MR imaging of the elbow in the injured athlete

Proximal radioulnar joint, but not posterolateral, instability in patients with symptomatic minor instability of the lateral elbow

BACKGROUND

The elbow joint is stabilized laterally by a complex of bony and ligamentous structures, such as the lateral ulnar collateral ligament and radial lateral collateral ligament (RLCL). Pathogenesis of many elbow conditions like symptomatic minor instability of the lateral elbow (SMILE) is based on ligamentous incompetency. The aim of this study is to measure ligament elongation in SMILE patients and determine the correlation with the development of this pathologic condition.

MATERIALS AND METHODS

Twenty-eight patients were included in this study: half of them were operated for suspected SMILE whereas the others were affected by other elbow diseases. All the patients underwent elbow arthroscopy. During this procedure, 4 parameters were analyzed: annular drive through (ADT), ulnar-humeral stressed distance (UHSD) at 45° and 30° of flexion, and loose collar sign (LCS). A dedicated arthroscopic mini-spreader introduced through an arthroscopic portal was used to take measurements.

RESULTS

Statistically significant differences were found for LCS (P = .0003) and ADT (P = .000002). UHSD at 30° and 45° elbow flexion was slightly higher in SMILE patients, but not significantly.

DISCUSSION AND CONCLUSIONS

Progressive stretching of the RLCL and annular ligament may lead to their elongation, resulting in a pathologic anteroposterior shifting of the radial head and a lower congruence between the inner surface of the annular ligament and the radial head cartilage, resulting in proximal radioulnar instability. The study shows how RLCL and annular ligament are elongated in SMILE patients compared with controls, causing instability of the proximal radioulnar joint and confirming that ligament incompetency is involved in the SMILE condition.

Sports-related peripheral nerve injuries of the upper limb

Peripheral nerve injuries in athletes affect the upper limb more commonly than the lower limb. Common mechanisms include compression, traction, laceration, and ischemia. Specific sports can have unique mechanisms of injury and are more likely to be associated with certain neuropathies. Familiarity with these sport-specific variables and recognition of the common presentations of upper limb neuropathic syndromes are important in assessing an athlete with a suspected peripheral nerve injury. Evaluation may require imaging modalities and/or electrodiagnostic testing to confirm a nerve injury. In some cases, diagnostic injections may be needed to differentiate neuropathic versus musculoskeletal etiology. Early and accurate diagnosis is essential for treatment/management and increases the likelihood of a safe return-to-sport and avoidance of long-term functional consequences. Most nerve injuries can be treated conservatively, however, severe or persistent cases may require surgical intervention. This monograph reviews key diagnostic, management, and preventative strategies for sports-related peripheral nerve injuries involving the upper limb.

Magnetic Resonance Imaging for Elbow Pathology: Overused by Both Orthopaedic Surgeons and Primary Care Providers

Background

Magnetic resonance imaging (MRI) use by both orthopedic surgeons and primary care providers (PCP) for analysis of elbow pathology is expensive and growing in frequency. In light of this, scrutiny regarding the appropriate utilization of this technology is increasing. Currently, there is no literature investigating the appropriateness of MRI use for complex elbow pathology from either orthopedic surgeons or PCPs.

Methods

A retrospective chart review was performed on consecutive elbow MRIs performed at a tertiary care center between January 1, 2012, and December 31, 2015. A total of 225 patients were included. Patients meeting the inclusion criteria were divided into two cohorts, determined by whether the ordering provider was an orthopedic surgeon or a PCP. MRI referrals were made by orthopedic surgeons in 94 patients and by nonorthopedic surgery providers in 131 patients. MRI diagnoses of no pathology, muscle/tendon tear, neuritis/nerve injury, tendinosis, ligament injury/instability, osteoarthritis/degenerative joint disease/decreased range of motion/contracture, or fracture/osteochondral injury were analyzed, as were the interventions of no intervention, nonprocedural treatment (therapy, orthosis, or nonoperative modality), nonsurgical procedure/referral for procedure, referral to surgeon, surgery, additional imaging/electrodiagnostic nerve testing, or other.

Results

1. Orthopedic surgeons are more accurate in their diagnoses after MRI, while PCPs order more MRI scans for ‘routine’ diagnoses typically made without MRI. 2. When the MRI did not validate an orthopedic surgeon’s preimaging diagnosis, rates of surgery decreased. The same discrepancy in diagnosis leads to an increase in orthopedic surgeon referrals within the PCP cohort. 3. An MRI was ordered for “pain” by orthopedic surgeons and PCPs in approximately 30% of the patients in both groups with a similarly low rate of pathology discovery.

Conclusions

The unexpected result of this study is that there is still a large quantity of MRI exams being conducted by orthopedic surgeons for the preMRI diagnosis of “pain.” In both groups, there was a similar rate of negative imaging. We expected orthopedic surgeons who have advanced knowledge in musculoskeletal pathology would be less likely to order an MRI for pain and would also less likely order an MRI that resulted in no pathology. This places an increased and unnecessary burden on the financial aspect of the health care system.

Avulsion injuries: an update on radiologic findings

Avulsion injuries result from the application of a tensile force to a musculoskeletal unit or ligament. Although injuries tend to occur more commonly in skeletally immature populations due to the weakness of their apophysis, adults may also be subject to avulsion fractures, particularly those with osteoporotic bones. The most common sites of avulsion injuries in adolescents and children are apophyses of the pelvis and knee. In adults, avulsion injuries commonly occur within the tendon due to underlying degeneration or tendinosis. However, any location can be involved in avulsion injuries. Radiography is the first imaging modality to diagnose avulsion injury, although advanced imaging modalities are occasionally required to identify subtle lesions or to fully delineate the extent of the injury. Ultrasonography has a high spatial resolution with a dynamic assessment potential and allows the comparison of a bone avulsion with the opposite side. Computed tomography is more sensitive for depicting a tiny osseous fragment located adjacent to the expected attachment site of a ligament, tendon, or capsule. Moreover, magnetic resonance imaging is the best imaging modality for the evaluation of soft tissue abnormalities, especially the affected muscles, tendons, and ligaments. Acute avulsion injuries usually manifest as avulsed bone fragments. In contrast, chronic injuries can easily mimic other disease processes, such as infections or neoplasms. Therefore, recognizing the vulnerable sites and characteristic imaging features of avulsion fractures would be helpful in ensuring accurate diagnosis and appropriate patient management. To this end, familiarity with musculoskeletal anatomy and mechanism of injury is necessary.

Distal Triceps Tendon Injuries

Distal triceps ruptures are uncommon, usually caused by a fall on an outstretched hand or a direct blow. Factors linked to injury include eccentric loading of a contracting triceps, anabolic steroid use, weightlifting, and traumatic laceration. Risk factors include local steroid injection, hyperparathyroidism, and olecranon bursitis. Initial diagnosis can be complicated by pain and swelling, and a palpable defect is not always present. Plain radiographs can be helpful. MRI confirms the diagnosis and directs treatment. Incomplete tears can be treated nonsurgically; complete tears are best managed surgically. Good to excellent restoration of function has been shown with surgical repair.

T1ρ-Mapping for Musculoskeletal Pain Diagnosis: Case Series of Variation of Water Bound Glycosaminoglycans Quantification before and after Fascial Manipulation® in Subjects with Elbow Pain

Diagnosis and management of musculoskeletal pain is a major clinical challenge. Following this need, the first aim of our study was to provide an innovative magnetic resonance technique called T_1ρ to quantify possible alterations in elbow pain, a common musculoskeletal pain syndrome that has not a clear etiology. Five patients were recruited presenting chronic elbow pain (>3 months), with an age between 30 and 70 years old. Patients underwent two T_1ρ-mapping evaluations, one before and one after the series of Fascial Manipulation^® (FM) treatments. After the first MRI evaluation, a Disability of the Arm, Shoulder and Hand (DASH) questionnaire was administered to quantify the symptoms and pain intensity. Patients then received three sessions of FM, once a week for 40 min each. A statistically significant difference was found between bound and unbound water concentration before and after FM treatment. Our preliminary data suggest that the application of the manual method seems to decrease the concentration of unbound water inside the deep fascia in the most chronic patients. This could explain the change in viscosity perceived by many practitioners as well as the decrease of symptoms due to the restoration of the normal property of the loose connective tissue. Being able to identify an altered deep fascial area may better guide therapies, contributing to a more nuanced view of the mechanisms of pain.

MRI overestimates the full-thickness tear of distal triceps tendon rupture

PURPOSE

Injury to the distal triceps brachii tendon is rare. Imaging radiographs are used to confirm the findings of physical examination, classify the extent of injury, and guide treatment. Magnetic resonance imaging (MRI) is considered the gold standard of diagnostic imaging. However, no previous study has reported on the accuracy of differentiation between partial- and full-thickness triceps tendon tears. Our study's aim was to define the accuracy of MRI in differentiating partial- from full-thickness tear of the distal triceps tendon. We hypothesized that MRI has low accuracy in differentiating partial- from full-thickness tears.

METHODS

A total of eight patients with nine triceps tendon tears underwent surgical repair from 2011 to 2015. MRI of the elbows were retrospectively reviewed for the presence and type of tear, tendon involvement, and location of the tear, and later correlated with surgical findings.

RESULTS

Of the three surgically confirmed complete tears, MRI correctly reported a complete tear in all patients. Of the six partial tears confirmed at surgery, MRI correctly identified four tears. In two cases, MRI described a complete tear, but only a partial tear was noted at surgery.

CONCLUSION

False-positive MRI assessment of distal triceps injury is not rare. Surgeons should rely on clinical examination in assessing distal triceps tendon injury, with imaging studies providing an adjunctive role in the diagnosis and decision-making.

Imaging bicipitoradial bursitis: a pictorial essay

Although bicipitoradial bursitis is not commonly seen, when it does occur, it can frequently lead to diagnostic difficulty, mimicking either a soft-tissue tumor or infection. Lack of awareness of this uncommon entity can lead to unnecessary anxiety or tissue biopsy. This pictorial essay discusses the normal anatomy of the bicipitoradial bursa and the spectrum of imaging findings of bicipital bursitis.

Magnetic resonance imaging-based classification for ulnar collateral ligament injuries of the elbow

BACKGROUND

Magnetic resonance imaging (MRI) arthrography has been considered the gold standard for imaging ulnar collateral ligament (UCL) injuries. No classification system has been described for UCL tears to help discuss and guide treatment options. We propose that an MRI-based UCL classification system would correlate with valgus laxity and help predict surgical management.

METHODS

The MRIs from 240 patients who underwent UCL reconstruction were reviewed and classified according to a system based on severity and location of the UCL injury. Bilateral elbow valgus stress radiographs were used to compare the amount of valgus laxity associated with each grade of UCL injury. Additional data from the imaging review included intraligamentous calcifications, T-sign presence, and a newly described "vacuum sign."

RESULTS

The amount of valgus stress opening increased with the classification severity as follows: type I, 0.13 mm; type II, 0.20 mm; type III, 0.63 mm; and type IV, 0.76 mm.

CONCLUSIONS

We propose a new classification for UCL injuries based on MRI findings that helps predict valgus laxity, improve communication, and guide treatment for UCL pathology in throwing athletes.

Elbow Imaging in Sport: Sports Imaging Series

Elbow pain is a frequent presenting symptom in athletes, particularly athletes who throw. The elbow can be injured as a result of acute trauma, such as a direct blow or a fall onto an outstretched hand or from chronic microtrauma. In particular, valgus extension overload during the throwing motion can precipitate a cascade of chronic injuries that can be debilitating for both casual and high-performance athletes. Prompt imaging evaluation facilitates accurate diagnosis and appropriate targeted interventions.

Endoscopic Resection of the Bicipitoradial Bursa

The bicipitoradial bursa lies at the insertion of the biceps tendon on the radial tuberosity. It is an unusual site for chronic bursitis. It can be treated conservatively with aspiration and steroid injection. Surgical excision of the bursa is indicated in case of infection cause, failed conservative treatment with recurrence of the enlarged bursa and pain after aspiration, the presence of nerve compression with neurological impairment, mechanical limitation to flexion and extension of the elbow or biceps tendon degeneration, and/or functional impairment. Open resection through the anterior approach requires extensive dissection to expose the radial tuberosity and the radial neck, which increases the risk of neurovascular injury. Endoscopic resection is possible through distal biceps tendoscopy and endoscopy around the radial neck. It is technically demanding and should be reserved to the experienced elbow arthroscopist.

Distal Triceps Tendon Injuries

Acute triceps ruptures are an uncommon entity, occurring mainly in athletes, weight lifters (especially those taking anabolic steroids), and following elbow trauma. Accurate diagnosis is made clinically, although MRI may aid in confirmation and surgical planning. Acute ruptures are classified on an anatomic basis based on tear location and the degree of tendon involvement. Most complete tears are treated surgically in medically fit patients. Partial-thickness tears are managed according to the tear severity, functional demands, and response to conservative treatment. We favor an anatomic footprint repair of the triceps to provide optimal tendon to bone healing and, ultimately, functional outcome.

Triceps tendon rupture: the knowledge acquired from the anatomy to the surgical repair

Triceps injuries are relatively uncommon in most traumatic events, and the distal triceps tendon ruptures are rare. Recently, the knowledge of this tendon lesion has increased, and it seems to be related to more precise diagnostic and clinical assessments. The most common mechanism of injury remains a forceful eccentric contraction of the muscle, while several other risk factors have been studied as chronic renal failure, endocrine disorders, metabolic bone diseases as well as steroid use. Olecranon bursitis and local corticosteroid injections may also play a role. The commonest site of rupture is at the tendon's insertion into the olecranon and rarely at the myotendinous junction or intramuscularly. The surgical intervention is recommended in acute complete ruptures, and non-operative treatment is reserved for patients with major comorbidities, as well as for partial ruptures with little functional disability and in low demanding patients. Various techniques and approaches as the direct repair to bone, the tendon augmentation, the anconeus rotation flap and the Achilles tendon allograft have been proposed for the management of these challenging injuries. The goal of surgical management should be an anatomical repair of the injured tendon by selection of a procedure with a low complication rate and one that allows early mobilization. This manuscript focuses the triceps tendon ruptures starting from the anatomy to the diagnosis and entity of the triceps tendon injuries, as well as the indications and guidelines for the management.

Bicipitoradial Bursitis: A Review of Clinical Presentation and Treatment

The bicipitoradial bursa lies at the insertion of the biceps tendon on the radial tuberosity. It is an unusual site for chronic bursitis and most often results from repetitive mechanical trauma or overuse. Other causes include tuberculosis, immunological complications of rheumatological disease and synovial chondromatosis. Accurate diagnosis requires imaging studies and sometimes histological study. It can be treated conservatively with aspiration and steroid injection. Surgical excision of the bursa is indicated in the case of infection cause, failed conservative treatment with recurrence of the enlarged bursa and pain after aspiration, presence of nerve compression with neurological impairment, mechanical limitation to flexion, and extension of the elbow or biceps tendon degeneration and/or functional impairment.