Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5779_Библиотеки_им_академика_М_И_Перельмана
.pdf
70 Chapter 3
LATE RA L ELBOW
Common Extensor Tendon
1. Patient position: Sitting with elbow flexed and forearm mid-supination/pronation
2. Probe/transducer position: The probe is placed on the lateral epicondyle as the bony landmark
and oriented along the common extensor tendon for the LX view. The probe is then rotated
90 degrees to visualize the tendon in the SX view (Figure 3-25).
A
Figure 3-25. Common extensor
tendon. (A) Probe placement. (B) LX
view of the common extensor tendon
(white arrow) showing the lateral
epicondyle (LE) and radial head (RH).
(C) SX view of the common extensor
tendon (white arrow) overlying the
lateral epicondyle (LE).
3. Relevant anatomy: The common extensor tendon originates from the lateral epicondyle.
4. Points to remember: Deep to the common extensor tendon, the radial collateral ligament
(RCL) can be seen.
B
C
Elbow 71
Lateral Collateral Ligament Complex
Relevant anatomy of the region is shown in Figure 3-26.
Figure 3-26. Anatomy of radial/lateral collateral ligament of the elbow. There are 3 ligaments in the lateral collateral
ligament complex: RCL, annular ligament, and lateral UCL.
1. Patient position: Same position as that for common extensor tendon scanning for the RCL.
The elbow is flexed more than 90 degrees and resting on the table for the ulnar attachment of
the annular ligament and lateral UCL scanning.
2. Probe/transducer position: The probe is placed on the lateral epicondyle and oriented along
the common extensor tendon. The RCL is visualized deep to the common extensor tendon
extending between the lateral epicondyle distal surface and annular ligament around the
radial head. The annular ligament with its ulnar attachment is visualized by placing the probe
across the radius and ulna on the dorsal aspect of the forearm. The lateral UCL is visualized by
placing the probe on the posterior aspect of the forearm in oblique orientation to visualize the
LX of the lateral UCL spanning from the ulna to the humerus (Figures 3-27 through 3-29).
9
AB
Figure 3-27. RCL. (A) Probe placement. (B) RCL (white arrows) visualized deep to the common extensor tendon
extending between the lateral epicondyle (LE) distal surface and the annular ligament around the radial head (RH).
72 Chapter 3
A
B
Figure 3-28. Ulnar attachment of the annular ligament. (A) Probe placement.
(B) Annular ligament with its ulnar attachment (white arrows) visualized by
placing the probe across the radius and ulna on the dorsal aspect of the
forearm.
AB
Figure 3-29. Lateral UCL. (A) Probe placement. (B) Lateral UCL (white arrows)
visualized by placing the probe on the posterior aspect of the forearm in
oblique orientation to visualize the LX of the lateral UCL.
3. Relevant anatomy: There are 3 ligaments in the lateral collateral ligament complex: RCL,
annular ligament, and lateral UCL.
4. Points to remember: There is blending of the fibers of the ligaments of the lateral collateral ligament; therefore, understanding the orientation of the attachment of each ligament helps in identification and better visualization of each component of the lateral collateral ligament complex.
Elbow 73
Radial Nerve
1. Patient position: Sitting with elbow in extension
2. Probe/transducer position: The probe is placed transversely on the anterior elbow, and the bra-
chialis and brachioradialis muscles are identified. The radial nerve is visualized between the
brachialis and brachioradialis muscles in the SX view. The probe is then rotated 90 degrees to
obtain the LX view of the nerve (Figures 3-30 and 3-31).
A
Figure 3-30. SX view of the radial
nerve at the level of the anterior elbow.
(A) Probe placement. (B) Radial nerve
bundle (white arrow) between the
brachioradialis (BRD) and brachialis (BR)
muscles.
B
74 Chapter 3
A
Figure 3-31. LX view of the radial nerve at the level of the anterior elbow. (A) Probe placement. (B) LX view of the radial
nerve (white arrows) overlying the anterolateral joint area. (RH = radial head.)
B
3. Relevant anatomy: At the level of the anterior elbow, radial nerve branches are visualized
between the muscle plane of the brachialis and brachioradialis. The radial nerve appears
hyperechoic and is accompanied with small blood vessels.
4. Points to remember: Color Doppler or power Doppler ultrasound can be used to differentiate
radial nerve branches from accompanying small blood vessels.
Elbow 75
POSTERIOR ELBOW
Joint Anatomy
1. Patient position: Sitting with elbow flexed to 90 degrees; posterior elbow pointing toward the
examiner
2. Probe/transducer position: The probe is placed on the posterior aspect of the elbow in the LX to
visualize the joint and olecranon fossa area. The probe is then rotated 90 degrees to visualize
the joint region in the SX view, moving distal to proximal to visualize the joint and then the
olecranon fossa region (Figures 3-32 and 3-33).
A
C
B
Figure 3-32. LX view of the posterior elbow joint. (A) Probe placement. (B)
LX view of the posterior elbow. Structures visualized from distal to proximal:
triceps insertion on the olecranon (OL), joint area (big white arrow), olecranon
fossa (white triangle) with overlying fat pad (hyperechoic). The triceps muscletendon complex (small white arrows) is superficial to the joint and bony
interface. (Tr = trochlea.) (C) Relevant joint anatomy and probe placement.
76 Chapter 3
A
Figure 3-33. SX view of the posterior
elbow joint. (A) Probe placement. (B)
SX view at the olecranon fossa (white
arrow) level. (C) SX view at the joint
level.
B
C
3. Relevant anatomy: Structures visualized posteriorly from distal to proximal: triceps insertion
on the olecranon, joint area, olecranon fossa with overlying fat pad, and triceps muscle-tendon
complex superficial to the joint and bony interface.
4. Points to remember: 90-degree flexion helps in better visualization of the joint and fossa
region. Adding extension restricts visualization of the joint and fossa. Adding more flexion
exposes the cartilage-lined humeral trochlea for scanning.
Elbow 77
Triceps Tendon
1. Patient position: Same position as in posterior joint scanning
2. Probe/transducer position: The probe is placed along the triceps tendon in the LX as it attaches
on the olecranon process. The probe is then rotated 90 degrees to scan the tendon in the SX
view (Figures 3-34 and 3-35).
A
Figure 3-34. LX view of the triceps tendon. (A) Probe placement. (B) LX view of the triceps tendon (white arrows)
attaching to the olecranon process (OL). Also shown is the joint space (white star) and olecranon fossa (white triangle).
B
AB
Figure 3-35. SX view of the triceps tendon. (A) Probe placement. (B) SX view of the
triceps tendon (white arrow) overlying the olecranon process.
3. Relevant anatomy: The long head, lateral head, and medial head of the triceps form a single
tendon distally. The triceps tendon attaches on the olecranon process.
4. Points to remember: 90-degree flexion helps in better visualization of the tendon as it takes the
slack out of the tendon or adds stretch to the tendon to counter anisotropy artifact. Scanning the
tendon in 0-degree extension will result in a darker appearance of the tendon due to anisotropy.
78 Chapter 3
Olecranon Bursa
1. Patient position: Same position as in posterior elbow joint scanning
2. Probe/transducer position: The probe is placed in the LX over the olecranon process. The probe
is then rotated 90 degrees to scan the area in the SX view (Figure 3-36).
A B
Figure 3-36. LX view of the olecranon bursa. (A) Probe placement. (B) The
probe is placed in the LX over the olecranon process. Lots of gel and very light
pressure are needed to scan the olecranon bursa region because increased
pressure will push the fluid away from the probe, resulting in nonvisualization
of the existing ef fusion. The gel interface between skin and probe helps in
minimal to no deformation of the subcutaneous tissue. Bursa is a potential
space and is not depicted in normal states.
3. Relevant anatomy: The olecranon bursa is a subcutaneous bursa overlying the olecranon pro-
cess bony surface.
4. Points to remember: Lots of gel and very light pressure are needed to scan the olecranon bursa
region, especially in early stages of bursal effusion or bursitis. Increased pressure will push
the fluid away from the probe, resulting in nonvisualization of the existing effusion. The gel
interface between the skin and probe helps in minimal to no deformation of the subcutaneous
tissue. Bursa is a potential space and is not depicted in normal states.
Elbow 79
REFERENCES
1. Tagliafico AS, Bignotti B, Martinoli C. Elbow US: anatomy, variants, and scanning technique. Radiology.
2015;275(3):636-650.
2. Konin GP, Nazarian LN, Walz DM. US of the elbow: indications, technique, normal anatomy, and pathologic
conditions. Radiographics. 2013;33(4):E125-E147.
3. Kalume Brigido M, De Maeseneer M, Jacobson JA, Jamadar DA, Morag Y, Marcelis S. Improved visualization of
the radial insertion of the biceps tendon at ultrasound with a lateral approach. Eur Radiol. 2009;19(7):1817-1821.
4. Smith J, Finnoff JT, O’Driscoll SW, Lai JK. Sonographic evaluation of the distal biceps tendon using a medial
approach: the pronator window. J Ultrasound Med. 2010;29(5):861-865.
5. Eames MH, Bain GI, Fogg QA, van Riet RP. Distal biceps tendon anatomy: a cadaveric study. J Bone Joint Surg
Am. 2007;89(5):1044-1049.
6. Tagliafico A, Michaud J, Perez MM, Martinoli C. Ultrasound of distal brachialis tendon attachment: normal and
abnormal findings. Br J Radiol. 2013;86(1025):20130004.
7. Creteur V, Madani A, Sattari A, Bianchi S. Sonography of the pronator teres: normal and pathologic appearances. J Ultrasound Med. 2017;36(12):2585-2597.
8. Malagelada F, Dalmau-Pastor M, Vega J, Golanó P. Elbow anatomy. In: Doral MN, Karlsson J, eds. Sports
Injuries: Prevention, Diagnosis, Treatment and Rehabilitation. Berlin, Germany: Springer-Verlag; 2014:1-30.
9. De Maeseneer M, Brigido MK, Antic M, et al. Ultrasound of the elbow with emphasis on detailed assessment of
ligaments, tendons, and nerves. Eur J Radiol. 2015;84(4):671-681.
Соседние файлы в папке Библиотека им академика М.И. Перельмана