Skin, Soft Tissue, and Musculoskeletal Ultrasound

Point-of-care ultrasound may be used to assist in the diagnosis of skin, soft tissue, and musculoskeletal concerns in the emergency department. Frequently, linear or curvilinear probes are used to perform these studies and ultrasound may be used to assist in common emergency department procedures related to these conditions.

Ultrasonography in diagnosis of distal biceps tendinosis: A case series

Introduction

Biceps tendinosis, a milder form on the spectrum of biceps tendinopathy, is unusual at the distal insertion site. Patients with distal biceps tendinosis may experience pain and dysfunction which could inhibit their activities of daily living. Diagnosis of distal biceps tendinosis may be facilitated with ultrasonography (US), whose accuracy is increasingly recognised, while providing many benefits over other modalities, like magnetic resonance imaging (MRI).

Case report

We report two cases of distal biceps tendinosis diagnosed by US with clinical details, imaging findings and patient management. Two patients present with elbow pain after nontraumatic activities. US revealed a thickened distal biceps tendon with mild heterogeneous hypoechogenicity without fibre disruption or retraction in both cases and evidence of hyperemia on Doppler with surrounding bursal fluid in case 2.

Discussion

Tendinosis has variable aetiologies, but US commonly cannot differentiate among these; therefore, patient's clinical history is the major component in determining the underlying cause. Chronic progression of tendon pathology leads to partial and full thickness tears. Tendinosis has a characteristic US appearance. US has many benefits and clinicians may use this modality to assess possible pathological structures with ease, convenience and efficiency compared with using MRI.

Conclusion

Distal biceps tendinosis may present with clinical symptoms of pain and decreased activities of daily living, and may progress to more severe forms of tendinopathy. Early diagnosis is beneficial for the treatment outcomes of this condition. US can visualise distal biceps tendinosis with reliability, providing an alternative diagnostic technique with many benefits compared with MRI.

Reliability and Validity of the Hook Test for Diagnosis of Distal Biceps Tendon Ruptures

PURPOSE

Although the initial description of the distal biceps tendon (DBT) hook test (HT) reported 100% sensitivity (Sn) and specificity (Sp), subsequent retrospective series have demonstrated imperfect validity. The purpose of this investigation was to prospectively assess the validity and reliability of the HT for complete DBT ruptures. We aimed to determine the Sn/Sp and interrater reliability for the HT.

METHODS

A consecutive series of adult patients presenting to our outpatient clinics with an elbow complaint was prospectively examined. Patients were included if they had undergone advanced imaging (magnetic resonance imaging or ultrasound) that imaged the DBT and underwent DBT repair. There were four participating surgeons, all of whom were blinded to magnetic resonance imaging/ultrasound prior to performing the HT. To determine the Sn/Sp of the HT and advanced imaging, intraoperative findings served as the primary reference standard. The interrater reliability of the HT was calculated for cases in which a primary examiner (surgeon) and secondary examiner (physician assistant or resident) performed the HT.

RESULTS

Of 64 patients who had undergone advanced imaging, 28 (44%) underwent DBT surgery and were included in the assessment of Sn/Sp. The mean age was 49 years, and all patients were men. The Sn and Sp of the HT were 96% and 67%, respectively. Advanced imaging demonstrated 100% Sn and Sp. Twenty-five patients were evaluated by a primary and secondary examiner. The interrater reliability was substantial (Cohen kappa, 0.71).

CONCLUSIONS

The Sn and Sp of the HT were 96% and 67%, respectively, when assessed prospectively. Advanced imaging findings (magnetic resonance imaging/ultrasound) demonstrated 100% Sn and Sp. The HT can be performed reliably by examiners with varying experience levels. Considering the imperfect validity of the HT, we caution against the use of this examination alone to diagnose DBT ruptures.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic II.

Acute and Chronic Elbow Disorders

Elbow pain is very common and can be due to many pathologic conditions. After radiographs are obtained, advanced imaging is often necessary. Both ultrasonography and MR imaging can be used to evaluate the many important soft-tissue structures of the elbow, with each modality having advantages and disadvantages in certain clinical scenarios. Imaging findings between the two modalities often correlate. It is important for musculoskeletal radiologists to understand normal elbow anatomy and how best to use ultrasonography and MR imaging to evaluate elbow pain. In this way, radiologists can provide expert guidance to referring clinicians and best guide patient management.

Ultrasound is more reliable than clinical tests to both confirm and rule out pathologies of the long head of the biceps: a systematic review and meta-analysis

PURPOSE

To synthesize the literature and critically appraise current evidence to determine the most accurate physical examination (clinical test or ultrasound) to detect pathologies of the long head of the biceps tendon (LHBT).

METHODS

A search was performed on PubMed, Embase®, and Cochrane. Studies that compared the diagnostic accuracy of clinical tests or ultrasound versus arthroscopy for the assessment of LHBT pathologies were included.

RESULTS

Seven studies were included reporting on a total of 448 patients. One study on instability using ultrasound reported sensitivity and specificity of 1.00 and 0.96, respectively. Two studies on full-thickness tears using ultrasound reported sensitivity and specificity of 0.88-0.95 and 0.71-0.98, respectively. Four studies on partial-thickness LHBT tears reported sensitivity and specificity of 0.17-0.68 and 0.38-0.92, respectively, for clinical tests, versus 0.27-0.71 and 0.71-1.00, respectively, for ultrasound. Three studies on other LHBT pathologies reported sensitivity and specificity of 0.18-0.79 and 0.53-0.85, respectively, for clinical tests, versus 0.50 and 1.00, respectively, for ultrasound.

CONCLUSION

To detect LHBT pathologies, sensitivity is high-to-excellent using ultrasound, and moderate using Neer's sign and Speed's test, while specificity is high-to-excellent also using ultrasound, as well as the belly press, lift-off and Kibler's tests. The clinical relevance of these findings is that clinical tests are only reliable either to confirm or rule out LHBT pathologies, whereas ultrasound is reliable both to confirm and rule out LHBT pathologies. While diagnostic imaging cannot substitute for patient history and physical examination, the reliability and accessibility of ultrasound render it practical for routine use, particularly if clinical tests render unclear or contradictory findings.

LEVEL OF EVIDENCE

Level III.

The Beauty of Musculoskeletal Ultrasound: Spot Diagnoses

INTRODUCTION

 Ultrasound is a powerful technique in musculoskeletal (MSK) imaging, and it can replace MR imaging in many specific clinical scenarios. This article will feature some common and less common spot diagnoses in musculoskeletal ultrasound.

SPOT DIAGNOSIS

 Cases were collected by members of the Educational Committee of the ESSR ( European Society of Musculoskeletal Radiology) with expertise in musculoskeletal ultrasound. Sixteen clinical entities are discussed based on the features that allow US spot diagnosis.

CONCLUSION

 Clinical history, location, and ultrasound appearance are the keys to spot diagnoses when performing musculoskeletal ultrasound.

KEY POINTS

  · Musculoskeletal ultrasound can be the primary and only modality in common spot diagnoses in specific clinical settings.. · Clinical history, location, and ultrasound appearance are keys to spot diagnoses.. · Knowledge of spot diagnoses in musculoskeletal ultrasound facilitates daily clinical practice..

CITATION FORMAT

· Drakonaki EE, Martinoli C, Vanhoenacker FM et al. The Beauty of Musculoskeletal Ultrasound: Spot Diagnoses. Fortschr Röntgenstr 2022; DOI: 10.1055/a-1965-9961.

ACR Appropriateness Criteria® Chronic Elbow Pain

Chronic elbow pain can be osseous, soft tissue, cartilaginous, and nerve related in etiology. Imaging plays an important role in differentiating between these causes of chronic elbow pain. This document provides recommendations for imaging of chronic elbow pain in adult patients. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

3D imaging has good specificity but poor sensitivity for the diagnosis of pathologies of the long head of the biceps: a systematic review and meta-analysis

PURPOSE

To systematically review and meta-analyse the literature to determine which three-dimensional (3D) imaging modality provides the best diagnostic accuracy to detect pathologies of the long head of the biceps tendon (LHBT).

MATERIALS AND METHODS

A search was performed on PubMed, Embase^®, and Cochrane. Studies that compared the diagnostic accuracy of 3D imaging modalities versus arthroscopy for the assessment of LHBT pathologies were included. Studies assessing superior labral anterior posterior (SLAP) lesions were excluded.

RESULTS

Fifteen studies were included; nine were eligible for meta-analysis. Six studies on instability indicated a sensitivity of 0.68 (CI 0.46-0.84) and specificity of 0.76 (CI 0.68-0.82). Four studies on full-thickness tears indicated a sensitivity of 0.56 (CI 0.28-0.81) and specificity of 0.97 (CI 0.93-0.99). Four studies on partial-thickness tears indicated a sensitivity of 0.52 (CI 0.20-0.82) and specificity of 0.64 (CI 0.25-0.91). Two studies on any tear indicated a sensitivity of 0.58 (CI 0.28-0.83) and specificity of 0.99 (CI 0.93-1.00). Only one study on other pathologies indicated a sensitivity of 0.61 and specificity of 0.84.

CONCLUSION

To diagnose LHBT pathologies, 3D imaging modalities overall have low-to-moderate sensitivity, but high-to-excellent specificity. The consistency in reported sensitivity is generally poor, while the consistency and reported specificity is good for the detection of instability, full-thickness tears and any tear, but poor for the detection of partial-thickness tears. 3D imaging may be adequate to rule out LHBT pathologies, but are not sufficiently reliable to confirm the presence of such pathologies.

LEVEL OF EVIDENCE

III.

Distal biceps tendon ruptures: more efficient diagnostics for a better outcome

Distal biceps tendon ruptures are a rare pathology, but can have significant functional repercussions. Rapid, accurate diagnosis and treatment are essential for a favorable prognosis. During the diagnostic process of distal biceps tendon ruptures, several problems can emerge. An answer to the following clinical questions is given based on an extensive literature review. - Which clinical tests are the most sensitive/ specific for clinical examination? - Can ultrasound evaluation of the distal biceps tendon be optimized? - Is ultrasound an equivalent alternative to MRI in the diagnosis of distal biceps tendon injuries? An extensive literature search was conducted through Pubmed and Embase. The search strategy was developed systematically in the Medline data- base (PubMed interface), using medical subject headings as well as free text words. A standardized clinical examination of the distal biceps tendon consisting of the Hook test, the Passive Forearm Pronation Test and the Biceps Crease Interval test has a high accuracy for correct diagnosis of full-thickness ruptures. Furthermore, Cobra sign, Supinator view and Pronator view give an additional value to the standard ultrasound examination of the distal biceps tendon. Finally, ultrasound can be considered a trustworthy and cost-effective alternative to MRI in evaluation of distal biceps tendon ruptures.

The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part I: Extraarticular Pathologies

The first part of the guidelines and recommendations for musculoskeletal ultrasound, produced under the auspices of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB), provides information about the use of musculoskeletal ultrasound for assessing extraarticular structures (muscles, tendons, entheses, ligaments, bones, bursae, fasciae, nerves, skin, subcutaneous tissues, and nails) and their pathologies. Clinical applications, practical points, limitations, and artifacts are described and discussed for every structure. After an extensive literature review, the recommendations have been developed according to the Oxford Centre for Evidence-based Medicine and GRADE criteria and the consensus level was established through a Delphi process. The document is intended to guide clinical users in their daily practice.

Ultrasound-guided repair of the distal biceps tendon

Surgical repair of the distal biceps tendon rupture can be a challenge, especially when patients present with a retracted tendon. The tendon stump is often difficult to find and retrieve. In this aticle, we described a technique using ultrasound imaging at the start of the procedure. Under ultrasound guidance, a breast biopsy needle is used to help localize and mark the retracted tendon edge as well as the distal rupture site. Ultrasound is also used to mark important neurovascular structures at risk to help speed up exposure and avoid complications.

Biceps, Brachialis, and Triceps

Tendon injuries at the elbow affect mostly the distal biceps and can progressively degenerate over time or rupture in an acute event. The degree of retraction may depend on the integrity of the lacertus fibrosus, a fibrous expansion that merges with the forearm flexor fascia. Biceps disorders are frequently associated with fluid or synovitis of the adjacent bicipital bursa; primary bursal disorders (primary inflammatory synovitis) can also be observed. Distal triceps is less frequently injured than the distal biceps, and tears usually manifest as distal ruptures with avulsion of a small flake of bone from the tip of the olecranon. Brachialis injuries are uncommon and the consequence of sudden muscle stretching during forced elbow hyperextension, as in posterior elbow luxation.

Imaging of Elbow Injuries

Familiarity with throwing mechanics during elbow range of motion allows accurate diagnosis of sports-related elbow injuries, which occur in predictable patterns. In addition, repetitive stress-related injuries are often clinically apparent; however, imaging plays an important role in determining severity as well as associated injuries that may affect clinical management. A detailed understanding of elbow imaging regarding anatomy and mechanism of injury results in prompt and precise treatment.

Ultrasound in Sports Injuries

Utilization of musculoskeletal ultrasound, in particular for sports medicine, has dramatically increased in recent years. Ultrasound is an important adjunct tool to physical examination and other imaging methods in the evaluation and management of the injured athlete. It offers unique advantages in specific clinical scenarios. Dedicated training and a standardized scanning technique are important to overcome the inherent operator dependence and avoid diagnostic pitfalls. Ultrasound guidance can also improve accuracy in targeted percutaneous injection therapies. This article reviews the general ultrasound appearance of muscle, tendon, ligament, and nerve abnormalities in the athlete with a focus on sport-specific injuries.

Distal Biceps Tendon Tears: Diagnosis and Treatment Algorithm

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Distal biceps tendon (DBT) tears occur most commonly in middle-aged men after a sudden, forced eccentric contraction of the flexed elbow.

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An understanding of the multiple risk factors, mechanisms, and pathophysiological causes is essential for proper and timely diagnosis.

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High clinical suspicion and routine physical examination with appropriate special examination tests, including the hook test, the passive forearm pronation test, the biceps crease interval test, and the bicipital aponeurosis flex test, can help with rapid and accurate diagnosis and guide appropriate and timely management.

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Treatment for DBT tears depends on the extent (complete versus incomplete) and timing (acute versus chronic) of the injury, and options include nonoperative management, repair, and reconstruction with or without repair of the bicipital aponeurosis.

Ultrasound of the distal biceps brachii tendon using four approaches: reproducibility and reader preference

OBJECTIVES

To determine which sonographic appearance of the distal biceps brachii tendon (DBBT) is preferred by readers, and if images obtained by two different operators are reproducible.

METHODS

We performed an IRB-approved prospective sonographic evaluation of the DBBT in 50 healthy elbows using four different approaches (anterior, lateral, medial, posterior) performed by two operators. Five musculoskeletal radiologists independently reviewed the images, and ranked the four approaches based on overall appearance of echogenicity of the tendon, visualized length, and visualization of the insertion.

RESULTS

The medial approach was preferred in 79.6% of elbows, anterior in 17.6%, lateral in 2.8%, and the posterior approach was never preferred. The difference was statistically significant (P < 0.001). Kappa values for the five readers were 0.61 to 0.8 for choosing the images produced by the medial approach.

CONCLUSION

The appearance of the DBBT using the medial approach is preferred by readers and is reproducible between different operators.

Outcomes of distal biceps tendon repair using a dual incision, cortical button technique: a single surgeon study

Background

The purpose of this study was to evaluate patient-reported outcomes, function, complication rates, and radiographs in a series of patients with distal biceps tendon repair using the dual incision cortical button technique by a single surgeon. By having a single surgeon perform the surgery, the technique is standardized to all patients. Twenty-two patients consented to participate in the study. The average time from surgery to review was 2.2 years. Patient satisfaction was assessed using the DASH, Oxford, and Mayo Elbow Performance Scores.

Methods

Range of movement was assessed and compared to the unaffected limb using a goniometer. Isometric flexion and supination strength was tested using a standardized dynamometer—both measurements taken by a single physiotherapist. Radiographs were discussed at the time of the review by 2 orthopedic surgeons to check for heterotopic ossification.

Results

The mean DASH score was 6.3 postsurgery at the time of follow-up. There was no significant difference in active range of movement between the repaired and nonrepaired arm in flexion, extension, supination, or pronation. Four radiographs showed evidence of heterotopic ossification (HTO)—none showed synostosis. For patients with HTO, there was evidence that supination was inhibited compared to those patients who did not have HTO.

Conclusion

Our study found that at an average of 2 years of follow-up these patients had good outcomes clinically with no major complications. HTO was present in only 4 patients, and there was a significant difference in supination compared to those who did not have HTO. These patients had an average DASH of 14 compared to a score of 4.5 in those who did not have an HTO. The study showed that the dual incision cortical button repair remains a procedure with excellent patient outcomes at the risk of HTO.

Ultrasound Examination Techniques for Elbow Injuries in Overhead Athletes

Elbow pain is a frequent complaint among overhead athletes. Standard evaluation of the elbow uses history and physical examination, with radiographic imaging and MRI aiding in the confirmation of diagnosis. Musculoskeletal ultrasonography (US) provides dynamic, functional assessment of tendons and ligaments in the elbow, allowing the visualization of structures under stress and motion. Stress US offers the ability to detect injuries to the ulnar collateral ligament by measuring changes in joint space under stress. The freedom of dynamic imaging means results are dependent on the skill of the US operator to obtain the most accurate and complete evaluation. US is cost efficient and portable, allowing for quick examination at the point of care. This article provides a technique guide for sports medicine specialists performing US examination of the elbow.

Ultrasonographic Technique, Appearance, and Diagnostic Accuracy for Common Elbow Sports Injuries

Ultrasonography is a valuable diagnostic imaging tool because of its availability, tolerability, low cost, and utility in real-time dynamic evaluation. Its use in diagnosing elbow injuries has expanded recently and continues to do so. In particular, stress ultrasonography represents a unique imaging technique that directly visualizes the ulnar collateral ligament (UCL) and allows the assessment of ligament laxity, offering an advantage over magnetic resonance imaging and magnetic resonance arthrography in this patient population. Furthermore, ultrasonography has shown particular usefulness in instances where invasive techniques might be less desirable. This is particularly important in athletes since more invasive procedures potentially result in lost time from their sport. Ultrasonography is an important imaging tool that complements a thorough history and physical examination in the evaluation of elbow injuries in athletes. The use of ultrasonography in orthopaedic sports medicine has been investigated previously; however, to our knowledge, there has been no comprehensive review regarding the utility of ultrasonography for common elbow injuries in athletes. The current study provides a comprehensive, detailed review of the utility and indications for the use of ultrasonography for common elbow injuries in athletes.

A comprehensive review of the normal, abnormal, and post-operative MRI appearance of the distal biceps brachii

The biceps brachii myotendinous unit is a common source of shoulder, arm, and elbow pain. Its complex anatomy can present a challenge when interpreting MR images. We discuss the clinical and imaging presentations of injury related to the proximal biceps brachii separately in another manuscript. The purpose of this manuscript is to review the distal biceps anatomy along with pathology and post-operative appearance as seen on MRI.

Distal biceps hook test - Sensitivity in acute and chronic tears and ability to predict the need for graft reconstruction

BACKGROUND

The aim of this study was to assess the sensitivity of distal biceps hook test - O'Driscoll hook test - in a retrospective series of acute and chronic distal biceps tendon tears and investigate the ability of the test to predict the need for graft reconstruction.

METHODS

We retrospectively evaluated 234 consecutive distal biceps tendon tears operated in a single centre. The result of O'Driscoll hook test and perioperative findings of distal biceps were documented in standard fashion.

RESULTS

The perioperative and O'Driscoll hook test data were available in 202 cases. The sensitivity for the distal biceps hook test was 78% in all tears and 83% in complete tears. The sensitivity was significantly lower in partial tears (30%) and in cases where lacertus fibrosus was found to be intact (45 %). When O'Driscoll hook test was positive and the delay from initial injury to operative intervention was eight weeks or more, there was over 75% probability of achilles tendon allograft reconstruction. When O'Driscoll hook test was negative, the probability of reconstruction even after 12 weeks' delay was only 20%.

DISCUSSION

O'Driscoll hook test is useful when establishing distal biceps tendon tear diagnosis, but a negative test does not exclude rupture. In delayed cases, a positive test may predict the need for reconstruction.

Distal biceps tendon rupture: diagnostic strength of ultrasonography and magnetic resonance

OBJECTIVE

The main purpose of this study is to determine the agreement between two radiological tests, ultrasonography and magnetic resonance, in the diagnosis of distal brachial biceps tendon injury.

MATERIAL AND METHOD

A retrospective study was made of patients over 3 years who underwent distal brachial biceps tendon reattachment open surgery, and whose preoperative diagnosis was complemented either by ultrasonography, by magnetic resonance or both. The agreement was calculated by Cohen's kappa coefficient (k).

RESULTS

Information of 79 patients was analyzed. The concordance was excellent between resonance and surgical findings (k=.950), and a good Cohen's kappa coefficient was also achieved between both ultrasonography and surgery (k=.706) and between information of sonography and magnetic resonance (k=.667).

CONCLUSIONS

Resonance and ultrasonography could be considered reliable diagnostic tests to determine the acute rupture of the distal brachial biceps tendon in patients with consistent aetiology and physical examination.

Diagnosis and Management Strategies for Distal Biceps Rupture

Rupture of the distal biceps tendon most commonly is secondary to mechanical overload during eccentric muscle contraction. Due to deficits of strength and endurance, surgical repair usually is recommended. Although both single- and double-incision approaches have been described, double-incision techniques have been shown to better re-create the native anatomic insertion. However, excellent and comparable clinical outcomes have been demonstrated with both techniques. Fixation with a cortical button and interference screw has been shown to be the strongest construct biomechanically; however, several modern constructs provide adequate strength. Surgical technique should focus on restoration of anatomy, early range of motion, and prevention of complications. [Orthopedics. 2019; 42(6):e492-e501.].

Magnetic resonance imaging versus ultrasound in diagnosis of distal biceps tendon avulsion

INTRODUCTION

The severity of distal biceps tendon (DBT) injuries ranges from partial to complete tears leading to various clinical manifestation. Accuracy of early diagnosis and selection of treatment are critical to long-term recovery outcomes. Magnetic resonance imaging (MRI) or ultrasonography (US) are two commonly modalities for pre-operative diagnosis. The objective of this study was to determine the efficiency of MRI and ultrasonography US in the diagnosis of DBT rupture confirmed by operative findings.

HYPOTHESIS

MRI and US are equally effective in terms of accuracy, sensitivity and specificity.

MATERIAL AND METHODS

A total of 31 patients with DBT avulsion and surgical treatment were recruited for this retrospective study. All these patients received both US and MRI examinations prior to surgery. DBT avulsion was classified into partial tear and complete tear. Diagnosis outcomes by MRI and US were analyzed and compared statistically for the accuracy, sensitivity, and specificity in discriminating partial and complete DBT tears.

RESULTS

The accuracy of MRI and US was 86.4% and 45.5% in diagnosis of complete DBT rupture, respectively. Accuracy rate of MRI (66.7%) was the same as US in diagnosis of partial tear. Overall accuracy rate of MRI (80.6%) was higher than US (51.6%) in diagnosis all DBT avulsion with an odds ratio of 3.9. Sensitivity and specificity of MRI were 76.0% and 50.0%, while that of ultrasonography were 62.5% and 20.0%.

CONCLUSIONS

The findings of this study suggest that MRI is a more accurate imaging modality at correctly identifying the type of DBT tear although US is more cost-effective.

LEVEL OF EVIDENCE

III, Cohort study, Diagnosis study.

The Acutely Injured Elbow

The acutely injured elbow can present as a diagnostic challenge, encompassing a spectrum of conditions that involve the various osseous and soft tissue structures of this complex joint. Imaging plays a vital role in the management of these patients by providing an accurate interpretation of the underlying trauma sustained, which can have important implications on the preservation of joint function and stability. This article examines the mechanisms, patterns, classifications, and imaging findings of acute elbow injuries, providing key concepts for the radiologist in the interpretation of these injuries.

[Muscular injuries of athletes : Importance of ultrasound]

CLINICAL/METHODICAL ISSUE

Muscular injuries represent the most common musculoskeletal lesions. Especially in professional athletes an imaging clarification is essential in order to define the exact location of the lesion, the affected muscles, the extent and degree of the injury as well as to define possible concomitant complications. The best possible therapy can be initiated and a necessary rest period for a low risk resumption of sporting activity can be individually specified.

STANDARD RADIOLOGICAL METHODS/METHODICAL INNOVATIONS

Due to technical improvements, for example mobile devices and thus increased rapid availability as well as relative cost-effectiveness compared to other modalities, the imaging evaluation of muscle injury would nowadays be unthinkable without ultrasound.

PERFORMANCE

The article discusses general prerequisites for the performance of muscle ultrasound as well as a standardized examination algorithm of muscle injuries beginning with general and leading to special tips and tricks.

ACHIEVEMENTS/PRACTICAL RECOMMENDATIONS

Despite the known investigator dependence, ultrasound enables a reliable and unerring imaging clarification of muscle injuries. For this reason, ultrasound should be considered as the first-line diagnostic imaging modality when dealing with muscle trauma.

Treatment of primary total distal biceps tendon rupture using cortical button, transosseus fixation and suture anchor: A single center experience

INTRODUCTION

There remains as of yet no consensus on the optimal treatment for total or partial distal biceps tendon repairs. As such, the purpose of this study was to assess functional outcome, the impact of complications and cost effectiveness, in patients undergoing primary distal biceps tendon repair by either cortical button (CB), transosseous suture (TO) or suture anchor (SA).

HYPOTHESIS

There is no difference in functional outcome and cost effectiveness, in patients undergoing distal biceps tendon repair.

MATERIAL & METHODS

A retrospective analysis was performed on prospectively collected data from 47 consecutive patients treated for total or partial distal biceps tendon rupture. Functional outcome was assessed by the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Strength measurements (e.g., flexion, supination and pronation) in the operated and non-operated extremities were recorded with the use of a dynamometer. Furthermore, all complications, as well as their impact on functional outcome and costs for surgical intervention were evaluated.

RESULTS

Minimum follow-up time was 35 weeks, average 46.3±13.8 weeks. The overall DASH score was 7.9±4.7. There were no differences in functional outcome (i.e., DASH score) between CB, TO, SA (p=0.32), nor were there differences in regards to strength (supination, flexion and pronation) (p=0.60) and ability to return to work & sports activity. The total complication rate was 21.6%. Complications had a significant impact on functional outcome (p=0.003). Re-rupture occurred 2 times in the SA group. In 5 patients, revisional surgery had to be performed. The shortest operation times and the lowest material costs were observed in the TO group (p=0.004).

DISCUSSION

All reported fixation methods for total or partial distal biceps tendon rupture yielded good functional results. However, transosseous suture fixation for total distal biceps tendon rupture, performed through a double incision approach by an experienced surgeon, seems to be a simple, inexpensive and successful method, offering satisfying clinical results.

LEVEL OF EVIDENCE

IV, a retrospective, comparative study.

Point-of-Care Ultrasound in Trauma

The use of point-of-care ultrasound in trauma is widespread. Focused Assessment with Sonography for Trauma examination is a prototypical bedside examination used by the treating provider to quickly determine need for intervention and appropriate patient disposition. The role of bedside ultrasound in trauma, however, has expanded beyond the Focused Assessment with Sonography for Trauma examination. Advancements in diagnostics include contrast-enhanced ultrasound, thoracic, and musculoskeletal applications. Ultrasound is also an important tool for trauma providers for procedural guidance including vascular access and regional anesthesia. Its portability, affordability, and versatility have made ultrasound an invaluable tool in trauma management in resource-limited settings. In this review, we discuss these applications and the supporting evidence for point-of-care ultrasound in trauma.

Management of Biceps Tendon Pathology: From the Glenoid to the Radial Tuberosity

Management of proximal and distal biceps tendon pathology is evolving. The long head of the biceps tendon, if inflamed, may be a pain-producing structure. In appropriately indicated patients, a symptomatic long head of the biceps tendon can be surgically managed via tenotomy, tenodesis, and/or superior labrum anterior to posterior repair. In some patients, primary superior labrum anterior to posterior pathology can be managed via biceps tenodesis. Determining which procedure is most appropriate and which technique and implant are preferred for a given patient with biceps tendon pathology is controversial. Less debate exists with regard to the timing of distal biceps tendon repair; however, considerable controversy exists with regard to selection of an appropriate surgical technique and implant. In addition, the treatment of patients with a chronic and/or retracted distal biceps tendon tear and patients in whom distal biceps tendon repair fails is extremely challenging. Orthopaedic surgeons should understand the anatomy of, nonsurgical and surgical treatment options for, and outcomes of patients with proximal or distal biceps tendon pathology.

Distal biceps tendon injuries: A clinically relevant current concepts review

Distal biceps tendon (DBT) conditions comprise a spectrum of disorders including bicipitoradial bursitis, partial tears, acute and chronic complete tears.

In low-demand patients with complete DBT tears, non-operative treatment may be entertained provided the patient understands the potential for residual weakness, particularly in forearm supination.

Most acute tears are best treated by primary repair using either single-incision or double-incision techniques with good clinical outcomes.

Single-incision techniques may carry a higher risk of nerve-related complications, whereas double-incision techniques have historically been considered to carry a higher risk of heterotopic ossification, particularly if the ulna is exposed.

Various fixation techniques, including bone tunnels, cortical buttons, suture anchors, interference screws or a combination seem to provide different fixation strength but similar clinical outcomes.

Some chronic tears may be repaired primarily, provided tendon tissue can be identified; alternatively, autograft or allograft reconstruction can be considered, and good outcomes have been reported with both techniques.

Cite this article: Alentorn-Geli E, Assenmacher AT, Sanchez-Sotelo J. Distal biceps tendon injuries: a clinically relevant current concepts review. EFORT Open Rev 2016;1:316-324. DOI: 10.1302/2058-5241.1.000053.

Acute distal biceps ruptures: single incision repair by use of suture anchors

Objective

Clinical and functional assessment of the surgical treatment for acute injury of the distal insertion of the biceps brachial performed with a surgical technique using a single incision in proximal forearm and fixation with suture anchors in the radial tuberosity.

Methods

This study reviewed the medical records of patients who underwent surgical treatment of distal biceps injury during the period between January 2008 and July 2014. In a mean follow-up of 12 months, 22 patients with complete and acute injury, diagnosed through physical examination and imaging studies, were functionally assessed in the postoperative period regarding the range of motion (degrees of flexion-extension and pronation–supination), the presence of pain (VAS), the Andrews Carson-score, and the Mayo Elbow Performance Score (MEPS).

Results

During the postoperative follow-up assessment, no patient reported pain by VAS scale; all were satisfied with the esthetic appearance of the surgery. The range of articular movement remained unchanged at 95.4% of patients, with the loss of 8° of supination in one patient. No changes in muscle strength were observed. The results of the Andrews-Carson score were good in 4.6% and excellent in 95.4% of cases; the MEPS presented 100% of excellent results. The rate of complications was 27.2%, similar to the literature.

Conclusion

Surgical repair of acute injury of the distal biceps trough a single incision in the proximal forearm and fixation with two suture anchors in the radial tuberosity is an effective and safe therapeutic option, allowing early motion and good functional results.

Imaging of regional pain syndromes; from syndromes to conditions using imaging?

Musculoskeletal regional pain syndromes often lead to patient referrals in general and rheumatological practice. Detailed history taking and clinical examination can in most cases reveal the cause for pain and direct the subsequent management of the conditions. Yet, when in doubt, imaging methods have to support the clinical assessment. This paper presents the underlying pathologies of the most frequently encountered regional pain syndromes and the role of musculoskeletal ultrasonography and magnetic resonance imaging in their visualization. It presents data, where available, on diagnostic accuracy and comparisons with gold standards. The article stresses the advantages and disadvantages of the analyzed imaging modalities and suggests the future research agenda.

'A torn shoulder': an emergency department case study

BACKGROUND

Rupture of the biceps is not a very common presentation to the emergency departments; as a result, it is poorly documented, especially in nursing literature. It is important that these patients are appropriately managed by registered advanced nurse practitioners. As the diagnosis of rupture is usually made on clinical grounds with imaging assisting in the diagnosis, left untreated these injuries can lead to considerable functional deficits.

METHODS

The following paper is a case study based on a patient who presented to the emergency department with a proximal biceps rupture following trauma. The paper focuses on the clinical assessment and management of patients who present to the emergency department with these injuries.

RESULTS

This case study increases awareness of bicep ruptures and its management in the ED. Discussion points include the neurovascular assessment of these patients, the appropriateness of diagnostic imaging, and in-depth clinical examination techniques.

CONCLUSION

Rupture of the biceps tendon is often a result of a sudden forceful extension of the elbow against a previously contracted biceps and flexed elbow. The patient often describes a popping noise and presents with a 'popeye' deformity over their biceps. It is important to be vigilant with these injuries as early recognition will optimise the patients' outcomes.

Elbow magnetic resonance imaging: imaging anatomy and evaluation

The elbow is a complex joint. Magnetic resonance imaging (MRI) is often the imaging modality of choice in the workup of elbow pain, especially in sports injuries and younger patients who often have either a history of a chronic repetitive strain such as the throwing athlete or a distinct traumatic injury. Traumatic injuries and alternative musculoskeletal pathologies can affect the ligaments, musculotendinous, cartilaginous, and osseous structures of the elbow as well as the 3 main nerves to the upper limb, and these structures are best assessed with MRI.Knowledge of the complex anatomy of the elbow joint as well as patterns of injury and disease is important for the radiologist to make an accurate diagnosis in the setting of elbow pain. This chapter will outline elbow anatomy, basic imaging parameters, compartmental pathology, and finally applications of some novel MRI techniques.

The accuracy of diagnostic ultrasound imaging for musculoskeletal soft tissue pathology of the extremities: a comprehensive review of the literature

Musculoskeletal diagnostic ultrasound imaging (MSK-DUSI) has been growing outside the traditional radiology speciality. Increased use of this technology has been reported in several healthcare settings, however an apparent gap in the knowledge of the accuracy of this diagnostic technology indicated a review was warranted. We undertook a structured review of the literature to assess the accuracy of MSK-DUSI for the diagnosis of musculoskeletal soft tissue pathology of the extremities. An electronic search of the National Library of Medicine’s PubMed database (1972 to mid-2014) was conducted. All relevant systematic reviews of diagnostic studies, all diagnostic studies published after the date of the latest systematic reviews and relevant diagnostic studies outside the scope the systematic reviews that directly compared the accuracy of MSK-DUSI (the index test) to an appropriate reference standard for the target condition were included. A fundamental appraisal of the methodological quality of studies was completed. The individual sensitivity, specificity and likelihood ratio data were extracted and entered into diagnostic accuracy tables. A total of 207 individual studies were included. The results show that MSK-DUSI has acceptable diagnostic accuracy for a wide spectrum of musculoskeletal conditions of the extremities. However, there is a lack of high quality prospective experimental studies in this area and as such clinicians should interpret the results with some caution due to the potential for overestimation of diagnostic accuracy.

Distal Biceps Injuries

A review of distal biceps tendon injuries is presented. Notable and recent studies on the incidence, presentation, diagnosis, and treatment are outlined. The benefits and risks of 1- and 2-incision techniques for repair are discussed, and classic studies are reviewed.

Right Lower Quadrant Pain in a Young Female: Ultrasound Diagnosis of Rectus Abdominis Tear

BACKGROUND

Right lower quadrant pain in young females presents a frequent diagnostic challenge for emergency physicians, with a broad differential and several important diagnoses. Using an "ultrasound first" imaging strategy can help decrease the use of computed tomography scans, with associated savings in radiation exposure, cost, and other resource use.

CASE REPORT

We report a case of right lower quadrant pain in a young woman. After her initial history and physical examination, appendicitis was the leading differential. A bedside ultrasound was performed, leading to the uncommon diagnosis of rectus abdominis muscle tear. The sonographic findings of a muscle tear include increase in size, loss of linear, homogeneous architecture, and decreased echogenicity. Making this diagnosis at the bedside using ultrasound obviated the need for further imaging, avoiding unnecessary radiation exposure, and decreasing emergency department length of stay and overall cost, while leading to a tailored treatment plan. Why Should an Emergency Physician Be Aware of This? Rectus abdominis tear is a cause of right lower quadrant pain that may mimic appendicitis and should be considered in patients with this complaint. The ability to make this diagnosis with bedside ultrasound may assist in several important patient-oriented outcomes.

Treatment of distal biceps tendon rupture: why, when, how? Analysis of literature and our experience

INTRODUCTION

The rupture of the distal biceps tendon is a relatively uncommon lesion. Even if conservative treatment may be an option in low demanding patients, young and active subjects may benefit from an early surgical reinsertion. Many techniques and fixation devices have been described, but in the literature, there are no clinical evidences that show the superiority of any of these. In this article, we report an analysis of the "state of the art" and our case series of surgical reinsertion with the double approach transosseous technique.

MATERIALS AND METHODS

Between 2003 and 2013, 26 patients underwent surgical reinsertion, either for acute or for chronic lesions of distal biceps tendon. We evaluated 21 acute cases treated with double approach using DASH and SECEC Elbow Scores. The mean follow-up was 22 months. Range of motion, supination and flexion strength were also recorded.

RESULTS

Mean final ROM was 6-132° in F/E and 89-0-87° in P/S; flexion and supination strength were 96 and 88 % compared to the opposite side. The main complications were two cases of heterotopic ossifications: one asymptomatic fracture of the proximal radius and one temporary neurapraxia of the radial nerve.

CONCLUSIONS

Analysing the literature and our outcomes, we underline the importance of timing for surgery, in young and compliant patients, with a valid rehabilitation protocol for excellent results. The choice of surgical technique remains controversial, and we believe that the double approach transosseous reinsertion is a safe, costless and relatively non-invasive technique, offering satisfactory results when performed early.

Assessment of neuromuscular conditions using ultrasound

Upper extremity pain in persons with spinal cord injury is a common cause of morbidity. Ultrasound of nerve, muscle, and tendon has the potential to become a valuable modality in assessing this population, and has the advantage of reduced health care costs, portability, and use in populations that cannot tolerate MRI. It has the potential to detect issues before the onset of significant morbidity, and preserve patient independence. Upper extremity ultrasound already has many studies showing its utility in diagnosis, and newer techniques have the potential to enhance its use in the diagnosis and management of musculoskeletal conditions.

Musculoskeletal imaging: types and indications

Musculoskeletal imaging includes radiographs, computed tomography scans, bone scans, magnetic resonance imaging, and musculoskeletal ultrasonography. Each modality has its advantages and disadvantages. This article presents general guidelines regarding which imaging modality to order when evaluating patients with musculoskeletal complaints. However, it must be remembered that imaging is not meant to replace a thorough history and physical examination, but instead should be seen as a suite of methods to confirm suspected diagnoses.