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(3) Musculoskeletal Imaging > S2_L3 Anatomy & Radiologic Evaluation of the Elbow > Flashcards

S2_L3 Anatomy & Radiologic Evaluation of the Elbow Flashcards

1
Q

MRI Image Interpretation: Soft Tissue & Synovial Tissues

  1. Triceps tendon ruptures that are less common
  2. Common extensor tendon injuries (Tennis Elbow)
  3. Bicipitoradial bursa may be assessed for inflammation

A. Anterior compartment
B. Lateral compartment
C. Medial compartment
D. Posterior compartment

A
  1. D
  2. B
  3. A
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2
Q

MRI Image Interpretation: Soft Tissue & Synovial Tissues

  1. Imaging must be done with the elbow in both flexion and extension
    to check patency of ligaments and muscles
  2. Common flexor tendon injuries (Little Leaguer’s Elbow)

A. Anterior compartment
B. Lateral compartment
C. Medial compartment
D. Posterior compartment

A
  1. D
  2. C
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3
Q

MRI Image Interpretation: Soft Tissue & Synovial Tissues

  1. Avulsions at the attachment sites will show edema and hemorrhage extending into the defect
  2. Partial tears are identified by changes in tendon girth and an abnormally high signal within the tendon on T2 weighted images

A. Anterior compartment
B. Lateral compartment
C. Medial compartment
D. Posterior compartment

A
  1. B
  2. A
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4
Q

MRI Image Interpretation: Soft Tissue & Synovial Tissues

Modified TF
A. A complete biceps tendon rupture is the most common rupture at the elbow, defined by a gap between the retracted tendon ends.
B. This rupture is located in the anterior compartment.

A

TT

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5
Q

MRI: Soft Tissue & Synovial Tissues (Medial Compartment)

Modified TF
A. MCL ligament tears are associated in throwing/pitching athletes.
B. Axial views are best to identify torn fibers and abnormal signals in the normally linear low signal ligament.

A

TF

B: Coronal views are best to identify torn fibers and abnormal signals in the normally linear low signal ligament.

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6
Q

MRI: Soft Tissue & Synovial Tissues (Medial Compartment)

Modified TF
A. Findings in medial epicondylitis include tendon degeneration, tendon disruption, partial tears, and muscle strain.
B. Coronal and axial imaging show possible alterations in tendon thickness, discontinuity of torn fibers, and low signals associated with inflammation.

A

TF

B: Coronal and axial imaging show possible alterations in tendon thickness, discontinuity of torn fibers, and high signals associated with inflammation.

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7
Q

MRI: Soft Tissue & Synovial Tissues (Posterior Compartment)

Modified TF
A. An olecranon burisitis occurs when the triceps tendon abnormally glides over the medial epicondyle which may cause the ulnar nerve to dislocate.
B. A snapping triceps tendon is identified as a high signal focal collection of fluid over the olecranon and may be associated with gout, a tear of the triceps muscle, or student’s elbow (repetitive pressure on the olecranon).

A

FF

A: A snapping triceps tendon occurs when the triceps tendon abnormally glides over the medial epicondyle which may cause the ulnar nerve to dislocate.
B: An olecranon bursitis is identified as a high signal focal collection of fluid over the olecranon and may be associated with gout, a tear of the triceps muscle, or student’s elbow (repetitive pressure on the olecranon).

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8
Q

MRI: Soft Tissue & Synovial Tissues (Lateral Compartment)

Modified TF
A. Sprains of the LCL are seen as a thickened/thinned ligament with a high signal surrounding it.
B. On the other hand, complete tears will show discontinuity of the fibers.

A

TT

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9
Q

MRI: Soft Tissue & Synovial Tissues (Posterior Compartment)

Modified TF
A. Tears of the LCL are less common, but are seen in association with lateral epicondylitis and/or elbow dislocation;
it is compromised due to biomechanical changes secondary to other lateral elbow conditions.
B. MRI findings in lateral epicondylitis are the same as medial epicondylitis.

A

TT

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10
Q

MRI Image Interpretation of the Elbow

It is the “footprint” of the injury on MRI

A. Alignment of anatomy
B. Bone signal
C. Edema
D. Soft tissue and synovial tissue

A

C. Edema

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11
Q

Advanced Imaging Evaluation: CT Scan & MRI

  1. Check for occult fractures not seen by conventional radiographs
  2. Assess the radial head and its articulation to the capitulum
  3. Check for bony disruptions at sites of tendon attachments

A. Alignment on CT Scan
B. Alignment of anatomy on MRI

A
  1. B
  2. A
  3. B
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12
Q

Advanced Imaging Evaluation: CT Scan & MRI

  1. On axial slices, check the humeroulnar and humeroradial articulations
  2. Check for associated bone injury that may have resulted during dislocation or trauma
  3. On sagittal slices, assess the configuration of the ulnar trochlear notch and its articulation to the trochlea.

A. Alignment on CT Scan
B. Alignment of anatomy on MRI

A
  1. A
  2. B
  3. A
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13
Q

Advanced Imaging Evaluation: CT Scan & MRI

Check for deviations of the geography of bones and joint articulations that signal fracture, dislocation, or bone destruction.

A. Alignment on CT Scan
B. Alignment of anatomy on MRI

A

A. Alignment on CT Scan

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14
Q

Advanced Imaging Evaluation: CT Scan & MRI

  1. Assess for bony destruction signifying disease or infection
  2. Define radiographically ambiguous or occult fractures not seen in x-ray
  3. Check for trabeculae, osseous cysts, cortical hypertrophy, sclerosis, or destruction

A. Bone Density on CT Scan
B. Bone Signal on MRI

A
  1. A
  2. B
  3. A
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15
Q

Advanced Imaging Evaluation: CT Scan & MRI

  1. Check for bone bruises or marrow edema, stress fractures, and osteochondral injuries.
  2. As in radiographs, cortical bone is most dense, while cancellous bone is seen as less dense in the medullary cavity.

A. Bone Density on CT Scan
B. Bone Signal on MRI

A
  1. B
  2. A
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16
Q

Advanced Imaging Evaluation: CT Scan & MRI

  1. Utilize T2 sequence with fat compression
  2. Identification of free fragments
  3. Assess for effusions, sweilling, bursitis, muscle atrophy

A. Cartilage / Joint Spaces on CT Scan
B. Soft tissues on CT Scan
C. Edema on MRI

A
  1. C
  2. A
  3. B
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17
Q

Advanced Imaging Evaluation: CT Scan & MRI

  1. Assess the humeroradial and humeroulnar joint spaces for smooth chondral surfaces
  2. Check for presence of edema due to inflammatory process of injuries in all tissues (both bony and soft)

A. Cartilage / Joint Spaces on CT Scan
B. Soft tissues on CT Scan
C. Edema on MRI

A
  1. A
  2. C
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18
Q

Advanced Imaging Evaluation: CT Scan & MRI

TRUE OR FALSE: Osteochondral lesions are more common at the capitulum and radial head, as these are the commonly damaged areas/ structures surrounded by cartilage.

A

True

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19
Q

CT Scan of the Elbow: Soft Tissues

  1. Biceps mucscle and tendon
  2. Common flexor tendon originating on the medial epicondyle
  3. Extensor supinator groups of muscle

A. Anterior soft tissues
B. Posterior soft tissues
C. Lateral soft tissues
D. Medial soft tissues

A
  1. A
  2. D
  3. C
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20
Q

CT Scan of the Elbow: Soft Tissues

  1. Brachioradialis
  2. Brachialis muscle and tendon
  3. Anconeus muscle

A. Anterior soft tissues
B. Posterior soft tissues
C. Lateral soft tissues
D. Medial soft tissues

A
  1. C
  2. A
  3. B
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21
Q

CT Scan of the Elbow: Soft Tissues

  1. Flexor-pronator group of muscles
  2. Triceps muscle
  3. Common extensor tendon originating from the lateral epicondyle

A. Anterior soft tissues
B. Posterior soft tissues
C. Lateral soft tissues
D. Medial soft tissues

A
  1. D
  2. B
  3. C
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22
Q

Basic MRI Protocol for Image Interpretation of the Elbow

  1. Inversion Recovery (IR)
  2. GRE (Gradient Echo)
  3. T2 weighted (with fat suppression)

A. Define the anatomy
B. Detect abnormal fluid

A
  1. B
  2. A
  3. B

NOTE: Chronic injuries may not have edema unlike acute injuries and aberrations in anatomy need to be considered

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23
Q

Basic MRI Protocol for Image Interpretation of the Elbow

  1. T1 weighted
  2. Proton Density (PD)

A. Define the anatomy
B. Detect abnormal fluid

A
  1. A
  2. A
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24
Q

MR Arthrography

Modified TF
A. MR arthrography is useful at the elbow to detect tears of the collateral ligaments and defects of the cartilaginous surfaces.
B. The contrast produces distension of the joint that allows for better visualization of smaller structures.

A

TT

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25
Q

Case: MD is thinking of unstable lesion or osteochondral fractures of the capitulum as the diagnosis for patient G.N., however, routine radiographs were non-diagnostic. What advanced imaging can be performed to aid in the diagnosis?

A

MR Arthrography

Since it is used in diagnosing unstable lesions or osteochondral fractures of the capitulum if radiographs are non-diagnostic.

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26
Q

Routine Radiologic Evaluation of the Forearm: Lateral View

Modified TF
A. The patient’s elbow is flexed and forearm is resting in its ulnar border supinated ~35º (FA is in midprone position).
B. This view demonstrates the elbow, the entire length of the radius and ulna, and the wrist.

A

FT

A: The patient’s elbow is flexed and forearm is resting in its ulnar border supinated ~45º (FA is in midprone position).

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27
Q

Routine Radiologic Evaluation of the Forearm: Lateral View

Modified TF
A. In the lateral view, the radial head is superimposed on the coronoid process.
B. Also, much of the ulna and radius are superimposed, and it is important to note the bowing and contour of the shafts as the radius and ulna are not straight.

28
Q

Routine Radiologic Evaluation of the Forearm: Anteroposterior View

Modified TF
A. In the AP view, the central ray passes through the middle of the forearm, demonstrating the elbow, entire radial and ulnar shafts, and the wrist.
B. The image is taken while the elbow is flexed, the forearm is in anatomic position or supinated, and the olecranon is in its fossa.

A

TF

B: The image is taken while the elbow is extended, the forearm is in anatomic position or supinated, and the olecranon is in its fossa.

29
Q

Routine Radiologic Evaluation of the Forearm: Anteroposterior View

TRUE OR FALSE: In the AP view, both proximal and distal articulations of the forearm can be visualized.

30
Q

Routine Radiologic Evaluation of the Elbow: Oblique View (IR)

Modified TF
A. The internal oblique view crosses the proximal ulna over the radius superimposing these structures.
B. The coronoid process is visible without superimposition and is best demonstrated in this view, so this view is done to specifically see the intactness of the coronoid process.

A

FT

A: The oblique view (IR) crosses the proximal radius over the ulna superimposing these structures.

31
Q

Routine Radiologic Evaluation of the Elbow: Oblique View (IR)

Modified TF
A. The internal oblique view may be obtained with the patient’s arm in IR 70º or pronated and with the elbow in full extension.
B. The patient will be sitting with the hands on the table, palms facing down.

A

FT

A: The internal oblique view may be obtained with the patient’s arm in IR 90º or pronated and with the elbow in full extension.

32
Q

Routine Radiologic Evaluation of the Elbow: Oblique View (ER)

Modified TF
A. The patient is positioned with the elbow extended and externally rotated 55º from the anatomic position or fully supinated.
B. This position best demonstrates the radial head, neck and tuberosity to be viewed free of any superimposition, used for suspected radial head fracture or nurse maid’s elbow.

A

FT

A: The patient is positioned with the elbow extended and externally rotated 45º from the anatomic position or fully supinated.

33
Q

Routine Radiologic Evaluation of the Elbow: Oblique View (ER)

Modified TF
A. In the external oblique view, the capitulum and lateral epicondyle are viewed in profile.
B. The humeroulnar and humeroradial joint spaces are also visible in this view.

34
Q

Routine Radiologic Evaluation of the Elbow: Anteroposterior View

Modified TF
A. The central ray is diagonal to the elbow joint in taking the AP view.
B. The patient’s arm is placed in the anatomic position (fully extended and externally rotated), and is usually done in sitting position.

A

FT

A: The central ray is perpendicular to the elbow joint in taking the AP view.

35
Q

Routine Radiologic Evaluation of the Elbow: Anteroposterior View

Modified TF
A. In the AP view, the olecranon process is seen to be articulated in the olecranon fossa, and the humeroradial and humeroulnar joints are well demonstrated.
B. On the other hand, a portion of the radial head, neck, and tuberosity is superimposed on the ulna.

36
Q

Routine Radiologic Evaluation of the Elbow: Lateral View

Modified TF
A. In the lateral view, there is superimposition of the lateral and medial epicondyles.
B. Only the posterior radial head is imaged without superimposition in this view.

A

TF

B: Only the anterior radial head is imaged without superimposition in this view.

37
Q

Routine Radiologic Evaluation of the Elbow: Lateral View

Modified TF
A. In the lateral view, the coronoid process of the olecranon is superimposed with the anterior portion of the radial head.
B. The fat pads of the coronoid and radial fossae are visualized as a circular shape above the distal humerus.

A

FF

A: In the lateral view, the coronoid process of the olecranon is superimposed with the posterior portion of the radial head.
B: The fat pads of the coronoid and radial fossae are visualized as a triangular shape above the distal humerus.

38
Q

Routine Radiologic Evaluation of the Elbow: Lateral View

Modified TF
A. In the lateral view, the image is taken with the elbow flexed to 90º, and demonstrates the distal humerus and proximal radius and ulna.
B. The central ray is perpendicular to elbow joint and this is done in sitting, with the hand on the table and FA supinated.

39
Q

Routine Radiologic Evaluation of the Elbow:

Modified TF
A. In the lateral view, calcification implies possible inflammation in the bursa, a characteristic of nurse maid elbow.
B. The olecranon process is seen in profile articulating with the olecranon fossa in this view.

A

FT

A: In the lateral view, calcification implies possible inflammation in the bursa, a characteristic of student’s elbow.

40
Q

Basic Projections and Radiologic Observations of the Elbow

Modified TF
A. The minimum recommended projections for the elbow include the AP and lateral views.
B. The oblique views are not always indicated, and for trauma cases, additional radiographs of the forearm are needed (AP and lateral views).

41
Q

Specific Clinical Indications of MRI of the elbow (Yes or No)

  1. Refractory tennis elbow
  2. Limited or painful range of motion contracture
  3. Unexplained elbow swelling
  4. Neuropathy whose cause is localized to the shoulder
A
  1. Yes
  2. Yes
  3. Yes
  4. No (localized to the elbow)
42
Q

Specific Clinical Indications of MRI of the elbow (Yes or No)

  1. Prolonged, refractory, or unexplained elbow pain
  2. Sports injuries, especially in throwing athletes
  3. Elbow instability that can be acute, recurrent, or chronic
  4. Painful elbow snapping or mechanical symptoms
A
  1. Yes (Pts have done X-Rays and PT sessions but did not see any abnormality or any decrease in impairment)
  2. Yes
  3. Yes
  4. Yes
43
Q

CT Scan of the Elbow

Modified TF
A. CT Scans extend from the top of the distal humeral metaphysis to the proximal ulnar metaphysis and from the medial to lateral humeral epicondyles.
B. Typically, radiologists review the axial slices first, then saggital, and lastly coronal.

A

FT

A: CT Scans extend from the top of the distal humeral metaphysis to the proximal radial metaphysis and from the medial to lateral humeral epicondyles.

44
Q

Modified TF
A. At the stage of maturity, the secondary ossification center of the capitulum is easily visible on imaging.
B. The body fully ossifies at the age of 25.

A

TF

B: The body fully ossifies at the age of 21.

45
Q

Carrying Angle

Modified TF
A. The carrying angle is the angle from the longitudinal axis of the distal humerus and the proximal ulna.
B. The angle is greater in men than women, with a normal value of 15º.

A

TF

B: The angle is greater in women than men, with a normal value of 15º.

46
Q

Case: J.K. was advised to undergo an MRI procedure as the MD suspects osteochondral lesions on their (L) elbow, but they have
non-removable body piercings. What imaging can be performed instead of MRI?

47
Q

TRUE OR FALSE: Evaluation of any condition can be done using articular contrast for a CT Arthogram if MR Arthrogram is contraindicated or unavailable.

48
Q

Elbow Sectional Anatomy

Enumerate the 2 preferred arm positions for MRI and CT Scan when the patient positioned in prone or supine with their arm overhead

A
  1. “Mighty Mouse” (one arm) position
  2. “Superman” (both arms) position
49
Q

TRUE OR FALSE: The elbow functions to adjust the extremity’s height and length and the functional position of the head to accommodate prehensile tasks efficiently, thus it is important in object manipulation.

A

True

NOTE: No elbow = no function

50
Q

Elbow anatomy

Enumerate the 3 separate synovial articulations in 1 joint capsule

A

Humeroulnar joint, humeroradial joint, proximal radioulnar joint

51
Q

Elbow anatomy

Modified TF
A. The humeroradial joint is known as the elbow joint.
B. Both the humeroulnar and humeroradial joints have 1 degree of freedom for flexion and extension.

A

FT

A: The humeroulnar joint is known as the elbow joint.

52
Q

Indications for CT Scan of the Elbow (Yes or No)

  1. Severe trauma
  2. Assessment of alignments and displacement of fracture fragments
  3. Identification of loose bodies in the elbow joint
  4. Neoplasm and infections of bone, joint, or soft tissue
A
  1. Yes
  2. Yes
  3. Yes
  4. No (These are indications for MRI)
53
Q

Advanced Imaging Evaluation

Modified TF
A. MRI can reveal occult fracture abnormalities of the synovium, muscle, tendons, and joint capsule.
B. CT Scan may also be used to identify occult fractures, osteochondral lesions, and specific locations of the loose bodies.

54
Q

Advanced Imaging Evaluation

It is appropriate for the examination on tendon tears, bursitis or epicondylitis.

A. MRI
B. CT Scan
C. Diagnostic ultrasound
D. X-ray

A

C. Diagnostic ultrasound

55
Q

Advanced Imaging Evaluation

Modified TF
A. Radiographs are the first imaging test to confirm bone and soft tissue abnormalities of the elbow.
B. Radiographs often suffice to either exclude an abnormality and direct further imaging or diagnose the problem and facilitate treatment.

A

TT

NOTE: Radiographs may reveal intraarticular loose bodies, osteophytes, heterotrophic ossification, or calcium deposits.

56
Q

The following are indications for MRI of the elbow, EXCEPT:

A. Arthritides
B. Symptomatic plicae, synovial folds, and elbow menisci
C. Biceps and triceps tendinopathy, partial and complete tears
D. Cartilaginous lesions, chondral fractures and flaps, chondromalacia, degenerative arthritis
E. None

A

E. None

NOTE: Arthritides can be due to primary inflammatory and erosive, infectious, neuropathic, degenerative, crystal-induced (gout or pseudogout), post-traumatic etiologies.

57
Q

Elbow Sectional Anatomy

What does the FABS position stand for?

A

Flexed Elbow
ABducted Arm
Supinated Forearm

58
Q

The following are indications for MRI of the elbow, EXCEPT:

A. Epicondylitis
B. Olecranon and bicipitoradial bursitis (septic, traumatic, crystal-induced, inflammatory)
C. Soft tissue injuries associated with a known fracture
D. Ligamental disorders (LCL, MCL, annular ligament sprains)
E. None

59
Q

The following are indications for MRI of the elbow, EXCEPT:

A. Cubital tunnel syndrome
B. Marrow edema syndromes
C. Joint effusions and inflammatory or proliferative synovitis
D. Intraarticular bodies (chondral, osteochondral, osseous)
E. None

60
Q

The following are indications for MRI of the elbow, EXCEPT:

A. Occult fractures, stress fractures
B. Marrow abnormalities (bone contusions, osteonecrosis)
C. Peripheral nerve disorders and ulnar or median nerve impingement
D. Primary and secondary bone and soft tissue tumors
E. None

61
Q

TRUE OR FALSE: MRI is useful for early detection of osteochondritis dissecans.

62
Q

TRUE OR FALSE: An example of a contraindication for MRI is extensive tattoos.

63
Q

TRUE OR FALSE: The most common type of dislocation of the elbow is when only the radius is dislocated.

64
Q

TRUE OR FALSE: The most common mechanism of injury at the upper extremity is a fall on an outstretched hand.

65
Q

TRUE OR FALSE: Complications of fractures of the radial head include wrist pain, tears of the TFCC, and posttraumatic arthritis.

66
Q

TRUE OR FALSE: Residual pain and deformity is common after fractures of the elbow.

67
Q

TRUE OR FALSE: MR Arthrography is useful at the elbow to detect tears of the collateral ligaments.

(3) Musculoskeletal Imaging (25 decks)

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