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Today we are honored to welcome Dr.

0:31

Steven Pomerance for a lecture entitled MRI of the elbow.

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Dr. Steven j Pomerance is the CEO

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and Medical Director of ProScan Imaging, chair of Naples,

0:41

Florida Community Hospital Network,

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and the founder of MRI Online.

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He's authored numerous medical textbooks in MRI,

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including the MRI, total Body Atlas.

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Dr. Pran is also an AVID conference, lecturer

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and chairs the fellowship training program in MR.

0:57

And advanced an imaging.

1:00

At the end of the lecture, please join Dr.

1:02

Po Moran's in a q and a session

1:03

where he will address questions you may

1:05

have on today's topic.

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Please remember to use the q

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and a feature to submit your questions so we can get to

1:11

as many as we can before our time is up.

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With that, we are ready to begin today's lecture. Dr.

1:16

Pomerance, please take it from here.

1:19

Thank you everybody, and welcome to MRI Online, now known

1:23

as modality.

1:25

We're talking, uh, MRI of the elbow,

1:29

and we're gonna focus, uh, initially on anatomy

1:32

and then get into some additional details,

1:35

which we'll break down for you in a moment.

1:37

You know, the octopus is flexible

1:39

with an infinite number of movements.

1:42

It's configured with three joints, including an elbow

1:45

to perform essential functions.

1:47

So that's three joints per tentacle, so

1:49

that's eight tentacles times three joints.

1:52

There are 24 joints in the arms of an octopus.

1:56

So in anatomy, we're gonna focus on some key checkpoints,

2:00

uh, specifically the skeleton.

2:02

We're gonna look at, uh, some signs

2:04

of dislocation like the Osborne Codal lesion.

2:07

We'll look at some basic anatomy grooves bumps,

2:11

and then we'll talk about ligaments, the medial

2:13

and lateral collateral ligament complexes, the fat pads,

2:16

the tendons, and we'll show you where some

2:18

of the major nerves live in order to diagnose entrapment,

2:22

neuropathies, uh, the cubital tunnel, pronator tes tunnel

2:26

for the median nerve, the posterior interosseous nerve

2:29

or radial tunnel, and the anterior interosseous nerve.

2:33

And I'd like to start out a little bit with technique.

2:37

Uh, the patient can lie

2:38

with the arm at the side in a much more comfortable position

2:42

using either a rigid or flexible coil.

2:45

I like to have my patients with their hand, um, in,

2:49

in a thumb up position, which is most comfortable for them.

2:53

So somewhere between pronation and supination.

2:56

Um, some patients when you have to have

2:59

very high resolution imaging with microscopy, coil scanning,

3:03

may have to go into the superman position arm over the head,

3:06

but this is only sustainable for about, uh, 30 minutes.

3:10

There are some unique issues with the elbow

3:13

that are often present that requires, you know,

3:15

some prompt intervention.

3:17

First of all, the fractures may be quite complex

3:20

that may involve the interosseous membrane

3:23

and the, the nature of the fracture may indicate the nature

3:27

of the injury and the presence of elbow dislocation.

3:30

We've got the Essex Lo pesti fracture, the montega fracture,

3:34

OID fractures with the Yo Driscal classification fractures

3:38

of the distal humerus and radius.

3:40

And some of these, like these first two are often,

3:43

uh, board questions.

3:45

Now let's begin with, um, some gross anatomy.

3:49

Uh, the elbow is composed of three bumps in two grooves.

3:52

Here's one of the bumps, the Capella,

3:55

and it fits very nicely into

3:58

the concavity of the radius.

4:01

Uh, so the radius should be pretty balanced at the apex

4:04

of this concavity for when it starts to shift out laterally.

4:08

You may have posterolateral, uh, instability syndrome.

4:12

You've got an ulnar humeral articulation right here.

4:16

You've also got a radial ulnar articulation,

4:19

right, right here.

4:21

Another variation that you're going

4:23

to see in the elbow is something called the

4:25

lateral synovial fringe.

4:28

And the fringe is a sort of ill-defined tissue right here.

4:31

And sometimes with that fringe is a more condensed band.

4:36

You know, it's, it's like a clicka

4:37

that you might see in the knee.

4:38

Some people have even called it a lateral clicka.

4:41

And then posteriorly, you often have these very small

4:46

vertically or obliquely oriented vascular grooves

4:49

that are hyperintense not to be confused with Capella

4:54

or os osteocondral defects.

4:56

Now, many injuries that occur in the elbow occur

4:59

with a fall on an outstretched hand, also known

5:02

as a poosh mechanism of falling.

5:05

You get axial compression and bending of the elbow,

5:09

and sometimes when you try

5:11

and get up, your arm is on the turf or on the ground

5:14

and somebody hits you from the back

5:17

of the elbow pushing the elbow forward.

5:19

And this may give you a, a varus deformity.

5:22

On the other hand, if you have a hyperextension injury,

5:25

you will have a, a valgus deformity.

5:28

You can also have supination type injuries at et cetera.

5:32

So the mechanism of injury is easily ascertained

5:36

by looking at the pattern of bone anatomy

5:38

and the pattern of ligamentous anatomy.

5:40

And this is going to become more clear in a few moments.

5:44

So on the left is a diagram showing you, um,

5:48

grossly the skeleton with the ulna, the coronoid process.

5:53

Uh, here is the humerus

5:55

and here are the teardrops on either side of the humerus.

5:59

And most of you are familiar with the, the teardrop sign,

6:02

especially when the fat pad anteriorly is displaced forward

6:06

on an X-ray, you know that you have, uh, an effusion.

6:10

Uh, here's why that occurs.

6:11

Here's the fat pad with some of the fibers

6:14

of the brachialis, distended superiorly

6:17

and anteriorly by a large effusion.

6:19

You can see a microtrabecular injury of the radius.

6:22

And for those of you paying close attention,

6:24

you can see the Osborne Codal fracture of a dislocation

6:29

that has occurred in the elbow.

6:30

More on that in a few moments.

6:33

So here's an example of an 8-year-old with a joint effusion.

6:37

Uh, this time the joint effusion is small enough so

6:40

that you see the posterior fat pad,

6:41

but not the anterior fat pad.

6:43

Here's another patient with a larger joint effusion.

6:47

Now you see both the posterior fat pad

6:50

and the anterior fat pad that that is lifted up.

6:53

And of course, buried in there somewhere is the attachment,

6:57

uh, of the brachialis.

6:59

Now we said the, the relationship of the humerus ulna

7:03

and radius is divided up into two grooves and three bumps,

7:07

and here are those bumps.

7:08

Here's the Capella bump.

7:10

Here is the medial and the lateral humeral bump.

7:14

This is known as the Capella groove.

7:16

This is known as the trochlear groove,

7:19

and there should be a best fit scenario where this part

7:22

of the jigsaw puzzle fits into

7:24

that part of the jigsaw puzzle.

7:26

And the same thing is true on the radial side

7:29

of the articulation.

7:31

When that best fit configuration is lost, then we refer

7:35

to this as the sloppy hinge syndrome.

7:39

Now, if you drop your arm to your side, all of you'll notice

7:43

that your arm doesn't go straight down, your arm comes down

7:47

and goes off in a slight valgus orientation.

7:51

So the, this is known as the valgus carrying angle.

7:54

It's about about six degrees.

7:56

Uh, a couple of other interesting unique features,

8:00

uh, to, to the elbow.

8:02

The anterolateral radius is not covered by cartilage,

8:05

so don't confuse this with an OCD.

8:08

The anterior capsule is loose inflection

8:10

and tight in extension and the elbow along with the humerus.

8:15

This is vital information, have the tightest capsules

8:18

for the size of the joint, which means

8:20

that when you have something in these joints like PVNS,

8:25

you're going to get the largest pressure types of erosions.

8:29

The synovium lies the inner aspect of the fibrous membrane

8:33

and redundant synovial folds are very common,

8:36

especially posteriorly.

8:38

In the reon fossa, you've got synovial membranes, the

8:43

peron in the back, the peri humeral in the front,

8:45

and the peri ligamentous, medial and lateral.

8:48

And we've already shown you the synovial fringe.

8:51

And here it is again. Here is the lateral synovial fringe.

8:56

It can get pretty big, pretty deep, and pretty conspicuous.

9:00

It can even, uh, masquerade as something akin

9:05

to aika.

9:06

Um, when they get symptomatic,

9:08

they're usually thickened about three millimeters

9:11

or greater, but the key is to see inflammation in this area

9:15

and that inflammation may extend into the cartilage

9:18

of bone or bone.

9:19

So while these, these reflections are normal,

9:23

they can be symptomatic just as they can be, uh,

9:26

symptomatic in the knee.

9:28

Here's an example of a symptomatic one.

9:30

Here's a diagram, short and stubby.

9:32

There are some abnormalities under the diagram in the

9:35

Capella, in the radius,

9:37

even though there is some bear area over here.

9:40

And then if we go down here, inferiorly to the MRI look at

9:45

how thick these tissues are with an effusion

9:48

as a secondary sign.

9:49

This is all part of the fringe right here.

9:51

This is a bit too thick.

9:53

And then when you look at the gross specimen

9:56

arthroscopically, you can see

9:58

quite a thick synovial fringe projecting Edward.

10:02

Let's take a 21-year-old with elbow injury

10:04

after being positioned in a sling, uh, for quite some period

10:09

of time, the trauma was relatively minor.

10:12

Now, when the patient came out of their sling,

10:15

which was put on the patient for medial symptoms,

10:19

they ended up having more central ill-defined symptoms.

10:23

And because of the restriction of this sling

10:26

and the alteration in pronation

10:28

and supination, this patient developed from the sling from

10:33

the restriction, a, an erosion

10:36

that occurs right at the radio, uh,

10:39

trochlear bump right here, the central bump.

10:42

And so here's an erosion that occurred, uh, as a result

10:46

of elbow restriction.

10:48

You can also see that the elbow is normally dry

10:51

and there's a small amount of

10:52

what I call trace effusion of the elbow.

10:55

So in a young individual, the elbow should be dropped.

10:58

Here is the sagittal

10:59

or lateral projection demonstrating what is a pretty

11:03

substantive erosion in, in the back

11:06

of the humerus in this patient.

11:08

There's also a little bit of thickening

11:09

of the posterior para plica,

11:12

but do not confuse this object right here, this defect,

11:16

which is a normal defect that occurs in the trochlea in the,

11:20

in the sagittal projection.

11:21

We also said earlier that there are normal areas

11:25

of irregularity

11:26

and vascular grooves in the back of the Capella.

11:29

So those are two important variations back

11:31

of the Capella irregularity

11:33

and right in the trochlear groove seen in the sagittal

11:37

projection almost exclusively.

11:40

And here's an example of somebody with an abnormal elbow.

11:43

So-called sloppy hinge syndrome.

11:46

Look on the right at the T one weighted image.

11:52

You could be on your fourth pint of Jack Daniels,

11:55

and you can easily see these

11:58

osteophytes projecting on either side.

12:01

But look at how the ulna does not sit

12:06

directly into this groove right here.

12:08

That apex is off from that depression very slightly.

12:12

So everything is starting to shift.

12:14

So despite the fact that there is oa,

12:17

there is already the development of sloppy hidden syndrome

12:20

so that when the patient flexes

12:22

and extends, their range of motion is diminished.

12:25

The friction, uh, between the structures is enhanced

12:30

and eventually they knock off a pe piece

12:32

of cartilage anteriorly, which is where cartilage likes

12:35

to go here and here near the ano.

12:39

Here's another example of somebody with a sloppy hinge,

12:43

not shown, but that

12:45

that friction has also irritated the posterior para clicka.

12:50

Remember we have several clicka, one in the front,

12:52

one in the back, one medial, one lateral.

12:54

The most famous one is the lateral synovial fringe.

12:58

The second most famous one is

13:01

theon fringe or applica.

13:03

And here it is induced synovial hyper hypertrophy.

13:07

No, this is not fluid, it's too speckly looking

13:10

to be simple fluid.

13:12

It's inflamed fluid with synovial hypertrophy.

13:16

Bural, uh, primary bursa are often flat.

13:20

They're subcutaneous, they're usually over bony

13:23

protuberances, and they, they are synovial line.

13:27

They may be tethered to the skin of the periosteum example,

13:31

the ome bursa, the annular

13:33

or sfor recess bursa, locations for bursa,

13:36

subcutaneous submuscular, peri tendons, peri ligamentous,

13:41

and subfascial.

13:42

You can have secondary bursa that form.

13:45

So-called pseudo bursa, like adventitial bursa

13:49

that form in the first and fifth metatarsal head.

13:52

Callous causes of bursa inclu, uh, bursitis include acute

13:57

or repetitive trauma, gout, infection,

14:00

tumor like processes and inflammation.

14:02

If you see reon bursitis in a 40

14:06

to 50-year-old man without a history of trauma,

14:09

it is gout till proven otherwise.

14:11

The differential diagnosis

14:13

of bursal distension includes hematoma

14:16

and degloving, uh, fascial degloving.

14:19

So-called morel lavalle syndrome.

14:21

There are a few eponyms, uh, in bursitis including

14:25

au bursitis, which is sometimes called minor's elbow,

14:29

and sometimes it's also called student's elbow

14:32

because the student leans on their elbow while studying

14:35

for the, for the amat or for the big pathology exam.

14:39

There's an example of ano bursitis,

14:42

but no, not just any bursitis.

14:45

Look inside it. It's got this funny looking

14:49

heterogeneous tissue.

14:52

It's in a man, the man is in his early forties,

14:55

and as stated, this is gout till proven

14:57

otherwise, and it was gout.

14:58

On the other hand, this is a woman in her forties.

15:02

There is distension everywhere in the back, in the front,

15:05

but there's also these large confluent areas

15:08

of intermediate signal intensity.

15:10

Well, I suppose they could be tophi,

15:13

but with a capsule markedly distended, it is a woman

15:17

and the extent of synovitis, you, you have

15:20

to choose rheumatoid arthritis as the first choice.

15:23

And it is, there is a, a focal area

15:26

of panis formation in this patient with ra.

15:30

Now let's turn our attention to elbow instability.

15:33

We've got static and dynamic, uh, stabilizers, uh,

15:36

uh, of the elbow.

15:38

The main static stabilizers are the lateral

15:42

and medial collateral ligaments.

15:44

The lateral collateral ligament can be broken down into a

15:47

proper anterior short stubby collateral

15:51

and a slightly more circuitous thinner lateral ulnar

15:54

collateral ligament.

15:56

The medial collateral ligament

15:58

can be broken down into three segments,

16:00

but the most important one by far is the anterior bundle

16:05

of the MCL.

16:07

The dynamic stabilizers include the common extensor on the

16:11

lateral side and the common flexor on the medial side,

16:15

common extensor lateral, common flexor medial.

16:18

And it makes this this triangle almost like a fortress.

16:22

And this is further supported by the conformity

16:26

and the fit of the, of, of, of the trochlea,

16:30

the cap, sorry, the trochlea, the humerus, and the radius.

16:35

So now let's begin with the lateral side of the elbow.

16:40

We, we start with the, sorry, let's begin

16:42

with the medial side of the elbow.

16:44

My apologies. The anterior bundle

16:46

of the UCL is the most important stabilizer.

16:50

The floor of the cubital tunnel formed

16:52

by the posterior bundle, the roof

16:54

of the cubital tunnel formed by the transverse bundle.

16:56

And these hardly ever tear

16:58

unless you have a massive dislocation.

17:02

The transverse superficial bundle in the back is sometimes

17:05

referred to as the ligament, uh, uh, of cooper.

17:08

Now the reason these are important is

17:10

because they house, uh, the ulnar nerve.

17:14

The anterior bundle of the UCL is fan shaped.

17:17

It spreads out a little bit distally,

17:19

it also spreads out proximally.

17:21

And this spreading phenomenon

17:23

may reduce the signal intensity as you go more distal

17:27

or go more proximal from

17:29

that more tight dark signal intensity

17:32

that you see in the mid substance.

17:34

Now, like the knee, like the knee, the UCL,

17:39

the anterior bundle of the UCL is a three layered dragon.

17:44

It has a superficial layer, which is very subtle.

17:47

It's very hard to see.

17:48

It's the flexor digitorum superficialis of pon neurosis,

17:53

which I can only show you here as this little whitish area

17:57

because it's inflamed.

17:58

This is what a grade one UCL sprain looks like.

18:02

Then the next layer, which is analogous

18:04

to the tibial collateral ligament is the anterior bundle

18:08

of the UCL.

18:10

Then the next layer, which is analogous to the menis femoral

18:14

and meniscal tibial ligament is the capsular layer.

18:18

So layer number one, layer number two,

18:21

layer number three, I'm not gonna go

18:24

through the gross anatomy on this specimen, uh,

18:27

due to time constraints.

18:29

Let's take this, this world famous nationally famous

18:33

quarterback who had a deceleration injury while trying

18:37

to throw the ball.

18:39

He went back into the game.

18:41

His, his deceleration injury occurred when the hand struck

18:44

another player's helmet he could throw,

18:47

but he could only throw 30 to 40 yards.

18:50

Normally he could throw 60 yards with only 60% velocity.

18:53

He came out of the game

18:55

and we performed this mighty mouse superman position,

18:59

prone position, arm over the head,

19:03

high resolution microscopy image using a specialized coil.

19:08

And on the T one weighted image, it doesn't look too bad.

19:11

However, look at this little space here.

19:15

I really like this to snuggle up all the way onto the

19:19

sublime tubercle of the oma.

19:21

I don't like to see any space here at all.

19:24

I might allow half a millimeter

19:26

or a millimeter as long as there's no inflammation.

19:29

Now let's go to the proton density, fat suppression image.

19:33

We've got three findings here.

19:35

I've got two of them labeled one

19:37

and two labeled one, swelling of the flexor digitorum

19:42

superficialis upon neurosis.

19:45

And that arrow below it looks like it's pointing

19:49

to the same thing, but it's really not.

19:51

It's pointing to this little divot right here

19:53

and then want it to get too close.

19:55

A partial tear of the mid substance on the outside surface,

20:00

but also on the inside surface we're talking

20:04

microns of resolution.

20:05

And finally, the last finding,

20:08

which I have labeled number two, is this separation,

20:12

this stripping of the distal bundle

20:14

of the UCL from the sublime tubercle of the ulna.

20:19

In a consultation in New York City,

20:22

the aggressive physician said this must be repaired.

20:25

However, we said that based on our 20

20:29

or more years of experience that this would heal, he decided

20:33

to get a second opinion from Peyton Manning's doctor over in

20:37

Indianapolis, who also said it would heal.

20:40

And the injury occurred in November.

20:42

By May, he was throwing full force without an operation.

20:46

Had he had an operation, he would've been out

20:49

for over a year.

20:50

So the microscopy coil and its high resolution

20:55

and the experience really saved the day on that one.

20:58

Here's a coronal projection showing you one

21:00

that's much easier fan shaped proximal UCL anterior bundle.

21:06

The distal bundle is separated.

21:08

You can see the space from the sublime tubercle of the ulna,

21:12

a fairly easy one, elbow dislocations.

21:15

Here you see anterior dislocation of the humerus relative

21:19

to the ulna and, and the radius best depreciated on the true

21:24

lateral projection.

21:25

Although I have multiple obliquities here for you,

21:28

you already saw this example showing you the teardrop sign

21:33

with diffuse swelling

21:34

and blood in the joint fracture of the radius,

21:37

the Osborne Codal dislocation fracture analogous

21:41

to the heel sax injury in in the shoulder.

21:46

Let's take a look at something

21:48

that could easily be misconstrued for this.

21:50

A look-alike. This is not an Osborne co oral lesion

21:54

because those are acute, those occur with dislocations.

21:58

This patient has never had a dislocation.

22:01

So knowledge of the history is your friend,

22:05

especially an orthopedic MRI sclerosis is also helpful.

22:10

All right, we got sclerosis dark on MR. Dark on ct.

22:15

The abnormality is markedly etched.

22:17

You can see an erosion higher up off to the side.

22:22

So no, this is not an Osborne codal fracture lesion.

22:26

It's a chronic posterior

22:28

and trochlear osteochondral erosion secondary

22:32

to abnormal friction

22:34

and valgus extension overload in somebody

22:36

with a sloppy hint syndrome.

22:38

Here's the, here's a trochlear abnormality in another

22:41

individual that also has sloppy hint syndrome.

22:44

Another thrower, this is, this one is also etched

22:48

and chronic and the patient also has never dislocated.

22:52

Look how sharp edged it is.

22:55

Let's talk about the stages of posterior dislocation.

22:58

I don't want you to memorize these zero through three.

23:02

Some people go one through four.

23:05

I just, I'd like you to just think about it

23:06

with a little bit of common sense.

23:08

They've subluxed

23:09

or dislocated, all the collaterals are intact,

23:13

they subluxed or dislocated.

23:15

The next thing you do is you check

23:17

the lateral side, both ligaments.

23:19

You check the medial side,

23:21

all three components of the ligament.

23:24

And then finally the last thing you do

23:26

is you check the skeleton.

23:27

If you just do that

23:29

and describe, you don't need to go to these stages and

23:32

unless you're an MSK radiologist performing at a high level

23:37

and even then the surgeon doesn't really care about your

23:40

grade, just so that you get the anatomic information right.

23:45

And this is a, a diagram just showing you these grades zero

23:49

through three not so important.

23:51

Let's take this 23-year-old man with laxity

23:54

of the medial collateral ligament

23:56

and a type one OID fracture.

23:58

And yes, there are, there are types of corona fractures

24:03

that you can think,

24:04

you can think about a little bit like dense fractures.

24:07

You know, you got the dense tip, you got the den body,

24:09

you got the dense base.

24:11

OID fractures are a lot like that.

24:14

Um, sometimes you may see the OID break off

24:17

and you may get loose bodies, uh, you know, floating

24:20

around within the joint that have come from the oid.

24:24

Here's a sagittal T one, here's a sagittal uh, pd.

24:27

Here are some fibers, some superficial fibers

24:30

of the brachialis, the deep fibers

24:33

of the brachialis attached to the oid.

24:35

So that's a problem there.

24:36

There's the capsule right here attaching to the oid.

24:39

That's also a problem. But where is our oid?

24:43

It has taken a vacation, so the tip

24:46

of the OID has come undone.

24:49

Now these areas that are located in the joint,

24:52

which is distended with fluid represent coagulated blood.

24:55

The fragment of the OID is right here,

24:57

so there aren't any so-called loose bodies.

25:00

Here's another dislocation.

25:02

If you went back and looked at the grading system,

25:04

usually the dislocators with uc, ucls are kind

25:08

of a higher grade, but sometimes you get 'em both.

25:11

Sometimes you get both the lateral side and the medial side.

25:14

Here's an easy one.

25:15

All I want you to do is figure out

25:18

where the collaterals are.

25:20

I'm not gonna show you the lateral side just yet,

25:22

but the medial side fan shaped, that's okay,

25:26

a little gray, that's okay.

25:28

It comes down and it does not snuggle right up onto the

25:32

sublime tubercle of the illness.

25:34

So this is a distal UCL tear in a patient with a known

25:39

clinical dislocation.

25:40

Now here's the same patient. We're not done yet.

25:43

We said the UCL was torn, but we said you can get them both.

25:48

And this patient had them both.

25:50

Here's the proper collateral ligament.

25:51

There might be a little space there,

25:53

but here clearly there is not abutment attachment.

25:57

There is delamination of the proper

26:01

radial collateral ligament from the radius.

26:03

So he is got it on the medial side.

26:05

He's got it on the lateral side.

26:08

Now a kissing cousin

26:09

of the proper radial collateral ligament is the lateral

26:12

ulnar collateral ligament, also known as the luck.

26:17

It comes off from the back

26:19

and wraps around the radius

26:22

to insert on the supinator crest right here,

26:25

the supinator crest of the ulna.

26:28

This shows it coming out

26:30

and around under the ulna, but not so well.

26:32

You can't really appreciate how it ducks

26:35

underneath the radius, sorry, how it ducks

26:37

underneath the radius and inserts on the supinator crest.

26:41

So here's the takeoff of the luck goal coming around

26:45

behind the radius.

26:46

And here's a double takeoff right here,

26:48

which isn't too common.

26:51

Here's again, a view of the luck.

26:55

It has a circuitous course rather than a straight thick

27:00

stubby course that we see

27:02

with the proper collateral ligament.

27:04

Another stabilizer is the annular ligament,

27:07

and there's a small recess in here known as the sfor recess.

27:12

Let's look this time at the sagittal projection.

27:15

Do not, do not confuse the common extensor mechanism,

27:19

which is a little more superficial from

27:23

the lateral ulnar collateral ligament,

27:25

which sometimes has a funnel shaped takeoff right here,

27:28

usually single bundled around the back of the radius

27:32

to insert on the supinator crest.

27:34

Not shown, but this area of distension

27:38

in the proximal radial neck is known as the sfor recess.

27:43

Here's an example of both the proper short stubby, anterior

27:49

proper collateral ligament with nice

27:52

snugly attachment to the radius.

27:55

And here's the takeoff, the funnel shape takeoff

27:58

of the lateral ulnar collateral ligament.

28:01

We don't see the rest of it

28:02

because it's just simply going out

28:04

of plane from this one slice,

28:06

but it'll make its way over to this crest, which is known

28:09

as the supinator crest nurse maid's elbow.

28:14

We all learned about that in medical school.

28:17

If you're a little older like I am, we used

28:19

to say, well, what is that?

28:21

Well, they say, well, it's a pulled elbow.

28:23

Well, what is that? Well, we're not sure

28:25

what the anatomic abnormality is,

28:27

but maybe it's an injury to the annular ligament and,

28:30

and maybe the radial radial head slips out of there.

28:33

We now know that to be true.

28:35

So our our positing about what it was, was correct,

28:40

wasn't my positing.

28:41

People much smarter than me posited it

28:43

at Children's Hospital.

28:45

And here we have the swollen,

28:47

bloody interrupted annular ligament.

28:49

You can't appreciate that the radiuss subluxed, but it is.

28:54

So another type of lateral collateral ligament insult is a

28:58

50-year-old female who complained

29:00

of persistent lateral right elbow pain with crepitus

29:04

and right hand numbness since a motor vehicle accident, uh,

29:08

that occurred in July.

29:10

This one's quite easy.

29:11

Look at our gorgeous ulnar collateral ligament anterior

29:15

bundle fan shaped and comes down and attaches snugly

29:20

and neatly on the sublime cubicle of the ulnar,

29:23

but not not the radial collateral ligament

29:26

that is stubby

29:28

and never reaches its position onto

29:32

the distal humerus.

29:33

Superficial to it is the common extensor mechanism.

29:38

Let's take this 39-year-old man with posterior chronic pain,

29:42

rule out ligamentous injury with elbow dislocation.

29:45

Here is a sagittal view showing a much bigger,

29:49

uh, oid fracture.

29:50

There it is, there's the big chipper right there.

29:53

And every, every time I think of trip chip chipper, I think

29:56

of the movie Fargo, that's maybe not such a healthy thing.

30:00

But there inside the joint, uh, is an effusion.

30:04

And there inside the effusion that is blood

30:07

that is actually not a fragment.

30:09

It's not dark enough to be such.

30:11

But when you see this, now you've got a search

30:14

for the position of the capsule, which looks pretty good,

30:17

attaching to the tip.

30:19

You might search for the attachments of the, the brachial,

30:22

which looked pretty good.

30:24

That wasn't the point of the study.

30:26

Now there is an a driscal classification of OID fractures

30:31

and generally the higher the grade,

30:33

the more violent the dislocation.

30:35

It's pretty easy because the tip is grade one.

30:39

And then as you get deeper down,

30:41

more posterior on the coronoid, the fractures get bigger,

30:45

the fragments get bigger and the dislocations get worse.

30:49

So it's not so fancy, uh, the a driscal classification

30:52

of coronoid fractures, but,

30:54

but here is really a key fracture along

30:57

with the coronoid fracture that helps you

31:00

decide you've had a dislocated elbow

31:02

and that is the Osborne Codal lesion, the kissing cousin,

31:07

the mimicker of the hill sax lesion in the shoulder.

31:10

It's on the posterior aspect of the humerus

31:12

and an anterior dislocation,

31:15

and it's often a sign of a medial

31:17

or lateral collateral injury as well.

31:20

Now, don't confuse this sort

31:22

of undulation in the back right here,

31:24

which is more superficial, not associated with edema.

31:29

And unfortunately I'm not showing you the edema

31:31

with this much deeper, more etched defect

31:34

with more acute edges to it.

31:36

This is a real Osborne codal irregularity

31:39

and the one on the left is not.

31:42

Here is an example of a patient

31:44

that has sustained a vari insole.

31:47

There is your lateral collateral ligament.

31:50

It really never makes it, uh, to, to the humerus.

31:54

And here it's, it's clear. Here's the T one weighted image.

31:57

This is the lateral ulnar collateral ligament.

32:00

It should be a funnel shaped object, something

32:03

that looks like this.

32:06

It should look like this kind of funnel shaped

32:09

and then continuing on

32:10

and then right around the radius on its way

32:12

to the supinator crest, it is clearly not doing that.

32:16

So that is a lal tear.

32:18

Now compare that, that you're in the back.

32:20

Now these are both pictures of the lal.

32:23

It's a little clearer on the T one than it is on the stir.

32:26

But then have a look at a more anterior slice.

32:30

The more anterior slice shows you the fat stubby cigar in

32:35

its mouth of the radial collateral ligament.

32:37

The proper collateral ligament going from the humerus

32:42

to the radius so that one's intact.

32:44

So this was a pure luck injury.

32:47

Here's a patient with posterolateral recurrent

32:50

instability syndrome.

32:52

Frequently in that phenomenon,

32:54

both the common extensor mechanism,

32:56

which it is the undersurface of it is injured.

33:01

The common extension may be swollen.

33:03

It is, it is here again,

33:06

but where is your proper collateral ligament?

33:09

You don't really, the space is completely empty.

33:12

And as you go back a little bit, I mean where is,

33:14

where is your luck?

33:16

The luck is peeled off.

33:17

Right here you have this smoky high signal intensity tissue.

33:22

On the T one you see virtually nothing

33:24

'cause it's filled in with granulation tissue

33:26

and inflammatory tissue.

33:28

So that one had both a proper

33:30

and a posterior lateral ulnar collateral

33:32

ligament injury or luck.

33:34

Both components of the LCL 46-year-old female fell on

33:38

5 1 21 she had a dislocation

33:41

and this one was flat out nasty.

33:44

This is a low field 0.3 tesla machine, T one coronal

33:49

PD uh, sorry, stir sequence at low field.

33:54

And this is your water and fat weighted image.

33:56

Where is your lateral collateral ligament?

34:00

You're pretty far anterior, so that's the proper.

34:03

It's just truncated and cut off.

34:06

But where is your ulnar collateral ligament? Anterior band.

34:10

It's reduced to a pile of dust.

34:14

That's what's left of it right there.

34:16

Never makes it to sublime tubercle.

34:18

So both of them are torn. It's a complex instability.

34:23

And with cases like this, now you really have

34:25

to worry about the rest of the medial collateral ligament.

34:29

You know, the posterior bundle and the transverse bundle.

34:32

I mean, look at that thing right there.

34:34

The posterior bundle goes on the road

34:36

to perdition, it goes nowhere.

34:38

It's truncated right there.

34:40

The transverse bundle superficially goes nowhere.

34:44

It's just floating out there in the breeze.

34:46

The anterior muscle groups are interrupted

34:50

and the the ulnar nerve is right here.

34:52

Fortunately, the ulnar nerve isn't really much involved.

34:56

It is a little bit of dus,

34:58

but this patient has all three components

35:01

of the medial collateral ligament that are trashed.

35:05

Let's turn our attention now to tendons and muscles.

35:08

We've got anterior, posterior medial

35:10

and lateral, uh, on the tendon side.

35:12

On the muscle side we've got biceps, brachialis, triceps,

35:16

oconus flexors and extensors.

35:19

Let's talk a little bit about tendons.

35:21

Now, tendons are usually oriented in the long axis.

35:26

They're tendon subunits known as fales or bundles,

35:30

and within these bundles are microfiber units.

35:33

So there's units upon units upon units.

35:36

You can get infiltration of tendons without interruption

35:40

of these subunits.

35:42

AKA gout, you have endo tendon.

35:46

The surface of the tendon is connected to epi epi tenon,

35:51

but that does not equal a sheath.

35:53

You can also have epi tenon.

35:55

The common extensor

35:56

and flexor tendons have have epi tenon,

35:59

you have the anterior posterior biceps,

36:01

the brachialis and the triceps.

36:03

They all have epi tenon. Then you have peritol.

36:07

This is loose elar connective tissue that's applied

36:11

to the epi tenon.

36:12

It's the outermost layer

36:14

and the perone is seen most classically in the Achilles

36:18

and the patella tendon.

36:20

In the Achilles, you absolutely get peritonitis.

36:25

And then you have true tendon sheath which

36:28

replace the perone.

36:30

And most of these, not all but most are synovial line.

36:34

They're less fibrotic than their peron counterparts.

36:38

The nomenclature is based on depth orientation, the sheath,

36:43

and also when you're describing tendon injuries,

36:47

delaminations versus splits, that's probably a story

36:50

for a little bit later or another day.

36:52

You can have tendon infiltration,

36:54

you can have tendon retraction

36:56

and the descriptors can get very complex.

36:59

And I get complex when we're talking about the shoulder,

37:02

but I don't have time to delve into all the nomenclature

37:06

for tendon injuries in the elbow.

37:08

But let's start out with a little bit of simplicity here.

37:12

There's the anterior bundle of the UCL.

37:15

It's not perfect, it's got a little bit of signal between it

37:18

and the sublime tubercle.

37:20

Fortunately this is not a thrower.

37:22

It looks a little better on the T one weighted image.

37:24

And the overwhelming majority, like all of it, is related

37:29

to this large hypertrophic tear involving the flexor

37:33

pronator mass, which is how we would describe it, uh,

37:38

on the MRI with with Glo, we'd give it a length or width

37:43

and and a depth and see if there's full delamination

37:46

with retraction, which in this case there is not.

37:50

Let's look at this. 43-year-old, uh, referred for, uh,

37:54

severe, sharp and dull pain on the inner elbow since a

37:58

work-related injury.

38:00

This is a little more typical of what we have come to know

38:04

and love as medial epicondylitis, also known

38:08

as golfer's elbow.

38:11

On the other side you've got tennis elbow

38:13

and you usually see these focal five to eight

38:16

or nine millimeter areas of deep under surface tearing

38:20

that have a strong predilection

38:23

for the extensor carp radiologist, brevis or ECRB.

38:28

We've also got a beautiful view of our luck,

38:32

our funnel shaped luck origin.

38:35

There it is coming around, going

38:37

to the Christus super naus of the ulna.

38:40

That's beautiful. And there's the common extensor mechanism

38:44

that is also beautiful

38:46

and there's our anterior bundle of UCL also beautiful with

38:51

medial epicondylitis syndrome.

38:55

The pronator tarries its origin is

38:57

above the medial epicondyle humeral head

39:00

and it has a, an ulnar head that attaches

39:03

to the OID process.

39:05

So the coronary process is a busy beaver, right?

39:08

You've got portions of the pronator going there.

39:11

You've got portions of the, um, the brachialis going there

39:14

and you got the capsule going there.

39:17

So uls it is not a good thing.

39:19

Then you've got, you know,

39:20

insertion on the tendonous lateral aspect

39:23

of the radial shaft of the pronator tes.

39:26

So the pronator tes has an origin of the medial epicondyl,

39:29

but the oid as well.

39:31

The median nerve is separated from the ulnar artery

39:35

by the ulnar head of the pronator terries

39:38

and it lies between the two heads

39:40

and can get compressed between those two heads.

39:43

And this is known as pronator Terry syndrome

39:45

or honeymoon paralysis.

39:48

14-year-old man with injury from pitching a baseball

39:51

about a week ago.

39:53

Here is the frontal coronal projection.

39:56

We've got swelling of the apophysis, swelling

39:59

of the underlying bone

40:00

because, uh, the apophysis is doing a little bit

40:03

of wiggling, some interstitial tearing

40:06

of the adjacent musculature and generalized swelling.

40:10

And this is what advanced Apophysis looks like in the

40:14

immature elbow, but do appreciate the integrity,

40:19

the intact appearance of the anterior bundle

40:22

of the UCL, even though it's swollen.

40:24

Secondarily, it is still there.

40:27

It was an 11-year-old male

40:29

injured in playing baseball two weeks ago.

40:32

He was pitching, I don't know

40:34

what an 11-year-old is doing, uh, pitching.

40:38

Uh, but, but they all, they all are these days, you know,

40:41

I think we're overusing these children in some

40:44

of these repetitive sports.

40:46

But this one was landed on the elbow when catching the ball,

40:50

so it wasn't while he was pitching.

40:52

And he is got posterior elbow pain,

40:54

so we'll cut him some slack.

40:56

There is the distal anterior bundle of the UCL.

41:01

There is a little slit right here.

41:04

Hard to know whether that's just a recess or a tear

41:07

'cause it's only about a half

41:08

to three quarters of a millimeter.

41:10

I suspect it's a normal one,

41:12

but all the abnormalities are up here

41:15

where the patient has avol a piece of bone.

41:18

There's swelling of the proximal UCL Now this is a real

41:23

proximal UCL injury with avol bone,

41:26

with diffuse swelling in the adjacent flexor pronator mass.

41:30

Here's a 13-year-old female gymnast with lateral elbow pain.

41:35

This one's interesting

41:37

because she's got, remember she's 14, look at her

41:41

osteoarthritic spurring.

41:44

These gymnasts take an incredible beating on the balance

41:47

beam and on floor exercise,

41:49

and unfortunately she's developed a VN of the elbow,

41:53

which almost always occurs

41:56

in the trochlea, not in the Capella.

41:58

You get OCDs traumatic direct insults from

42:03

impaction and valgus in the Capella.

42:06

But the a VN occurs in the trochlea.

42:09

You see the sclerosis

42:11

and the hyperintense reparative hyperemia around it

42:15

with premature oa.

42:17

That is, is a potential career ending problem.

42:20

Let's turn our attention to the lateral muscles and tendons.

42:24

Here's a patient with a lateral epicondyle tear.

42:28

Now what's nice about this is one of the treatments

42:31

for tanus elbow

42:32

or lateral epicondylitis is to cut

42:36

the common extensor mechanism.

42:38

So this patient has already done the job for us.

42:41

They've already cut the common extensor mechanism,

42:44

so there really isn't any treatment here other than physical

42:47

therapy and to try and get the swelling

42:50

and blood out of this elbow.

42:52

The other thing you should be doing is

42:55

weighing in on the status of the radial collateral ligament,

42:58

which here is intact, but here is not intact.

43:02

So it's an incomplete tear, full depth tear,

43:04

but incomplete tear.

43:06

The, the fibers that are,

43:08

that are more in the front are intact.

43:10

The ones that are more in the back are

43:12

cleaved a little bit right there.

43:15

Let's talk about the anterior tendons and muscles.

43:18

Let's start out with the brachialis.

43:20

Now we said the pronator,

43:21

Terrys has its origin from the oid.

43:23

The brachialis has an insertion on the oid.

43:26

There are superficial and deep heads.

43:28

The superficial head is larger

43:30

and arises from the anterolateral aspect of the middle third

43:33

of the humerus and the lateral intermuscular septum.

43:38

The deep head smaller arises from the anterior distal

43:43

humerus and medial intermuscular septum.

43:47

The deep head is slightly lateral to the superficial head

43:50

by the way, and it inserts on the OID process.

43:55

The brachialis has very broad contact with the capsule.

43:59

So in dislocations, when the capsule is torn,

44:02

it is very common for the brachialis to be torn.

44:06

Most of the time the surgeon will not try

44:10

to repair the brachialis with sutures.

44:12

It's like trying to sow spaghetti.

44:16

So the superficial head has a circular, uh, terminus, uh,

44:21

that inserts on the ulnar tuberosity, the deep,

44:24

which is the main head as a terminal thin pon neurosis

44:29

that attaches on the tip of the coronary process.

44:32

And once again, intimate contact with the capsule.

44:36

Let's have a look at the, the brachialis.

44:39

Now here where proximal, here where distal,

44:41

here's the big fat brachialis.

44:43

There's a little bit of the central superficial tendon.

44:46

There's the deep tendon.

44:47

It's a little bit wispy looking,

44:49

but it's going right on the tip right there.

44:52

There's the tip of the coronary process

44:54

and there's the slightly frayed deep portion

44:57

of the brachialis.

44:59

Here's a laid out view of the brachialis.

45:01

You can bend the arm

45:02

and put the patient in the scanner in the mighty

45:05

mouse, uh, position.

45:07

And here you're seeing very nicely, uh, the, the deep head

45:11

of the brachialis as it attaches to the coronary process.

45:15

This was a dislocate

45:17

and there are areas of tearing involving the brachialis

45:21

muscle here.

45:22

Here's another one. This is a patient with a biceps injury.

45:27

It's, it's very easy to confuse the, the biceps with the,

45:30

with the brachialis.

45:31

The brachialis goes to the, to the ulna,

45:34

the biceps goes to the radius.

45:36

You gotta kind of tease them out.

45:38

The radius is on the lateral side.

45:40

So here's our biceps laid out.

45:43

There is a short head and a long head.

45:45

Sometimes they insert together,

45:47

sometimes they insert separately.

45:49

The short head arises from the coracoid,

45:52

the long head from the superior glenoid tubercle.

45:55

You're more familiar with the long head.

45:57

They cross the elbow as a flat tendon

45:59

and insert on the radial tuberosity.

46:02

There's a broad medial expansion right in your

46:06

antecubital space.

46:07

This is known as the erti fibrosis,

46:10

and it merges with a fascia of the flexor tendons.

46:14

So injuries of the erti are pretty serious

46:17

because they, they do involve some other structures.

46:21

As mentioned, the insertion can have one

46:24

or two separate heads for short and long,

46:26

and sometimes you have two separate heads 10% of the time.

46:31

Most of the time though, 90% of the time they join six

46:35

to seven centimeters proximal to the insertion.

46:38

I'm not so concerned

46:40

with you today about learning which insertion is which

46:44

on the radial tuberosity and distal to it

46:47

'cause it's not that important.

46:48

And it doesn't happen often.

46:51

There is your biceps brachii, it's starting

46:54

to form a little bit of tendon.

46:56

More biceps brachii starting to flatten out

46:59

into the ERUs fibrosis.

47:01

Don't confuse it though with adjacent, uh, vasculature.

47:06

Here's the, here's the artery, here's the vein.

47:08

Brachial artery, brachial vein, some smaller vessels.

47:11

And of course, here's your, here's your brachialis.

47:14

And on the medial side, uh, here's your pronator tears.

47:18

Let's keep going. Sorry.

47:20

Here is your, here is your brachial radis.

47:23

My apology on this side is your pronator,

47:26

Terry's, let's keep looking.

47:28

Now there's your ERUs fibrosis flattening out, not

47:32

to be confused with the brachial artery and vein.

47:35

And here you are on the, uh, on, on the lateral side.

47:41

Uh, there is the brachialis inserting on the Prolia,

47:44

there is the biceps brachii inserting on the

47:48

biceps lateral side.

47:50

Medial side. Just to clarify,

47:53

that's your pronator terries, my apology.

47:56

That's your brachial radis.

47:58

And the reason that's important is

48:00

because you've got two heads of the, of the pronator terries

48:05

and you, you've got the, the deep head

48:07

and the superficial head.

48:08

And between the two, you're gonna find the median nerve,

48:11

which is a pretty big structure on,

48:14

on the medial side and the back.

48:15

You're also gonna find the ulnar nerve,

48:18

and you'll see that a little better here

48:20

coming up in a few moments.

48:21

And then here between this thickened fibrotic, uh, area

48:26

of normal, normal fascial tissue, uh, you're, you're going

48:31

to find not shown here

48:33

because it's covered up by arrows, the superficial

48:35

and deep branches of the radial artery sitting between the,

48:40

the extensor mechanism and the supinator.

48:44

More on that in a few moments.

48:46

Here's a coronal projection showing the biceps

48:49

brachii on the radius.

48:51

The brachialis with its two heads, uh,

48:54

going onto the, to the onus.

48:56

So the brachi has two heads and the biceps has two heads.

49:00

And you gotta follow them carefully

49:02

because look, look how they come together.

49:04

That's brachialis, that's biceps.

49:06

So you have to really tease them out.

49:09

On successive coronal projections, there's an example

49:13

of an acute biceps injury.

49:15

Short axis axial, long axis,

49:19

sagittal lateral view.

49:21

There is your biceps, uh, tendon.

49:25

It is already fused long and short.

49:27

Head six milli centimeters above its attachment.

49:30

This should come all the way down to the radial tuberosity.

49:34

It does not, it's ruptured.

49:35

And there's your intact brachialis.

49:39

In the sagittal projection,

49:40

we've got a number of findings here.

49:43

The, the biceps brachii is diffusely, swollen

49:46

and bloody and fat.

49:47

It should go all the way down here,

49:49

even though you're not seeing the radius.

49:52

The OID tip looks perfect.

49:54

The superficial and deep fibers of the

49:58

brachialis look perfect.

50:00

There's the attachment of the superficial,

50:02

there's the attachment of the deep.

50:03

But look at the erti fibrosis or biceps of pon neurosis.

50:09

It's swollen, it's a little bit frayed,

50:11

and there is a defect in it.

50:13

That's a serious injury.

50:15

There's another example of a biceps injury,

50:18

a little less severe here.

50:20

You can see the short and long heads

50:23

and some swelling between the two.

50:27

Evaluate for biceps rupture, well, it's not ruptured.

50:30

Uh, most of the fibers are still on,

50:32

but there is extensive her tendonitis

50:35

around the two heads of the biceps.

50:37

One of the unusual examples where you can see the two heads

50:40

inserting, uh, simultaneously.

50:43

Here's another one. Even though it's not totally gone,

50:46

what's left of it is trash.

50:48

Just a one millimeter little wisp of the bicep.

50:52

Short head is all that remains in this case

50:55

of a 54-year-old man who reached out

50:57

to catch a very heavy rack and then the swelling around it.

51:01

And then you would go ahead and follow it more proximally.

51:04

Here is another one. This one's quite easy.

51:07

I call this the cobra sign.

51:08

It looks like the cobra's getting ready to strike.

51:12

That should be inserting somewhere down here.

51:14

The erti fibrosis has turned into dust.

51:17

I'll often refer to this as a prelier tear, A tear

51:21

where the fibers of the biceps brachii have retracted

51:25

proximal to the erti as opposed to those that are distal

51:29

or post erti.

51:32

Now sometimes in the erti it will fill with blood.

51:37

So don't confuse this with a mass

51:39

or with a muscular structure or with a tophus

51:43

or with a rheumatoid nodule.

51:45

This is blood from a rupture

51:47

that fills the lacerte fibrosis,

51:50

which is housed in a very thin fibrous pseudo capsule.

51:55

And then there's swelling around it as well.

51:57

There's a 65-year-old complaining

51:59

of elbow pain going into the forearm.

52:01

There's a slightly different type of injury.

52:03

This is somebody with diffused tendinopathy,

52:06

but that's not all, I mean, look inside the tendon.

52:09

Remember we said the tendons consist of subunits.

52:12

Subunits are parallel to one another.

52:14

Look at how disorganized on the T one

52:17

and on the T two weighted image, the interstitium

52:21

of the biceps is.

52:23

So it would be really improper to call this tendinopathy.

52:27

It's more appropriate

52:28

because of the loss of the internal anatomy

52:30

to call this a scarred interstitial tear.

52:33

And then look at that defect right there.

52:35

There's also some substantive tendon loss.

52:39

Let's turn our attention now

52:40

to the posterior tendon and muscle groups.

52:43

The triceps there are insertions to the reon

52:47

and the anti brachial fossa.

52:49

Near the econs, we have a superficial group

52:53

that's the most important group,

52:55

A long head on the medial side,

52:57

and then a lateral head on the lateral side.

53:02

And then we have a deep head, a medial head,

53:04

which has a very short stubby,

53:07

virtually non-existent tendon.

53:09

The long head is the famous one.

53:11

It comes off the infra glenoid tubercle.

53:13

The lateral head comes off the back of your arm just

53:17

above the poster lateral radial groove.

53:19

The medial head comes off the lower aspect

53:23

of the humerus along the posterial medial radial groove.

53:27

So it's a short stubby little structure.

53:30

Let's look from the back.

53:32

Let's just take this image right here.

53:34

You are viewing from posterior, so this would be lateral.

53:38

This would be medial. Here's a scapula to get you oriented.

53:41

There's your long head coming off the inferior tuber

53:44

tubercle of the glenoid.

53:46

There is your lateral head coming off the upper

53:50

aspect of the humerus.

53:51

And there's your short stubby medial head

53:54

that is virtually devoid of a tendon.

53:57

That is, that is deeper.

54:00

Here we have the long

54:01

and the lateral head, long head, lateral head,

54:04

and then the fan shaped attachment of such.

54:08

Um, and then let's,

54:09

let's keep moving along here just in the interest of time.

54:13

Here is the superficial group of the tricep,

54:17

which consists of the long and the lateral head.

54:20

I have 'em labeled with a yellow arrow.

54:22

And then here's the medial head.

54:24

Look at the paucity of tendon hypo intensity

54:28

that one sees for the medial head, which by the way,

54:31

rarely tears or ruptures.

54:33

It's usually the superficial component that evolves either

54:37

with or without a piece of bone.

54:39

Now, triceps ruptures are rare.

54:41

They're less than 1% of extremity tendon injuries.

54:45

Average age about 50.

54:46

Usually men, sometimes they're taking cortisone

54:49

or anabolic steroids.

54:51

And here's what they look like.

54:52

You're on one side of the elbow, it looks pretty good

54:55

because you're seeing one head.

54:58

You go to the other side, maybe you're on the long head

55:01

or lateral head side

55:03

and you know you've lost most of the superficial tendon.

55:06

There's a few deep fibers that remain.

55:08

So what would you call this?

55:10

A partial depth tendon that's eccentric off to one side.

55:14

Then you'd look at the coronial, you'd say, oh,

55:17

it's 50% from side to side.

55:19

You'd give a measurement of the retraction

55:22

and you'd go on to say

55:23

that the deep medial head fibers are intact.

55:25

So that's a, it's a little bit tricky if

55:28

you don't know the anatomy.

55:29

Here's another example of a, of an upper extremity injury.

55:34

This time the triceps itself is still there.

55:38

All the abnormality is superficial to the triceps.

55:41

It's a T one weighted image. No, that's not simple fluid.

55:44

That is dilute blood.

55:46

This is a patient with morel lavalle degloving syndrome.

55:50

The oconus, it covers the posterior annular ligament

55:54

and attaches to the lateral croon and upper posterior ulnar.

55:59

Its origin is from a small posterior tendon from the

56:02

lateral epicondyle.

56:06

The reason it's important is there's a variant called the

56:09

accessory oconus.

56:11

Let's have a look. Short axis view from our total body

56:16

atlas and MRI.

56:17

This is where lateral epicondylitis occurs.

56:21

Here's our pronator terries with its two heads.

56:24

You can see the deep positioning of the median nerve.

56:27

You can see the superficial and deep components, superficial

56:31

and motor components of the radial nerve.

56:35

And then we've got the ulnar nerve sitting between some

56:38

of the muscular soft tissues.

56:40

But I'm showing it for the oconus,

56:43

which sits a little bit lateral to the raddon.

56:46

But if you had an extra oconus like this blue ball,

56:50

it might get in the way of the ulnar nerve,

56:54

especially if you're a little bit more proximal.

56:57

Let's have a look where we are a little bit more

57:00

proximal right here.

57:02

This is the medial epicondyle.

57:05

There's the lateral epicondyle,

57:06

that's a T one, that's a T two.

57:08

And there is U oconus and we have twins.

57:12

We have an extra oconus on the other side.

57:16

Look at its close apposition and

57:19

and relationship to the ulnar nerve,

57:21

which is just a little bit swollen.

57:24

No, it shouldn't have a little bright

57:26

signal in the middle of it.

57:27

That structure by the way, is the accessory oconus.

57:31

And here's another example.

57:33

Different patient showing you a large accessory oconus.

57:38

Let's talk about some nerves

57:39

and we'll start out with the ulnar nerve.

57:42

We already defined some of the anatomy.

57:44

We've got a deep and superficial ligamentous component

57:48

that forms the cubital tunnel.

57:50

And inside that tunnel is the ulnar nerve, which happens

57:53

to travel with a small recurrent ulnar artery and a

57:58

and a little bit, a little vein.

58:00

Then superficial to that, that ligament

58:03

of cooper right there is this very thin wispy structure

58:07

here, which you can barely see called osborne's fascia,

58:10

cooper's ligament osborne's fascia lore

58:14

of the cubital tunnel.

58:16

And then we've got these structures anteriorly,

58:19

which support the anterior aspect of the tunnel,

58:22

including the anterior bundle of the UCL

58:25

and the common flexor mechanism.

58:27

Here's a coronal look at the elbow.

58:30

There's your triceps tendon with its fan shaped attachment

58:34

and there is your ulnar nerve.

58:36

It should be pretty uniform in its size.

58:39

Maybe it'll flatten out a little bit when it goes

58:41

behind the condyle.

58:43

It shouldn't go from dark to white to dark.

58:45

And on a T two, it should maintain a uniform

58:49

intermediate signal intensity.

58:51

It should look nothing like this. That's the ulnar nerve.

58:56

It shouldn't have this black band

58:58

of fibrotic tissue around the outside.

59:01

It shouldn't have this disorganized mi, this disorganized

59:05

OID hyperintense look, that looks like the nerve is going

59:09

to explode any minute.

59:12

It's too big. First of all,

59:13

the nerve should only be about six to eight millimeters.

59:16

This one was 1.2 centimeters.

59:18

That's what cubital tunnel syndrome looks like.

59:21

Here's a 3-year-old man with reon region pain

59:24

and numbness in the for and and hand.

59:26

I believe this was an MVA case. Yes it was.

59:30

And here's your PD spur.

59:32

Now I don't mind on a PD spur.

59:35

If the nerve's a little bright,

59:36

that doesn't bother me too much.

59:38

If that was a T two, it would bother me a lot.

59:41

But here's what does bother me.

59:43

Look at where the nerve is positioned.

59:46

It's perched on the back of the ulna. It shouldn't be there.

59:50

It should be over here so it's in the wrong position.

59:54

And then look at its shape on the T one.

59:55

It's got this really weird oval shape

60:00

and it's perching out of its groove.

60:02

And by the way we call it a groove

60:04

because it should be a receptacle.

60:08

Instead your convex back here.

60:11

So you've got a deformity of the postal medial aspect

60:15

of the humerus, which is contributing to this.

60:18

You know, what's the treatment for this?

60:20

To ly cooper's ligament to ly osborne's fascia

60:25

and to do nothing, do not touch that nerve.

60:28

That nerve does not like to be manipulated by man or woman.

60:32

Otherwise the patients don't do very well.

60:35

Let's go up a little bit higher.

60:37

I don't mind that the nerve's a little bit swollen right

60:39

here, but I do, uh, sorry, that's a little bit hyperintense

60:43

'cause it's a pd, fat suppression.

60:45

But I do mind the size it should be six to eight millimeters

60:49

and it's a lot bigger than that.

60:51

Let's turn our attention now

60:52

to the anterior interosseous nerve, which when

60:56

insulted forms the syndrome of kilo and Nevin.

60:59

Now you can hardly ever see this nerve.

61:02

There's a differential diagnosis for it,

61:04

but it's a very easy diagnosis.

61:07

You see this almost triangulated pattern of neurogenic edema

61:11

anterior to the interosseous membrane.

61:14

This nerve being a branch of the median nerve.

61:18

How about the radial nerve? This one's often overlooked.

61:22

The poor kissing cousin injuries of this nerve

61:26

and this tunnel are known as the supinator syndrome,

61:29

the posterior interosseous nerve syndrome.

61:33

They have pain in the dorsum of the forearm posteriorly

61:38

and they have gradual weakening of the fist.

61:41

They'll also have a positive Tinel sign.

61:43

So if you tap on the anterior aspect of their of

61:48

of their forearm, they're gonna get some discomfort.

61:51

Here's an example of the motor aspect

61:55

of the radial nerve.

61:56

You can see it with decent enough image quality.

61:59

You've got a little bit of fat on either side.

62:01

You've got a little bit of dark fry brush tissue right here.

62:06

I don't know if you can see it. I'm gonna put an arrow on it

62:08

with my pen just so you can see it.

62:11

This right there, right there, right there.

62:15

That is known as fros arcade.

62:19

Now here's a very unfortunate case.

62:22

You are looking at a coronal projection for those of you

62:25

that are quick on the trigger.

62:26

There's the liver, there's the kidney.

62:29

So it's an AP projection.

62:30

The lungs over here, you're looking at an AP orientation.

62:34

And sadly this is not an artery or vein.

62:38

This is a radial nerve.

62:40

Now that's the normal size of the common radial nerve.

62:45

That is a huge radial nerve.

62:47

Diffusely infiltrated by IgG MU in a patient

62:52

that suffers from an autoimmune, sorry,

62:55

a per neoplastic phenomenon in which the

62:58

nerves got attacked.

63:00

Very similar to the syndrome known as poem syndrome,

63:04

polyneuropathy organomegaly, endocrinopathy M spike,

63:09

and skin lesions that we see with myeloma.

63:11

This patient had an unusual form of lymphoma that eventually

63:16

entered her superior

63:18

and recurrent laryngeal nerve and took her life.

63:20

Here's the short axis view. No, that is not a vessel.

63:23

That is the radial nerve.

63:26

Here's a 46-year-old who had biceps repair six weeks ago

63:30

and now has posterior interosseous nerve syndrome

63:33

by physical exam by a hand surgeon.

63:37

Now sometimes what they'll do to reattach some

63:40

of these tendons is they'll anchor them through the bone

63:45

and put a flat object that may may be made of acrylic

63:49

and they'll pull the strings of the suture through

63:52

and then tie them on the other side to make sure

63:56

that everything is snug.

63:58

So thi this is the radius, this is the ulna,

64:00

and here is our supinator.

64:02

That's Ros's Arcade.

64:05

So we know that the radial nerve structures are gonna live

64:08

in here somewhere, even though we don't directly see them.

64:12

Now take a look at the water weighted image.

64:14

This geographic muscle by muscle area

64:18

of edema corresponds exactly to the motor distribution

64:23

of the radial nerve, which you obviously have

64:25

to memorize or learn.

64:27

And then once you know what the procedure was

64:30

and that this is a complication of that procedure,

64:33

you're gonna make the correct diagnosis.

64:35

Then finally, not to be forgotten as the median nerve,

64:38

we got our ulnar nerve.

64:40

We, we got our radial nerve with its superficial sensory

64:45

and deep motor division, but now we have the deep

64:48

and superficial heads of the pronator terry

64:51

and the median nerve.

64:53

Let's have a look at this.

64:54

82-year-old man concerned for biceps injury.

64:59

He doesn't have a biceps injury.

65:01

In fact, the biceps was absolutely fine,

65:04

but his pronator, Terrys

65:07

and flexor pronator mass has this large object

65:12

associated with it that is heterogeneous.

65:15

Has some met hemoglobin associated with it?

65:18

Uh, no, these are, that's an artery right there.

65:21

We've got some other blood vessels

65:22

and tendons in the neighborhood.

65:24

But where is our median nerve?

65:26

Our median nerve is getting squished right here.

65:29

Right there is the median nerve.

65:31

So this is somebody that suffered from pronator TE syndrome.

65:35

There is our hematoma involving the flexor pronator mass.

65:39

Look at the signal of our median nerve, which is one

65:41

of the bigger nerves in the body.

65:43

It looks almost like a vein. It's too big. It's too bright.

65:48

This is pronator Terry Syndrome, also known

65:50

as honeymoon paralysis.

65:52

You know, 'cause sometimes when you're on your honeymoon

65:56

and you fall asleep

65:57

and your new partner's head is on your arm, you don't turn

66:00

to them and say, darling, your head is too heavy.

66:04

You just go to sleep.

66:06

And when you wake up you have honeymoon paralysis.

66:08

Here's another example of somebody with

66:13

a dysplastic, large median nerve,

66:17

but look at the object arising from the median nerve

66:20

that has a little bit of internal speculation

66:23

and is round consistent with a median nerve schwannoma.

66:27

So we covered a lot of ground today.

66:29

We talked about the skeleton

66:30

and showed you some really

66:33

critical bone abnormalities like the Osborne co lesion,

66:36

the hill sax fracture of the elbow, the OID fracture.

66:40

We talked about the ligaments,

66:42

how there are two major ligaments on the lateral side

66:45

and one major ligament on the medial side

66:48

with two minor ligaments

66:50

that help house the ulnar nerve.

66:54

We spent some time on the common flexors and extensors.

66:58

We showed you the short and long axis of the biceps.

67:01

Described their anatomy.

67:03

We showed you the two heads of the brachialis.

67:05

We showed you the three heads of the triceps, one of which

67:09

is usually not consequential the medial head.

67:12

And we finished with a flurry talking about cubital tunnel,

67:17

pronator tear syndrome,

67:18

the posterior interosseous nerve syndrome,

67:21

or the syndrome necrosis, arcade,

67:23

and the anterior interosseous nerve syndrome, also known

67:27

as the syndrome of kilo and Nevin.

67:30

At this point I ran just a little bit over.

67:33

I'll take some questions.

67:36

Perfect. I do see one question in the q

67:38

and A for you right now, and I'm sure

67:39

a couple others will pop in.

67:41

Do you see that button on your end?

67:42

Or you may read you the question.

67:44

Let's see. It says,

67:45

can we get a certificate after this webinar?

67:48

Do you see one that says open on there?

67:51

Open. There's, there's one

67:53

question. Do you want me to read it to you?

67:55

Pardon? Do would you like me to read it to you?

67:58

Perfect. Okay.

68:00

Which standard sequences perform for MRI elbow?

68:05

Okay. And the same question for the ulnar nerve.

68:11

Well for the ulnar nerve, um,

68:13

you've gotta have one critical sequence

68:16

and that is high quality axial imaging.

68:20

And I like to have a T one and a T two spin echo.

68:25

I find the proton density axial spur less valuable

68:29

because the nerve's always gonna be bright.

68:32

You're looking for the caliber of the nerve.

68:34

Its consistency, its position in the groove.

68:38

I don't wanna see the nerve go light to dark to light.

68:41

I like to see it have a homogeneous gray signal intensity.

68:47

The other projection that's useful

68:48

for the ulnar nerve is dis, is the coronal projection.

68:52

You kind of follow the nerve down to the epicondyle,

68:55

you lose it and then you follow it down again.

68:57

Why do I like that? Because

68:59

that will help me see if the nerve goes from thin

69:02

to fat to thin again.

69:04

So a caliber change is really important.

69:07

Not so much behind the epicondyle,

69:09

but if I have a caliber change above the epicondyle

69:12

or below the epicondyle, I get worried.

69:15

Now for my standard elbow, I like to have at least

69:19

one PD fat sat

69:21

and at least one T one and at least one T two.

69:26

Now where am I gonna put these? It depends on the diagnosis.

69:30

If I'm looking for medial

69:33

or lateral epicondylitis, medial lateral elbow pain,

69:37

I'm gonna lob most of my sequences in the,

69:39

in the coronal projection with a few axials.

69:42

I'm not gonna focus so much on the sagittal.

69:44

If I'm worried about the biceps

69:46

and the triceps, I am always going to have

69:50

a lateral projection

69:51

and I like to have a lateral T one, T two and pd.

69:57

So depends on where the pathology is.

70:00

If the pathology's in the front and the back, the sagittal

70:03

and axial are gonna be your friends,

70:04

especially the sagittal.

70:05

If the pathology's on the sides, then the coronal

70:09

and to a lesser extent the axial

70:11

are going to be your friend.

70:14

Any other questions?

70:17

Yes, we have a few in here for you.

70:19

Uh, eventual burse do not have synovial lining, correct

70:24

Adventitial burse adventitional bur se,

70:27

which are also known as eventual per se.

70:30

'cause they eventually form.

70:31

Uh, usually you see those in your, under your toes,

70:34

especially if you're a high heel wearer.

70:37

You get a pressure lesion,

70:38

which is basically a fibrous callus

70:41

most common under the fifth and under the first.

70:44

Eventually that callous will hollow out

70:47

and it'll fill with fluid.

70:49

So you're surrounded by this dense, thick, fibrous tissue,

70:52

but there is no synovial lining. Next question.

70:57

All right. The tear of lateral

70:59

and long head of triceps, do you call it total triceps tear?

71:03

That

71:05

Is a very good question.

71:07

If you tear the lateral head

71:10

and the long head, do I call that a complete

71:14

or total triceps tear?

71:16

I do because I know in my heart that the medial head

71:21

just about never tears.

71:23

So if I lose both those structures

71:25

and they're retracted,

71:27

I will call it a full depth, full width tear.

71:30

And then I will go on to specify

71:32

involving both the lateral and long heads.

71:36

Now, in the rare event

71:38

that I have also torn the medial head, I'll then say

71:42

separately that the medial head muscular bundle

71:45

with its short tendon is also disrupted.

71:48

So I'll leave that as kind of a separate subject.

71:50

That's just how I do it. Great question.

71:55

Okay. Um, this one is the trochlea is for the AV n

71:59

and the other lateral side is for what?

72:02

The, the trochlea is for AV N

72:04

and the Capella is for osteochondral defect, usually seen

72:08

with valgus extension overload. Next question.

72:13

All right, this one looks like the

72:14

last one in the queue right now.

72:15

Can you briefly explain lacerda fibrosis syndrome at the

72:18

anterior face of the elbow?

72:21

Sure. Can I briefly ex explain lacer

72:25

fibrosis syndrome at the anterior aspect of the elbow?

72:28

So the ERUs is attached to fibrous remnants

72:33

of the common flexor

72:35

and a little bit to the common extensor.

72:37

So sometimes those attachments will get interrupted.

72:41

You'll get micro tears, you'll get inflammation

72:43

and swelling, and the serus becomes a little bit hypermobile

72:46

and you'll get pain in the antecubital fossa

72:49

and you'll see a little bit of swelling there.

72:51

Next question.

72:52

All right, I saw one more just pop in.

72:54

When would you use gad for the elbow?

72:57

When would I use gad, uh, for the elbow?

73:00

Um, usually when I've had too much tequila, I will give,

73:03

give gad for the elbow.

73:04

I hardly ever give gadolinium.

73:06

Now, if I have a lesion, say a cystic lesion,

73:10

and I'm not sure if I have a ganglion or a mix soma

73:13

or a schwannoma and I need to see enhancement,

73:15

then I will give gadolinium.

73:17

I rarely, and I mean rarely will put

73:20

gadolinium into the joint.

73:22

It's an easy arthrogram to do. Why might I do it?

73:26

I've got clicking or catching in a high performance athlete

73:29

and I have not come up

73:31

with an explanation on a non-contrast study.

73:35

In that case, I will then introduce gadolinium into the

73:39

intraarticular space to see if I can find a clicka

73:43

or a nasty fringe or a body.

73:48

All right. Those are all of our questions today. Dr.

73:51

Pomerantz, thank you so much for taking the time

73:53

to give us this great lecture and be with us today.

73:57

It's been a pleasure. Thank you all. Have a great day,

74:00

And thank you so much to everyone else

74:01

for participating in our noon conference.

74:03

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74:06

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74:08

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74:11

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74:14

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74:16

where Dr. Maria Cortez will deliver a lecture entitled

74:19

Acute Encephalitis.

74:21

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74:23

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74:25

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74:27

Thanks again and have a great day.