So, we chose, and for the ELBO, we wanted to choose, we typically go with our high-resolution linear probe, and that gives us the most definition that we want to get. And for most patients, this should be adequate, very – I don't see many cases where you may need to move on to a curvy linear probe in this case. So, this kind of brings us to the overview of what we're looking for. So, the complete ultrasound examination of the ELBO is broken down into four parts or compartments, and then each compartment focuses on specific structures as listed here. I think based on clinical evaluation, our biggest concern with this patient was the distal bicep. So, we kind of focused on the anterior and lateral areas of the ELBO within this examination, but of course, each compartment in general when we're evaluating the ELBO will correspond to some different pathologic condition that will kind of – that can be evaluated for and that you can rule out as you're examining the ELBO under ultrasound. So, again, we're going to focus right now on the first part of the anterior ELBO, and this is kind of where we, based on clinical – based on our clinical evaluation, we wanted to start our exam and focus our main efforts. So, we did talk about probe choice, and now we want to talk about patient positioning. As you can see here, I think as – when I was training in the emergency department, it's more so the patient kind of stays and you move around them, but as I – you know, moving to clinic as far as, you know, being comfortable evaluating a patient, I think patient positioning becomes even more important. So, for this examination and to really optimize the images, I like to have the patient supine with the arm abducted and the ELBO fully extended with some supination, as you can see here clearly allowing us to really get a stable patient and allow for a high image quality. Just a little overview of the anatomy of the area. Main focus is going to right be in the – kind of see in this image where my mouse is, where the distal bicep is actually cut off, but we have several structures that kind of come together in this area, and when we move – when we think about where we're going to have our probe, we place it in this transverse or short axis view first, and we'll end up kind of panning up and down this area until we find what I like to refer to as our home base. And a lot of the structures in there I'll talk about in the next slide, but we're really looking at distal bicep. We can see radial nerve from that area, brachioradialis. Lying underneath – lying deepest as far as muscle is concerned is the brachialis, and then we can see pronator teres and median nerve as well. So, as I mentioned before, I know I refer to the home base – I did play baseball, so it's kind of par for my vocabulary. Again, patient and probe positioning, and this will give us this image right here, and this is where I like to start all my examinations. I think that it offers a really good, you know, spot to just kind of – if you feel lost and you don't know where you really are, you can kind of always come back to this spot, find your area, and reorient yourself, and then move to – move on with your examination, move on to the next structure you want to evaluate. So right here, we can see we have our cartilage surface marked by the star, and it really gives a nice characteristic appearance, and so that's why I think it's a really good starting point and a really good home base to kind of return back to if you get lost. The brachialis is going to be lying kind of deep to everything. You can see it's separated out. This would be more lateral, and the dot would be lateral in this case, and so we have the brachioradialis. We have the pronator teres more medially. The first area that pops up is going to be the radial nerve lying, and that's the hyper-echoic structure kind of in this fascial plane between the brachioradialis and the brachialis muscle. We have the median nerve more medially adjacent to the pronator teres, and then this structure that's adjacent to – just lateral to the brachial artery is going to be the distal biceps tendon – or, sorry, the biceps tendon, and this isn't – I'll talk more about this upcoming, but this does get a little tricky to visualize the biceps tendon clearly as we approach this home base, but to finish it out, we have the artery. We have the vein. The second star kind of in the septum at times moving right through here, you can – sometimes I saw in textbooks it was described depending on where you are in the – along the arm, there is the – you can sometimes see the musculocutaneous nerve in here as well, and so lastly, we have the capitulum, and we have the postropia. This is just a nice slide I found when I was kind of going through what to kind of share during this presentation. I really like it just because it puts everything together into one place. We have the cross-sectional anatomy and really gross anatomy of the elbow and what we're going to look at with the ultrasound, as well as what we see on the ultrasound screen, and then all while the – like, seeing how we want to position our probe. So I like to – a lot of protocols I've seen when you're evaluating the distal bicep, they suggest going right to the – right to the long axis of the distal bicep where it inserts on the radial tuberosity. However, I've found that I like to evaluate it. We've found more so that if we kind of start proximal and glide distally with the probe in short axis, we like to evaluate the bicep's tendon first in short axis as we follow down the bicep muscle belly. And so this is – this is kind of the first clip that I have, and it's starting proximal sliding, gliding the probe distally, and really finding and following down the bicep's muscle to where the muscular tendon is junctioned and tendon then form. I'll just play this for us. If we look right at the top of the screen where the cursor is, we can see where the bicep's tendon begins to form. Bicep comes down and we begin to form the musculotendinous junction, and then it further kind of coalesces into the bicep's tendon. Now, the problem is, and we can see here, that as we get closer to the home base, as it goes through more time, the bicep's tendon really becomes subject to anisotropy as it dives deep, and that's, you know, the main concern with trying to evaluate it during for its full breath in short axis. But, you know, that's the main focus of kind of this clip and looking at it in short axis. We can also see the brachialis muscle come in as well as the brachioradialis pronator teres and the rest of home base as we glide more distally. So now this brings us to our patient. So that was, what I just showed was more of a normal anterior elbow, and so what I'd like to share now is a couple clips of the patient's examination while in short axis. And so I'll kind of, if you kind of focus on that same area of the screen as the clip progresses, we can clearly see that there is, it does not look the same for left, just to be kind of blunt with it. And we can see that the tendon itself, as we're expecting it to form this tight fibular structure and, you know, really look like a tendon we're used to seeing, it really is boggy, it's edematous, and it's significantly larger than what we'd expect. Also, we can kind of see it forming a lot more, a lot more proximal than when we would anticipate seeing it. This next slide is just kind of further down. We couldn't really get the, you know, we were moving slowly, couldn't get the whole thing, so we went ahead and took a second video here. And as you can see, it remains quite edematous, and there's, looks like there's fluid in this first with it, within it, it's hypoechoic as we get closer to that home base. And really, that hypoechoic signal is a lot, we're seeing that a lot sooner than we would anticipate if the tendon were intact, when we would think we were going to see anisotropy. But, you know, that hypoechoic signal is a lot more proximal than what we would anticipate. The next step is to evaluate the distal bicep in what we're kind of classically going to want to look at it, and that's long axis closer down to the radial tuberosity and its insertion point. Here we have the patient, again, with the arm abducted, they're supinated, but they have about 20 degrees of flexion in this, in this case when we're examining the distal bicep. I added this gross anatomy and anatomy slide just together to kind of give an idea of where the angle that we're looking at in relation to the radius and the remainder of the elbow. And what we like to do is we, when we're looking for the distal bicep, what we want to do is we want to start medially with the probe kind of parallel to what we would expect the radio, and with the probe kind of parallel to what we would expect the radio, the radius to be, we want to glide back and forth, we want to look, we want to start gliding towards the radius, and we want to angle our probe just slightly. And what we'll see in the next image is that we look for the brachial artery, and that gives us a very good acoustic window to evaluate the biceps tendon, just inferior to that, just deep to that. And so again, here's patient positioning for the distal bicep long axis examination. And here we have kind of, this is our gold, our gold picture, so to speak, of what we really, really want to find. And we can see clearly a tight fibular pattern of the biceps tendon coming down and inserting on the radial tuberosity and the acoustic window of the brachial artery, just superficial to that. It's really, you can really appreciate the artery in, you know, in video, given that it's pulsating at the time of the examination. So here's just another one of those kind of all-in-one slides showing the gross dissection probe positioning and what we would expect to see on our ultrasound screen. One of the benefits I think we all can agree on with ultrasound is that the dynamic examination is very helpful when we're looking at a specific area or a structure. And as we can see here, supination will really show motion of the biceps tendon, it'll show it tightening and getting taunt with movement of the forearm, and this can A, help us identify what we're looking for, but B, help us identify maybe some occult partial tears or things like that, and it also kind of can clear up some anisotropy if we're looking at that at the insertion site, but here we can also see the brachial artery kind of passing back and forth as it pulsates and providing us with a good acoustic window. So that we just saw was unfortunately not the patient's, but a normal example of a distal bicep, and here we have a clip of our patient's distal bicep, and I'll let this run a couple times. So here we can see the radial tuberosity coming into frame where we would expect there to be a clear insertion of the distal biceps tendon, however, there is what's lacking is that tight fibular pattern, we can see it maybe very faintly, and there could be some maybe scant fibers that are still there, but for the most part, it's a void where the tendon should be, and we can see kind of more laterally towards our dot over here that, or I guess more proximally towards our dot, we have a hyper kind of bundle, and it looks as though that is where the distal biceps tendon has kind of settled after this essentially complete rupture, and that's where we have our proximal stump. We did want to go ahead and give a measurement to estimate how much retraction there would be, and in this case there was five centimeters, we did, as you can see, our most distal point here is right down to the radial tuberosity, and we did kind of go back into this proximal stump there. There are, so we did not do it for this patient specifically, but I wanted to include these into the talk today, there are some other windows that we can evaluate the distal biceps tendon, and they aren't the best for seeing the details of the insertion point, but they are both dynamic examinations and evaluations that can really, if you're having trouble discerning a complete versus incomplete or partial tear, they can give some additional information. So the first one is going to be a long axis view of the distal bicep through our lateral window with the patient's elbow at 90 degrees, and they're going to be supinating there, supinating at the hand as we evaluate the ultrasound, and here we can see what we're looking for, and as we can see right here in the screen, we have our distal bicep coming in here, and if we play this, as the patient supinates, we can see tension building on the biceps tendon, which would indicate that the tendon itself is in fact intact. I'll just play it one more time. The second window is called the Cobra, and you have the patient flex the elbow fully pronate and then flex the wrist as well, and again, you're looking at a head on over the, it's almost like a posterior elbow view, and what you're looking for is the insertion of the distal biceps on the radial tuberosity as it lies adjacent to the ulna here, and we can, as we, as the patient will supinate and pronate, we can see the insertion kind of come into window, and again, this is just an added, added evaluation, and it's, you know, in more of a dynamic state. This is just another one of the kind of all-in-one cross-sectional pictures of the probe positioning, what you find on your screen, and our cross-sectional anatomy here. So looking in, continuing to look at the anterior elbow and long axis, we do want to look at our joint recesses, and the first will be the radial capitellar joint and long axis, and so here we see our image, we're looking at the radial fossa here with our fat pad, and then we see the cartilage, the hyaline cartilage over top of the capitella. Again, another joint recess to look for is going to be the humeral ulnar joint, and this is going to be in long axis as well, and here we see, we have the coronoid fossa with our anterior elbow fat pad, and then we have the hyaline cartilage of the trochlea here. So that kind of rounded out, you know, the majority of our anterior ultrasound examination. We saw our median nerve in the home-based view, and as it came into view when we glided more proximal to distal, and you can evaluate it in that. What I did not include was a long axis view of that, but what I'd like to move on to now is our lateral elbow examination, and that will include the common extensor tendon, the lateral collateral ligament, radial head and annular recess, and more so the radial nerve and anything. So for patient positioning, we want to have their elbow flexed at 90 degrees again, and we have the probe that will look at these common extensor tendons, and this will help us look at them in long axis, short axis first. So just to look over some anatomy, we have the extensor carpi radialis brevis, extensor digitorum communis, and the extensor carpi ulnaris inserting onto the lateral epicondyle, and we'll glide our probe kind of in this fashion where we're moving up and down the lateral epicondyle to evaluate the insertion point of these tendons. Over here, we can see just that. As we come in, we can see our common extensor tendons inserting up onto the lateral epicondyle. If we pause when the radial head is in view, we can see our radial collateral ligament, and we can see our annular ligament sitting on top of the radial head here. And so what we want to pay attention to closely is this insertion point onto the lateral epicondyle of our common extensor tendons there. This is included in this examination with this patient, even though we had a very high suspicion of the distal bicep rupture to make sure we weren't missing anything or missing any associated injuries. We move on to short axis examination of the same area, and what we really – I found this most useful just to scrutinize for bony abnormalities and cortical change, but you can still see some of the insertion points of these tendons there. Here we just have the lateral epicondyle come into view here, and as they bundle up and insert onto the epicondyle right there. If we start from the beginning, we're looking at – in this region here, we're looking at extensor carpi radialis brevis, digitorum communis, and extensor carpi ulnaris, and as they come in, and I'll insert onto the lateral epicondyle. Let's play through it one more time. And we do want to include the imaging of the annular recess, which is adjacent to the radial head, and just to make sure that we don't have any sort of fusion or hypophilic signal there. We can see that coming down in this region here. And then lastly, we wanted to evaluate the radial nerves, and it's like looking at the anterior elbow and finding our home base, but we move it a little bit laterally, and as we can see in the anatomy, we focus right over top of the radial nerve, right before it branches off into the superficial radial nerve and the posterior neuropsteous nerve. And we'll kind of be moving our probe in this fashion here as we glide up and down those structures. So here it is in short axis. You can see right in the middle, our radial nerve is present, and it is right as it kind of branched off a little bit distal to where ideally I would want to be, but we can follow the posterior anopsteous coming down into the septum between the two heads of the supinator and come in right in here. Let's play that through one more time. You know, the main thing we're looking for is any, you know, increase in diameter of the nerve, any swelling of the nerve there. Finally, you can also identify this in long axis. It was a bit of a challenge, but you can see the path of the radial nerve coming right down this way between the two heads of the supinator. And again, this is a good view to kind of look for uniformity of the nerves and evaluate for any sort of change in size or kind of edema in the nerve or anything like that. This patient, you know, did not have any abnormalities kind of associated with the injury he sustained, and the remainder of the exam, you know, was normal after evaluating for the distal bladdup. So, this kind of, now we've done our examination, we have to put that into words. And so, at our institution and where I am, we like to use a templated report, and it's really more of a checklist to make sure you're hitting all of the kind of high points that you want to look for. And each report can, you know, it starts out with, especially, so for example, in the elbow, a report starts and all four compartments are present within kind of our templated report, and you can kind of add or subtract as you may need to to customize your report. But we want to make sure we at least address every kind of, every important structure that is included in a complete examination. And in this examination, most notably, the most notable finding was the complete full thickness tear from the insertion of the distal biceps tendon on the radial tuberosity with, excuse me, approximately five centimeters of retraction. And we do kind of just say the rest of the things are normal, but we make sure that it's known that we did look and evaluate them. My preferences, I do like this kind of report personally, mainly because it helps me kind of keep a protocol and a checklist in my mind as I'm doing an examination.

2nd Edition, CASE 07

2nd Edition

Elbow and Forearm

ultrasound elbow examination

patient positioning

high-resolution linear probe

distal bicep tendon

anisotropy

templated report