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

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Intraarticular Injections

PROTOCOL

• Confirm the indication (history, imaging)• Consent & Complications• Sterile Conditions• Aftercare instructions (rehabilitation)• Follow up (pain diaries-VAS scores)

• Checklist

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Intraarticular Injections

SHOULDERGlenohumeral Joint

Anterior & Posterior Approach

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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

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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

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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

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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