Nerve Disease at the Elbow
Nerve Disease at the Elbow
Nerve Disease at the Elbow
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<strong>Nerve</strong> <strong>Disease</strong> <strong>at</strong><br />
<strong>the</strong> <strong>Elbow</strong><br />
Carlo Martinoli, MD<br />
Radiologia – DISSAL<br />
Università di Genova, Italy<br />
Maribel Miguel-Pérez, MD<br />
Human An<strong>at</strong>omy, Faculty of Medicine<br />
(Bellvitge), University of Barcelona, Spain<br />
Check-list<br />
! Ulnar <strong>Nerve</strong><br />
! Radial <strong>Nerve</strong> (posterior interosseous)<br />
! Median <strong>Nerve</strong> (anterior interosseous)<br />
22 nd Annual Conference on Musculoskeletal Ultrasound<br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012
cutaneous<br />
l<strong>at</strong>eral<br />
Brachioradialis<br />
Biceps<br />
T<br />
pron<strong>at</strong>or<br />
teres<br />
lf<br />
FDS<br />
radial<br />
nerve<br />
posterior<br />
interosseous<br />
arcade of<br />
Frohse<br />
cutaneous<br />
medial<br />
supin<strong>at</strong>or<br />
Brachialis<br />
pron<strong>at</strong>or<br />
teres<br />
brachial<br />
artery<br />
median<br />
nerve<br />
22 nd Annual Conference on Musculoskeletal Ultrasound<br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012
Triceps<br />
FCR<br />
Brachialis<br />
triceps<br />
Biceps<br />
Brachial Artery<br />
Median <strong>Nerve</strong><br />
Pron<strong>at</strong>or Teres<br />
Lacertus Fibrosus<br />
Ulnar <strong>Nerve</strong><br />
22 nd Annual Conference on Musculoskeletal Ultrasound<br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012
UN<br />
Ulna<br />
Condylar Groove<br />
! Osteofibrous ring formed by <strong>the</strong> medial epicondyle and <strong>the</strong><br />
medial coll<strong>at</strong>eral ligament and bridged by <strong>the</strong> cubital tunnel<br />
retinaculum (Osborne ligament)<br />
Olecranon<br />
Ulnar nerve<br />
*<br />
MCL<br />
ME<br />
22 nd Annual Conference on Musculoskeletal Ultrasound<br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012
UN<br />
FCU<br />
Cubital Tunnel Syndrome - proximal<br />
! Diffuse fl<strong>at</strong>tening of <strong>the</strong> nerve and associ<strong>at</strong>ed swelling of <strong>the</strong><br />
nerve portion proximal to <strong>the</strong> level of compression are <strong>the</strong><br />
ME<br />
main findings<br />
mht<br />
mht<br />
! mean cross-sectional area of <strong>the</strong> ulnar nerve in ME<br />
normal popul<strong>at</strong>ion Æ 7.9±3.1mm 2<br />
UN<br />
Humerus<br />
Extension<br />
ME<br />
mht<br />
O<br />
Jacob, 2004<br />
UN<br />
Ulna<br />
Flexion<br />
ME<br />
UN<br />
Humerus<br />
UN<br />
mht<br />
Trochlea<br />
22 nd Annual Conference on Musculoskeletal Ultrasound<br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012<br />
O
UN<br />
*<br />
FCU<br />
Cubital Tunnel Syndrome<br />
ANCONEUS EPITROCHLEARIS<br />
! accessory muscle (3%-28% incidence) replacing cubital tunnel<br />
retinaculum (Osborne ligament)<br />
! accessory to <strong>the</strong> medial head of <strong>the</strong> triceps<br />
! variable imaging appearance (from slender to bulky)<br />
! increased pressure within <strong>the</strong> cubital tunnel during elbow<br />
flexion Æ ulnar neurop<strong>at</strong>hy<br />
O<br />
! removal of muscle for refractory cases ME of neuritis<br />
ME<br />
UN<br />
*<br />
O<br />
UN<br />
*<br />
ME<br />
ME<br />
O<br />
ME<br />
22 nd Annual Conference on Musculoskeletal Ultrasound<br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012<br />
O
Ulnar <strong>Nerve</strong> Instability<br />
! The Osborne retinaculum retains <strong>the</strong> ulnar nerve<br />
posterior to <strong>the</strong> medial epicondyle during elbow flexion<br />
ME<br />
O<br />
<strong>Elbow</strong> extension flexion<br />
Friction neuritis<br />
22 nd Annual Conference on Musculoskeletal Ultrasound<br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012
UN<br />
MH<br />
MH<br />
FCU<br />
FCU<br />
TM<br />
TM TT<br />
TT<br />
TT<br />
Flexion… Extension…<br />
Snapping Triceps Syndrome<br />
! Disloc<strong>at</strong>ion of <strong>the</strong> MH of <strong>the</strong> triceps can occur in combin<strong>at</strong>ion with<br />
disloc<strong>at</strong>ion of <strong>the</strong> UN, with or without discomfort on <strong>the</strong> medial side of<br />
<strong>the</strong> elbow and with or without ulnar neurop<strong>at</strong>hy Ætwo snaps<br />
ME<br />
MHT<br />
O<br />
ME<br />
First snap<br />
MHT<br />
O<br />
Second snap<br />
ME<br />
O<br />
Jacobson, 2001<br />
MHT<br />
22 nd Annual Conference on Musculoskeletal Ultrasound<br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012
Cubital Tunnel Syndrome - distal<br />
PROPER CUBITAL TUNNEL<br />
! Distal to <strong>the</strong> condylar groove, <strong>the</strong> ulnar nerve enters in a<br />
tunnel formed between <strong>the</strong> ulnar and humeral heads of<br />
<strong>the</strong> FCU muscle, which are connected by <strong>the</strong> arcu<strong>at</strong>e<br />
ligament<br />
UN TT<br />
FCU<br />
ME<br />
O<br />
fcu<br />
1 fcu<br />
22 nd Annual Conference on Musculoskeletal Ultrasound<br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012<br />
2
Radial <strong>Nerve</strong><br />
ECRB<br />
PIN<br />
Supin<strong>at</strong>or<br />
Sensory<br />
22 nd Annual Conference on Musculoskeletal Ultrasound<br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012
Posterior Interosseous <strong>Nerve</strong><br />
SCANNING TECHNIQUE<br />
! PROXIMAL to DISTAL ➙ <strong>the</strong> probe should be swept down from anterior to posterior<br />
while pron<strong>at</strong>ing <strong>the</strong> forearm<br />
! DISTAL to PROXIMAL ➙ <strong>the</strong> probe should be swept up from posterior to anterior<br />
while supin<strong>at</strong>ing <strong>the</strong> forearm<br />
22 nd Annual Conference on Musculoskeletal Ultrasound<br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012
PIN<br />
LEASH of HENRY<br />
! arterial branches arising from <strong>the</strong> recurrent radial artery<br />
! <strong>the</strong>y cross over <strong>the</strong> PIN just proximal to <strong>the</strong> arcade of Frohse<br />
! prominent vessels (hypertrophied leash ≥6 vessels) may cause PIN<br />
compression Husarik et al. Radiology 2009<br />
ARCADE of FROHSE<br />
PIN<br />
Supin<strong>at</strong>or<br />
Leash of Henry<br />
PIN<br />
PI Neurop<strong>at</strong>hy – zone #1<br />
PIN<br />
! PIN constriction <strong>at</strong> <strong>the</strong> arcade of Frohse<br />
Leash of Henry<br />
PIN<br />
PIN<br />
Supin<strong>at</strong>or<br />
Supin<strong>at</strong>or<br />
Supin<strong>at</strong>or<br />
Anterior Ganglia<br />
Arcade of Frohse<br />
22 nd Annual Conference on Musculoskeletal Ultrasound<br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012
PIN<br />
Supin<strong>at</strong>or<br />
PIN<br />
PI Neurop<strong>at</strong>hy – zone #2<br />
right left<br />
! PIN constriction within <strong>the</strong> supin<strong>at</strong>or tunnel<br />
PIN<br />
s<br />
Sensory<br />
s<br />
T1w<br />
s<br />
s<br />
s<br />
s<br />
GdfsT1w<br />
Radius<br />
22 nd Annual Conference on Musculoskeletal Ultrasound<br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012
PIN<br />
Supin<strong>at</strong>or<br />
PI Neurop<strong>at</strong>hy – zone #3<br />
ANATOMICAL CONSIDERATIONS<br />
! after exiting <strong>the</strong> supin<strong>at</strong>or, <strong>the</strong> PIN sends a recurrent branch for<br />
<strong>the</strong> EDC<br />
! it <strong>the</strong>n descends <strong>the</strong> forearm supplying <strong>the</strong> extensor muscles<br />
and ends <strong>at</strong> <strong>the</strong> wrist sending sensory fibers to <strong>the</strong> carpal<br />
ligaments and joints<br />
PIN<br />
recurrent<br />
branch<br />
supin<strong>at</strong>or<br />
EDC<br />
22 nd Annual Conference on Musculoskeletal Ultrasound<br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012
supin<strong>at</strong>or<br />
PI Neurop<strong>at</strong>hy – zone #3<br />
! Isol<strong>at</strong>ed compression of <strong>the</strong> recurrent branch<br />
EDC<br />
recurrent<br />
branch<br />
Short-axis<br />
superficial<br />
deep<br />
ECU<br />
EDC<br />
Long-axis<br />
ECRB<br />
22 nd Annual Conference on Musculoskeletal Ultrasound<br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012
adial<br />
artery<br />
FDS<br />
ulnar<br />
artery<br />
median<br />
nerve<br />
arcade of<br />
flexors<br />
Median <strong>Nerve</strong><br />
anterior interosseous<br />
nerve<br />
FCR<br />
anterior interosseous<br />
artery<br />
Pron<strong>at</strong>or<br />
Quadr<strong>at</strong>us<br />
ulnar<br />
artery<br />
FCU<br />
22 nd Annual Conference on Musculoskeletal Ultrasound<br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012
Supracondylar Process<br />
! originally described by Tiedmann in 1822 as an<br />
“exostosis of <strong>the</strong> humerus”<br />
! found in 0.3%-2.7% humans<br />
! starting from a large base, about 7cm proximal to<br />
<strong>the</strong> medial epicondyle and directed distally to end<br />
COMPARATIVE in a beak-like ANATOMY apex<br />
Kessel et al. JBJS 1966<br />
biceps<br />
Lemur C<strong>at</strong><br />
triceps<br />
22 nd Annual Conference on Musculoskeletal Ultrasound<br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012
a<br />
MN<br />
pt!<br />
Stru<strong>the</strong>rs Ligament<br />
Supracondylar Process Syndrome<br />
!<br />
!<br />
!<br />
originally described by<br />
!<br />
Stru<strong>the</strong>rs<br />
originally<br />
(medical<br />
described<br />
student)<br />
by Solieri<br />
in<br />
in<br />
1848<br />
1929<br />
fibrous band joining<br />
!<br />
<strong>the</strong><br />
median<br />
apex of<br />
nerve<br />
<strong>the</strong> supracondylar<br />
entrapment<br />
process<br />
with <strong>the</strong> medial epicondyle Æ osteofibrous tunnel<br />
! pain and numbness in <strong>the</strong> hand,<br />
this ligament represents <strong>the</strong> exacerb<strong>at</strong>ed lower part by of elbow <strong>the</strong> l<strong>at</strong>issimo- extension and<br />
condyloideus muscle forearm pron<strong>at</strong>ion<br />
UN!<br />
! weakness in <strong>the</strong> flexors of <strong>the</strong> forearm<br />
a! a!<br />
Transverse<br />
MN!<br />
MN!<br />
H!<br />
H!<br />
Transverse a!<br />
v! v!<br />
MN!<br />
Longitudinal<br />
H!<br />
H!<br />
pt!<br />
22 nd Annual Conference on Musculoskeletal Ultrasound<br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012
Pron<strong>at</strong>or<br />
Teres<br />
MN<br />
Anterior Interosseous Neurop<strong>at</strong>hy<br />
Brachialis<br />
MN<br />
pron<strong>at</strong>or<br />
Anterior<br />
Interosseous<br />
fds<br />
! The anterior interosseous nerve may be<br />
compressed alone or toge<strong>the</strong>r with <strong>the</strong> main<br />
trunk of <strong>the</strong> median nerve<br />
! fractures, fibrous bands, anomalous muscle (Gantzer),<br />
accessory tendons<br />
! Loss in bulk and increased reflectivity of <strong>the</strong><br />
innerv<strong>at</strong>ed muscles<br />
fpl<br />
R<br />
MN<br />
fdp<br />
fds<br />
AIN<br />
U<br />
fpl<br />
R<br />
MN<br />
FDS<br />
FPL<br />
FCR<br />
MN<br />
fdp<br />
FDP<br />
fds<br />
R<br />
Contral<strong>at</strong>eral<br />
22 nd Annual Conference on Musculoskeletal Ultrasound<br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012
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