RC 110 - The elbow: a comprehensive approach
1. To understand that assessing this joint requires a multimodality approach with careful attention to technique, imaging protocol, choice of coils and sequences.
2. To learn about the pivotal role of the radiologist in evaluating elbow imaging to provide relevant information to the arthroscopist.
The elbow is a complex hinge joint commonly injured in trauma and subject to chronic overuse syndromes in both athletic and non-athletic individuals. Understanding of the anatomy, systematic image evaluation as well as structured reporting are crucial for accurate diagnosis and to assist in surgical decision making. Recognised pitfalls and normal variants should not be confounded with pathology. Chronic overuse injuries or instability may have subtle imaging manifestations and some injuries may clinically emulate or exacerbate other entities; therefore, imaging prior to intervention is essential. Relevant parameters of tendon injury for treatment planning and the imaging appearance of the different instability patterns of the elbow joint due to lesion of the valgus/varus stabilizers need to be identified. Ulnar neuropathy at the elbow is the most common and best recognised, but there are other nerve entrapment syndromes that should not be missed. The choice of imaging modality for soft tissue derangement at the elbow includes MR and US, whereas CT is usually reserved for osteoarticular evaluation. US allows dynamic evaluation and may demonstrate findings which would otherwise be missed at static examinations. This session will provide a profound review of the imaging appearance of tendon anatomy and pathology, ligament injury and instability and nerve entrapment syndromes at the elbow with different imaging modalities. Interventional techniques for treating elbow tendon disease will also be discussed
1. To become familiar with the normal imaging anatomy and pathological appearances of the elbow tendons.
2. To learn about interventional radiological techniques for treating elbow tendon disease.
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1. To become familiar with patterns of abnormality seen in elbow instability.
2. To learn about the imaging findings of elbow instability.
The elbow joint is an intrinsic very unstable joint. It derives its stability from the capsula, joint crossing muscles, tendons and ligaments. Ligament injuries are not frequent although it depends upon the patient population. In sports people, e.g. throwing sports like baseball, it is quite common. The most common stabilising ligaments are on the ulnar and radial side. On the ulnar side, the ulnar collateral ligament (UCL) is the most important one often injured in situations where acute (severe) valgus stress is applied to the elbow. The most common chronic instability due to a ligament injury of the elbow, however, is the posterolateral instability. The most important structure on the radial side involved in this type of instability is the lateral ulnar collateral ligament (LUCL). At the same time this is also one of the most challenging ligaments to visualise for the radiologist. After a brief introduction of the anatomy, the mechanisms of injury to the medial and lateral ligaments will be discussed. Optimisation of the imaging protocol will be reviewed with the respective values of ultrasound and MRI.
1. To understand the radiological anatomy of the peripheral nerves at the elbow.
2. To learn about the imaging findings of nerve entrapments at the elbow.
The most common condition around the elbow is the cubital tunnel syndrome. It is a compression neuropathy that can occur either at the condylar groove or at the edge of the arcuate ligament. Causes of compression include direct extrinsic compression on the condylar groove, bone abnormalities, and soft tissue lesions. Clinical findings include elbow pain and sensory symptoms in the innervated area. Diagnosis is mainly based on electrophysiological studies but US may demonstrate the presence of nerve thinning/thickening and associated abnormalities. Ulnar nerve instability at the cubital tunnel is also common but is asymptomatic in up to 47% of patients. When symptoms are present, US may demonstrate nerve thickening with hypervascularisation. The median nerve is infrequently impinged around the elbow. Anterior interosseous neuropathy occurs where nerve branches off the median nerve, in proximity to the pronator teres and the tendinous bridge connecting the heads of the flexor digitorum superficialis. When this syndrome is clinically suspected, US evaluation is usually inconclusive. However, abnormal reflectivity of innervated muscles can be seen. The median nerve may also be impinged as passing the pronator teres muscle. Posterior interosseous neuropathy is an uncommon condition of impingement at three different locations around the elbow, but more typically near or behind the supinator muscle at the proximal third of the forearm, where the nerve enters a strong fibrous arcade (i.e. arcade of Frohse). Clinical presentation is typical and US is able to identify the thickened nerve impinging in the arcade of Frohse.