Diagnostic efficiency of conventional ultrasound, shear wave elastography, and superb microvascular imaging in evaluating ulnar neuropathy at the elbow.

INTRODUCTION/AIMS: The current diagnosis of ulnar neuropathy at the elbow (UNE) relies mainly on the clinical presentation and nerve electrodiagnostic (EDX) testing, which can be uncomfortable and yield false negatives. The aim of this study was to investigate the diagnostic value of conventional ultrasound, shear wave elastography (SWE), and superb microvascular imaging (SMI) in diagnosing UNE. METHODS: We enrolled 40 patients (48 elbows) with UNE and 48 healthy volunteers (48 elbows). The patients were categorized as having mild, moderate or severe UNE based on the findings of EDX testing. The cross-sectional area (CSA) was measured using conventional ultrasound. Ulnar nerve (UN) shear wave velocity (SWV) and SMI were performed in a longitudinal plane. RESULTS: Based on the EDX findings, UNE severity was graded as mild in 4, moderate in 10, and severe in 34. The patient group showed increased ulnar nerve CSA and stiffness at the site of maximal enlargement (CSA mean at the site of max enlargement [CSAmax] and SWV mean at the site of max enlargement [SWVmax]), ulnar nerve CSA ratio, and stiffness ratio (elbow-to-upper arm), compared with the control group (p < .001). Furthermore, the severe UNE group showed higher ulnar nerve CSAmax and SWVmax compared with the mild and moderate UNE groups (p < .001). The cutoff values for diagnosis of UNE were 9.5 mm2 for CSAmax, 3.06 m/s for SWVmax, 2.00 for CSA ratio, 1.36 for stiffness ratio, and grade 1 for SMI. DISCUSSION: Our findings suggest that SWE and SMI are valuable diagnostic tools for the diagnosis and assessment of severity of UNE.

Olecranon bone age assessment in puberty using a lateral elbow radiograph and a deep-learning model.

OBJECTIVES: To improve pubertal bone age (BA) evaluation by developing a precise and practical elbow BA classification using the olecranon, and a deep-learning AI model. MATERIALS AND METHODS: Lateral elbow radiographs taken for BA evaluation in children under 18 years were collected from January 2020 to June 2022, retrospectively. A novel classification and the olecranon BA were established based on the morphological changes in the olecranon ossification process during puberty. The olecranon BA was compared with other elbow and hand BA methods, using intraclass correlation coefficients (ICCs), and a deep-learning AI model was developed. RESULTS: A total of 3508 lateral elbow radiographs (mean age 9.8 ± 1.8 years) were collected. The olecranon BA showed the highest applicability (100%) and interobserver agreement (ICC 0.993) among elbow BA methods. It showed excellent reliability with Sauvegrain (0.967 in girls, 0.969 in boys) and Dimeglio (0.978 in girls, 0.978 in boys) elbow BA methods, as well as Korean standard (KS) hand BA in boys (0.917), and good reliability with KS in girls (0.896) and Greulich-Pyle (GP)/Tanner-Whitehouse (TW)3 (0.835 in girls, 0.895 in boys) hand BA methods. The AI model for olecranon BA showed an accuracy of 0.96 and a specificity of 0.98 with EfficientDet-b4. External validation showed an accuracy of 0.86 and a specificity of 0.91. CONCLUSION: The olecranon BA evaluation for puberty, requiring only a lateral elbow radiograph, showed the highest applicability and interobserver agreement, and excellent reliability with other BA evaluation methods, along with a high performance of the AI model. CLINICAL RELEVANCE STATEMENT: This AI model uses a single lateral elbow radiograph to determine bone age for puberty from the olecranon ossification center and can improve pubertal bone age assessment with the highest applicability and excellent reliability compared to previous methods. KEY POINTS: Elbow bone age is valuable for pubertal bone age assessment, but conventional methods have limitations. Olecranon bone age and its AI model showed high performances for pubertal bone age assessment. Olecranon bone age system is practical and accurate while requiring only a single lateral elbow radiograph.

Assessing ulnar neuropathy at the elbow using magnetoneurography.

OBJECTIVE: To measure neuromagnetic fields of ulnar neuropathy patients at the elbow after electrical stimulation and evaluate ulnar nerve function at the elbow with high spatial resolution. METHODS: A superconducting quantum interference device magnetometer system recorded neuromagnetic fields of the ulnar nerve at the elbow after electrical stimulation at the wrist in 16 limbs of 16 healthy volunteers and 21 limbs of 20 patients with ulnar neuropathy at the elbow. After artifact removal, neuromagnetic field signals were processed into current distributions, which were superimposed onto X-ray images for visualization. RESULTS: Based on the results in healthy volunteers, conduction velocity of 30 m/s or 50% attenuation in current amplitude was set as the reference value for conduction disturbance. Of the 21 patient limbs, 15 were measurable and lesion sites were detected, whereas 6 limbs were unmeasurable due to weak neuromagnetic field signals. Seven limbs were deemed normal by nerve conduction study, but 5 showed conduction disturbances on magnetoneurography. CONCLUSIONS: Measuring the magnetic field after nerve stimulation enabled visualization of neurophysiological activity in patients with ulnar neuropathy at the elbow and evaluation of conduction disturbances. SIGNIFICANCE: Magnetoneurography may be useful for assessing lesion sites in patients with ulnar neuropathy at the elbow.

The efficacy of pediatric elbow radiographic guidance in diagnosis of lateral humeral condyle fracture.

Although lateral humeral condyle fracture is common, the incidence of missed diagnosis is very high. Delayed and missed diagnosis led to significant morbidities and loss of functions. We designed a pediatric elbow radiographic guidance aiming to improve the accuracy of diagnosis. This study was aimed to evaluate the efficacy of the radiographic guidance for the diagnosis of lateral condyle fracture. A cross-sectional study was conducted after defining the essential parameters as a guidance for assessing the pediatric elbow radiographs. We included medical students, emergency medicine, orthopedic, and radiology residents and fellows into this study. A questionnaire was used to evaluate the efficacy of the guidance. All participants underwent a pretest evaluation, followed by studying the guidance, and then finished a posttest evaluation. Baseline characteristics, diagnostic scores, and parameter evaluation scores were collected. The pretest and posttest scores were analyzed using paired t-test. Association between baseline characteristics and diagnostic scores were analyzed using multiple regression analysis. We included 177 participants. Average diagnostic score was significantly increased after using the guidance, from 12.2 ± 1.9 to 13.0 ± 1.7 (p < 0.0001). Medical students showed the most improvement, from 11.9 ± 1.9 to 13.1 ± 1.3 (p <0.001). All means of essential parameter evaluation scores were significantly improved in overall participants.The pediatric elbow radiographic guidance is useful for evaluation and diagnosis of lateral condyle fracture, especially for young physicians and trainees. Therefore, this should be recommended in routine medical education and general practice.

Elbow calcific tendinosis initially detected by ultrasonography: a case report.

INTRODUCTION: Calcific tendinosis is a common condition caused by the deposition of hydroxyapatite crystals within the tendons that can impact any tendinous insertion. In this situation, ultrasound (US) may be a viable imaging modality in addition to radiography. CASE PRESENTATION: A 56-year-old Iranian male presented with left elbow pain. US evaluation at the lump site revealed a subcutaneous lipoma. Ultrasonography showed a thickened and diffusely heterogeneously hypoechoic pronator teres tendon. These characteristics were consistent with the diagnosis of calcific tendinosis. DISCUSSION AND CONCLUSION: Radiography is the most common and practical imaging modality for calcific tendinosis diagnosis. Despite this, the real-time nature of ultrasonography makes it both diagnostic and therapeutic in this condition. Other conditions, such as lipoma, may interfere with the proper diagnosis of calcific tendinosis.

Flexed elbow, abducted shoulder, forearm supinated (FABS) reconstruction from three-dimensional elbow MRI: diagnostic performance assessment in biceps head anatomy and pathology.

AIM: To determine inter-reader analysis and diagnostic performance on digitally reconstructed virtual flexed, abducted, supinated (FABS) imaging from three-dimensional (3D) isotropic elbow magnetic resonance imaging (MRI). MATERIALS AND METHODS: Six musculoskeletal radiologists independently evaluated elbow MRI images with virtual FABS reconstructions, blinded to clinical findings and final diagnoses. Each radiologist recorded a binary result as to whether the tendon was intact and if both heads were visible, along with a categorical value to the type of tear and extent of retraction in centimetres where applicable. Kappa and interclass correlation (ICC) were reported with 95% confidence intervals. Areas under the receiver operating curve (AUC) were reported. RESULTS: FABS reconstructions were obtained successfully in all 48 cases. With respect to tendon intactness, visibility of both heads, and type of tear, the Kappa values were 0.66 (0.53-0.78), 0.24 (0.12-0.37), and 0.55 (0.43-0.66), respectively. For the extent of retraction, the ICC was 0.85 (0.79-0.91) when including the tendons with and without retraction and 0.78 (0.61-0.91) when only including tendons with retraction. For tear versus no tear, AUC values were 0.82 (0.74-0.89) to 0.96 (0.91-1.01). CONCLUSION: Digital reconstruction of FABS positioning is feasible and allows good assessment of individual tendon head tears and retraction with high diagnostic performance.

Ultrasonographic evaluation of ulnar nerve morphology in patients with ulnar nerve instability.

INTRODUCTION/AIMS: Ulnar nerve instability (UNI) in the retroepicondylar groove is described as nerve subluxation or dislocation. In this study, considering that instability may cause chronic ulnar nerve damage by increasing the friction risk, we aimed to examine the effects of UNI on nerve morphology ultrasonographically. METHODS: Asymptomatic patients with clinical suspicion of UNI were referred for further clinical and ultrasonographic examination. Based on ulnar nerve mobility on ultrasound, the patients were first divided into two groups: stable and unstable. The unstable group was further divided into two subgroups: subluxation and dislocation. The cross-sectional area (CSA) of the nerve was measured in three regions relative to the medial epicondyle (ME). RESULTS: In the ultrasonographic evaluation, UNI was identified in 59.1% (52) of the 88 elbows. UNI was bilateral in 50% (22) of the 44 patients. Mean CSA was not significantly different between groups. A statistically significant difference in ulnar nerve mobility was found between the group with CSA of <10 versus ≥10 mm2 (p = .027). Nerve instability was found in 85.7% of elbows with an ulnar nerve CSA value of ≥10 mm2 at the ME level. DISCUSSION: The probability of developing neuropathy in patients with UNI may be higher than in those with normal nerve mobility. Further prospective studies are required to elucidate whether asymptomatic individuals with UNI and increased CSA may be at risk for developing symptomatic ulnar neuropathy at the elbow.

Dynamic Stress Ultrasound Assessment of Professional Baseball Players' Elbows After Ulnar Collateral Ligament Reconstruction.

BACKGROUND: There is a paucity of data analyzing dynamic stress ultrasound (SUS) findings in elite pitchers who have undergone ulnar collateral ligament (UCL) reconstruction (UCLR) and returned to sport. PURPOSE: To identify longitudinal, perioperative changes in the elbows of professional baseball pitchers who have undergone UCLR and to compare these findings with a matched cohort of healthy pitchers. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This study used prospectively collected data from dynamic elbow SUS analyses of professional baseball pitchers within a single Major League Baseball organization. Pitchers were divided into 2 cohorts: a UCLR cohort and healthy cohort. The UCLR cohort eligibility included availability of (1) SUS from preseason of injury/UCLR and (2) SUS from ≥2 years after surgery. These players were 1:1 matched to players with no history of upper extremity injury to form the healthy cohort. Ligament thickness and ulnohumeral joint space at rest and under stress were directly measured. Joint laxity was calculated by subtracting joint space at rest from joint space under stress. The term "relative" was used to describe calculated differences where nondominant measurements were subtracted from dominant-side measurements. RESULTS: Eight pitchers were included in the UCLR group and matched to 8 healthy pitchers (mean age at initial SUS examination, 19.6 years). At a minimum follow-up of 2 years, there were no significant differences between groups in terms of relative or dominant arm rest space, stress space, or laxity. Longitudinally (final measurements - baseline measurements), the mean relative ulnohumeral rest space decreased in the UCLR group and increased in the healthy group (-0.36 mm vs +0.50 mm; P = .032). The finding of increased UCL thickness in the UCLR group was expected, as UCL grafts are typically thicker than native ligaments. CONCLUSION: Ulnhohumeral joint stability was achieved after UCLR as indicated by similar rest space, stress space, and joint laxity in dominant arms compared with a matched healthy cohort. A significant decrease in relative rest space after UCLR may represent the achievement of stability in surgery patients. Alternatively, the increase in ulnohumeral rest space seen in the healthy cohort may represent adaptive changes from pitching at a professional level.

Paediatric bilateral 'floating elbow'.

A child sustained an ipsilateral supracondylar humerus (SCH) and distal both-bone forearm fractures bilaterally, in addition to facial injuries, following a fall from height. He was managed surgically by closed reduction and pinning for both SCH and distal end radius fractures bilaterally. At the final follow-up, all the fractures had united uneventfully, and he had no functional limitations or cosmetic concerns. We conclude that a floating elbow in the paediatric population is an uncommon injury, and the bilateral scenario is even rarer. One should be vigilant for compartment syndrome; early surgical fixation may give better results.

Association Between Draft Order and Stress Sonography of the Ulnar Collateral Ligament of the Elbow in Professional Baseball Pitchers: An 18-Year Study.

BACKGROUND: The Major League Baseball (MLB) draft is a common route for players to enter professional baseball in the United States. Players taken in earlier rounds are typically higher-performing players. When looking at pitchers specifically, higher performance at the amateur level may be associated with an increased frequency of adaptive change in the throwing elbow. PURPOSE: To determine whether pitchers taken in earlier rounds of the MLB draft have a greater frequency or extent of pathological change in the elbow, as measured by dynamic stress ultrasound. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Dynamic stress ultrasounds (SUSs) were performed over 18 years on the dominant and nondominant arms of 651 professional pitchers. The 383 drafted players were grouped according to the round in which they were drafted (rounds 1-5, 6-10, 11-20, 21+). Groups were compared with respect to "relative" ulnar collateral ligament (UCL) thickness (dominant-nondominant), relative ulnohumeral joint laxity (joint space distance under stress minus joint space at rest), and the presence of pathology (calcifications, tears, hypoechoic foci, osteophytes). In addition, a subgroup analysis was done to compare the progression of SUS findings over 3 years in players for which data were available. RESULTS: Draft round groups did not differ by age, number of previous spring training, or handedness. Comparing baseline measurements, there was no significant relationship between draft round and relative UCL thickness (P = .932), relative laxity (P = .996), or presence of pathology detectable on SUS (P = .642). However, increased relative UCL thickness was significantly associated with the presence of pathology on SUS (odds ratio, 1.45; 95% CI, 1.26-1.69; P < .001). Longitudinally, there was no significant relationship between draft round and 3-year progression of relative laxity, relative UCL thickness, or clinical progression of pathology. CONCLUSION: Higher-performing pitchers are drafted earlier in the MLB draft. This may be attributable to peak pitch velocity, in-game performance, visibility gained during player showcases, or any number of other sport-specific variables. However, despite this, there was no significant relationship between draft round and adaptive changes to the elbow or specific properties of the UCL on stress ultrasound.