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Distal Biceps Tendon and Bicipitoradial Bursa Injection

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Other Names

Anatomy of the cubital fossa. Note the relationship between the distal biceps tendon, bursa, and the adjacent neurovascular structures.[1]
Diagram shows the position of the bicipitoradial bursa during pronation and supination. With pronation, the interval between the radius and ulna is decreased, resulting in increased intrabursal pressure.[1]
  • Distal Biceps Tendon Injection
  • Bicipitoradial Bursa Injection
  • Distal Biceps Tendon Aspiration
  • Bicipitoradial Bursa Aspiration

Background

  • This page refers to Distal Biceps Tendon and Bicipitoradial Bursa Injection and Aspiration

Key Points

  • A high frequency, linear array transducer is recommended
  • A posterior approach is recommended (described below)
  • It is critical to identify the regional neurovascular structures during pre-procedure ultrasound
  • Do not inject into the tendon
  • Aspiration approach will vary based on size and location of the bursa, neurovascular structures

Anatomy

  • Cubital Fossa
  • Distal Biceps Tendon
    • Courses laterally and deep to insert on the radial tuberosity if the proximal radius
  • Bicipitoradial Bursa
    • Located between the distal biceps tendon anteriorly, radial tuberosity posteriorly[2]
    • Purpose is to decrease friction between distal tendon, proximal radius during pronation/ supination

Palpation vs Ultrasound Guidance

  • To date, there are no studies comparing ultrasound-guided and palpation-guided approaches
  • Because of the deep location, proximity to important neurovascular structures, imaging guidance is recommended

Indications


Contraindications

Absolute

  • Tendon tear or rupture
  • Anaphylaxis to injectates
  • Overlying cellulitis, skin lesion or systemic infection

Relative

  • Can be treated with less invasive means
  • Hyperglycemia or poorly controlled diabetes
  • Lack of symptom improvement with previous injection

Procedure

Patient supine, arm flexed at the elbow, forearm hyperpronated. The transducer is positioned in the short-axis plane on the posterior forearm. Approach is radial to ulnar, in plane with the transducer.[1]
Ultrasound image of the distal biceps tendon attachment to the radius (R) using the posterior approach. The forearm is hyperpronated to bring the tendon out from the posterior acoustic shadow of the ulna (U). The overlying supinator (S) and anconeus (A) are seen. The arrow identifies the target of the peritendinous injection, just superficial to the tendon in the vicinity of the interosseous space.[1]
Ultrasound findings typical of bicipitoradial bursitis. The encysted fluid with echoes and septations around the distal biceps tendon. Note the neurovascular structures are marked but not labeled[3]

Equipment

  • Sterile including chloraprep, chlorhexadine, iodine
  • Ultrasound with sterile probe cover
  • Gloves
  • Needle: typically 21-25 gauge, 1.5 inch
  • Syringe: 5-10 mL
  • Gauze
  • Ethyl Chloride
  • Bandage
  • Injectate
    • Local anesthetic
    • Corticosteroid/ injectate

Ultrasound Findings

  • Transducer: High Frequency, Linear
  • Identify
    • Distal biceps tendon
    • Proximal neurovscular structures
  • View
    • Posterior view is best procedurally but provides limited diagnostic utility
    • Lateral and medial approaches provide excellent diagnostic information but are more limited procedurally because neurovascular structures are in the needle trajectory[4][5]
  • Common ultrasound findings for tendon:
    • Typical for tendinosis (hypoechogenicity, focal thickening, calcification, neovascularity, etc).
    • Important to distinguish from rupture as that would more likely benefit from surgical consultation
  • Common ultrasound findings for bicipitoradial bursa:
    • Regular walls containing anechoic fluid or a mix of anechoic fluid[6]
    • Hypoechoic septae and debris
    • Dystrophic calcification has also been rported[7]

Ultrasound Guided: Short Axis, In-Plane

  • Patient Position
    • Patient is supine, arm flexed at elbow and forearm is hyperpronated
  • Probe Position and Needle Orientation (see image)
    • Short axis plane on the forearm (3-4 cm distal to olecranon)
    • Needle orientation is in plane
    • Approach is radial to ulnar
  • Target
    • Peritendinous placement: just superficial to the tendon, between tendon and supinator muscle. Injectate placed near interosseous space
    • Bicipitoradial bursa: advance through tendon, place deep between distal biceps tendon and radius
  • Pearls and Pitfalls
    • Identify neurovascular structures during pre-procedural planning
    • For peritendinous injections, superficial placement is adequate and avoids advancing needle through tendon
    • Contents of bursa are often viscous and require a large gauge needle for aspiration
    • There is no single, reliable technique for aspiration of the bursa given all the variations in relationship to the neurovascular structures

Aftercare

  • No major restrictions in most cases
  • Can augment with ice, NSAIDS

Complications

  • Skin: Subcutaneus fat atrophy, skin atrophy, skin depigmentation
  • Painful local reaction
  • Infection
  • Hyperglycmia
  • Tendon, nerve or blood vessel injury
  • Tendon rupture
    • Frequency unknown
    • Using ultrasound guidance, the tendon should never be injected

See Also


References

  1. 1.0 1.1 1.2 1.3 Malanga, Gerard, and Kenneth Mautner. Atlas of ultrasound-guided musculoskeletal injections. McGraw-Hill, 2014.
  2. Kannangara S, et al. Scintigraphy of cubital bursitis. Clin Nucl Med. 2002;27(5):348–350.
  3. Case courtesy of Maulik S Patel, Radiopaedia.org, rID: 48835
  4. Kalume Brigido M, et al. Improved visualization of the radial insertion of the biceps tendon at ultrasound with a lateral approach. Eur Radiol. 2009;19(7):1817–1821
  5. Smith J, et al. Sonographic evaluation of the distal biceps tendon using a medial approach: the pronator window. J Ultrasound Med. 2010;29(5):861–865.
  6. Liessi G, et al. The US, CT and MR findings of cubital bursitis: a report of five cases. Skeletal Radiol. 1996;25(5):471–475.
  7. Skaf AY, et al. Bicipitoradial bursitis: MR imaging findings in eight patients and anatomic data from contrast material opacification of bursae followed by routine radiography and MR imaging in cadavers. Radiology. 1999;212(1):111–116.
Created by:
John Kiel on 5 September 2023 14:26:08
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Last edited:
9 September 2023 15:12:11
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