Ovid: Musculoskeletal Imaging Companion

Editors: Berquist, Thomas H.
Title: Musculoskeletal Imaging Companion, 2nd Edition
> Table of Contents > Chapter 8 – Elbow/Forearm

Chapter 8
Thomas H. Berquist
Laura W. Bancroft


Fractures/Dislocations: Distal Humeral Fractures
FIGURE 8-1 Distal humeral fracture. Lateral (A) and AP (B) radiographs of an extension supracondylar fracture. The distal fragment is displaced posteriorly (arrow).


FIGURE 8-2 Supracondylar fracture line is not clearly seen, but the capitulum lies posterior to the anterior humeral line (black line),
indicating a fracture. The anterior humeral line should intersect the
midcapitellum. There is also a positive posterior fat pad sign (arrow).
Suggested Reading
Anderson SE, Otsuka NY, Steinbach LS. MR imaging of pediatric elbow trauma. Semin Musculoskel Radiol 1998;2:185–198.
Kinik H, Atalar H, Mergen E. Management of distal humeral fractures in adults. Arch Orthop Trauma Surg 1999;119:467–469.
Murphy BJ. MR imaging of the elbow. Radiology 1992;184:525–529.


Fractures/Dislocations: Epicondylar Fractures
FIGURE 8-3 AP radiograph of the elbow in a young pitcher with an avulsed medial epicondyle (arrow).


Suggested Reading
Larson RL. Epiphyseal fractures in the adolescent athlete. Orthop Clin North Am 1973;4:839–851.


Fractures/Dislocations: Adult Distal Humeral Fractures
FIGURE 8-4 AP radiograph demonstrating the medial and lateral columns (black lines)
with the trochlea (T) between the columns. Fractures may be
extra-articular (1), across both columns (2), or intra-articular (3)
involving one or both columns.



FIGURE 8-5 Adult distal humeral fracture patterns. (A) Extra-articular. (B) One condyle. (C) Both condyles. (D,E) Both condyles with comminution.


FIGURE 8-6 AP radiograph of a lateral column fracture entering the margin of the trochlea (arrowheads). (B) AP radiograph of an intra-articular “T” fracture. (C) AP radiograph after internal fixation of a “Y”-type fracture.


FIGURE 8-7 CT images of a lateral column fracture reformatted in the coronal (A) and (B) sagittal planes.
Suggested Reading
DL, Kloen P, Anand N, et al. Open reduction and internal fixation of
delayed unions and nonunions of fractures of the distal part of the
humerus. J Bone Joint Surg 2003;85A:33–44.
Ring D, Jupiter JB. Complex fractures of the distal humerus and their complications. J Shoulder Elbow Surg 1999;8:85–97.


Fractures/Dislocations: Capitellar Fractures
FIGURE 8-8 Lateral view of the elbow demonstrating a capitellar fracture (arrow) and displaced fat pad (open arrow).
Suggested Reading
Fowles JV, Dassab MT. Fractures of the capitellum humeria. J Bone Joint Surg 1975;56A:794–798.


Fractures/Dislocations: Fractures of the Proximal Radius


FIGURE 8-9 Fat pad sign. (A) Normal position of the fat pads. AP (B) and lateral (C) radiographs of a radial head fracture with displaced fat pads on the lateral view (arrows).


FIGURE 8-10 CT images in the sagittal plane (A,B) demonstrate a minimally displaced comminuted radial head fracture (arrows) with associated capitellar fragments (open arrow).
Suggested Reading
Corbett RH. Displaced fat pads in elbow trauma. Injury 1978;9:297–298.
Geel CW, Palmer AK. Radial head fractures and their effect on the radioulnar joint: A rationale for treatment. Clin Orthop 1992;275:79–84.


Fractures/Dislocations: Ulnar Fractures
FIGURE 8-11 (A) Lateral view of the elbow showing a displaced olecranon and radial head fractures. (B) Fractures were internally fixed using plate and screw fixation.
Suggested Reading
Rettig AC, Waugh TR, Evanski PM. Fracture of the olecranon. A problem of management. J Trauma 1979;19:23–28.


Fractures/Dislocations: Coronoid Fractures


FIGURE 8-12 (A)
Lateral radiograph demonstrating the locations of Types I to III
coronoid fractures. Lateral radiograph of the elbow after reduction of
a posterior dislocation shows a small fragment from the coronoid tip (arrow) (Type I).
Suggested Reading
Regan W, Morrey BF. Fractures of the coronoid process of the ulna. J Bone Joint Surg 1989;71A:1348–1354.


Fracture/Dislocations: Elbow Dislocations
FIGURE 8-13 AP (A) and lateral (B) radiographs of a posterolateral dislocation with associated fracture of the radial head (arrow) and neck.
Suggested Reading
Koyle SG. Posterior dislocations of the elbow. Clin Orthop 1991;269:201.
O’Driscoll SW, Morrey BF, Korinek S, et al. Elbow subluxations and dislocations: A spectrum of instability. Clin Orthop 1992;280:186–197.
DMW, Wild LM, Schemitsch EH, et al. Standard surgical protocols for
treatment of elbow dislocations with radial head and coronoid
fractures. J Bone Joint Surg 2004;86A:1122–1130.


Fractures/Dislocations: Monteggia Fractures


FIGURE 8-14 Monteggia fracture. (A) Oblique radiograph showing an anterior dislocation of the radial head with a proximal ulnar fracture. Postreduction AP (B) and lateral (C) radiographs with internal fixation of the ulnar fracture.
Suggested Reading
Bado J. The Monteggia lesion. Clin Orthop 1967;50:71–86.


Fractures/Dislocations: Forearm Fractures


FIGURE 8-15 Forearm fracture. Mechanism of injury: direct blow in (A) and fall on the outstretched arm (B) with forces that tend to displace the fracture.


FIGURE 8-16 Incidence of proximal, mid-, and distal forearm fractures.


FIGURE 8-17 Postreduction radiograph of a comminuted ulnar fracture with associated dislocation of the radial head.
Suggested Reading
MW, Gordon JE, Zissimos AG. Compression plate fixation of acute forearm
fractures of the diaphysis of the radius and ulna. J Bone Joint Surg 1989;71A:159–169.


Osteochondritis Dissecans
FIGURE 8-18 Axial T1- (A) and fast spin-echo T2-weighted (B) with fat suppression and sagittal fast spin-echo T2-weighted (C) fat-suppressed images demonstrate an undisplaced osteochondritis dissecans of the capitellum (arrow).
Suggested Reading
Herzog RJ. Magnetic resonance imaging of the elbow. Magn Reson Q 1993;9:188–210.
Kijowski R, De Smet AA. Radiography of the elbow of patients with osteochondritis dissecans of the capitellum. Skel Radiol 2005;34:266–271.


Soft Tissue Trauma: Biceps Tendon
FIGURE 8-19 Lateral radiograph showing irregularity of the radial tuberosity (arrows) caused by chronic microtrauma.


FIGURE 8-20 Biceps tendon tear. Axial (A) and sagittal (B) T2-weighted images of a biceps tendon tear (arrow) with retraction and surrounding hemorrhage and edema.
Suggested Reading
Chew ML, Giuffre BM. Disorders of the distal biceps brachii tendon. Radiographics 2005;25:1227–1237.
Fitzgerald SW, Curry DR, Erickson SJ, et al. Distal biceps tendon injury. MR imaging diagnosis. Radiology 1994;191:203–206.


Soft Tissue Trauma: Triceps Tendon Injuries
FIGURE 8-21 Axial T1- (A) and T2- (B) weighted images showing abnormal signal intensity and thickening of the triceps (arrow) caused by a high-grade tear.
Suggested Reading
Tiger E, Mayer DP, Glazer R. Complete avulsion of the triceps tendon. MRI diagnosis. Comput Med Imaging Graphics 1993;17:51–54.


Soft Tissue Trauma: Flexor/Extensor Tendon Injuries
FIGURE 8-22 Extensor tendinopathy. Axial (A) and coronal (B) T2-weighted images showing tendon thickening and abnormal signal intensity (arrow) in the extensor tendon.


FIGURE 8-23 Partial tear of the common extensor origin. Axial (A) and coronal (B) T2-weighted images showing increased signal intensity (arrow) resulting from a partial tear.


Suggested Reading
Kijowski R, DeSmet AA. Magnetic resonance imaging findings in patients with medial epicondylitis. Skel Radiol 2005;34:196–202.
Kraushaar BS, Nirschl RL. Tendinosis of the elbow (tennis elbow). J Bone Joint Surg 1999;81A:259–278.
PAA, Spruyt M, Assendelft WJJ, et al. The predictive value of
diagnostic sonography for effectiveness of conservative treatment of
tennis elbow. AJR Am J Roentgenol 2005;185:1113–1118.


Soft Tissue Trauma: Muscle Injuries
FIGURE 8-24 Anconeus strain. Axial T2-weighted image of the elbow showing increased signal intensity (arrow) resulting from repetitive microtrauma.
Suggested Reading
Herzog RJ. Magnetic resonance imaging of the elbow. Magn Reson Q 1993;9:188–210.


Soft Tissue Trauma: Ligament Injuries


FIGURE 8-25 Radial collateral ligament tear. AP radiograph of an elbow arthrogram showing contrast extravasation (arrow) resulting from ligament disruption.


Partial tear of the anterior band of the ulnar collateral ligament.
Coronal T2-weighted image showing increased signal intensity about and
in the ligament (arrow) resulting from a partial tear.
Suggested Reading
JA, Morrison WB, Zon KH, et al. MR imaging and MR arthrography of the
ulnar collateral ligament of the elbow: Prospective evaluation of
2-dimensional pulse sequences for detection of complete tears. Skel Radiol 2001;30:625–632.
A, Jacobson J, Brossmann J, et al. Collateral ligaments of the elbow.
Conventional MR imaging and MR arthrography with oblique coronal plane
and elbow flexion. Radiology 1997;204:806–812.
SI, Teefey SA, Paletta GA, et al. Sonography of the medial collateral
ligament of the elbow: A study of cadavers and healthy male volunteers.
AJR Am J Roentgenol 2002;180:389–394.


Neoplasms: Bone Tumors
FIGURE 8-27 Osteoid osteoma. Sagittal fast spin-echo fat-suppressed T2-weighted images (A,B) showing an osteoid osteoma (arrow in A). There is edema and a large reactive joint effusion (open arrows), typical of osteoid osteoma.


Benign No. in Elbow and Forearm/Total/%
Osteoid osteoma 23/331/7%
Chondromyxoid fibroma 2/45/4.4%
Giant cell tumor 12/568/2%
Osteochondroma 12/872/1.4%
Chondroma 2/290/0.6%
Malignant No. in Elbow and Forearm/Total/%
Ewing sarcoma 22/512/4%
Lymphoma 28/694/4%
Myeloma 15/814/2%
Osteosarcoma 19/1649/1%
Chondrosarcoma 9/895/1%
Fibrosarcoma 3/255/1%
Suggested Reading
Unni KK. Dahlin’s bone tumors: General aspects and data on 11,087 cases. 5th ed. Philadelphia: Lippincott-Raven; 1996.


Neoplasms: Soft Tissue Tumors
FIGURE 8-28 Ganglion cyst. Axial T1- (A) and T2- (B) weighted images showing a benign cyst (arrow) with uniform increased intensity on T2-weighted and low signal intensity on T1-weighted sequences.


FIGURE 8-29 Malignant fibrous histiocytoma. Axial T1- (A) and T2-weighted (B) images of this malignant lesion. Signal inhomogeneity is most easily appreciated on the T2-weighted image (B).
Suggested Reading
Berquist TH. Magnetic resonance imaging of musculoskeletal neoplasms. Clin Orthop 1989;244:101–118.


FIGURE 8-30 Soft tissue abscess. Sagittal T2-weighted (A) and post–gadolinium-enhanced fat-suppressed (B) images showing a large nonenhancing fluid collection.


FIGURE 8-31 Sagittal T1- (A) and T2-weighted (B) images demonstrate diffuse soft tissue edema and abnormal signal intensity in the ulna due to osteomyelitis.
Suggested Reading
Berquist TH, Broderick DF. Musculoskeletal infection. In: Berquist TH, ed. MRI of the musculoskeletal system. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2006:916–947.


FIGURE 8-32 Rheumatoid arthritis. AP radiograph showing joint space narrowing and erosive changes.



FIGURE 8-33 Osteoarthritis. (A) AP radiograph showing bone sclerosis and osteophytes typical of osteoarthritis. (B) Axial T2-weighted MR image showing a joint effusion with osteophytes (open arrows).


FIGURE 8-34 Gout. (A) AP and lateral radiographs demonstrate prominent nodular swelling (arrows). Sagittal (B,C)
post-contrast fat-suppressed T1-weighted images demonstrate enhancement
of the distended bursal lining caused by gouty inflammation.
Suggested Reading
Brower AC. Arthritis in black and white. 2nd Ed. Philadelphia: WB Saunders; 1997:325–342.


Nerve Entrapment Syndromes
FIGURE 8-35 Ulnar nerve in the arm and the arcade of Struthers.
FIGURE 8-36 Ulnar nerve in the cubital tunnel.


FIGURE 8-37 Radial and posterior interosseous nerves.


FIGURE 8-38 Neurovascular anatomy of the elbow and forearm.


FIGURE 8-39 Ulnar neuritis. Axial T1- (A) and T2- (B) weighted images showing an enlarged ulnar nerve (arrow) with increased signal intensity on T2-weighted image (B).
Suggested Reading
Beltran J, Rosenberg ZS. Diagnosis of compression and entrapment neuropathies of the upper extremity. Value of MR imaging. AJR Am J Roentgenol 1994;163:525–531.
Major N. Magnetic resonance imaging of the elbow. Curr Probl Diagn Radiol 2000;1:27–40.
O’Driscoll SW, Horii E, Carmichael S, et al. The cubital tunnel and ulnar neuropathy. J Bone Joint Surg 1991;73A:613–617.

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