Ultrasound of the elbow with emphasis on the sonoanatomy of the distal biceps tendon and its importance for the surgical treatment of tendon lesions

Abstract

Degenerative or traumatic ruptures of the distal biceps tendon are less common than proximal lesions. Distal lesions lead to a significant loss of function with usually considerable discomfort for patients. Therefore, precise diagnostics using operator-dependent high-resolution musculoskeletal ultrasound with illustration of the extent of the affected tendon lesion are important for optimizing patient management. In this article, we discuss the precise high-resolution musculoskeletal ultrasound and sonoanatomy of the distal biceps tendon and emphasize its importance for the surgical treatment of tendon lesions. In this review and pictorial essay, we first focus on the description of the precise anatomy and ultrasound anatomy of this clinically important region. Furthermore, we highlight different ultrasound scanning techniques for the correct assessment of the distal biceps tendon. Various approaches for optimal sonographic assessment of the distal biceps tendon have been suggested in the literature: the anterior approach, the lateral access, the medial access and the posterior approach. In the second part of the article, we focus on the evaluation of surgical repair techniques of distal biceps tendon lesions considering the extent of the rupture zone of the distal biceps tendon based on the ultrasound findings. Surgical techniques are explained from the orthopedic surgical point of view.

EURO-MUSCULUS/USPRM Dynamic Ultrasound Protocols for Elbow

“… 17–19 Of note, the abovementioned maneuver can also be performed using a longitudinal acoustic window to dynamically and panoramically expose the proximal and distal facets of the radial tuberosity (Video 8, http://links.lww.com/PHM/B477). Indeed, the latter technique will better show the tendon of the long head of the biceps brachii attaching to the proximal footprint and the tendon of the short head of the biceps brachii inserting to the distal footprint of the radial tuberosity 19 . Last, the two components of the DBBT are separated by a septum originating from the endotenon (areolar connective tissue), which simultaneously stabilizes the two tendons but also allows for their independent gliding 20 .…”

“…22 As previously mentioned for the radial tuberosity window, several pathological conditions of the DBBT can lead to irregular passage of the tendon between the radius and ulna. 19 In addition, posttraumatic or congenital dysmorphism of the radius/ulna can result in mechanical block at the level of the proximal radioulnar space. Accordingly, the authors suggest combining the dorsal and medial approaches for prompt dynamic examination of this (complex) anatomical compartment of the elbow, that is, proximal radioulnar tunnel.…”

“…Biomechanically, the proximal radioulnar tunnel/space is reduced by 50% (at the level of the radial tuberosity) in full pronation, and the DBBT occupies 85% of the tunnel during the same maneuver 23 . Normally, during pronation and supination of the forearm, the DBBT slips smoothly between radius and ulna; however, in pathological conditions, a thickened tendon can be entrapped in the proximal radioulnar tunnel generating an extra-articular impingement 19,22 . Last, bicipitoradial bursitis should be considered among the possible causes of painful impingement especially in patients with rheumatic diseases 24 …”

“…Of note, the abovementioned technique can be also performed to better define a painful snapping DBBT. However, several pathological conditions like focal tendinosis, calcific tendinopathy, and hypertrophic scarring (due to partial tear or surgical repair) can lead to mechanical impingement 19,22 . Biomechanically, the proximal radioulnar tunnel/space is reduced by 50% (at the level of the radial tuberosity) in full pronation, and the DBBT occupies 85% of the tunnel during the same maneuver 23 .…”

“…Active/passive pronation and supination of the forearm (Video 37, http://links.lww.com/PHM/B506) can be performed to evaluate impingement at the level of the proximal radioulnar space 22 . As previously mentioned for the radial tuberosity window, several pathological conditions of the DBBT can lead to irregular passage of the tendon between the radius and ulna 19 . In addition, posttraumatic or congenital dysmorphism of the radius/ulna can result in mechanical block at the level of the proximal radioulnar space.…”