ULTRASOUND OF THE ELBOW - Normal

Click to enlarge Transverse plane through the proximal forearm. REF:Grays anatomy.

Note: Move your mouse over the ultrasound image to see highlighted anatomy.

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
Radial Nerve scan plane.	Radial Nerve - normal.

For detailed protocol on scanning the lateral elbow

Anterior Elbow

• Elbow joint
• Biceps tendon
• Median Nerve

Common extensor tendon insertion to the lateral humeral epicondyle.	Longitudinal anterior elbow joint.
Biceps insertion onto radial tubercle- Longitudinal.	Normal Biceps tendon insertion.
Biceps tendon and median nerve at elbow crease-Transverse.	Median nerve and biceps tendon in antecubital fossa.

For detailed protocol on scanning the anterior elbow

Medial Elbow

• Common Flexor Tendon
• Ulna nerve
• Ulna Collateral Ligament

Common Flexor tendon insertion.	Normal Common Flexor Tendon.
Ulna collateral ligament.	Normal ulna collateral ligament.
Scan Plane for Transverse Ulnar nerve.	Normal Ulnar Nerve in the ulna groove.

For detailed protocol on scanning the lateral elbow

Posterior Elbow

• Triceps tendon
• Olecranon Bursa
• Olecranon Fossa

Longitudinal triceps insertion.	Normal longitudinal triceps insertion.
Olecranon fossa Transverse scan plane.	Transverse Olecranon Fossa.

For detailed protocol on scanning the posterior elbow

ULTRASOUND OF THE ELBOW PROTOCOL

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, oedema
• Guidance of injection, aspiration or biopsy
• 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.

SCANNING TECHNIQUE

• Take a good history.
• As with any scan, be systematic. Treat the elbow as a cylinder. Begin laterally then scan the front, medial and posterior aspects.

PATIENT POSITION

Patient seated to provide easy access and movement of the elbow.

This can be:

1. On a high swivel chair
2. Seated on the side of the bed.
3. Seated on a chair opposite the ultrasound bed, facing you with their arm resting on the bed.

LATERAL ELBOW 

• For example images of pathology, click here to go to the elbow pathology page.

Common Extensor Tendon (CET) - 'Tennis Elbow':

• Flex the elbow.
• Put the toe of the probe on the lateral humeral epicondyle with the heel towards to wrist.
• The CET will be a fibrillar echogenic flat topped insertion.

Look for:

• Convexity indicating swelling (should be flat)
• Loss of fibrillar architecture
• Calcification
• Hyperaemia

Radial Nerve

• With the arm supinated.
• Place the probe transversely, centered on the lateral aspect of the anterior elbow crease.
• The radial nerve is directly beneath.
• Follow it proximally around the back of the upper arm.
• Then distally into the forearm where it divides into superficial and deep branches.

Look for:

• Ganglia
• Entrapment of the deep branch through the supinator.

Radial Collateral Ligament (RCL)

Is difficult to see (As with the Ulna collateral ligament).

• Is a fan-like band.
• With the elbow flexed.
• The RCL is seen as an extension from the annular ligament around the radial head up to the humerus deep to the CET.

Look for:

• Absence of the fibrillar architecture

ANTERIOR ELBOW

• For example images of pathology, click here to goto the elbow pathology page.
• Have the arm supinated and gently flexed.

Joint

• Scan in sagittal across the antecubital fossa to assess for a joint effusion.

Biceps Brachii Tendon insertion

• Begin in transverse and follow distally
• Rotate into longitudinal and follow to the insertion
• You will need pressure on the heel and to angle from the ulna aspect as the tendon dives to insert onto the radial tuberosity.

Look for:

• Continuous integrity of the tendon from the musculo-tendinous junction to the insertion.

MEDIAL ELBOW 

For example images of pathology, click here to goto the elbow pathology page. 

Common Flexor Tendon (CFT)-'Golfers Elbow':

• Flex the elbow.
• Put the toe of the probe on the medial humeral epicondyle with the heel towards to wrist.
• The CFT will be a fibrillar echogenic flat topped insertion.

Look for:

• Convexity
• Loss of fibrillar architecture
• Calcification
• Hyperaemia

Ulna Collateral Ligament (UCL) Is difficult to see (As with the radial collateral ligament).

• Is a fan-like band. Usually the posterior aspect is affected.
• With the elbow flexed.
• The UCL is seen posterior and beneath the common flexor tendon.

Look for:

• Absence of the fibrillar architecture

Ulna Nerve

• With the elbow flexed.
• Place the probe transversely, across the Olecranon and medial humeral epicondyle.
• The ulna nerve is directly beneath in the ulna groove.
• Follow it proximally around the back of the upper arm.
• Then distally down to the wrist.

Look for:

• Ganglia
• Subluxation out of the groove during extension.

POSTERIOR ELBOW

For example images of pathology, click here to goto the elbow pathology page.

•  Triceps Insertion:
  • Place the heel of the probe on the tip of the Olecranon tip.
  • Assess in longitudinal and transverse.
  • Check the integrity of the tendon.

•  Olecranon Fossa:
  • In longitudinal the dip in the posterior humerus is deep to the triceps.
  • In transverse the lateral borders of the fossa are visible.
  • Check for loose calcific bodies or fluid.

•  Olecranon Bursa:
  • If particularly rounded and swollen, this can be difficult maintain contact to scan.
  • You may need a standoff pad or pile of thick gel over the slightly flexed Olecranon tip.
  • The swollen Olecranon bursa will be seen as a complex fluid collection over the Olecranon tip.
  • Usually has increased vascularity.

BASIC HARD COPY IMAGING 

An elbow series should include the following minimum images.

• Common extensor tendon
• Radial nerve
• Biceps brachii tendon
• Median nerve
• Anterior joint
• Common Flexor tendon
• Ulna collateral ligament
• Ulna nerve
• Triceps insertion
• Olecranon fossa
• Olecranon bursa
• Document the normal anatomy and any pathology found, including measurements and vascularity if indicated.