Ultrasound-guided Elbow Injections

1. Ade Wijaya, MD – April 2019

2.  Elbow is a complex joint
 Susceptible to injury (acute or chronic repetitive)
 Sport-related
Lee KS, Rosas HG, Craig JG. Musculoskeletal ultrasound: elbow imaging and procedures. InSeminars in musculoskeletal radiology 2010 Sep (Vol. 14, No. 04, pp. 449-460). © Thieme Medical Publishers.

3.  Lateral epicondylosis (tennis elbow)
 Medial epicondylosis (golfer's elbow), ulnar collateral ligament
sprain, ulnar nerve entrapment, pronator syndrome,
radiocapitellar degenerative joint disease, triceps injuries
 Distal biceps tendinopathy
 Ulnar nerve entrapment
 Triceps tendinopathy
 Radial tunnel syndrome
Lee KS, Tuite MJ, Rosas HG. Elbow injuries in sports: essentials for radiologists and clinicians. In: Robinson P, ed. Essential Radiology for Sports Medicine. New York, Dordrecht,
Heidelberg, London: Springer; 2010

4.  Most common
 > 50 % of tennis players
 Repetitive microtrauma with mucoid degeneration of the
common extensor tendon where it attaches to the lateral
epicondyle of the humerus
 A pathological tendon may demonstrate hypoechogenicity,
increase in caliber, fibrillar disruption, or hyperemia upon
Doppler investigation
Field L D, Savoie F H. Common elbow injuries in sport. Sports Med. 1998; 26(3) 193-205
Kijowski R, De Smet A A. The role of ultrasound in the evaluation of sports medicine injuries of the upper extremity. Clin Sports Med. 2006; 25(3) 569-590, viii
Levin D, Nazarian L N, Miller T T et al.. Lateral epicondylitis of the elbow: US findings. Radiology. 2005; 237(1) 230-234

5. Bradley M, O’Donnell PAtlas of Musculosceletal Ultrasound Anatomy. Cambridge University Press 2002

6. Hypoechoic; hyperemia
Kijowski R, De Smet A A. The role of ultrasound in the evaluation of sports medicine injuries of the upper extremity. Clin Sports Med. 2006; 25(3) 569-590, viii
Levin D, Nazarian L N, Miller T T et al.. Lateral epicondylitis of the elbow: US findings. Radiology. 2005; 237(1) 230-234

7. Key Points:
 High-frequency linear array transducer
 25 G – 1.5 inch needle
 Aspiration of effusion  significant pain relief
 It is important to attempt to keep steroid medication superficial
to the CET in the peritendinous region
Malanga GA, Mautner KR. Atlas of Ultrasound-Guided Musculoskeletal Injections. McGrawHIll 2014.

8. Lee KS, Rosas HG, Craig JG. Musculoskeletal ultrasound: elbow imaging and procedures. InSeminars in musculoskeletal radiology 2010 Sep (Vol. 14, No. 04, pp. 449-460). © Thieme Medical Publishers.
Malanga GA, Mautner KR. Atlas of Ultrasound-Guided Musculoskeletal Injections. McGrawHIll 2014.

9.  Pain from the common flexor tendon origin at the medial
epicondyle of the humerus
 Repetitive pronation and wrist flexion with eventual
pathological changes occurring between the pronator teres
and flexor carpi radialis origin
 In medial epicondylosis, the common flexor tendon may exhibit
hypoechogenicity, loss of the normal fibrillar pattern, increased
caliber, and hyperemia from neovascularization on Doppler
investigation
Kijowski R, De Smet A A. The role of ultrasound in the evaluation of sports medicine injuries of the upper extremity. Clin Sports Med. 2006; 25(3) 569-590, viii
Field L D, Savoie F H. Common elbow injuries in sport. Sports Med. 1998; 26(3) 193-205

10. Bradley M, O’Donnell PAtlas of Musculosceletal Ultrasound Anatomy. Cambridge University Press 2002

11. http://www.ultrasoundcases.info/Slide-View.aspx?cat=341&case=6786

12. Key Points:
 high-frequency linear array transducer
 25 G – 1.5 inch needle
 Aspiration of effusion  significant pain relief
 In plane, long axis
Malanga GA, Mautner KR. Atlas of Ultrasound-Guided Musculoskeletal Injections. McGrawHIll 2014.

13. Malanga GA, Mautner KR. Atlas of Ultrasound-Guided Musculoskeletal Injections. McGrawHIll 2014.

14.  Short axis; The probability of traumatizing normal tissue is
lessened
Malanga GA, Mautner KR. Atlas of Ultrasound-Guided Musculoskeletal Injections. McGrawHIll 2014.

15. Bradley M, O’Donnell PAtlas of Musculosceletal Ultrasound Anatomy. Cambridge University Press 2002

16. Sprain Normal
Thickening and loss of the normal fibrillar structure
Lee KS, Tuite MJ, Rosas HG. Elbow injuries in sports: essentials for radiologists and clinicians. In: Robinson P, ed. Essential Radiology for Sports Medicine. New York, Dordrecht,
Heidelberg, London: Springer; 2010

17. Dynamic ultrasound assessment can show asymmetrical widening (>1.0 mm)
between the (A) nonstressed (+) and (B) stressed (x) ulnotrochlear joint space (star)
Glousman R E. Ulnar nerve problems in the athlete's elbow. Clin Sports Med. 1990; 9(2) 365-377

18. Normal Abnormal
Malanga GA, Mautner KR. Atlas of Ultrasound-Guided Musculoskeletal Injections. McGrawHIll 2014.

19. Key Points:
 High-frequency linear array transducer
 20- or 22-gauge needle with distal to proximal approach with
arm abducted in external rotation
 Identify the location of the ulnar nerve in order to not penetrate
it during injection
 In plane, long axis
Malanga GA, Mautner KR. Atlas of Ultrasound-Guided Musculoskeletal Injections. McGrawHIll 2014.

20. Malanga GA, Mautner KR. Atlas of Ultrasound-Guided Musculoskeletal Injections. McGrawHIll 2014.

21.  Near its insertion onto the radial tuberosity
 Often associated with a single acute traumatic event with an
audible popping sound and intense pain
 The mechanism of injury is usually forced extension with the
elbow flexed at 90 degrees
Hume P A, Reid D, Edwards T. Epicondylar injury in sport: epidemiology, type, mechanisms, assessment, management and prevention. Sports Med. 2006; 36(2) 151-170
Frostick S P, Mohammad M, Ritchie D A. Sport injuries of the elbow. Br J Sports Med. 1999; 33(5) 301-311

22. Bradley M, O’Donnell PAtlas of Musculosceletal Ultrasound Anatomy. Cambridge University Press 2002

23. Normal
Lee KS, Tuite MJ, Rosas HG. Elbow injuries in sports: essentials for radiologists and clinicians. In: Robinson P, ed. Essential Radiology for Sports Medicine. New York, Dordrecht,
Heidelberg, London: Springer; 2010

24. (A) Longitudinal and (B) transverse ultrasound
Lee KS, Tuite MJ, Rosas HG. Elbow injuries in sports: essentials for radiologists and clinicians. In: Robinson P, ed. Essential Radiology for Sports Medicine. New York, Dordrecht,
Heidelberg, London: Springer; 2010

25. Key Points:
 High-frequency linear array transducer
 The posterior approach is recommended for injection
 Use a 25-gauge, 2-inch needle, or equivalent, for injection
 Use an 18-gauge, 2-inch needle, or equivalent, for aspiration
 Identify the regional neurovascular structures during the
preprocedural planning.
 Do not inject into the tendon
Malanga GA, Mautner KR. Atlas of Ultrasound-Guided Musculoskeletal Injections. McGrawHIll 2014.

26. Malanga GA, Mautner KR. Atlas of Ultrasound-Guided Musculoskeletal Injections. McGrawHIll 2014.

27. NormalTendinopathy
Partial-thickness Tear
Lee KS, Rosas HG, Craig JG. Musculoskeletal ultrasound: elbow imaging and procedures. InSeminars in musculoskeletal radiology 2010 Sep (Vol. 14, No. 04, pp. 449-460). © Thieme Medical Publishers.

28. Key Points:
 High-frequency linear array transducer
 Use a 22- to 25-gauge, 1.5- to 2-inch needle for peritendinous
injection
 Identify the regional neurovascular structures during the
preprocedural planning
 Do not inject into the tendon
Malanga GA, Mautner KR. Atlas of Ultrasound-Guided Musculoskeletal Injections. McGrawHIll 2014.

29. Malanga GA, Mautner KR. Atlas of Ultrasound-Guided Musculoskeletal Injections. McGrawHIll 2014.

31. Normal
Lee KS, Rosas HG, Craig JG. Musculoskeletal ultrasound: elbow imaging and procedures. InSeminars in musculoskeletal radiology 2010 Sep (Vol. 14, No. 04, pp. 449-460). © Thieme Medical Publishers.

32. Lee KS, Rosas HG, Craig JG. Musculoskeletal ultrasound: elbow imaging and procedures. InSeminars in musculoskeletal radiology 2010 Sep (Vol. 14, No. 04, pp. 449-460). © Thieme Medical Publishers.

33. Key Points:
 High-frequency linear array transducer
 Use a 25-gauge, 1.5 inch needle
 Identify the regional neurovascular structures during the
preprocedural planning
Malanga GA, Mautner KR. Atlas of Ultrasound-Guided Musculoskeletal Injections. McGrawHIll 2014.

34. Malanga GA, Mautner KR. Atlas of Ultrasound-Guided Musculoskeletal Injections. McGrawHIll 2014.

35. THANK YOU