 I am Dr. Ashwin Lavande, I am practicing musculoskeletal ultrasound for the last 15 years now. And today our topic is elbow joint. So, we will be scanning on Samsung RS80 with the 4 to 18 megahertz probe, we will be scanning various structures all around the elbow and I will show you certain tips and tricks about scanning those structures. Thank you. So, in the next 12 to 15 minutes we will see how we scan the elbow structures from all the 4 aspects of the joint. So, we start scanning the elbow from the anterior aspect and what we do is after palpating the medial and the lateral epicondyls we keep the probe joining them in the cubitul fossa over the distal end of humerus. So, when you see the distal end of humerus that is the distal end of the humerus in the transverse plane. So this is the lateral aspect which is the rounded capital M and this is the trochlea. This muscle which you see on the anterior aspect of the distal end of humerus is your brachialis on which lies the ecogenic biceps tendon, medial to which lies the brachial artery which is pulsating, medial to that you have your median nerve which is between the pronator teres and the brachialis muscles. And if you go laterally you will see your brachioradialis and the brachialis with the radium nerve in between both these muscles. So now what we do is we scan the distal biceps tendon because that is the a little tricky structure to scan. So that is your distal biceps muscle belly and that is the ecogenic tendon forming within the center of the biceps muscle. This is your brachialis. So as you come down that is your tendon which is forming there and then I will decrease in the depth taking the focal spot up so that you can see the tendon fibrolo-pateco pattern in the transverse plane. You turn your probe 90 degrees and there you see the biceps coming out from the tendon coming out from the muscle. That is the biceps muscle tendon junction. This is the fat plane between the biceps and the brachialis and that is how you trace the biceps all the way up to the radial tuberosity which is located below the radial neck on the posterior medial aspect. So as you go down this tendon turns complete 90 degrees and that is why you are not able to see the distal tendon if you keep the normal neutral position of the hand. So what we do is we do a hypersupination kind of a manoeuvre and then we then I decrease the depth take my focal spot down and then I go a little more on the medial aspect and tilt my probe laterally and try to see through the brachial artery the distal biceps tendon. So that is the distal biceps tendon which is coming and inserting on the radial tuberosity so that is the footprint of the distal biceps which is quite a long footprint. It is around 3 centimeters square and here you see the two components of the distal biceps tendon inserting on the radial tuberosity. So the anterior one is the short tendon component which is inserting distally and the posterior one is the long tendon of biceps which is inserting a little proximally. So these are the two components of the distal biceps tendon and this is in hypersupination. If I do a little pronation the radial tuberosity goes posteriorly and you are not able to see the moment I do a hypersupination it again comes anteriorly. So this is how you can do a dynamic examination and see for the distal biceps. The other way of seeing the distal biceps tendon is to do a cobra manoeuvre where you flex the tendon flex the forearm at the elbow and do this position and then you keep the probe transverse in the upper forearm and see for the radius and ulna. So that is your radius I am decreasing the depth so that you see it better and that is the ulna. So this is your footprint of the biceps that is the footprint. So now because he has done a hypopronation your radial tuberosity has pointed is going more posterior that is why you see the footprint here and that is the fat plane. When you do pronation supination you are able to see how the biceps footprint moves anteriorly on supination and again posteriorly on pronation. So when you are giving local steroid injections around the distal biceps in the bicebeto radial bursa which is located around the distal tendon of around the around the distal biceps tendon your needle should come from here and you should give this steroid injection within this fat plane here so that the entire tendon is bathed in that. Then after seeing the distal biceps tendon we again go back to the same place and decrease the depth take the focus spot up so that we see something we see a structure here coming from the distal biceps tendon and going into the subcutaneous tissue plane. So this is your laceratus fibrosis which hooks the biceps tendon into the facial plane so that is your laceratus fibrosis there over the brachyl artery and that is your pronator tereis muscle. Now we go to the anterior joint recesses so this is your distal humerus and the moment you turn your probe transverse over the lateral aspect of the anterior joint recess you see the square shaped head of radius that is the articular cartilage, highline cartilage and this is the capital M over which the highline cartilage is there so this is your anterior joint recess and this is your radial fossa where the radial head will come and articulate that is the anterior fat pad which is intraarticular but extra sinus wheel and whenever there is elbow joint diffusion this will be lifted up away from the bone. You go a little to the medial side and there you will see the coronoid process of ulna articulating with the trochlea and that is the coronoid fossa with the fat pad there. This is your entire brachialis muscle which you saw earlier that is your brachyl artery which further divides into radian ulnar. This is your median nerve which I have showed you in my earlier video how it goes between the brachialis and the brachialis and further as you go down it will go between the two heads of pronator teres. So here you can see the median nerve going between the two heads of pronator teres which is your pronator tunnel. So we won't go into the details here as we have already discussed it earlier. After this we then go to the lateral aspect and we see again come to the distal end of humerus, increase our depth, decrease our depth and take the focus spot up and see for the radial nerve between the brachioradialis and the brachialis. So radial nerve is a single trunk as you go higher up in the arm there and as you come down it has already divided into two branches. So these are the two branches. This is your cutaneous branch of radial nerve and that's your posterior introsius nerve. See my arrow I am tracing the posterior introsius nerve as it goes through the two heads of supinator and you can see there that's my radial nerve sorry the posterior introsius nerve going into the supinator tunnel. This is the radial nerve going into the super between the superficial and the deep heads of supinator and for seeing for the dynamic entrapment I have to do pronation supination and see for the entrapment of the nerve at this level. So when I do this and if you don't see any indentation on the any significant indentation on the nerve while doing this maneuver then your radial nerve is a posterior introsius nerve is normal. So what you are supposed to do is measure the nerve approximately before it enters the tunnel and within the tunnel and compare it with the opposite side and see for any dynamic entrapment at the arcade of Frosch. Now after scanning the anterior structures we go to the medial aspect we palpate the medial epicondyle first and then we keep the probe in the long axis over the medial epicondyle. So when we do this I am taking the focal spot up so that the image comes a little better. So now if you appreciate here my upper cranial end of the probe is on the medial epicondyle which you can appreciate here on the screen and my caudal portion of the probe is pointing towards the thinner eminence. So when I do this I am seeing a thick fleshy triangular common flexor origin there and the moment I turn the caudal portion of the probe towards the hypothena eminence I will see the anterior bundle of the annacolate ligament which you can appreciate here. It is so beautifully seen with this probe which comes which starts from 4 MHz and goes to 18 MHz and this is your joint recess between the humerus and the annan. This is the sublime tubercle of annan where this ligament comes and inserts it is like the medial stabilizer of the joint and for seeing the intactness I have to do this particular dynamic maneuver just to see if the joint space is widening and if the ligament is intact. So again towards the hypothena eminence you see the ligament and towards the thinner eminence you see the entire bulk of the common flexor origin. Then what we do is we go slightly more posteriorly and join these two bony prominences that is the medial epicondyle and the olecranon process. So if I keep my arrow on that is the medial epicondyle there and that is my olecranon process there. So when I join these two processes what I see here is a structure which is there in the groove behind the medial epicondyle that is your annan nerve showing a nice fascicular echo pattern. On top of the annan nerve you see a ligament which joins the medial epicondyle and the olecranon process and that is your osmone retinaculum or osmone ligament. And underneath the annan nerve this band like structure which you can see the fibers that is your posterior bundle of the annaculator ligament which again is a stabilizer of the elbow. Then as you go higher up you will see the annan nerve and the medial head of triceps which is coming in directly inserting on the olecranon there. So this we will also see from the posterior aspect. You have to always see for space occupying missions in the at the start of the cubital tunnel behind the medial epicondyle here because sometimes you have an accessory muscle here called as Anconius epitrocleris which is not there in this gentleman. But this is the place where you should start looking for annan nerve as it goes distally into the cubital tunnel. So now we scan a little more posteriorly and here what I am doing is I am joining the two bony prominences that is the medial epicondyle and that is the olecranon. And what you see here the structure behind the medial epicondyle is your annan nerve showing a nice fascicular echo pattern overlying which is your osmone retinaculum which keeps the annan nerve in place and does not allow it to subluxate beyond the level of the medial epicondyle. This band like structure in the floor of the cubital tunnel is your posterior bundle of annaculator ligament. And one has to look out for compression distally in the cubital tunnel at the level of the as the as the nerve enters the flexocopy annaris both heads. Now we go to the lateral aspect where you keep the hand like this in semi-pronation and palpate the lateral epicondyle and keep your cranial portion of the probe on the lateral epicondyle. So when you keep the cranial portion of the probe on the lateral epicondyle what you are seeing here is the common extensor origin. The common extensor origin is slightly longer slender as compared to the common flexor origin and what you are seeing here is there are three components of the common extensor origin. So two components in fact the superficial part if you go you see one particular layer of the tendon and this is the deeper portion of the tendon. So the superficial layer anteriorly is composed by the extensor digitorum and if you go posteriorly it is composed by the extensor copy annaris whereas the majority of the deeper fibers are by the extensor copy radialis previs. Now if you can appreciate this particular bony contour you can actually see that this is the whole footprint or the origin of the tendon and this particular lateral epicondyle if you see the tendon origin you have to divide the lateral epicondyle into the upper two thirds and lower one third. So upper two thirds is the actual origin of the tendon up till here and this particular curved fibers which you see here along the lower to one third this is nothing but your lateral collateral ligament or the radial collateral ligament which is arising from the portion the lower portion of the lateral epicondyle. So this is your radial collateral ligament fibers and these are your fibers of the ECRB and these are the fibers of the extensor digitorum anteriorly and ECU posteriorly. So whenever you have tennis elbow this is the area which gets affected you may you may have this fascicular echopattern or the febrile echopattern of the tendon is lost you see hypoechoic areas here and sometimes even tears and when the tendon heals you see increased vascularity because of the new vascularization there. So tennis elbow one has to keep the probe in this fashion on the lateral epicondyle and see for the common extensor origin here you can also see it in the short axis. So this is your common extensor origin on the lateral epicondyle. When you are scanning the lateral aspect you should also not forget to see the lateral recess of the radiocapital joint where you see this ecogenic triangular area here that's nothing but the synovial fringe which sometimes get impinged and can give rise to pain arising from the radiocapital joint and mimicking a tennis elbow. So whenever we give steroid injections in tennis elbow cases we always give them the surface of the tendon sometimes make dry needling here and also go into the radiocapital joint and inject a little steroid remaining steroid in the joint out here. So now we scan the elbow from the posterior aspect and what you need to do here is first palpate the olecranon process keep the caudal portion of the probe on the olecranon process decrease your depth sorry increase your depth and take your focus spot in the right place and then you can see that's the olecranon process and that's the distilled tricep tendon inserting on the olecranon this is your actual joint recess between the olecranon and the humerus and then as you go higher up you will see the olecranon fossa along the posterior aspect of the distilled end of humerus which is filled up with the posterior fat pad and that's your triceps muscle medial fibres you turn the probe again at 90 degrees and then come towards the olecranon process so that's your central triceps tendon this is your medial head triceps which is directly inserting on the olecranon there along with the triceps tendon and the triceps tendon other muscle heads are inserting on it the long head sorry the long head and the lateral head and that's the central triceps tendon forming this is the trough shaped olecranon fossa along the distilled end of the posterior aspect of the humerus which is filled up with the posterior fat pad so when I turn the probe along the long axis of the humerus distilled end this is the olecranon fossa that's your olecranon process there and when he is extending the hand just extend your hand please slowly slowly slowly flex it flex it slowly yeah now you extend it extend it slowly see now that olecranon process is coming and it will go into the olecranon fossa there extend it completely and then the entire fat gets obliterated and pushed up extend flex again so this is the place where you have to look out for refusions and see for lifting up of the posterior fat pad so in cases of rheumatoid arthritis where you are supposed to give injections we come from here at this level from here and then your needle will go directly here and infiltrate the joint at this level so that it directly fills up the joint recess and goes anteriorly posteriorly and in the medial and lateral recesses as well when you are scanning for the olecranon fossa you are supposed to take a thick gel pad total extend curve yeah and keep it over the olecranon here so this is the place where you are supposed to see for the olecranon process and the olecranon fossa so that's your distilled triceps fibers which were earlier showing an artifactual hypoecogenicity because of anisotropy here you see the entire footprint of the distilled triceps tendon and your subcutaneous olecranon fossa is located somewhere here in the normal person the bursa is imperceptible but this is the place where you have to look out for any bursal fluid in cases of inflammation there is also a sub-tenderness bursa which is located here like your retrocalculial bursa underneath the tendo achilles but that is usually not visualized and never usually gets inflamed so this is your distilled triceps tendon inserting on the olecranon and medially if you go you will have your medial head triceps which directly inserts on the bone so that's why in cases of triceps stares even though the tendon goes slightly higher up after retraction the whole unit does not retract because the medial head of triceps is still attached to the bone so last but not the least this is your ulnar nerve which is going along the medial head of triceps medial border and then it is going behind the medial epicondyle into the ulnar groove and the osbone retinaculum on top of it so that's about the ultrasound of elbow joint from multiple aspects but more or less ultrasound of elbow is a targeted examination for any of these structures and you have to tailor your examination accordingly thank you very much for your attention.