Journal of Medical Ultrasound (2016) 24, 168e169

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Ultrasound in Medicine
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IMAGING FOR RESIDENTS

A Female Adult with Persistent Medial Elbow

Pain After a Fall
Ying-Hua Chung 1, Ke-Vin Chang 2*

1
Department of Family Medicine, Mennonite Christian Hospital, Hualien, and 2 Department of Physical
Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan

Section 2dAnswer Discussion

A 54-year-old woman had persistent right elbow pain and Olecranon fractures usually result from direct contusion to
swelling after a fall. She also complained of numbness over the elbow or from a fall onto an outstretch hand with elbow
her right medial elbow and little finger. There was no held in semiflexion. Avulsion can also occur from a forceful
obvious fracture on the plain film. The following ultrasound pull of the triceps muscles on its insertion on the olecranon.
image shows the axial view of the posterior medial elbow Stress fracture is more common in baseball players and
(Figure 1). What is your impression? gymnasts. The diagnosis is usually made based on ante-
roposterior and lateral plain radiographs of the elbow.
Because ulnar nerve passed through the ulnar groove of the
medial epicondyle, it is commonly injured in elbow frac-
tures. Thus, a careful neurological examination for the
Interpretation ulnar nerve is necessary, including motor function of the
interosseous muscles and sensation over the palmar aspect
In the axial plane between the olecranon and medial epi- of the little and ring finger [1].
condyle (Figure 1), there was a bony fragment beside the
olecranon (black arrowhead). The posterior band of the
ulnar collateral ligament (red arrows), which connects the
medial epicondyle and olecranon and forms the floor of the
cubital tunnel, was disrupted. The hypertrophic and
hypervascular synovium (as seen in Figure 2) pushed the
ulnar nerve (white arrow) outside the cubital tunnel. The
ultrasonographic diagnosis included olecranon fracture,
tear of the posterior band of the ulnar collateral ligament,
and subluxation of the ulnar nerve.

Conflicts of interest: All contributing authors declare no

conflicts of interest.
* Correspondence to: Dr Ke-Vin Chang, Department of Physical
Medicine and Rehabilitation, National Taiwan University Hospital,
Bei-Hu Branch, Number 87, Neijiang Street, Wanhua District, Taipei
City 108, Taiwan. Figure 1 Ultrasound images show the axial view of the
E-mail address: pattap@pchome.com.tw (K.-V. Chang). medial elbow.

http://dx.doi.org/10.1016/j.jmu.2016.08.005
0929-6441
Persistent Medial Elbow Pain After a Fall
Figure 2 Power Doppler image of the posterior elbow in the
long axis view.
The cubital tunnel is a space at the posterior medial
elbow. It contains several structures, the most important of
which is the ulnar nerve. The medial wall of the cubital
tunnel is formed by the medial epicondyle of the humerus,
whereas the lateral wall is composed of the olecranon
process of the ulna. The floor contains the posterior and
transverse bands of the ulnar collateral ligament. The roof
of the cubital tunnel is formed proximally by the cubital
tunnel retinaculum (arcuate ligament) and distally by the
deep fibers of the flexor carpi ulnaris aponeurosis. Given its
superficial location, the ulnar nerve is susceptible to
trauma as well as impingement from degenerative changes.
The ulnar nerve is prone to subluxation during elbow flexion
in case of disruption of the structure pertaining to the
cubital tunnel. Hence, cubital tunnel syndrome usually
develops in patients whose work involves repeated or
169
prolonged elbow flexion, such as typing with the elbows
placed against the hard surface. The patients feel numb-
ness over the ulnar aspect of hands first. If the entrapment
persisted, the intrinsic muscles of hands may eventually
suffer from weakness and atrophy [2].
Ultrasound is a wonderful tool to examine the peripheral
nerve [3e5]. The cross-sectional area of the ulnar nerve
becomes larger proximal to the compression side, in case of
cubital tunnel syndrome [3]. The dynamic study of ultra-
sound is exclusively useful to diagnose ulnar nerve sublux-
ation during flexion and extension of the elbow. Additional
findings such as ulnar collateral ligament injuries and chip
fractures can be found as well. For patients with medial
elbow pain and numbness but negative findings on the plain
films, the present case demonstrated the importance of
ultrasound in exploring its etiology.
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