Musculosekeltal Diseases and Disorders: Elbow and Forearm

1. Musculosekeltal Diseases and Disorders: Elbow and Forearm PTP 521

2. Anteroposterior view: A • Alignment: • Identify the structures from a proximal to distal view • Radial head should be aligned with the capitulum but not directly in contact with it • Olecranon should be centered in the olecranon fossa • Carrying angle should be noted and be ~ 15 dg.

3. Abnormal Anteroposterior View • This view will demonstrate the following pathologies, if present: • Fractures of the distal humerus – supra, trans, and intercondylar • Fractures of the medial and lateral epicondyles • Fractures of the capitulum, trochlea and lateral aspect of radial head • Varus and Valgus deformities • Secondary ossification centers of the distal humerus

4. Anteroposterior view: B • Bone Density: pay particular attention to the radial head for any chips/fractures • Look for Trabecular lines • Pay attention to the medial and lateral epicondyles for any lucencies or breaks in the margins

5. Ossification Centers • 6 ossification centers around the elbow joint. • Mnemonic C-R-I-T-O-E (Capitulum - Radius - Internal or medial epicondyle - Trochlea - Olecranon - External or lateral epicondyle). • The ages at which these ossification centers appear are highly variable and differ between individuals. • As a general guide you could remember 1-3-5-7-9-11 years. • None should be open at age 13. www.radiologyassistant.nl/en/4214416a75d87

6. C and S • Cartilage: • Evaluated with an MRI, joint space is noted with the radial head and capitulum only • Soft Tissue: not seen well on an AP view • Fat Pad Sign (Sail Sign): evidence of swelling or bleeding anterior to the elbow emedicine.medscape.com/article/389069- imaging

7. Lateral View of the Forearm Anterior humeral line • Identify: trochlea, capitulum, radial head, coronoid process. • Alignment: • Line drawn through center of humeral shaft should intersect line through shaft of radius and be ~ 90 dg. Radiocapitulum line

8. Radiocapitulum line: • Unless there is a dislocation of the radius, a line drawn through the center of the radius, should ALWAYS pass through the center of the capitulum. • Bottom right: dislocation http://www.radiologyassistant.nl/en/4214416a75d87

9. Anterior Humeral Line • Line drawn along the anterior surface of the humerus, in a lateral view, should pass through the middle third of the capitulum http://www.radiologyassistant.nl/en/4214416a75d87

10. Abnormal Lateral View • The lateral view will demonstrate the following pathologies, if present: • Supracondylar fractures of distal humerus • Fractures of anterior radial head and olecranon • Complex dislocations of the elbow joint • Dislocation of the radial head • pad sign (sail sign)

11. Lateral View • Bone Density: view the radial head, trabecular lines

12. Cartilage: • Able to see a joint space between the radius and the capitulum • Trochlea and the coronoid process • Soft Tissue: • May or may not be seen in this view • Evaluate for changes in density of the tissue which may indicate swelling • Fat pad sign (Sail sign) can be seen in this view as well

13. External Oblique View • Radiohumeral joint (long white arrow) • Capitulum, radial head (yellow arrow) • Radial neck (orange arrow) • Radial tuberosity, coronoid process (dark blue arrowhead) • Trochlea notch/trochlea articulation (light blue arrowheads) • Proximal radioulnar articulation http://www.ceessentials.net/article29.html

14. Abnormal • The External Oblique view will demonstrate the following pathologies, if present: • Fractures of radial head and lateral epicondyle s614.photobucket.com/albums/tt228/ex_cowboy/?...

15. Internal Oblique • This view is taken to demonstrate the coronoid process, trochlea notch, and medial trochlea • Forearm is pronated ~ 45 dg • Abnormal: will demonstrate fractures of the medial epicondyle and the coronoid process http://www.ceessentials.net/article29.html

16. Radial Head/Capitulum or Trauma View • Trauma View is when the radius is completely on top of the ulna, not overlapped. • Humeroradialjoint (white arrow) • Radial head (dark blue arrow) • Capitulum (orange arrow) radial notch of the ulnar and radioulnar joint (yellow arrow) • Neck of the radius (light blue arrow) http://www.ceessentials.net/article29.html Look at this view and evaluate the difference between the lateral view and the trauma lateral view - Its in the radial head position

17. Radial Head /Capitulum Trauma View • The trauma view will demonstrate the following • Fractures of radial head, capitulum and coronoid process • Abnormalities of the humeroradial and humeroulnar joints

18. CT Imaging • Utilized to determine the following abnormal pathology: • Complex fractures around the elbow, particularly comminuted fractures • Healing process • Non union of bones • Secondary infections

19. CT Imaging of the Elbow • MRI seems to replace a lot of CT imaging because of the soft tissue around the elbow • These images are of a trochlear fracture (sorry, I couldn’t get better resolution) www.jortho.org/2008/5/3/e5/index.htm

20. These two CT images demonstrate the radioulnar articulation. • On the left is a coronal image of the elbow showing the radioulnar joint (A) and on the right the head of the humerus (C) and ulna (B) that form the joint. www.ceessentials.net/article29.html

21. On the left is a sagittal cut through the elbow • On the right a coronal cut through the elbow. • Both pictures demonstrate the humeroradial joint formed by the capitulum of the humerus (A) and the head of the radius (B). • Reconstructions from axial data www.ceessentials.net/article29.html

22. Humeroradial Joint • 3D volume rendered image demonstrating the humeroradial joint (A). • The sagittal CT image demonstrates this articulation formed by the articulation (B) fovea of the head of the radius, and (C) capitulum of the humerus. www.ceessentials.net/article29.html

23. Can you name the anatomy?(Don’t click until you are ready to answer) www.ceessentials.net/article29.html A = cornoid process, ulna B = coronoid fossa, humerus C = olecranon process D = olecranon fossa

24. Midsagittal plane CT • Demonstrates the positions of the anterior (B) and posterior (A) fat pads. • If these fat pads are elevated following trauma, it may indicate intra-articular hemorrhage secondary to fracture of the radial head or neck. • Sail sign as seen on the radiographs. www.ceessentials.net/article29.html

25. MRI Imaging • Demonstrates the following pathology: • Abnormalities of the ligaments, tendons and muscles • Lateral epicondylitis • Bicipital tendonitis • Ulnar collateral ligament injury • Radial collateral ligament injury • Bone Contusion • Capsular ruptures • Joint effusions • Synovial Cysts • Hematomas • OsteochondritisDissecans • Epiphyseal fractures in children

26. MRI Imaging • Axial view, T1 weighted • Humerus • Ulna • Tendons • Ligaments – image black • Nerves • Vascular • Muscles lateral medial

27. Axial View • What is the anatomy of 1-5? • 1= Biceps Brachii • 2= Brachialis • 3= Brachial artery • 4= Humerus • 5= Triceps http://anatomy.med.umich.edu/radiology/xray/arm_mri_zoom.html

28. CFT: common flexor tendon • CET: common extensor tendon • RCL: radial collateral ligament • UCL: ulnar collateral ligament

29. CORMPGR • Coronal Plane • Sequence: MPGR (Multiplanar Gradient Recalled) This is an echo pulsed sequence • This image demonstrates the humerus, ulna, radius is not in the picture just yet • Radial collateral lig • Ulnar collateral lig medial

30. CORPD • Coronal View • Proton Density • Here you can see the radius as well as the ulna, humerus, olecranon

31. US Imaging • Normal anterior elbow appearance at the humeroradial joint (wide short arrow) with the fat pad at the radial fossa demonstrated (thin arrow). www.gehealthcare.com/.../products/cme_msk.html

32. Normal distal biceps tendon (arrows) with insertion deep to vein (longitudinal) www.gehealthcare.com/.../products/cme_msk.html

33. Normal lateral common extensor tendon origin (arrows) with normal hyper- echogenicity of the longitudinal tendon www.gehealthcare.com/.../products/cme_msk.html

34. Normal medial epicondyle, common flexor tendon origin (large arrows on hyperechoic longitudinal tendon ) and ulnar collateral ligament (small arrows on hypoechoic ligament). www.gehealthcare.com/.../products/cme_msk.html

35. Normal ulnar nerve at the joint in longitudinal (left) and transverse (right) planes (arrows). www.gehealthcare.com/.../products/cme_msk.html

36. Musculoskeletal Injury • Systems that refer pain to area • Other joints that refer pain to area • Bone • Muscle • Tendon • Nerve • Ligament • Capsule and Joint • Other - Bursitis • Dislocations • Fractures • Strain and Inflammation • tendonosis • Entrapment • Sprain and Inflammation • Arthritis: OA and RA • Arthritic Disorders • Rupture • strain • Rupture • Osteochondrosis • Bruise • Other • Trigger Points

37. Fractures: Musculoskeletal Practice Pattern 4G Fractures of the Distal Humerus 1. Suprachondylar fractures: extra- articular • Most common fracture in children- 65% • Uncommon fracture in adults • Left arm more than right – protective response • 98% occur with arm extended and wrist dorsiflexed • Possible neurovascular complications: ~22% neuro and 10% vascular • Possible permanent impairment and deformity McKinnis LN, 2005

38. Gunstock Deformity • Common complication of a suprachondylar fracture

39. SX: • purple discoloration of hand, • severe pain in forearm muscles initially • paresthesias as the dysfunction progresses • Signs: • cool pale extremity with altered pulse • pain on passive stretch • swelling initially • numbness distal to the ischemic region

40. 2. Transcondylar: intracapsular but extraarticular fracture • Common in elderly 3. Epicondylar Fractures: extra-articular 4. Condylar Fractures McKinnis LN, 2005

41. 5. Intercondylar Fractures • T intercondylar, Y Intercodylar Medial or Lateral Condyle 6. Intra-Articular Fractures • Compressive forces across the elbow McKinnis LN, 2005

42. Volkmann's Ischemia Compartment Syndrome • Prolonged ischemia of the forearm muscles • muscle necrosis • replacement of tissue with fibrous tissue • severe deformities of the hand and wrist • paralysis of muscles. • Three stages: mild, moderate and severe • Causes: • Arterial injury caused by an open laceration, • Arterial disruption secondary to a severely displaced fracture or dislocation

43. Fractures of the Radial Head: Mason Classification System • Type I • Non-displaced fracture • Often missed on x-ray • Positive posterior fat pad sign • RX: minimal immobilization, early ROM

44. Radial Head Fracture • Type II • Displaced fracture • Separation or angulations of the fracture fragment • RX: ORIF, early motion

45. Radial Head Fractures • Type III • Comminuted fracture of the entire head • Children ages 4-14 • RX: ORIF and early motion

46. Radial Head Fractures • Type IV • Comminuted fracture • Dislocation of the elbow • Usually cause some functional limitation • RX: radial head resection

47. Fractures of the Coronoid Process • RX: • Open reduction generally necessary • Concern for elbow instability • Classified: Regan-Morrey • Type I: tip of coronoid • Type II: less than 50% coronoid tip • Type III: more than 50% of the coronoid boneandspine.com/wp-content/uploads/2009/02/c...

48. Fractures of the Olecranon • MOI: fall onto the flexed elbow • MOI: Boxer’s elbow: avulsion fracture of the olecranon

49. MonteggiaFracture • Dislocation of radial head – most common lateral or anterolateral, posterior rare • Fracture of ulnar metaphysis or diaphysis

50. Badu Classification of Monteggia Fractures Resnick D. Physical injury: extraspinal sites. In: Diagnosis of Bone and Joint Disorders. 3rd ed. 1992.