AJR 2004; 182:944-946
© American Roentgen Ray Society
Optimal Positioning for MRI of the Distal Biceps Brachii Tendon: Flexed Abducted Supinated View
B. M. Giuffrè1 and
M. J. Moss
1 Both authors: Department of Diagnostic Radiology, Royal North Shore Hospital,
St. Leonards, NSW 2060, Australia.
Received August 8, 2003;
accepted after revision October 6, 2003.
Address correspondence to B. M. Giuffrè
(brunog{at}med.usyd.edu.au).
Introduction
The distal biceps brachii tendon is an uncommon site for tendon injury,
representing 3% of all injuries of the biceps brachii tendon in the literature
[1,
2]. There have been many
suggestions for optimally imaging the elbow using MRI
[38].
Axial imaging is often used, providing short-axis images of the tendon, to
accurately show the anatomy and disease of the distal biceps tendon. In many
circumstances, a long-axis image of the tendon is also useful. On direct
sagittal images with the elbow extended, the distal biceps brachii tendon
usually suffers from partial volume-average effects because of its oblique
course to its insertion. We describe a novel way of positioning the patient
with the shoulder abducted, elbow flexed, and forearm supinated. This allows
us to obtain images of the distal biceps brachii tendon from the
musculotendinous junction to its insertion, usually on a single image.
Materials and Methods
Imaging was performed on a 1.5-T MRI scanner (Signa Horizon LX, release
9.0, General Electric Medical Systems) with either the extremity coil or the
dedicated shoulder phased array coil. In general, it was preferable for the
patient to lie prone for these views. The shoulder was abducted 180°, with
the arm beside the head. The elbow was flexed to 90°, with the forearm
supinated, thumb up, and a shoulder phased array coil was placed around the
elbow (Fig. 1). The position is
referred to in this article as the flexed abducted supinated view, but usually
in our practice it is termed the "FABS view," meaning the flexed
elbow with the shoulder abducted and the forearm in supination view.

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Fig. 1. Photograph shows patient positioning for flexed abducted
supinated view: patient is positioned prone on MRI table with elbow in flexed
abducted supinated view position. Notice position of arm, flexed at elbow and
abducted at shoulder with supinated forearm, thumb up.
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We initially performed a three-plane localizer, with either three or five
images in the axial, sagittal, and coronal planes. The coronal localizer
images (sagittal elbow anatomy) were used to plan the sequences along the long
axis of the distal biceps brachii tendon (along the line of the tendon if it
is visible). If the tendon was not clearly seen on the localizer images, the
series was planned nearly perpendicular to the radius, which was always
clearly seen (Fig. 2). The
normal flexed abducted supinated view showed the full length of the tendon
(Fig. 3). Images in axial, and
in some cases sagittal, planes were then also obtained with the shoulder in
abduction and the elbow extended in the overhead position. It is also possible
to obtain the axial and sagittal images with the arm by the side. Series with
and without fat suppression were performed (proton density fast spin echo;
TR/TE, 3,000/34 or 45) along the axis of the tendon (elbow flexed) and axial
to the elbow joint (elbow extended). The field of view was 15 x 15 cm,
and the slice thickness was 3 or 4 mm with interslice spacing of zero. For the
flexed abducted supinated view, usually 18 slices were obtained with an
approximate examination time of 2 min 40 sec.

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Fig. 2. Localizer MR image with lines shows slice positioning for
flexed abducted supinated view. Notice sections, sagittal to long axis of body
but coronal to anatomy at elbow. Ideal angulation is planned along distal
biceps brachii tendon, but often, as here, this structure is not clearly
visible on localizer images. In this case, sections nearly perpendicular to
radius provide reasonable and reproducible imaging plane.
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Fig 3. 32-year-old healthy male volunteer. Proton
densityweighted MR image (TR/TE, 3,000/34) of normal flexed abducted
supinated view of distal biceps brachii tendon shows straight course of tendon
from musculotendinous junction to insertion and homogeneous low signal of
tendon. Large arrow = radial tuberosity, arrowheads = distal biceps tendon,
small arrow = musculotendinous junction.
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Results
The MR images were independently reviewed by two radiologists experienced
in musculoskeletal imaging. We have imaged, using the flexed abducted
supinated view, 21 symptomatic patients with possible distal biceps brachii
tendon problem. In one case, both elbows were symptomatic and were imaged.
These patients were 3281 years old (mean age, 52 years) and were imaged
over the period from May 2001 to May 2003. Six asymptomatic healthy male
volunteers (age range, 3148 years) were also imaged using both
traditional sagittal and flexed abducted supinated positions.
Three cases among 22 elbows in the study group exhibited normal distal
biceps brachii tendons; in 14 cases, evidence of a partial tear or tendinosis
of the distal biceps brachii tendon (Figs.
4 and
5) was present; in four cases,
a complete tear (Fig. 6) was
present; and in one case, an intact repaired complete tear was seen. In all
cases, the full length of the biceps brachii tendon from musculotendinous
junction to insertion on the radial tuberosity could be shown in one or, at
most, two sections. In the 13 cases in which sagittal series were also
performed, a single section less commonly (n = 8) showed the full
tendon in one or two sections.

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Fig. 4. 49-year-old man with partial tear of right distal biceps
brachii tendon. Proton densityweighted MR image (TR/TE, 3,000/34) of
flexed abducted supinated view of partial tendon tear shows linear abnormal
signal adjacent to intact tendon extending from insertion to mid part of
tendon and blurring of fat adjacent to tendon. Arrowheads = linear abnormal
signal in distal tendon.
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Fig. 5. 53-year-old man with partial tear of right distal biceps
brachii tendon. Proton density fat-suppressed MR image (TR/TE, 3,000/45) shows
flexed abducted supinated view with partial tear and fluid around tendon.
Arrow = abnormal signal of partial tear, arrowheads = fluid around distal
tendon.
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Fig. 6. 49-year-old man with complete tear of left distal biceps
brachii tendon. Proton densityweighted MR image (TR/TE, 3,000/34) of
flexed abducted supinated view of complete tendon tear shows discontinuity of
tendon and abnormally thickened proximal part of tendon. Arrows = gap as
result of complete tear, arrowheads = thickened remaining distal biceps
brachii tendon.
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In four of these six asymptomatic volunteer evaluations, the flexed
abducted supinated view showed the complete length of the tendon in one
section; in the other two cases, it was seen in two sections. In the sagittal
series of the healthy volunteers, the full tendon was seen in one section in
only two cases.
Discussion
The distal biceps brachii tendon commences on the ventral surface of the
muscle belly, approximately 5 cm above the elbow, and inserts on the radial
tuberosity. The tendon is a flattened cord approximately 10 cm in length that
rotates as it approaches its insertion, the ventral surface turning to lie on
the radial side. The course is oblique, both superficialdeep and
ulnarradial. An aponeurotic extension, the bicipital aponeurosis,
extends medially from the musculotendinous junction to blend with the deep
fascia over the pronator teres muscle belly.
Complete rupture is often an avulsion from the radial attachment and is
often clinically evident. The differentiation of complete tears from partial
tears is sometimes confusing clinically, particularly if the lacertus fibrosis
remains intact. The treatment of complete tears without retraction or partial
tears can benefit from precise delineation of the extent of the abnormality
[3,
7]. MRI of distal biceps
brachii tendon tears has been described in several articles
[3,
7,
8].
MRI of the distal biceps brachii tendon is often difficult because of the
anatomic course of the tendon close to its insertion. Studies have described
several different methods of patient positioning for optimally imaging the
elbow using MRI
[38].
The patient is usually most comfortable supine with the arms by the sides. The
off-axis position of the arm makes fat suppression poor with resultant
variable signal homogeneity. Problems also occur with obese or large-framed
patients in whom difficulty fitting the coil and patient into the confined
space of the magnet bore is experienced. One alternative described involves
positioning the patient supine or prone with the arm outstretched above the
head, elbow extended, and forearm supinated
[4]. The signal strength and
homogeneity are superior in this overhead position.
Sagittal images through the distal biceps brachii tendon may be difficult
to interpret because of partial volume-averaging effects due to the oblique
course of the tendon to its insertion.
Flexion of the elbow is associated with contraction of the biceps muscle
belly, and the tendon is taut. With the forearm supinated, the radial
tuberosity is directed medially and with the elbow flexed, the distal tendon
is in an almost direct line from the muscle belly to its insertion. The flexed
abducted supinated view successfully achieves a longitudinal view of the
distal biceps brachii tendon often in one section, including the
difficult-to-assess insertion on the radial tuberosity. Because the tendon is
assessed longitudinally and is at full length, the differentiation of partial
from complete tears is made easier. The position of the elbow near the center
of the magnet makes fat suppression optimal, enhancing visualization of small
amounts of fluid.
The traditional axial image of the distal biceps brachii tendon is also a
valuable means of assessing this structure. Aside from providing a short-axis
image of the tendon, the axial series provides a familiar view of the
important associated structures such as the median and radial nerves at the
elbow.
In conclusion, the flexed abducted supinated view provides a reproducible
technique for MRI of the distal biceps brachii tendon, obtaining a
longitudinal image of the tendon from the musculotendinous junction to its
insertion, often in one section.
Acknowledgments
We thank David Connell for his inspiration for this positioning and Sandy
Huggett, radiographic technologist, Royal North Shore Hospital and Tim
McLellan, radiographic technologist, North Shore Radiology, for their
assistance with this work.
References
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Magn Reson Imaging Clin N Am1997; 5:439
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