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SON5024 MSK > Topic 4 elbow > Flashcards

Topic 4 elbow Flashcards

1
Q

Name the extensor tendons and their compartments

A
  1. Abductor pollicis longus tendon (APL)
  2. Extensor pollicis brevis tendon (EPB)
  3. Extensor carpi radialis longus tendon (ECRL)
  4. Extensor carpi radialis brevis tendon (ECRB)
  5. Extensor pollicis longus tendon (EPL)
  6. Extensor digitorum and extensor indices tendons
  7. Extensor digiti minimi tendon (EDM)
  8. Extensor carpi ulnaris tendon (ECU)
    Compartment 1 APL and EPB
    Compartment 2 ECRL and ECRB
    Compartment 3 EPL
    Compartment 4 Extensor digitorum and indices tendons
    Compartment 5 EDM
    Compartment 6 ECU
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2
Q

Name the flexor tendons of the wrist and describe where they are in the wrist

A

Flexor pollicis longus tendon in radial bursa (FPL)
Flexor carpi radialis tendon (FCR)
Palmaris longus tendon (PL)
Flexor digitorum superficialis tendons (FDS)
Flexor digitorum profundus tendons (FDP)
Flexor carpi ulnaris tendon (FCU)

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3
Q

Explain how the naming of tendons denotes its actions

A

If the name has CARPI in it, it will be a big tendon that mainly affects wrist movements, whilst anything with POLLICIS and DIG ITO RUM are mainly thumb and finger movers.

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4
Q

How is ultrasound useful in the clinical setting of lateral epicondylitis?

A
  • lateral epicondylitis remains a clinical entity
  • sonography can confirm the diagnosis and reveal the extent and severity of the disease.
  • In the absence of any significant findings, sonography can exclude posterior interosseous nerve entrapment and reveal lesions of the lateral collateral ligament.
  • The diagnosis of partial or complete tear may encourage the clinician to refer the patient directly to surgery because these injuries are less likely to respond to conservative treatment.
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5
Q

What is one of the shortfalls of ultrasound is assessing the elbow?

A

• its inability to identify an intraarticular cause for the patient’s symptoms

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6
Q

What is the advantage of sonography in imaging a biceps rupture?

A

• its ability to optimize the imaging plane with real-time scanning to best display tendon abnormality, particularly the irregular longitudinal profile of the partially torn tendon.

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7
Q

What must you never forget when scanning MSK?

A

• Always image the contralateral side for comparison

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8
Q

What structures can be identified at the lateral elbow?

A
  • lateral epicondyle
  • common extensor tendon origin (CETO)
  • radial collateral ligament (RCL)
  • radial nerve and branches
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9
Q

Which tendons make up the common extensor tendon?

A

• composed of fibres from the extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, and extensor carpi ulnaris.

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10
Q

Which tendon makes up most of the articular side of the CEO?

A

• the fibers of the extensor carpi radialis brevis

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11
Q

Which tendon makes up most of the superficial portion or the CEO?

A

• the extensor digitorum

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12
Q

What can overuse of any or all of these extensor muscles result in

A

• an ‘overuse syndrome’, commonly called lateral epicondylitis or tennis elbow.

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13
Q

What is tennis elbow?

A
  • degenerative process
  • not a true inflammatory condition
  • will lead to microtears and mucoid degeneration, and eventually macrotears.
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14
Q

What demographic is tennis elbow often seen in?

A

• often seen in tennis players, throwing athletes, and tradesmen

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15
Q

What movement is thought to cause tennis elbow?

A

• generally considered the result of repetitive microtrauma sustained during supination of the forearm and dorsiflexion of the wrist.

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16
Q

What does tennis elbow look like on ultrasound?

A
  • will vary from acute to chronic
  • The most common appearance of lateral epicondylitis is a focal hypoechoic area in the deep part of the tendon with a background of intrinsic tendinopathy
  • It may have a normal background or one characterized by a diffuse decrease in echotexture with loss of the normal fibrillar pattern
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17
Q

What can contour change indicate in the CEO?

A

o The normal CETO has a flattened superficial surface
o In acute disease, it will become swollen and take on an abnormal convexity.
o a chronic tear can become concave with significant loss of tendon substance.

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18
Q

What different tendon texture might you see in a pathological CEO?

A 
o	Loss of fibrillar pattern
o	decreased echogenicity
o	fluid or calcific deposits
o	anechoic tears
o	delamination type tears 
are all markers of tendon pathology.
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19
Q

What can bony change indicate at the CEO?

A

o most commonly seen as traction spurring off the tip of the lateral epicondyle
o more severe cases there can be marked enthesopathy and bony spurring.

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20
Q

Why must you be careful examining the CEO after a steroid injection?

A

• granulation tissue will commonly form four to six weeks post injection, creating echogenic deposits within the tendon and mimicking tears

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21
Q

How can partial tears appear at the CEO?

A

• Anechoic foci with no fibers intact

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22
Q

How might partial and complete tears present on a background of diffuse tendinopathy?

A

• Discrete cleavage planes on a background of decreased echotexture and loss of fibrillar pattern

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23
Q

What is diffuse tendinopathy characterised by?

A

• discrete lack of echotexture and fibrillar pattern alone, characteristic of diffuse tendinopathy

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24
Q

What can spurring at the CEO indicate?

A

• Spurring can be present at all levels of the disease

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25
Q

What are some differentials of tennis elbow?

A
  • entrapment of the posterior interosseous nerve
  • chondromalacia or osteochondritis dissecans of the radiocapitellar joint
  • an intraarticular body
  • posterolateral rotatory instability
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26
Q

Where do you find the RCL?

A
  • can be seen as an independent structure

* slightly anterior under the CETO

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27
Q

What is diagnostic of an RCL tear?

A
  • Look at the joint between the inferior end of the lateral epicondyle and the radial head.
  • If you see fluid arising from this joint and collecting at the underside of the CETO, then the radial collateral ligament which forms part of the joint capsule must be torn.
28
Q

Where does the radial nerve divide?

A

• As the radial nerve passes over the CETO, it divides into two branches
o the superficial
o the deep.

29
Q

What is the path of the superficial radial nerve?

A

• The superficial radial nerve continues along the posterolateral aspect of the forearm to the hand

30
Q

What is the path of the deep radial nerve?

A

also known as the posterior interosseous nerve (PIN), dives through the supinator muscle to run along the edge of the radius

31
Q

What is ‘radial tunnel syndrome’?

A
  • has presenting symptoms similar to extensor tendinosis
  • Posterior interosseus nerve PIN branch can become entrapped by a build-up of fibrous tissue on the edge of the supinator muscle, commonly called the Arcade of Frohse.
  • fibrous tissue can be caused by small tears and repair in the supinator muscle
  • usually accompanied by point tenderness.
32
Q

How does radial tunnel syndrome appear on ultrasound?

A
  • entrapment can be confirmed by pronating and supinating the forearm, watching the area of concern for any ‘jerking’ movement of the underlying structures.
  • Also check for any mass such as a ganglion or lipoma which could be compressing on the radial nerve and causing a neuropathy.
33
Q

Which structures should be identified at the anterior elbow?

A
  • anterior joint recess
  • biceps insertion
  • brachialis muscle
  • median nerve
34
Q

How should you scan the biceps tendon?

A

hyperextension and heel toe to prevent anisotropy

• Scan from the medial aspect using the pronator muscle as a window.

35
Q

How is the biceps tendon most commonly ruptured?

A

• Mechanism of injury of the distal biceps tendon is usually forced extension against a flexed elbow.

36
Q

How is a biceps tendon rupture diagnosed clinically?

A

o a palpable defect in the antecubital fossa
o a palpable mass in the anterior aspect of the arm corresponding to the retracted tendon
o and a weakness of flexion and supination.

37
Q

What is the ultrasound appearance of a biceps tendon rupture?

A
  • tendinous discontinuity
  • retraction
  • hypoechoic fluid in the gap
38
Q

How does a partial biceps tear appear on ultrasound?

A
  • Tendon appears thickened and wavy

* But can be traced to their attachments on the radial tuberosities on both longitudinal and transverse images

39
Q

Where is the brachialis tendon?

A
  • inserts onto the coronoid process of the ulna
  • is the deeper of the muscles on the anterior aspect.
  • It can be easily confused with the biceps.
40
Q

What structures are imaged at the medial elbow?

A
  • medial epicondyle
  • common flexor tendon origin (CFTO)
  • ulnar nerve
41
Q

What tendons make up the CFO?

A

flexor carpi radialis, flexor carpi ulnaris, flexor digitorum superficialis and pronator teres

42
Q

What is the object of a CFO examination?

A

o identify CFTO tendon changes;
o differentiate between tendonosis and partial and full thickness tears; and
o identify underlying ligamentous change.

43
Q

What is golfers elbow?

A

Medial epicondylitis
• Tendinosis at the CFTO
• With the growing popularity of rock climbing, this tendon is being subjected to enormous loading stress from finger flexion, and is being injured more commonly.

44
Q

How is the UCL damaged?

A

• This is commonly torn in throwing sports and a tear will be evident at ultrasound with careful evaluation.

45
Q

What are some ultrasound features of an olecranon fracture?

A

moderate joint effusion with low level echoes which is typical of blood (haemarthrosis)
cortical step in the bony surface

46
Q

Why is dynamic assessment of the ulnar nerve at the cubital tunnel important?

A

commonly subluxes medially out of the groove and across the medial epicondyle (up to 20% of people).

47
Q

How should the ulnar nerve be assessed?

A

• Scan while the arm is moved from full extension into gentle flexion.

48
Q

How does ulnar nerve neuropathy appear on ultrasound?

A
  • The nerve will look enlarged and hypoechoic

* may even remain subluxed once it is too big to relocate.

49
Q

Which to ways can ulnar nerve entrapment occur?

A
  • may develop if the ulnar groove contains a space occupying lesion, that is, ganglia, bone spurs
  • At the distal end of the groove the ulnar nerve can become entrapped by the heads of the flexor carpi ulnaris muscle, each head on the ulnar, and the humeral aspect.
  • This is commonly referred to as cubital tunnel syndrome.
50
Q

What structures can be imaged in the posterior elbow?

A
  • olecranon
  • triceps insertion
  • olecranon bursa
  • posterior joint recess
51
Q

What can cause olecranon bursitis?

A

• Leaning on the posterior elbows for extended and frequent periods of time can lead to this condition

52
Q

How does olecranon bursitis appear on ultasound?

A
  • will be evident as a fluid filled sac on the posterior elbow.
  • It is remarkably compressible which means that a very light touch is essential.
  • Extended field of view will show the dimensions of the bursitis.
53
Q

How does a joint effusion appear at the posterior elbow?

A
  • Fluid and loose bodies may be seen at the posterior joint.
  • do not apply too much transducer pressure, as you may obliterate the fluid.
  • This is an excellent alternative to the anterior joint for the demonstration of joint fluid.
54
Q

Briefly describe tennis elbow

A
  • also known as lateral epicondylitis

* is a tendinopathy of the common extensor tendon origin.

55
Q

What does tennis elbow appear as on ultrasound?

A
  • Ultrasound appearances will vary depending on the chronicity of the condition
  • can show contour changes with the superficial surface of the extensor origin being convex and bulging, or concave and dipping.
  • The tendon texture may be diffusely or focally hypoechoic, with some loss of fibrillar texture, or even anechoic zones or linear splits where tears have occurred.
  • There may also be bony changes such as small spurs or enthesopathy at the lateral epicondyle.
  • The more acute phase may show increased vascularity.
56
Q

Briefly describe golfers elbow

A
  • also known as medial epicondylitis

* is a tendinopathy of the common flexor tendon origin.

57
Q

How does golfers elbow appear on ultrasound?

A
  • Ultrasound appearances will vary depending on the chronicity of the condition
  • can show contour changes with the superficial surface of the extensor origin being convex and bulging, or concave and dipping.
  • The tendon texture may be diffusely or focally hypoechoic, with some loss of fibrillar texture, or even anechoic zones or linear splits where tears have occurred.
  • There may also be bony changes such as small spurs or enthesopathy at the lateral epicondyle.
  • The more acute phase may show increased vascularity.
58
Q

Briefly describe students elbow

A
  • olecranon bursitis

* when the patient has been leaning on the posterior aspect of their elbow for frequent and extended periods of time.

59
Q

How does students elbow appear on ultrasound?

A

• The underlying bursa becomes inflamed and thickened, and can be very painful to touch.
Fluid will be present

60
Q

Briefly describe radial tunnel syndrome

A
  • entrapment of the PIN branch of the radial nerve by a build up of fibrous tissue at the edge of the supinator muscle
  • called the Arcade of Frohse.
  • The build up of fibrous tissue is commonly from small tears of the supinator muscle.
  • These can be seen on ultrasound as small hypoechoic areas within the supinator muscle.
61
Q

How does radial tunnel syndrome appear on ultrasound?

A

• Ultrasound at the tender site during pronation and supination may show jerking of the underlying structures and confirm an entrapment of the PIN.

62
Q

Briefly describe pronator teres syndrome

A

• entrapment of the median nerve as it passes through the heads of the pronator teres muscle.

63
Q

How does pronator teres syndrome appear on ultrasound?

A

• Scanning transversely over the tender site and asking the patient to pronate and supinate the forearm, you may be able to see the median nerve being dragged down between the heads of the pronator teres muscle.

64
Q

What is cubital tunnel syndrome?

A
  • entrapment of the ulnar nerve just at the distal end of the ulnar groove.
  • The nerve gets tethered or entrapped between the two heads of the flexor carpi ulnaris muscle.
65
Q

How does cubital tunnel syndrome appear on ultrasound?

A
  • Flexing and extending the forearm and scanning over the posterior elbow will show limited movement of the ulnar nerve in the affected elbow
  • as opposed to the gentle rotational and lifting movements of the ulnar nerve seen in the normal elbow.

SON5024 MSK (15 decks)

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