
tumours, fibrous tumours, vascular tumours, and many
others can appear in the elbow. We show a case of a
satellite implant of melanoma.
Synovial osteochondromatosis is characterized by the
formation of cartilage by a process of metaplasia of the
synovium. Knee, hip and elbow are the most frequently
joints affected. This lesion is more common in males and it
occurs between 3-5th decades.
It is characterized by the presence of a periarticular soft
tissue mass with formation of intraarticular loose bodies
which can be calcified. Secondary osteoarthritis is frequent.

54. Thank You.