US guided intra-articular injection technique in the upper extremity: shoulder, elbow, wrist
Elena Drakonaki MD, PhD, PostDocConsultant MSK Radiologist
Heraklion, Greece & Oxford, UK
www.drakonaki.gr
AdvantagesSoft tissue & joint interventionReal time multiplanar imagingNo radiationCheap, practical & widely available
LimitationsLong learning curveSpinal intervention
Fluoroscopy & CT
no soft tissueradiation burden
no real time imagingradiation burden
Ultrasonography
Why US?
AdvantagesSoft tissue & joint interventionReal time multiplanar imagingNo radiationCheap, practical & widely available
Ultrasonography
LimitationsLong learning curveSpinal intervention
AdvantagesSoft tissue & joint interventionReal time multiplanar imagingNo radiationCheap, practical & widely available
Ultrasonography
www.drakonaki.grIntraarticular Injections: What’s the purpose?
Diagnostic Procedures
• Contrast Media injection for MR/CT Arthrography• Diagnostic Injections for Pain management• Biopsy-Aspiration
Therapeutic Procedures
• Intraarticular Injection of substances (hylouronic, steroid, anesthetic)
• Hydrodilation for adhesive capsulitis• Synovial Biopsy for inflammatory arthritis
TOPICS
• US-guided techniques: mainstream clinical practice
• Novel US techniques: potential applications
Fusion imaging
www.drakonaki.grIntraarticular Injections
Shoulder, Elbow, Wrist, Fingers
OFFICE-BASED SET UP• High resolution US systems• High frequency (6-18MHz) linear probes• Ergonomic probes• Ergonomic set up for patient positioning• Trained nurse/helper• First Aid Equipment
www.drakonaki.gr
Intraarticular Injections
PROTOCOL
• Confirm the indication (history, imaging)• Consent & Complications• Sterile Conditions• Aftercare instructions (rehabilitation)• Follow up (pain diaries-VAS scores)
• Checklist
www.drakonaki.gr
Intraarticular Injections
SHOULDERGlenohumeral Joint
Anterior & Posterior Approach
www.drakonaki.gr
SHOULDERwww.drakonaki.gr
Glenohumeral Joint
Anterior & Posterior Approach
Through Infraspinatus:
• Virtual convex on a linear array probe. • Needle at a steep angle (70-80 degreesparallel to the transducer
• Local anesthetic as the needle is advanced. • The syringe is changed(local anesthetic/corticosteroid) • Technically demanding(only needle tip artifact due to steepness).
0.8 × 50-mm bevelled needle (21-gauge) without a stylet.or 1.2 mm × 88.9-mm spinal needle (18-gauge, 3.5 inch)
SHOULDERwww.drakonaki.gr
Glenohumeral Joint
Anterior & Posterior Approach
• supine - shoulder slightly externally rotated• needle inserted at the level of the coracoid, • from lateral to medial towards medial border humeral head • Fluid flows through subscapular recess into joint space.
0.8 × 50-mm bevelled needle (21-gauge) without a stylet.or 1.2 mm × 88.9-mm spinal needle (18-gauge, 3.5 inch)
SHOULDERwww.drakonaki.gr
Glenohumeral Joint
Anterior & Posterior Approach
US-guided injections and especially the anterior approach are:
•less time consuming, USa approach (1:34 min)
•more successful on the first attempt: US (94%) fluoroscopy (72%)•cause less patient discomfort•obviate the need for radiation and iodine contrast.
Rutten et al, Eur Radiol 2009 Perdikakis E, Drakonaki E, et al, Skeletal Radiol. 2013
SHOULDERwww.drakonaki.gr
Hydrodilatation for Frozen Shoulder (capsulitis)
Park et al, Arch Phys Med Rehabil 2013Watson, Br J Sports Med 2007
20-40 mls saline\+/- steroid
Or
Hyaluronic acid
Break the adhesions and distend/break the capsuleImprovement in ROM, function, pain (2 y)
www.drakonaki.gr
Two ways: from the side or from the front
Allen, Drakonaki, Maybury, WilsonDigital book www.stlukesradiology.org.uk
SHOULDER
AcromioClavicular Joint
www.drakonaki.gr
Widest area is anterior superior23G blue needles (shallow course)
<2 mls in the joint
Allen, Drakonaki, Maybury, WilsonDigital book www.stlukesradiology.org.uk
SHOULDER
AcromioClavicular Joint
www.drakonaki.gr
Peck f et al, PMR 2010
Peri-articular or Intra-articular?Both effective in the short termIntraarticular is more effective during the crossover arm test at 3 weeks
Sabeti-Aschraf et al, Arthroscopy 2013
Guided or Blind Injections in ACJ?Cadaveric study, Accuracy: 100% for US, 40% for palpation
Sabeti-Aschraf et al, Knee Surg Sports Traumatol Arthrosc 2011
SHOULDER
AcromioClavicular Joint
SHOULDER
SternoClavicular jointwww.drakonaki.gr
23G blue needles (shallow course)
ElbowPosterior approach
www.drakonaki.gr
passing adjacent to the triceps tendon through the posterior fat pad and into the olecranon fossa of the humerus
Van Wagenberg Skeletal Radiol. 2013
The posterior transtriceps approach for intra-articular elbow diagnostics, definitely not forgotten.
ElbowLateral or Medial approach
www.drakonaki.gr
Risk of puncturing the collateral ligaments
Wrist Joint www.drakonaki.gr
• wrist on a rolled up towel • ulnar deviation or traction to open the joint• subcutaneous infiltration with lidocaine• 1–2cm distal to the Lister’s tubercle• between the II-III, III-IV compartment•The needle parallel to the probe
Distal Radioulnar Joint www.drakonaki.gr
transducer is axially positioned over the distal radius -ulna.23-25-G needle inserted short axis of the transducerdirected from proximally to distally 0.5-1 mL is injected
1st MTP
1st MCP
Τrapeziometacarpal Joint (rhizarthrosis)
MCPs, Interphalangeal jointswww.drakonaki.gr
Dorsal approachIn-plane OR out-of-plane 23-25-G Bend the needlefootprint transducer0.5-1 mL is injected
Fusion imaging: a new dimensionwww.drakonaki.gr
Summary
US-guided MSK intervention www.drakonaki.gr
Diagnostic and Therapeutic Intra-articular injections
Alternative to procedures otherwise performed under fluoro
Sterile conditions, in- OR out- of-plane technique, linear/hockey stick probe
Contribution of novel US technology is under investigation
www.drakonaki.grUS-guided MSK intervention
Thank you