How to Find the Ulnar Nerve at the Elbow

about the correct ultrasound scanning techinchs to find the ulnar erve at the sulcus ulnaris

Have you seen my recent post “Subluxating Ulnar Nerve at the Elbow”? If yes, you may find also interesting how to locate the ulnar nerve at the sulcus ulnaris and the specific ultrasound scans. Use your own elbow to practice or try to ask to a friend or collegue to “share” their anatomy; in other words… Practice is the mother of skills!

In the video below you can find everything needed for your training, so enjoy the video and if you have any questions don’t hesitate to contact me.

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Psoriatic Arthritis of the Elbow

About chronic synovitis of the elbow in a patient with psoriatic arthritis.

Sometimes patients come to our attention without a specific clinical history, referring just joint pain.

In case of this joint swelling and gross chronic synovitis always think to a rheumatic disorder. Remember that on MRI, psoriatic synovitis appears indistinguishable from that of rheumatoid arthritis. According to the EULAR (European League Against Rheumatism) recommendations – “A definitive diagnosis of rheumatic diseases can be made by assessing the medical history, by performing a physical examination or ordering specific laboratory tests and undertaking imaging investigations”.

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Coronal Ge Stir (left) and T1W Mri scans (0.3 Tesla).

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Coronal GeStir (left) and Sagittal T2w (right) Mri scans (0.3 Tesla). A gross synovitis with pseudonodular distension of the bicipitoradialis bursa is evident.

The Mri examination shows diffuse irregularity of the cortical bone surfaces and entheseal region of tendons and ligaments, with distension of adjacent bursae by fluid collection. All of these findings are well depicted on ultrasound exam.

This patient also suffered for a painful synovial impingement along the course of the posterior interosseous nerve at Frohse’s arcade, best seen with the dynamic ultrasound examination.

With the elastosonography exam you can discriminate the real fluid quote of this chronic synovitis.

Avoid joint aspiration in this kind of situations: it’s like putting a needle into the marmalade! 

Take home message? Keep calm and call a rheumatologist.

Weight Bearing Ultrasound Study of Patellar Tendon Degeneration.

About weight-bearing ultrasound study of patellar tendon.

Take a look at this clinical case in which the patient with a clear evidence of patella alta and lateral patellar compression syndrome, has a tendinopathy of the patellar tendon at its proximal insertion, with chronic anterior knee pain and instability.

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Sagittal T1w and Stir Mri sequences (0.3 tesla).

In orthostatism is most evident the increase of flow in vessels that are dilated because of inflammatory response.

This is the reason why I always perform the ultrasound examination both in clino and in orthostatism. Have you ever tried?

 

Medial Collateral Ligament Tear

This is the case of a professional football player with a  grade 2 injury of the medial collateral ligament; high signal and partial disruption of the ligament is seen on Mri exam. The study is completed by dynamic ultrasound and elastosonography evaluation;  in this picture the elastosonography signal works like a “contrast agent”, with the red color that depicts the real extent of the ligament tear.

Have you ever tried to change the point of view of your ultrasound images? Takea look at the picture below, in which both Mri and ultrasound images have the same angle orientation.

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Coronal T2w mri scan (0.3 Tesla) and ultrasound exam of the same patient.

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Medial collateral ligament tear: from grade 1 to grade 3. T2w coronal Mri scans (0.3 Tesla).

Accessory Plantaris Muscle

To be experienced in msk anatomy means to know also the anatomical variants; today I show you the pictures of a young football player with a “bad feeling” on the postero-lateral compartment of the knee, where a palpable nodularity is noted during the physical exam. With dynamic ultrasound investigation a well defined muscular structure adjacent to the lateral gastrocnemius insertion is noticed; mri scans confirmed the presence of the accessory muscle belly.

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Coronal T2 weighted (left) – Sagittal T1 weighted (right) Mri scans (0.3 Tesla) of the same patient.

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Comparison between Mri and ultrasound imaging modalities.

The accessory plantaris muscle is most frequently located with the origin of the normal plantaris muscle, but in this case merged with the origin of the lateral head of the gastrocnemius. These anatomical variants are frequently asymptomatic, but their relationship and effect on adjacent structures can mimic different kind of pathologies.

Adductor Muscle Injury

High risk of underestimating the real extent of an high degree muscle strain when using only ultrasound imaging, especially in acute phase; always use power-doppler integration to evaluate the intramuscular and perifascial edema. It’s often frequent to find also a subcutaneous fat pad inflamatory reaction adjacent to the site of injury. Never forget that the more muscle edema is present, the higher echogenicity you’ll find.

   High degree strain injury of the adductor longus muscle: dynamic ultrasound examination.

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Coronal (left) and Sagittal PdwSpair Mri scans (1.5 Tesla) of the same patient.


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Axial T2 weighted Mri scan (1.5 Tesla) and comparative Ultrasound examination.

Calcaneofibular Ligament Injury

There is usually a predictable kinematic pattern of injury involving the anterior talofibular ligament followed by the calcaneofibular ligament; don’t forget that finding a complete rupture of the calcaneofibular ligament means that also the anterior talofibular ligament must be injured.

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Coronal (left) and Axial (right) T2 weighted Mri scans (0.3 Tesla) demonstrate a complete rupture of the calcaneofibular ligament.

The ultrasound imaging needs an accurate dynamic evaluation to demonstrate the injured ligament.

In this young professional football player both the anterior talofibular and calcaneofibular ligaments are completely torn.

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Coronal (left) and Axial (right) T2 weighted Mri scans of the same patient: a complete rupture of the ATFL is evident.

The ultrasound dynamic investigation well defines the high degree injury of the ligament.