Elbow - Anterior View
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Classification
Case code:
GM-ANT-L-A1129
Joint:
Elbow
View:
Anterior
Severity:
Mild
Patient
Age:
64 years
Sex:
Male
Condition:
Extension -5° (lacks 5° full extension), Flexion 140° (slightly reduced)
Joint ROM:
Extension -5° (lacks 5° full extension), Flexion 140° (slightly reduced)
History
Patient diagnosed with moderate hemophilia A at age 6 following prolonged bleeding after tonsillectomy. Grew up in era of limited factor availability (1960s-70s), receiving cryoprecipitate and fresh frozen plasma on-demand only. Right elbow experienced first hemarthrosis at age 12 during recreational baseball, subsequently had approximately 4-5 episodes during adolescence and early adulthood. Started prophylaxis at age 52 when recombinant products became more accessible (FVIII 2000 IU twice weekly). Over past 12 years on prophylaxis, has experienced only 2 breakthrough elbow bleeds, both minor and trauma-related. Most recent episode 18 months ago, resolved quickly with factor replacement and rest. Reports occasional mild elbow stiffness in morning (resolves within 10-15 minutes) and slight discomfort after prolonged activities requiring repetitive elbow flexion-extension. Currently retired from career as electrical engineer. Maintains active lifestyle with golf twice weekly and woodworking hobby.
Physical Examination
Elbow inspection shows no obvious swelling or deformity. Very subtle fullness may be appreciated over anterior joint line with experienced palpation. No erythema or warmth. Minimal tenderness on deep palpation of anterior recess area. Range of motion mildly reduced: lacks 5° of full extension (stops at -5° rather than 0°), achieves 140° flexion (normal 145-150°), with mild sense of anterior tightness at extremes of motion. Supination and pronation fully preserved (85° and 80° respectively). No crepitus during movement. Muscle strength intact with 5/5 throughout. Carrying angle appears normal (approximately 10° valgus). Ligamentous stability testing normal. No cubital tunnel symptoms. Functional activities well-preserved: able to bring hand to mouth, reach overhead, and perform all activities of daily living without significant limitation. Mild discomfort noted only during terminal extension against resistance.
Ultrasound Findings
Ultrasound examination in anterior view reveals early changes:
- Anterior joint capsule: mild thickening (2.5mm)
- Anterior recess: minimal synovial proliferation, trace effusion
- Coronoid fossa: early subtle irregularity
- Radial head cartilage: minimal surface irregularities
- Capitellum: early changes with focal surface alteration
- Mild synovial thickening with minimal hyperemia
- Bony surfaces: minimal cortical irregularity
- No significant osteophytes or erosions
- Brachialis muscle: normal appearance
Anatomical Zones
Anterior humeral recess
The anterior recess demonstrates early pathological changes consistent with mild hemophilic arthropathy, showing initial synovial proliferation and subtle articular surface alterations from recurrent low-grade hemorrhagic insults over decades.
Synovial thickness and effusion:
2.6mm synovial thickening; trace effusion (2mm)
Findings:
The anterior recess of the elbow joint shows mild pathological alterations indicating early hemophilic involvement. The synovial membrane demonstrates mild thickening measuring 2.6mm (normal <1mm), appearing as a hypoechoic band lining the anterior joint capsule and extending into the coronoid and radial fossae. The synovial echostructure is slightly heterogeneous with focal areas of increased echogenicity suggesting early hemosiderin deposition. A small amount of anechoic fluid (approximately 2mm in anterior-posterior dimension) is visible within the anterior recess, representing trace joint effusion without significant internal echoes. The coronoid fossa demonstrates subtle irregularity of its normally smooth concave contour, with minimal undulation (2-3 areas of 0.5-1mm irregularity) of the hyperechoic bony surface representing early erosive alterations. The articular cartilage of the trochlea shows relative preservation of thickness (1.2-1.4mm) but demonstrates focal areas of surface irregularity, particularly in the central portion, measuring approximately 3x2mm where the normally smooth interface shows slight waviness. The capitellar articular surface shows early changes with a focal area (4x2mm) of slight cartilage surface irregularity in the anterior weight-bearing zone. The underlying subchondral bone maintains relatively intact cortical lines, though close inspection reveals 2-3 very small areas (0.5mm) of minimal cortical discontinuity. Two small hyperechoic foci (approximately 1mm each) are visible within the anterior recess, possibly representing hemosiderin deposits or tiny debris particles. The anterior fat pad shows mild anterior displacement but maintains normal hyperechoic adipose echostructure. The anterior joint capsule demonstrates mild thickening (2.5mm versus expected <2mm) with slightly heterogeneous fibrous architecture. Color Doppler examination reveals mild increase in synovial vascularity with 2-3 small vessels (0.3-0.5mm diameter) penetrating the synovial membrane, indicating low-grade inflammatory activity. Power Doppler confirms minimal flow within the thickened synovium. Dynamic examination during passive elbow flexion-extension demonstrates relatively normal opening and closing mechanics, though the synovial tissue appears slightly less mobile with subtle restriction of normal folding patterns.
Direct Comparison
Compare this case with reference cases of different severity grades for in-depth analysis.
Cases available for comparison: 3 of 3 possible
Additional Notes
This case represents early-stage hemophilic arthropathy of the elbow with mild alterations that remain largely subclinical. The patient's late start of prophylaxis (age 52) after decades of on-demand treatment likely contributed to these early changes, though the relatively infrequent bleeding history has resulted in milder disease than often seen in severe hemophilia. Current management includes continuation of prophylaxis with consideration for increasing frequency to three times weekly. Physical therapy prescribed focusing on elbow range of motion exercises, particularly terminal extension stretching to address the 5° extension deficit, and strengthening of biceps-triceps complex. Patient educated on activity modification: avoid high-impact activities or repetitive heavy lifting, use proper body mechanics for workshop activities, maintain golf swing with attention to elbow positioning. Close monitoring with repeat ultrasound in 6 months recommended to assess for stabilization versus progression. Prognosis is good with appropriate prophylaxis adherence and joint protection. This case demonstrates ultrasound's value in detecting early subclinical changes before significant functional impairment, allowing intervention when disease modification may still be possible.