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3.2 Lateral Compartment
The patient must be positioned with the fore-
arm slightly flexed on the arm (Fig. 3.10).
3.2.1 Common Extensor Tendon
This group of tendons must be evaluated on an
axial scan, placing the proximal edge of the
probe on the lateral epicondyle (Figs. 3.11,
3.12a, b). A short axis scan can be used to pre-
cisely locate the site of a possible tear.
The lateral collateral ligament can rarely
be differentiated from the tendon, due its sim-
ilar echotexture and its deep location.
3.2.2 Humeral-Radial Joint
Look for the humero-radial synovial meniscus
that fills in the gap of the lateral surface of
humeral-radial joint (Figs. 3.13 and 3.14a).
The patient must be asked to pronate and
supinate the forearm to correctly assess the
radial head and the annular ligament (Fig.
3.14b).
The annular ligament takes part in passive
stabilization of the elbow joint; it arises
from the anterior edge of the radial notch of
ulna, coursing around the radial neck, and
inserts on the posterior edge of the radial
notch.
Lateral Compartment
35
Fig. 3.10 Position
of the elbow
to evaluate
the lateral
compartment
Fig. 3.11 Anatomical scheme of the common extensor
tendon. ECU, extensor carpi ulnaris; *, extensor digiti
quinti; EDC, extensor digitorum communis;
ECRB, extensor carpi radialis brevis
3 Elbow
36
Fig. 3.12a Probe position to
evaluate the common exten-
sor tendon
Fig. 3.12b Longitudinal
scan of the common exten-
sor tendon (arrowheads).
R, radius; LE, lateral
epicondyle
Fig. 3.13 Anatomical scheme of the humeral-radial joint.
*, annular ligament; CH, capitulum humeri; R, radius;
U, ulna
Lateral Compartment
37
Fig. 3.14a Longitudi-
nal scan of the
humeral-radial joint.
*, humero-radial
syno
vial meniscus;
R, radius;
Ch, capitulum humeri
Fig. 3.14b Axial scan
of annular ligament
(arrowheads).
R, radius
3.3 Medial Compartment
The patient must be positioned with the fore-
arm slightly flexed on the arm, externally
rotated (Fig. 3.15).
3.3.1 Common Flexor Tendon
To assess the common flexor tendon (Fig.
3.16) on a longitudinal scan, the proximal
edge of the probe must be placed on the medi-
al epicondyle (epitrochlea) (Figs. 3.17a, b).
Note that this tendon is shorter and wider than
the common extensor tendon.
3.3.2 Medial Collateral Ligament
The anterior bundle of the medial collateral
ligament can be seen more deeply than the
common flexor tendon (Fig. 3.18).
This ligament can be more effectively
detected with the patient lying in a supine
position, with the arm abducted and external-
ly rotated, and the elbow flexed at 90° (Figs
3.19a, b).
Medial collateral ligament laxity can be
effectively detected with dynamic scans per-
formed while applying a valgus stress (Fig.
3.20).
The medial collateral ligament arises
from the lower surface of the medial epi-
condyle and then divides into three bun-
dles: the anterior one inserts on the ulnar
coronoid process; the middle one inserts on
the semilunar notch; and the posterior one
inserts on the olecranon.
3 Elbow
38
Fig. 3.15 Position of the elbow to evaluate the medial compartment
Fig. 3.16 Anatomical scheme of the common flexor ten-
don. PT, pronator teres; FCR, flexor carpi radialis; *, fle-
xor digitorum superficialis; circle, palmaris longus;
FCU, flexor carpi ulnaris; ME, medial epicondyle
Medial Compartment
39
Fig. 3.17a Probe
position to evalu-
ate the common
flexor tendon
Fig. 3.17b Longitudinal
scan of the common flexor
tendon (arrowheads).
U, ulna; *, humeral-ulnar
joint; ME, medial
epicondyle
Fig. 3.18 Anatomical scheme of the medial collateral
ligament (*). R, radius; U, ulna; H, humerus
3 Elbow
40
Fig. 3.19a Position of the elbow and probe to evaluate the medial collateral ligament
Fig. 3.20 Valgus stress maneuver
Fig. 3.19b Longitudinal scan of the anterior bundle of the medial collateral ligament (arrowheads). ME, medial epi-
condyle; U, ulna
3.4 Posterior Compartment
Except for the ulnar nerve, the anatomy of the
posterior compartment can be evaluated with
the elbow flexed 90° and the palm placed on a
table (Fig. 3.21).
3.4.1 Triceps Brachii Muscle
and Tendon
The triceps brachii muscle and tendon (Fig.
3.22) must be evaluated on both the long
(Figs. 3.23a, b) and short axis. The distal ten-
don can be affected by anisotropy.
Posterior Compartment
41
Fig. 3.21 Elbow position to evaluate the posterior com-
partment
Fig. 3.22 Anatomical scheme of the triceps brachii
muscle and tendon (*). O, olecranon; LE, lateral epi-
condyle; R, radius
3.4.2 Olecranon Fossa and Posterior
Olecranon Recess
Deeper than the triceps brachii tendon, the ole-
cranon fossa and the posterior olecranon
recess can be seen. Dynamic scans are needed to
detect the presence of intrarticular effusion.
3.4.3 Cubital Tunnel and Ulnar Nerve
The upper limb must be extended and inter-
nally rotated (Fig. 3.24).
The ulnar nerve is located within the
cubital tunnel, between the medial epicondyle
and the olecranon (Fig. 3.25) and cubital tun-
nel (Fig. 3.26).
Ulnar nerve stability can be assessed by
forced hyperflexion of the forearm on the arm
(Fig. 3.27).
The ulnar nerve courses in the axillary
cavity from the secondary trunk of the
brachial plexus. It is directed to the anteri-
or compartment of the arm, running along
the humeral artery and the median nerve.
Then it pierces the medial intermuscular
septum and reaches the posterior compart-
ment of the arm. In the elbow, it runs medi-
ally to the triceps brachii until the epi-
condyle-olecranon tunnel. Distally, it
enters the cubital tunnel.
3 Elbow
42
Fig. 3.23a Probe position to evaluate the triceps
brachii tendon along the longitudinal axis
Fig. 3.23b Longi-
tudinal scan of tri-
ceps brachii tendon
(arrowheads).
O, olecranon
Fig. 3.24 Probe posi-
tion to evaluate the ul-
nar nerve
Posterior Compartment
43
Fig. 3.26 Transverse scan of the cubital tunnel. White arrowheads, ulnar nerve; 1, humeral head of the flexor carpi ul-
naris muscle; 2, ulnar head of the flexor carpi ulnaris muscle; void arrowhead, Osborne retinaculum; U, ulna; H, humerus
Fig. 3.25 Transverse scan of the
epicondyle-olecranon tunnel.
Ulnar nerv
e (arrowheads); ME,
medial epicondyle; O, olecra-
non
Fig. 3.27 Dynamic evaluation to assess
ulnar nerve stability
Wrist evaluation can be started either on the
palmar or the dorsal side. The patient must be
sitting in front of the examiner, with the upper
limb lying on the table.
4.1 Palmar Side
Anatomical scheme of the palmar side of the
wrist is presented in Figs. 4.1a, b. For evaluation
of the palmar compartment, the hand lies on the
table with the palm facing up (Fig. 4.2).
4.1.1 Carpal Tunnel and Median
Nerve
The probe must be placed at the base of the
hand and the bony landmarks of the proximal
carpal tunnel must be looked for (the
scaphoid tubercle on the radial side and the
pisiform on the ulnar side). The probe must be
tilted correctly to obtain the right insonation
of the underlying tendons and nerves (Figs.
4.3a, b).
At this level, the proximal flexor retinaculum
and the flexor digitorum tendons can be seen.
Dynamic scans during finger flexion and
extension can help to detect tendons abnormal-
ities (e.g., muscular lesions or tenosynovitis).
On the radial side of the carpal tunnel, the
flexor carpi radialis tendon can be seen.
Severe anisotropy artifacts can be encoun-
tered at this level (Figs. 4.4a-d).
Then, the probe must be moved distally to
evaluate the distal section of the carpal tun-
nel (the tubercle of the trapezium on the radi-
al side and the hook of the hamate on the ulnar
side) (Fig. 4.5a, b).
Note that the median nerve must be
assessed along its whole course, since com-
pression can occur at both the proximal and
distal retinaculum.
A common anatomical variant of the medi-
an nerve is a bifid median nerve, sometimes
accompanied with the persistence of the medi-
an artery. This is normal and must not be con-
fused with a pathologic condition. Conversely,
the median nerve can be compressed by both
the proximal and distal retinaculum, thus
causing the occurrence of the carpal tunnel
syndrome.
A short axis scan allows for evaluation of
shape changes and mobility alteration while
the patient flexes and extends his fingers.
A long axis scan allows for a panoramic
evaluation of the nerve before, within, and
after the carpal tunnel (Fig. 4.6).
Wrist
4
Content s
4.1 Palmar Side
• Carpal Tunnel and Median Nerve
• Guyon Tunnel and Ulnar Nerve
4.2 Dorsal Side
• Extensor Tendon Compartments
• Distal Radio-Ulnar Joint
45
E. Silvestri, A. Muda, L. M. Sconfienza, Normal Ultrasound Anatomy of the Musculoskeletal System,
© Springer-Verlag Italia 2012