Ultrasonography of injuries and diseases of the elbow joint

Epicondylitis. A common disease characterized by pain in the supracondylosis of the humerus. It is often found in people whose profession is associated with repetitive movements of hands, especially pronation and supination (typists, musicians), or with physical stress on the hands at a certain static position of the body (locksmiths, dentists), as well as athletes (tennis players, golfers) . In clinical course, acute and chronic stages are distinguished. In the acute stage, the pain has a permanent character in the region of one of the epicondyles, radiates along the muscles of the forearm, the function of the elbow joint may be disrupted. There is pain in the compression of the hand, the inability to hold the hand in the extended position (symptom of Thompson), the retention of the load on the arm (symptom of fatigue), there is weakness in the hand. In the subacute stage and chronic course of pain arise during exercise, have a dull, aching character. Noticeable hypotrophy or muscle atrophy.

The most typical pathological condition is the lateral epicondylitis or the so-called "tennis elbow". The medial epicondylitis is called the "golf elbow" or "pitcher's elbow." Both these states arise from traumatic and inflammatory conditions in the fibers of the tendons of the corresponding muscle groups. Medial epicondylitis is associated with changes in flexor tendons. Lateral epicondylitis is associated with the pathology of the tendons of the extensor muscles. With the development of tendinitis, the tendon thickens, its echogenicity decreases. The structure may be heterogeneous with the presence of calcifications and hypoechoic areas reflecting intrasuperbial micro-ruptures. The pathological process at the onset of the disease has the character of aseptic inflammation of the periosteum and tendon-ligamentous apparatus in the shoulder epicondyle. In the future, degenerative-degenerative processes develop. Radiographically, about a third of patients, periosteal growths in the region of the epicondylitis, ulnar spurs, dilatations of the bone structure of the epicondyle, areas of the enostosis, etc., are revealed.

At ultrasound examination, the place where the forearm muscles attach to the humerus epicondyle can exhibit a typical degenerative pattern: hyperechoic fragments or tendon sites well delineated from surrounding tissues. Intraarticular bodies can also be defined. In the course of treatment, the ultrasound picture can change: hyperechoic patches can change their size and shape.

Tears of the distal part of the biceps tendon of the shoulder. Observed mainly in middle-aged people, weightlifters or athletes who work with weights. Among all injuries of the upper extremities, ruptures of the distal part of the tendon of the biceps brachium muscle account for up to 80% of cases. This type of injury significantly disrupts the function of the joint, so more often there are fresh gaps. When viewed, the biceps muscle is thickened and deformed, as compared to the contralateral limb. Flexion in the elbow joint is made with difficulty due to the muscles of the brachial, brachial and round pronator. Tears of the tendon of the biceps arm muscle arise at the place of attachment to the tuberosity of the radius. When palpation, you can feel the torn off proximal end of the tendon, shifted up to the lower third of the shoulder.

In ultrasound examination, tendon damage can occur with fractures of the radius. In the place of rupture above the tuberosity of the radius, a hypoechoic region appears, the fibrillation of the fibrillar structure of the tendon, the cubital bursitis, and the inflammation of the medial nerve are noted.

Tendons of the tendon of the triceps brachialis muscles. Discontinuities of this type are less common. Clinically, soreness is seen along the back surface of the elbow joint, a defect of the tendon above the elbow is palpable. With the elbow joint raised above the head, the patient can not straighten the patient's arm (complete rupture) or the action is accompanied by considerable effort (partial rupture).

Full gaps are noted more often than partial gaps. At partial ruptures in the place of rupture a hypoechoic region is formed - a hematoma. With complete ruptures, a hypoechoic region (hematoma) is formed at the attachment site of the tendon of the triceps muscle, bursitis of the ulnar process is joined, in 75% of cases there may be fractured fractures of the elbow process, ulnar nerve subluxation and fracture of the head of the radius.

Damage to the lateral ligaments. Isolated lesions of the lateral ligaments are rare. Most often combined with the rupture of the capsule, the fractures of the coronoid process of the ulna, the medial epicondyle, the head of the radius. The medial ligament is damaged more often than the lateral ligament. The mechanism of rupture of ligaments indirect - a fall on the arm straightened in the elbow joint.

Separation of ligaments often occurs at the place of attachment to the epicondyle of the humerus, sometimes with a bone fragment. The ligament rupture is indicated by abnormal mobility in the elbow joint, edema and bruising extending to the posterior surface of the forearm.

Fractures. Among fractures of the elbow joint are fractures of the condyles of the humerus, the elbow and coronoid processes of the ulna, the head of the radius. Most often there are fractures of the head of the radius, constituting up to 50% of all injuries of the elbow joint. This may damage the distal part of the biceps tendon of the shoulder.

In 20% of all cases of injuries of the elbow joint, there are fractures of the elbow process. In fractures of the ulnar process, the tendon of the triceps muscle of the shoulder is also damaged. If there is an ulnar edema, the ulnar nerve may be impaired.

Exudation in the joint cavity. When studying from the front access area of the coronary fossa, you can determine even a small amount of fluid in the elbow joint. Also, fluid can accumulate in the region of the pit of the elbow process, where intraarticular bodies are often detected.

Tendinitis and tenosynovitis. With tendinitis, the tendons of the biceps or the triceps thicken, the echogenicity decreases in the acute stage, these manifestations are particularly noticeable when compared with the contralateral side. Unlike ruptures, the integrity of the tendon is preserved. In chronic tendinitis at the site of attachment of the tendon to the bone, hyperechoic inclusions are formed. The tendon structure can be non-uniform.

Bursits. The most common bursitis in the region of the elbow process. Bursitis can accompany the ruptures of the triceps muscles of the shoulder or contribute to their occurrence. Bursitis is characterized by a hypoechoic cavity above the elbow process. The contents of the bag can have a different echogenicity from anechogenous to isoechogenic. Changes in the echogenicity of the contents also occur over time: hyperechoic inclusions may appear. With the long existence of changes, the walls of the bag become thick and hyperechoic. In the ultrasound angiography regimens, vessels in the walls of the bag and surrounding tissues are visualized. Kubital bursitis is less common. It can accompany ruptures of the distal part of the biceps tendon of the shoulder, and also occurs with tendonosis. In ultrasound examination, a shoulder bag is defined in the area of attachment of the biceps tendon of the shoulder to the tuberosity of the radius.

Compression of the ulnar nerve in a cubital tunnel is the most common cause of all ultrasound investigations of the ulnar nerve. Nerve compression occurs between the medial edge of the proximal ulna and the fibrous fibers that connect the two heads of the ulnar flexor of the wrist. The main ultrasound manifestations of the cubital tunnel syndrome include: thickening of the nerve proximal to compression, flattening of the nerve inside the tunnel, decreased nerve mobility within the tunnel. Measurements of the ulnar nerve are carried out with transverse scanning.

The calculations are carried out according to the area formula of the ellipse: the product of two mutually perpendicular diameters divided by four times the number n. Studies have shown that the average area of the ulnar nerve is 7.5 mm ² at the level of the epicondyle. The transverse diameter of the ulnar nerve in men is on average 3.1 mm, and in women 2.7 mm. Anteroposterior dimensions: 1.9 mm and 1.8 mm, respectively.

Dislocation of the ulnar nerve. Displacements are easily diagnosed by ultrasound when the nerve emerges from the furrow when the arm is bent at the elbow joint and returns to its place when it is extended. This pathology is associated with the innate absence of bounding bundles of the cubital tunnel. This pathology occurs in 16-20% of cases. Usually it is asymptomatic, but it can be manifested by pain, a feeling of tingling, fatigue or loss of sensation. With subluxation, the ulnar nerve is more susceptible to injury.

With ultrasound examination, the nerve is enlarged in size to an average of 7.2 mm x 3.7 mm. Scanning with nerve dislocation should be done without pressure on the area under investigation. The study is performed with a dynamic sample with extension and flexion of the arm in the elbow joint. When the nerve leaves the furrow, an offset is detected. This phenomenon is also observed with injuries of the distal humerus, anomalies of triceps weightlifters. However, in these cases, the displacement of the ulnar nerve is accompanied by a displacement of the medial head of the triceps. To the displacement of the ulnar nerve can also lead bursitis, triceps ruptures, aneurysms.