EULAR on-line course on Ultrasound

Sonoanatomy
Scanning technique
and basic pathology of
the elbow
Marina Backhaus, Wolfgang A. Schmidt, Sandrine Jousse Joulin

LEARNING OBJECTIVES
To recognise the normal ultrasonographic anatomy of the elbow
To perform a thorough ultrasound examination of the elbow including a complete set of the
standard EULAR scans.
To recognise synovial hypertrophy and joint effusion of the elbow joint.
To recognise bony erosions and osteophytes of the elbow joints.
To recognise enthesopathy and tendinitis at the medial or lateral epicondyle
To recognise bursitis

Sonoanatomy Scanning technique and basic pathology of the elbow Module 3

Abstract
This module presents the technical equipment, patient positions, probe positions, anatomical landmarks as
well as the main ultrasound standard scans and basic sonopathology of the elbow. Musculoskeletal
ultrasonography is an important imaging technique in the diagnosis of rheumatic diseases especially for early
manifestation. It allows sensitive detection of small joint fluid collections as well as differentiation of soft
tissue lesions and bone lesions. Doppler ultrasound allows differentiating between active and inactive disease.
A linear transducer with a frequency of at least 7.5
MHz is recommended for examining the elbow joint. The following standard scans are suggested for
sonographic evaluation of the elbow: 1) anterior humero-radial longitudinal scan, 2) anterior humero- ulnar
longitudinal scan to detect effusions, synovial proliferation, loose joint bodies, bone lesions
(osteoarthritis/arthritis), 3) anterior transverse scan over the trochlea to evaluate these structures in an
additional dimension, 4) posterior longitudinal scan and 5) posterior transverse scan of the olecranon fossa
with flexed/extended elbow to evaluate the same objectives as the above mentioned scans, and additionally
to detect olecranon bursitis, and optional 6) distal dorsal longitudinal scan to differentiate soft tissue lesions
such as rheumatoid nodules or gout tophi, 7) anterior transverse scan over the radial head to evaluate lesions
of the radial head, tendinopathy and calcinosis, 8) lateral humero-radial longitudinal scan to evaluate
epicondylitis, 9) medial humero-ulnar longitudinal scan to evaluate calcinosis, epicondylitis, signs of
compression of the ulnar nerve.

INTRODUCTION
The elbow joint is easy to examine clinically. However, small fluid collections or signs of inflammation sign are
better detectable by musculoskeletal ultrasonography (US) (1,2). US is an important tool in diagnosis of early
arthritis. A differentiation between soft tissue and bony lesions is possible. Bony lesions are earlier seen by US
than by x-ray (3-5). US is the prolonged diagnostic finger in Rheumatology (6); and it is useful in objectifying
the clinical findings.

INDICATIONS
The main indication for US of the elbow is the detection of inflammatory changes of the synovial capsule (e.g.
fluid collection, synovial proliferation), bony lesions (e.g. erosions, osteophytes, loose joint bodies), evaluation
of bursitis (exudative/proliferative), tendon rupture (e.g. distal biceps tendon), compression syndrome of the
ulnar nerve as well as tendinitis at the epicondyles (Table 1).
In case of planed injection and aspiration procedures US is helpful in finding the correct needle position (7).

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Sonoanatomy Scanning technique and basic pathology of the elbow Module 3

Table 1: Indication of US of the elbow
1. Effusion
2. Synovial proliferation
3. Bursitis
4. Bony lesions (erosions)
5. Osteophytes
6. Loose joint bodies
7. Differentiation between gout tophus and rheumatoid nodule
8. Tendinitis at the medial or lateral epicondyle
9. Calcinosis
10. Tendon rupture (distal biceps tendon)

TECHNICAL EQUIPMENT AND DOCUMENTATION

A linear transducer with a frequency of at least 7.5 MHz is recommended for examining the elbow joint. For
superficial lying lesions a higher frequency transducer is useful, e.g. 10-20 MHz. For differentiating between
active and inactive synovial proliferation an US devices with Doppler function is necessary.
Pathological findings are documented in two perpendicular planes and are stored electronically or printed. For
better reproducibility of findings standardization of probe position is necessary. According the guidelines of
EULAR (8) and the German ultrasound society, DEGUM (9), the proximal / cranial parts are seen on the left
side and the distal / caudal parts on the right side of the monitor in longitudinal orientation. In the short /
transverse axis the medial / ulnar parts are seen on the left side, and the lateral / radial parts are seen on the
right side of the monitor.

PATIENT POSITION
The patient is sitting in front or next to the US examiner. The anterior scans are examined in neutral position of
the elbow with supination of the hand and the posterior scans are scanned in neutral position and with up to
90 flexion of the elbow. In flexed position of the elbow small fluid collections are better seen in the olecranon
fossa. The dynamic examination is done by extension and flexion of the elbow.

STANDARD SCANS
The sonographic examination of the elbow is done by defined standard scans (8, 9) additionally by dynamic
scanning technique. For getting a better view over the whole joint multiplan scans are used in the long and
short axis. The standard scans are listed in table 2.

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Sonoanatomy Scanning technique and basic pathology of the elbow Module 3

Table 2: Standard scans of the elbow
1. Anterior humero-radial longitudinal scan (figure 1)
2. Anterior humero-ulnar longitudinal scan (figure 2)
3. Anterior transverse scan over the trochlea (figure 3)
4. Anterior transverse scan over the radial head (figure 4)
5. Posterior longitudinal scan (90 flexion / 180 extension) (figure 5)
6. Posterior transverse scan (90 flexion / 180 extension) (figure 6)
7. Posterior longitudinal scan (distal from the olecranon) (figure 7)
8. Lateral humero-radial longitudinal scan (along lateral epicondyle) (figure 8)
9. Medial humero-ulnar longitudinal scan (along medial epicondyle) (figure 9)
10. Longitudinal scan along sulcus ulnaris (figure 10)
11. Transverse scan along sulcus ulnaris (figure 11)

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Sonoanatomy Scanning technique and basic pathology of the elbow Module 3

EXAMINATION SEQUENCE AND ANATOMICAL LANDMARKS

The US examination starts in extension position of the elbow at the anterior aspect along the humero- radial
joint. The transducer is positioned parallel to the humero-radial joint.
The anatomical landmarks for each scan are:
1. Anterior humero-radial longitudinal scan: humerus, fossa radii, capitulum humeri, caput radii, joint capsule,
brachialis muscle (Figure 1)
The transducer is shifted from radial to ulnar to scan the humero-ulnar joint in the long axis.
Figure 1. Anterior humero-radial longitudinal scan (1. capitulum humeri, 2. radial head, 3. cartilage, 4.
synovium, 5. brachioradialis muscle)

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Sonoanatomy Scanning technique and basic pathology of the elbow Module 3

2. Anterior humero-ulnar longitudinal scan: humerus, coronoid fossa, trochlea humeri, coronoid processus,
brachialis, pronator teres muscle (Figure 2)
In order to confirm the results in the long axis the transducer is rotated 90 in the short axis along the trochlea.

Figure 2. Anterior humero-ulnar longitudinal scan (1. trochlea humeri, 2. coronoid process, 3. cartilage, 4.
synovium, 5. brachialis muscle)

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Sonoanatomy Scanning technique and basic pathology of the elbow Module 3

3. Anterior transverse scan over the trochlea: trochlea humeri, capitulum humeri, cartilage, joint capsule,
muscle (Figure 3)
When checking for lesions at the radial head the probe is positioned parallel to the radial head in the
transverse axis.

Figure 3. Anterior transverse scan over the trochlea (1. trochlea humeri, 2. capitulum humeri, 3. brachialis
muscle, 4. pronator teres muscle, 5. biceps brachii muscle, 6. median nerve, 7. biceps tendon, 8.
subcutaneous fat, 9. brachial artery, 10. cartilage)

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Sonoanatomy Scanning technique and basic pathology of the elbow Module 3

4. Anterior transverse scan over the radial head (Figure 4)
The posterior scans are done firstly in flexed position and secondly in neutral position of the elbow. The probe
is positioned along the humerus at the olecranon fossa in the long axis. For dynamic examination the elbow
joint is extended and flexed.
Figure 4. Anterior transverse scan over the radial head

5. Posterior longitudinal scan (90 flexion / neutral position): humerus, olecranon fossa, olecranon, triceps
brachii muscle (Figure 5)
In order to confirm the results in the long axis the transducer is rotated 90 in the short axis along the
olecranon.
Figure 5. Posterior longitudinal scan (90 flexion / neutral position)

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Sonoanatomy Scanning technique and basic pathology of the elbow Module 3

6. Posterior transverse scan (90 flexion / neutral position): epicondylus medialis, epicondylus lateralis (Figure
6)
Figure 6. Posterior transverse scan (90 flexion / neutral position)

For differentiating soft tissue masses such as olecranon bursitis, rheumatoid nodules, gout tophi, that
frequently occur near the olecranon, the probe is positioned over the olecranon or distal of the olecranon
along the ulna.
7. Posterior longitudinal scan (distal from the olecranon): olecranon, ulna (Figure 7)
Figure 7. Posterior longitudinal scan (distal to the olecranon)

8. Lateral humero-radial longitudinal scan (along lateral epicondyle): lateral epicondyle, caput radii, extensor
tendons attachment at the lateral epicondyle (Figure 8)
Pathological findings are confirmed in the second perpendicular plane. In diagnosis of epicondylitis medialis or
periosteoarthritis humero-ulnaris calcarea the medial longitudinal scan along the medial epicondyle is
performed. The probe is positioned along the medial epicondyle.
The lateral and medial epicondyles are scanned in case of suspected epicondylitis. The transducer is positioned
firstly parallel to the lateral epicondyle:

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Sonoanatomy Scanning technique and basic pathology of the elbow Module 3

Figure 8. Lateral humero-radial longitudinal scan (along lateral epicondyle)

9. Medial humero-ulnar longitudinal scan (along medial epicondyle): medial epicondyle, flexor tendons
attachment, ulna (Figure 9)
Posterior to the medial epicondyle is the sulcus ulnaris. In case of compression syndrome of the ulnar nerve
the sulcus is scanned in two perpendicular planes.
Figure 9. Medial humero-ulnar longitudinal scan (along medial epicondyle)

10. Longitudinal scan along sulcus ulnaris: ulnar nerve (Figure 10)
Figure 10. Longitudinal scan along sulcus ulnaris

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Sonoanatomy Scanning technique and basic pathology of the elbow Module 3

11. Transverse scan along sulcus ulnaris (Figure 11)
Figure 11. Transverse scan along sulcus ulnaris

The video clip presents an elbow US examination (See the images library).

BASIC PATHOLOGY OF THE ELBOW

Elbow ultrasound is often performed in rheumatology in search for effusions or synovitis. An experienced
clinician can easily palpate effusions. However, smaller effusions are not palpable, and it is often helpful to
know if the swelling is due to synovitis or effusion, or to another cause.
Effusion and synovitis
Effusion (anechoic or hypo-echoic, compressible and displaceable, not exhibiting color signals) or synovitis
(hypo-echoic, poorly compressible, not displaceable, perhaps exhibiting color signals) (10) can be found in
several areas of the elbow.
When performing the anterior scans, smaller effusions typically localize in the radial groove or the coronoid
fossa, because or the lowest pressure of the joint capsule in this region. The coronoid fossa and the radial
groove are some distance away from the joint space itself. Effusions may be missed if the sonographer
concentrates only on the region of the joint space. Very small amounts of normal fluid may be visible in the
fossa with a maximum diameter of 3.7 mm between bone surface and
capsule at the bottom of the fossa (11). Figure 12 shows a very small effusion which only shows up in the
coronoid fossa. The distance between bone and joint capsule as marked in the image is 4.0 mm. Figure 13
shows a larger effusion in which the joint capsule is pushed up by the effusion also close to the joint space.
Less commonly larger effusions lead to a tear of the joint capsule () at its distal aspect with fluid collection
distal to the joint space as shown in Figure 14.

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Sonoanatomy Scanning technique and basic pathology of the elbow Module 3

Figure 12. Small effusion of the elbow joint (anterior ulnar longitudinal view)

Figure 13. Larger effusion of the elbow joint (anterior ulnar longitudinal view)

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Sonoanatomy Scanning technique and basic pathology of the elbow Module 3

Figure 14. Large effusion of the elbow joint with tear of the joint capsule at its distal aspect (distal anterior
ulnar longitudinal view)

Each effusion should be visualized in a second plane (Figure 15). When doing the anterior transverse scans of
the elbow the sonographer should move the probe from the proximal end of the joint at the level of the
coronoid fossa to the distal end of the joint. The joint capsule attaches shortly distal to the joint space.
Figure 15. Effusion of the elbow joint at the level of the humerus (anterior transverse view)

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Sonoanatomy Scanning technique and basic pathology of the elbow Module 3

Effusions can also be detected from the posterior side. The sonographer places the probe longitudinally
proximal to the elbow in order to display the olecranon fossa. The olecranon fossa also communicates directly
with the joint that can be seen distally to it. Large effusions can fill the fossa completely (Figure 16) or can even
extend distally and posteriorly. Small effusions can only be visualized by flexing and extending the elbow. Very
small amounts of normal fluid may be visible in the fossa with a maximum diameter of 3.9 mm between bone
surface and capsule at the bottom of the fossa.
The olecranon fossa should be also examined in the second transverse view. Figure 17 shows the transverse
view of an effusion in the olecranon fossa.
Larger effusions and synovitis are visible also at the medial and lateral aspects of the joint. It is possible to
perform all standard scans of the elbow in search for effusions and synovitis. Figure 18 shows an effusion (1) at
the lateral aspect of the elbow joint.
Figure 16. Effusion (1) of the elbow in the olecranon fossa (posterior longitudinal view)

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Sonoanatomy Scanning technique and basic pathology of the elbow Module 3

Figure 17. Effusion (1) of the elbow in the olecranon fossa (posterior transverse view)

Erosions and osteophytes

These bony abnormalities most commonly localize at the medial and lateral aspects of the elbow joint. They
are particularly well visualized in the respective longitudinal scans. Particularly erosions need to be visualized
in two planes. Again, bony irregularities can occur at any region of the joint. Therefore it is advisable to scan all
the areas of the elbow in search for bony irregularities. Figure 18 shows a large osteophyte (2) with reflex
shadow at the proximal lateral aspect of the elbow joint in osteoarthritis.
Figure 18. Effusion (1) and osteophyte (2) at the lateral aspect of the elbow joint (lateral longitudinal view)

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Sonoanatomy Scanning technique and basic pathology of the elbow Module 3

Enthesiopathy
Enthesiopathy can also lead to erosions and other bony irregularities. Enthesiopathy of the elbow region
occurs most commonly at the lateral aspects of the humeral epicondyle, followed by the medial humeral
epicondyle and the triceps tendon. Without imaging it is practically impossible to find out if pain at the lateral
or medial epicondyles is due to pain syndrome or enthesiopathy. Therefore, ultrasound is very helpful in daily
clinical practice as pain often occurs in this region. The tendons become hypo-echoic, inhomogeneus and
thickened in case of enthesiopathy (Figure 19). Power Doppler ultrasound aids in determining whether the
enthesiopathy is acute or chronic. In acute disease, which is enthesitis, vascular perfusion in the tendons
overlying the enthesis is increased showing color Doppler signals (Figure 20). In chronic enthesiopathy
calcifications can occur in the tendons close to their insertion (Figure 21).
Figure 19. Enthesiopathy / enthesitis (1) of the extensor muscles tendon insertion at the lateral humeral
epicondyle (lateral longitudinal scan)

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Sonoanatomy Scanning technique and basic pathology of the elbow Module 3

Figure 20. Enthesitis of the flexor muscle tendon insertion at the medial humeral epicondyle (medial
longitudinal scan)

Figure 21. Chronic enthesiopathy with calcification (1) of the extensor muscles tendon insertion at the lateral
humeral epicondyle (lateral longitudinal scan)

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Sonoanatomy Scanning technique and basic pathology of the elbow Module 3

Bursitis
Olecranon bursitis is easily palpable. Ultrasound can help determine the content of the bursitis. Fluid is
anechoic and easily compressible. Septic bursitis often contains fluctuating particles (Figures 22 and 23). It may
be clinically difficult to distinguish a hard bursa which may occur in gout from a rheumatic nodule. Gouty tophi
occur as hyper-echoic, cloudy structures with partial or complete posterior shadowing (Figure 24) whereas
rheumatoid nodules are hypo-echoic, usually with rather clear borders and no or only few color signals (Figure
25). Figure 24 shows an olecranon bursitis in a patient with gout.
Nerve pathology
The ulnar, radial and median nerves can be easily visualized with ultrasound. Particularly the ulnar nerve is
important at the level of the cubital tunnel as entrapment leads to a hypoechoic swelling of the nerve (Figures
26 and 27). Ultrasound can distinguish between primary and secondary forms of nerve entrapment. Secondary
forms are due to compression because of synovitis, effusion, tumors or bony spurs.
Figure 22. Septic olecranon bursitis (longitudinal dorsal view of the bursa)

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Figure 23. Septic olecranon bursitis (transverse dorsal view of the bursa)

Figure 24. Olecranon bursitis in gout (longitudinal dorsal view of the bursa)

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Figure 25. Rheumatic nodule of the dorsal side of the forearm distal to the elbow (longitudinal view)

Figure 26. Abnormal hypo-echoic and enlarged (12 mm) ulnar nerve in the cubital tunnel (transverse view)

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Figure 27. Abnormal hypo-echoic and enlarged ulnar nerve in the cubital tunnel (longitudinal view)

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