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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5779_Библиотеки_им_академика_М_И_Перельмана
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50 Chapter 3
ANTERIOR ELBOW
Joint Anatomy
1. Patient position: Sitting with elbow resting on the table with full supination and extension
2. Probe/transducer position: The probe is placed transversely on the anterior aspect of the
elbow to visualize the joint in the short axis (SX) view. The probe is then rotated 90 degrees
to visualize the anteromedial and anterolateral aspect of the joint in the long axis (LX) view
(Figures 3-1 through 3-4).
AB
C
Figure 3-1. SX view of the anterior elbow. (A) Probe placement. (B) Ultrasound
image of the anterior elbow in the SX view. A hyperechoic bony interface
is lined by an anechoic cartilage interface. The distal biceps tendon (white
arrow) is hyperechoic and the most superficial tendon. (C) Relevant anatomy
and probe placement.
Elbow 51
Figure 3-2. Expanded SX view of the anterior elbow showing soft tissue structures. The radial nerve (yellow arrow)
is between the brachialis and brachioradialis muscles. The median nerve (white arrow) is between the brachialis and
pronator teres muscles.
A
Figure 3-3. Anterolateral LX view of the elbow. (A) Probe placement. (B)
Ultrasound image of the anterolateral elbow in the LX view, showing the
radial fossa (white arrow), joint (white triangle), and radial head and neck. (C)
C
Relevant anatomy and probe placement.
B
52 Chapter 3
A
B
C
Figure 3-4. Anteromedial LX view of the elbow. (A) Probe placement. (B)
Ultrasound image of the anteromedial elbow in the LX view, showing the
coronoid fossa (white arrow), joint (white triangle), coronoid process (CP), and
trochlea of the humerus. (C) Relevant anatomy and probe placement.
3. Relevant anatomy: The distal humerus is seen as a hyperechoic bony interface lined by
anechoic cartilage above the bony surface. The convex surface is the capitellum, and the concave surface is the trochlea, which is divided into lateral and medial facets.1 Overlying the
joint surface is the brachialis muscle belly. On the radial side, the brachioradialis muscle can
be seen. Between the brachialis and brachioradialis is the radial nerve. On the ulnar side, the
pronator teres muscle is seen. Between the brachialis and pronator teres, the median nerve is
seen next to the brachial artery.
4. Points to remember: Cartilage is best visualized with full extension of the elbow. Adding flexion may limit visualization of the cartilage-lined surface of the distal humerus.
Distal Biceps Tendon
Relevant anatomy of the distal biceps tendon (DBT) is shown in Figure 3-5.
Elbow 53
Figure 3-5. Relevant anatomy of the DBT, which twists from predominantly the frontal plane to the sagittal plane
before inserting on the radial tuberosity. As the DBT crosses the elbow joint, a thin fibrous structure, the lacertus
fibrosus or bicipital aponeurosis (green), fans out in the ulnar direction and merges with the superficial fascia to span
the flexor muscle compartment of the forearm.
54 Chapter 3
1. Patient position: Sitting with full supination and slight elbow flexion
2. Probe/transducer position:
a. SX view: The probe is placed transversely on the anterior aspect of the elbow to visualize
the DBT (Figure 3-6).
A
B
Figure 3-6. SX view of the DBT, anterior approach. (A) Probe placement. (B) SX
view of the DBT (white arrow).
b. LX view:
i. Anterior approach: The probe is rotated 90 degrees from the SX view to visualize the
DBT in the LX view, and the tendon is followed distally to its insertion site at the radial
tuberosity. In the distal part, passive supination of the forearm and increased pressure
on the distal part of the probe are needed to visualize the distal insertional fibers of the
DBT (Figure 3-7).
1,2
A B
Figure 3-7. LX view of the DBT, anterior approach. (A) Probe placement. (B) LX view of
the DBT (white arrows). (RH = radial head.)
Elbow 55
ii. Lateral approach: The probe is placed on the lateral aspect of the elbow with the elbow
flexed to 90 degrees and the forearm supinated to visualize the DBT in the LX view
through the acoustic window of the muscle mass of the forearm extensors, brachioradialis, and supinator muscle (Figure 3-8).
1,3
A
rectangle). (B) With the elbow flexed to 90 degrees and the forearm supinated, the DBT (white arrows) is visualized
in the LX view through the acoustic window of the muscle mass of the forearm extensors (E), brachioradialis, and
supinator muscle (S).
B
Figure 3-8. LX view of the DBT, lateral approach. (A) Probe placement:
probe (red rectangle), DBT (blue arrow), radius (yellow rectangle), ulna (black
56 Chapter 3
iii. Medial approach: With the elbow flexed to 90 degrees and the forearm supinated, the
probe is placed in the LX on the medial aspect to visualize the DBT through the acoustic
window of the flexor-pronator mass. The brachial artery is medial to the DBT and helps
enhance echogenicity of the DBT with this approach (Figure 3-9).
1,4
AB
Figure 3-9. LX view of the DBT, medial
approach. (A) Probe placement. (B) LX
view of the DBT (white arrows) showing
the brachial artery (white triangle). With
the elbow flexed to 90 degrees and
the forearm supinated, the probe is
placed in the LX on the medial aspect to
visualize the DBT through the acoustic
window of the flexor-pronator mass.
The brachial artery is medial to the DBT.
Elbow 57
iv. Posterior approach: This is a limited view of the distal portion of the DBT fibers. The
elbow is maximally flexed and resting on the table with the forearm in full pronation
and the wrist flexed. The probe is placed transversely between the radius and ulna at
the level of the radial tuberosity, about 4 cm distal to the olecranon process. A dynamic
maneuver of supination and pronation will show the DBT with pronation and cause it
to disappear upon supination (Figure 3-10).
1
A
B
C
Figure 3-10. LX view of the DBT,
posterior approach. (A) Probe
placement. (B) The DBT (white arrow)
between the radius and ulna. The
elbow is maximally flexed and resting
on the table with the forearm in full
pronation and the wrist flexed. The probe is placed transversely between the radius and ulna at the level of the radial
tuberosity, about 4 cm distal to the olecranon process. (C) Relevant anatomy and probe placement.
3. Relevant anatomy: The DBT twists from predominantly the frontal plane to the sagittal plane
before inserting on the radial tuberosity. As the DBT crosses the elbow joint, a thin, fibrous
structure called lacertus fibrosus, or bicipital aponeurosis, fans out in the ulnar direction and
merges with the superficial fascia to span the flexor muscle compartment of the forearm.
The footprint of the DBT on the radial tuberosity is divided into 2 parts: a larger proximal
footprint for the long head of the biceps fibers and a small, thin distal footprint for the short
head of the biceps fibers.5 The DBT is surrounded by bicipitoradial bursa, which in normal
states is not depicted on ultrasound.
4. Points to remember: Because of the 90-degree twist in the DBT fibers from the frontal plane
to the sagittal plane and the sudden change in the course of the tendon from being the most
superficial tendon at the level of the elbow joint to the most posterior as it inserts on the medial
aspect of radius, scanning the tendon in the LX view can be challenging. Knowledge of fiber
orientation and course of the tendon is helpful in proper visualization of the tendon. Full supination and increased pressure on the distal end of the probe to make the probe parallel to the
tendon is important to counter the refraction artifact due to the oblique direction of the fibers.
5
58 Chapter 3
Brachialis
1. Patient position: Sitting with elbow extension and resting on the table
2. Probe/transducer position: The probe is placed transversely on the anterior aspect of the elbow
to visualize the brachialis in the SX view, and then the probe is moved distally in the SX view
to visualize the distal portion of the brachialis. The probe is rotated 90 degrees to scan the
brachialis muscle tendon complex in the LX view as it attaches on the coronoid process of the
ulna (Figures 3-11 and 3-12).
BA
Figure 3-11. SX view of the brachialis.
(A) Probe placement. (B) SX view of
the brachialis muscle (white arrow) at
the proximal level. (C) SX view of the
brachialis muscle tendon (white arrow)
at the distal muscle tendon level.
C
Elbow 59
AB
Figure 3-12. LX view of the brachialis.
(A) Probe placement. (B) LX view
showing the superficial head (SH)
and deep head (DH) of the brachialis
attaching to the coronoid process.
3. Relevant anatomy: The brachialis is divided into 2 parts: The larger superficial head originates
from the anterolateral aspect of the middle third of the humerus and lateral intermuscular
septum, and the deep head originates from the distal third of the anterior aspect of the humerus and the medial intermuscular septum. The brachialis continues distally and inserts on the
coronoid process of the ulna. The superficial head attaches more distally than the deep head.
4. Points to remember: The tendon of the distal brachialis is thinner than the DBT. Variations of
the distal insertion of the brachialis tendon on the coronoid process of the ulna include purely
muscular, tendinous, or mixed.
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