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Normal Elbow MRI Report Template
Normal elbow MRI report template: marrow and capitellum, collateral ligaments, common extensor and flexor origins, distal biceps and triceps, ulnar nerve in the cubital tunnel, with notes on UCL tear grading, OCD and biceps tear wording.
EXAMINATION: MRI [right/left] elbow without intravenous contrast. CLINICAL HISTORY: [indication, e.g. “Elbow pain”] COMPARISON: None available. TECHNIQUE: Multiplanar, multisequence MR imaging of the [right/left] elbow without intravenous contrast. FINDINGS: Bones and marrow: Normal marrow signal in the distal humerus, proximal radius and proximal ulna. No fracture, stress reaction or marrow edema. The capitellum is normal with no osteochondral lesion. Articular cartilage: Preserved at the radiocapitellar and ulnotrochlear joints. No loose body. Ligaments: Ulnar collateral ligament: The anterior bundle is intact from the medial epicondyle to the sublime tubercle, with normal thickness and signal. Lateral collateral ligament complex: The radial collateral ligament, lateral ulnar collateral ligament and annular ligament are intact. Tendons: Common extensor origin: Intact, with normal signal at the lateral epicondyle. Common flexor origin: Intact, with normal signal at the medial epicondyle. Distal biceps: The distal biceps tendon is intact to its insertion on the radial tuberosity, with normal caliber and signal. The lacertus fibrosus is intact. No bicipitoradial bursitis. Triceps: Intact to its insertion on the olecranon. Brachialis: Intact. Nerves: The ulnar nerve is normal in caliber and signal within the cubital tunnel, with no subluxation or mass. The median and radial nerves are unremarkable. Joint: No significant joint effusion or synovitis. No plica. Bursae: No olecranon bursitis. Soft tissues: Unremarkable. No mass. IMPRESSION: 1. Normal MRI of the [right/left] elbow. No ligament or tendon tear, osteochondral lesion or occult fracture.
Dictation notes
- UCL tears are reported by location (proximal, midsubstance, distal at the sublime tubercle) and grade (sprain, partial thickness undersurface tear with the “T sign” on arthrography, complete) — in a thrower the distal partial tear is the one that goes to reconstruction.
- A capitellar osteochondral lesion is described by size, cartilage integrity, fluid undercutting and fragment displacement — stability is the decision point, and it is paired with the radial head for a loose body search.
- Distal biceps tears are complete or partial, retracted or not, with the gap measured and the lacertus fibrosus named (an intact lacertus limits retraction and can mask the clinical deformity).
- Lateral epicondylitis has a grading language: tendinosis (signal without a defect), partial thickness tear and full thickness tear with retraction — pair it with the lateral ulnar collateral ligament, which is injured in a quarter of the surgical cases.
- Check the ulnar nerve on every axial image from the arcade of Struthers to the flexor carpi ulnaris; nerve enlargement with T2 signal change, an anconeus epitrochlearis or subluxation at the cubital tunnel is a report-level finding.
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