AJR 2004; 183:51-53
© American Roentgen Ray Society
Sonography of Cubital Bursitis
Carolyn M. Sofka1 and
Ronald S. Adler
1 Both authors: Department of Radiology and Imaging, Hospital for Special
Surgery, 535 E 70th St., New York, NY 10021.
Received November 5, 2003;
accepted after revision January 21, 2004.
Address correspondence to C. M. Sofka
(sofkac{at}hss.edu).
Abstract
OBJECTIVE. The purpose of our study was to describe the sonographic
appearance of cubital bursitis in three patients and to illustrate the use of
sonographic guidance for therapeutic injections.
CONCLUSION. Cubital bursitis, a rare but painful condition of the
elbow, can be diagnosed with sonography. Cubital bursitis is seen as
distention of the bicipitoradial bursa in the proximal forearm, occasionally
with fluid or complex synovial debris in more severe cases. Power Doppler
imaging can aid in providing information about active inflammation. Two
patients in our series were treated using sonographically guided decompression
of the bursa and steroid injection with good clinical results.
Introduction
Few cases of cubital bursitis, a painful swelling of the bicipitoradial
bursa, have been reported in the literature
[1–4].
Most are isolated case reports of the condition with painful swelling in the
antecubital fossa
[1–3].
These reports used conventional radiography, CT, and nuclear medicine bone
scanning for diagnosis. The largest reported series in the radiology
literature by Liessi et al. [4]
describes five cases of the condition, with multimethod imaging including
conventional radiography, CT, MRI, and sonography. Their report described
enlargement of the bicipitoradial bursa on sonography with regular walls
containing anechoic or mildly complex hypoechoic fluid with internal septa,
and increased vascularity was noted on conventional color Doppler imaging in
some cases [4]. Our study is
the only report, to our knowledge, that describes not only the sonographic
appearance of cubital bursitis using new high-frequency transducers, but also
the usefulness of power Doppler imaging in suggesting the presence of active
inflammation, as well as the treatment of this condition using sonographic
guidance.
We reviewed our sonography database and found four cases of cubital
bursitis in three patients (one was a return visit), presenting as painful
swelling of the antecubital fossa, three of which were treated with
sonographically guided decompression and injection. We present an update on
the diagnosis of the condition with sonography, using power Doppler imaging
for supplemental diagnostic information as to the degree of inflammation. We
also present a new treatment option for cubital bursitis using sonographically
guided decompression to decrease symptoms of swelling and pain and to prevent
further distention of the bursa, which may lead to nerve compression.
Materials and Methods
Our institutional review board approved this study. We reviewed our
sonography database and found three patients (one man and two women; age
range, 25–71) with cubital bursitis, two of whom were treated with
sonographically guided decompression and injection
(Table 1). All patients
presented with pain and swelling in the antecubital fossa; no patient had
clinically detectable median nerve symptoms.
Scans were performed using either a medium- or high-frequency (7.5 or 12
MHz, respectively) linear transducer on a Sonoline Elegra sonography unit
(Siemens). Patients were imaged with the elbow fully extended and the
transducer placed over the ventral margin of the antecubital fossa. Two
patients had MRI correlation; both of these MRI examinations were performed
before sonography.
Results
On sonography, cubital bursitis is seen as a variable degree of distention
of the bicipitoradial bursa by fluid or hypoechoic soft tissue (Fig.
1A,
1B,
1C,
1D). In all our patients the
distal biceps tendon was intact. Fluid, occasionally with nodular soft-tissue
debris and small calcifications, was seen distending the bicipitoradial bursa.
Power Doppler imaging suggested active inflammation; moderate to marked
hyperemia was seen on power Doppler imaging in the three cases presented here
(Fig. 2A,
2B).
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Fig. 1A. —34-year-old man with cubital bursitis. Longitudinal
(A) and short-axis (B) sonograms of bicipitoradial bursitis
shows hypoechoic fluid distention of bursa insinuating around and superficial
to biceps tendon (arrows).
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Fig. 1B. —34-year-old man with cubital bursitis. Longitudinal
(A) and short-axis (B) sonograms of bicipitoradial bursitis
shows hypoechoic fluid distention of bursa insinuating around and superficial
to biceps tendon (arrows).
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Fig. 1C. —34-year-old man with cubital bursitis. Axial fast spin-echo
MR image shows high-signal-intensity material distending bicipitoradial bursa
(large arrow). Note relationship between fluid and biceps tendon
(small arrow).
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Fig. 1D. —34-year-old man with cubital bursitis. Short-axis sonogram
shows sonographically guided aspiration and injection of bicipitoradial bursa.
Note needle tip (arrow) in hypoechoic material distending bursa and
characteristic reverberation artifact from needle.
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Fig. 2A. —25-year-old woman with juvenile chronic arthritis.
Longitudinal sonogram shows marked distention of bicipitoradial bursa with
mixed anechoic and hypoechoic material containing low-level echoes
(arrow).
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In two patients, sonographically guided decompression of the bursae was
performed using a 22-gauge spinal needle (Fig.
1A,
1B,
1C,
1D). For the procedures, the
elbow was extended and the antecubital fossa was cleaned with a standard
iodine-based solution. For local anesthesia, 1% lidocaine (Xylocaine, Abbot
Laboratories) was used, and the spinal needle was advanced into the bursa
under sonographic guidance (Fig.
1A,
1B,
1C,
1D). After the synovial fluid
was aspirated, 2 mL of a mixture of 25%, 1% lidocaine; 25%, 0.5% bupivacaine
(Sensorcaine, Astra Pharmaceuticals); and 50% triamcinolone ([40 mg/mL]
Kenalog, Apothecon) was injected into the bursal sac.
Discussion
Reported cases of cubital bursitis are sparse in the literature. The
bicipitoradial or cubital bursa is located between the distal biceps tendon
and the radial tuberosity, tracking along the medial cortex of the radius and
wrapping around the distal biceps tendon
[2]. Anatomic studies have
shown two bursae in the anterior margin of the elbow: the interosseous medial
bursa, which, when enlarged, may compress the median nerve, and the
bicipitoradial bursa, which can cause compression on the posterior
interosseous nerve [5].
Communication may occur between these two bursae
[5]. Most often, bursitis
occurs from repetitive mechanical trauma with recurrent pronation and
supination [1].
Karanjia and Stiles [1]
reported two cases of the condition, and in their report they quoted only one
previously reported case in 1952. In both cases described by Karanjia and
Stiles, the patient presented with painful swelling in the proximal forearm
that increased with pronation. In one of the cases reported in this series,
the patient had paresthesia in the middle and index fingers. Both of these
patients were examined radiographically with only conventional radiographs,
which showed "roughening" of the bicipital radial tuberosity in
one patient and faint calcifications near the bicipital tuberosity in the
second patient.
We found in our patients occasional scattered foci of calcification in the
bursa. Dystrophic calcification was found in the resected bursa in both cases
presented by Karanjia and Stiles
[1]. This finding is similar to
the case reported by Matsumoto et al.
[3], in which synovial
chondromatosis was diagnosed at histologic inspection of the resected
bicipitoradial bursa.
In the case reported by Kannangara et al.
[2], the patient presented with
painful swelling in the antecubital fossa that increased on pronation. CT
showed a rim-enhancing mass adjacent to the radial insertion, and scintigraphy
showed marked hyperemia and delayed radiotracer uptake extending between the
proximal radius and ulna [2].
In the series of five cases in which Liessi et al.
[4] show the sonographic
appearance of cubital bursitis with CT and MRI correlation, sonography showed
either anechoic fluid or hypoechoic distention with thin internal septa of the
bicipitoradial bursa. We found in many areas of the musculoskeletal system, as
in the cases of cubital bursitis reported here, that power Doppler imaging can
correlate with patient symptoms and suggest areas of inflammation, thus
directing appropriate therapy. The hyperemia noted on scintigraphy likely
corresponds to the marked inflammation observed in such cases of cubital
bursitis [2]. Power Doppler
imaging allows a noninvasive method of determining increased vascularity and
inflammation. In all our cases, moderate to marked hyperemia was seen around
the bursae.
In conclusion, sonography can be used to evaluate patients with swelling in
the proximal forearm for cubital bursitis. We propose that knowledge of the
regional anatomy and an understanding of the typical sonographic appearance of
cubital bursitis—hypoechoic distention of the space between the distal
biceps tendon and radial tuberosity—are satisfactory for diagnosis and
that no additional imaging such as MRI or CT is required. Therapeutic
aspiration and injection of the bursa can be performed at the same time as the
diagnostic examination, with pain relief and safe decompression of the bursa,
using sonography to guide the needle and avoid regional neurovascular
structures.
References
- Karanjia ND, Stiles PJ. Cubital bursitis. J Bone Joint
Surg Br 1988;70:832
–833
- Kannangara S, Munidasa D, Kross J, van der Wall H. Scintigraphy of
cubital bursitis. Clin Nucl Med2002; 27:348
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- Matsumoto K, Hukuda S, Fujita M, Kakimoto A, Tachibana S. Cubital
bursitis caused by localized synovial chondromatosis of the elbow.
J Bone Joint Surg Am1996; 78:275
–277[Free Full Text]
- Liessi G, Cesari S, Spaliviero B, Dell'Antonio C, Avventi P. The
ultrasound, CT and MR findings of cubital bursitis: a report of five cases.
Skeletal Radiol1996; 25:471
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- Spinner RJ, Lins RE, Collins AJ, Spinner M. Posterior interosseous
nerve compression due to an enlarged bicipital bursa confirmed by MRI.
J Hand Surg Br1993; 18:753
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Abstract
Introduction
