Sonographic evaluation of the distal biceps tendon using a medial approach: the pronator window

Distale Bizepssehnenruptur

Die Ruptur der distalen Bizepssehne tritt am häufigsten bei Männern im mittleren Alter auf (30 bis 50 Jahre). Der typische Mechanismus ist die exzentrische Belastung in strecknaher Ellbogenstellung in Supination, wobei diese Verletzung mit Kraftsport und körperlich belastender Tätigkeit assoziiert ist. Epidemiologische Daten weisen auf eine Zunahme von distalen Bizepsrupturen in den letzten Jahrzehnten hin. Risikofaktoren wie die Verwendung anaboler Steroide, Kraftsport und Nikotinabusus zeigen einen Zusammenhang mit der Verletzung. Bei reduziertem Patientenanspruch oder relevanten Komorbiditäten ist auch unter einer konservativen Behandlung ein gutes funktionelles Ergebnis mit subjektiv guter Patientenzufriedenheit zu erreichen, allerdings unter zu erwartender relevanter Kraftminderung in Flexion (20 %) und Supination (40 %). Durch eine operative Refixation lässt sich das beste funktionelle Resultat erzielen, allerdings einhergehend mit einem nicht unerheblichen Komplikationsrisiko.

EURO-MUSCULUS/USPRM Dynamic Ultrasound Protocols for Elbow

ABSTRACT

In this dynamic protocol, ultrasound examination of the elbow using different maneuvers is described for several/relevant elbow problems. Scanning videos are coupled with real-time patient examination videos for better understanding. The authors believe that this practical guide-prepared by an international consensus of several experts (EURO-MUSCULUS: European Musculoskeletal Ultrasound Study Group and USPRM: Ultrasound Study Group of ISPRM [International Society of Physical and Rehabilitation Medicine])-will help musculoskeletal physicians perform a better and uniform/standard approach.

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.

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.

Distal Biceps Brachii Tendon Insertion: A Simple Method of Ultrasound Evaluation

Different ultrasound approaches have been proposed to evaluate the distal biceps brachii tendon, such as lateral, posterior, medial, and anterior, all allowing good visualization of the distal biceps tendon and its pathologic appearances. Here we describe a new method of ultrasound evaluation of the distal biceps tendon insertion with the patient in the so-called crab position. The crab position is used to evaluate the posterior compartment of the elbow but also the lateral and medial compartments. This position allows for coverage of 75% the elbow in a single position, with less discomfort for the patient and a fair amount of saved time. In this position, after the evaluation of the common extensor tendon in the long axis, turning the transducer 90° and moving it distally allows for optimal visualization of the distal biceps brachii tendon in the axial plane. It is a simple, quick approach that allows for excellent visualization of the insertion of the distal biceps brachii tendon while avoiding an anisotropic effect.

Ultrasound assessment in distal biceps tendon injuries: Techniques, pearls and pitfalls

Ultrasound assessment of the distal biceps tendon is challenging. The tendon has two components which are continuations of the long and short heads of the muscle, and these undergo 90° of rotation along their course. The tendon has a deep insertion to the radial tuberosity. Therefore, a combination of approaches and examination techniques are utilized to ensure complete evaluation. The various ultrasound approaches used to assess the distal biceps tendon, with their advantages and limitations, will be described. Selected examples of distal biceps tendon injuries, with magnetic resonance imaging (MRI) correlation in challenging cases, will be demonstrated.

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.

High-resolution ultrasound in the assessment of the distal biceps brachii tendinous complex

OBJECTIVE

To establish a high-resolution US technique that enables a systematic morphometric examination of the three components that form the distal biceps brachii tendinous complex; the internal bicipital aponeurosis, the distal biceps brachii tendon and the external bicipital aponeurosis (also known as lacertus fibrosus).

MATERIALS AND METHODS

Fifty cryopreserved cadaver body donor elbows were dissected to obtain morphometric reference values and to establish reliable landmarks for the US examination. Then, a systematic US technique was designed and validated by a one-to-one US/dissection analysis of 11 cryopreserved cadaver body donor elbows. Finally, the systematic US technique was carried out in 44 healthy volunteers and morphometric parameters were compared to those obtained in the first part of the study.

RESULTS

Mean dissection reference values: internal bicipital aponeurosis width 39.61 mm (10.02 SD) and thickness 0.75 mm (0.24 SD), distal biceps brachii tendon width 8.38 mm (1.87 SD) and thickness 2.73 mm (0.69 SD), external bicipital aponeurosis width 11.17 mm (5.84 SD) and thickness 0.85 mm (0.28 SD). One-to-one US/dissection correlation was overall good (intraclass correlation coefficient 0.876, p < 0.0001). When comparing volunteer US/dissection measurements, significant differences were encountered in all measures except for internal bicipital aponeurosis width. However, the overall magnitude of such significant differences was < 0.7 mm.

CONCLUSIONS

Using the systematics hereby proposed, high-resolution US is reliable for the morphometric assessment of the distal biceps brachii tendinous complex. The external bicipital aponeurosis is morphometrically the most variable structure.

Ultrasound classification of traumatic distal biceps brachii tendon injuries

OBJECTIVE

The present work is aimed at analysing ultrasound findings in patients with distal biceps brachii tendon (DBBT) injuries to assess the sensitivity of ultrasound in detecting the different forms of injury, and to compare ultrasound results with magnetic resonance imaging (MRI) and surgical results.

MATERIALS AND METHODS

A total of 120 patients with traumatic DBBT injuries examined between 2011 and 2015 were analysed. We compared ultrasound results with MRI results when surgery was not indicated and with MRI and surgical results when surgery was indicated.

RESULTS

For major DBBT injuries (complete tears and high-grade partial tears), the concordance study between exploration methods and surgical results found that ultrasound presented a slight statistically significant advantage over MRI (ultrasound: κ = 0.95-very good-95% CI 0.88 to 1.01, MRI: κ = 0.63-good-95% CI 0.42 to 0.84, kappa difference p < 0.01). Minor injuries, in which most tendon fibres remain intact (tendinopathies, elongations and low-grade partial tears), are the most difficult to interpret, as ultrasound and MRI reports disagreed in 12 out of 39 cases and no surgical confirmation could be obtained.

CONCLUSIONS

Based on present results and previous MRI classifications, we establish a traumatic DBBT injury ultrasound classification. The sensitivity and ultrasound-surgery correlation results in the diagnosis of major DBBT injuries obtained in the present study support the recommendation that ultrasound can be used as a first-line imaging modality to evaluate DBBT injuries.

[Distal biceps tendon rupture : Overview and own procedure]

Mainly males in their 40s and 50s suffer from distal biceps tendon rupture. The diagnosis is made by clinical evaluation and is usually confirmed by magnetic resonance imaging. Different approaches and reconstruction techniques have been described in the past, and the clinical results are mostly good and excellent. Thereby the decision regarding which technique to use lies with the surgeon. However, specific complications have been described and should be considered.

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.

Elbow US: Anatomy, Variants, and Scanning Technique

As with other musculoskeletal joints, elbow ultrasonography (US) depends on the examination technique. Deep knowledge of the relevant anatomy, such as the bone surface anatomy, tendon orientation, nerves, and vessels, is crucial for diagnosis. It is important to be aware of the primary imaging pitfalls related to US technique (anisotropy) in the evaluation of deep tendons such as the distal biceps and peripheral nerves. In this article, US scanning technique for the elbow as well as the related anatomy, primary variants, and scanning pitfalls are described. In addition, an online video tutorial of elbow US describes a possible approach to elbow evaluation. Online supplemental material is available for this article.