Ultrasound Guided
Joint Injections
- •
Most injections can be accomplished using a high-frequency linear ultrasound transducer.
- •
Ultrasound allows evaluation of the three elbow articulations (radiocapitellar, ulnotrochlear, and proximal radioulnar).
- •
Imaging of the posterior olecranon recess with the elbow in flexion is the most sensitive means to identify pathologic fluid.
Pertinent Anatomy
- •
The elbow joint is a synovial hinged joint consisting of an articulation between the humerus, radius, and ulna.
- •
The joint allows flexion at the elbow and forearm supination and pronation.
- •
The joint can be accessed from a medial, lateral, anterior, or posterior approach ( Fig. 17.1 ).
Fig. 17.1
(A and B) Illustration of pertinent bony and soft tissue anatomy anatomy of the elbow demonstrating lateral and posterior views.
Common Pathology
- •
Three primary patterns of arthritis can affect the elbow joint: rheumatoid (inflammatory), post-traumatic, and primary osteoarthritis. Intra-articular pathology can present with a joint effusion, synovitis, and associated intra-articular bodies.
- •
Stiffness, restriction of elbow extension, and painful mechanical symptoms are common symptoms associated with arthritis. Pain is typically deep or diffuse, and may present without any palpable tenderness.
Equipment
- •
Needle size: 25- or 27-gauge 1- or 1.5-inch needle.
- •
High-frequency linear ultrasound transducer.
Common Injectates
- •
Local anesthetics for diagnostics, corticosteroids.
- •
Prolotherapy, orthobiologics (platelet-rich plasma [PRP] bone marrow concentrate, etc.).
Injectate Volume
- •
2 to 3 mL
Technique: Lateral Approach
Patient Position
- •
Seated or supine.
- •
Elbow is flexed 40 degrees and the forearm is pronated with palm resting on the table ( Fig. 17.2 ).
Fig. 17.2
Intra-articular injection of the radiocapitellar joint using a 27-gauge needle. (A) Elbow position, transducer position, and needle position for the in-plane approach. (B) Ultrasound shows the needle trajectory (open arrow) . (C) Elbow position, transducer position, and needle position for the out-of-plane approach for entry into the lateral elbow joint. (D) Elbow position, transducer position, and needle position for the in-plane approach for entry into the lateral elbow joint. (D) Ultrasound shows the needle out-of-plane in the joint space ( open arrow ). Dashed circles indicate needle trajectory. Solid white arrow identify the needle trajectory.
Clinician Position
- •
Seated or standing directly next to the elbow being injected.
Transducer Orientation
- •
Long-axis to the radius over the radiocapitellar joint.
Needle Orientation
- •
In-plane to the transducer
- •
Or out-of-plane and short-axis to the transducer
Target
- •
In-plane: directed from distal to proximal into the radiocapitellar joint.
- •
Short axis: start in center of probe and direct into joint directly below transducer.
- •
See the injectate expand the joint without soft tissue distention.
Technique: Posterior Approach
Patient Position
- •
Prone position.
- •
Elbow is flexed approximately 90 degrees and the forearm is hanging over the table ( Fig. 17.3 ).
Fig. 17.3
Aspiration of the ulnar-olecranon joint using a 22-gauge needle in patient with triceps myositis and septic elbow joint. (A) Elbow position, transducer position, and needle position for the in-plane approach. (B) Ultrasound shows the needle (open arrow) trajectory.
Clinician Position
- •
Seated or standing directly next to the elbow being injected.
Transducer Orientation
- •
Short-axis to the tendon over the olecranon fossa.
Needle Orientation
- •
Short-axis to the triceps tendon and in-plane to the transducer from a lateral to medial direction.
Target
- •
Directed underneath the triceps tendon and into the joint.
- •
The ulnar nerve should be visualized at the medial epicondyle before the injection to avoid nerve injury.
Ligament Injections
Lateral Collateral Ligament Complex
- •
Most injections can be accomplished using a high-frequency linear ultrasound transducer.
Pertinent Anatomy
- •
Lateral collateral ligament (LCL) complex consists of four ligaments: accessory lateral collateral ligament (ALCL); annular ligament; lateral radial collateral ligament (LRCL); lateral ulnar collateral ligament (LUCL).
- •
LCUL is the primary stabilizer to varus and external rotation stress to the elbow.
Common Pathology
- •
Subtle instability of the LCL complex is challenging to identify on examination, but associated ligament injuries have been reported in up to 20% of cases of lateral epicondylitis. There seems to be a correlation with the severity of the injury to the common extension tendon and LUCL injury.
- •
Associated with a traumatic elbow dislocation, significant injury and instability is detected by conventional physical examination and characterized by mechanical symptoms: that is, clicking or catching.
Equipment
- •
Needle size: 25- or 27-gauge 1- or 1.5-inch needle.
- •
High-frequency linear ultrasound transducer.
Common Injectates
- •
Prolotherapy, orthobiologics (PRP, bone marrow concentrate, etc.).
- •
Avoid intraligamentous corticosteroids.
Injectate Volume
- •
2 to 3 cc.
Technique
Patient Position
- •
Seated or supine position.
- •
Elbow is flexed approximately 90 degrees and the forearm is pronated.
Clinician Position
- •
Seated or standing directly next to the elbow being injected.
Transducer Position
- •
Long-axis or longitudinal to the ligaments.
Needle Position
- •
Four ligaments comprise the LCL complex and the needle position should be adjusted to be in long-axis to the ligaments and in-plane to the transducer.
- •
The LRCL and LUCL should be approached from a distal to proximal orientation.
- •
The ALCL and annular ligament should be approached from a lateral to medial orientation ( Fig. 17.4 ).
Fig. 17.4
Intraligamentous injection of the lateral collateral ligament using a 25-gauge needle. Elbow position, needle position, and transducer placement are similar to the common extensor tendon injection. (A) Needle (open arrows) approaching lateral ulnar collateral ligament intraligamentous defect. (B) Needle (open arrows) approaching intraligamentous defect in the annular ligament (arrowheads)
Target
- •
Areas of hypoechogenicity and cortical irregularities.
- •
Fenestration of tendon and mild excoriation at sites of cortical irregularities until achieve change in the tissue texture.
- •
Regenerative injection (PRP, adipose-derived stromal cell [ADSC], bone marrow aspirate concentrate [BMAC]) should target areas of hypoechogenicity filling interstitial tears with injectate.
Pearls And Pitfalls
- •
For the ALCL and annular ligament injections, visualize the radial nerve first to avoid injury.
- •
Post-procedure pain medication should be offered and the patient should be informed that pain in the elbow region would likely be increased.
- •
Extremes of range of movement (ROM) should be limited in first 10–12 weeks after the procedure, especially repetitive supination.
- •
Medial Ulnar Collateral Ligament
- •
Most injections can be accomplished using a high-frequency linear ultrasound transducer.
Pertinent Anatomy
- •
Medial ulnar collateral ligament (MUCL) is composed of three bands: anterior band, posterior band, and transverse ligament.
- •
Anterior band is the primary restraint to valgus stress with the elbow in 30–120 degrees of flexion, coursing from the medial epicondyle to the sublime tubercle.
Common Pathology
- •
The MUCL is commonly injured in overhead throwing athletes due to valgus stress on the elbow during the late cocking and early acceleration phases.
Equipment
- •
Needle size: 25- or 27-gauge 1- or 1.5-inch needle.
- •
High-frequency linear ultrasound transducer
Common Injectates
- •
Prolotherapy, orthobiologics (PRP, bone marrow concentrate, etc.),
- •
Avoid intraligamentous corticosteroids
Injectate Volume
- •
2 to 3 cc.
Technique
Patient Position
- •
Supine position.
- •
Elbow and shoulder are flexed to approximately 90 degrees and the forearm is supinated.
Clinician Position
- •
Seated or standing directly next to the elbow being injected.
Transducer Position
- •
Long-axis or longitudinal to the ligaments.
Needle Position
- •
The needle position should be positioned in long-axis to the UCL and in-plane to the transducer.
Target
- •
Areas of hypoechogenicity within the ligament.
- •
Regenerative injection (PRP, ADSC, BMAC) should target areas of hypoechogenicity filling interstitial tears with injectate.
- •
Post-procedure pain medication should be offered and the patient should be informed that pain in the elbow region would likely be increased.
- •
Valgus stress should be limited in first 10–12 weeks after the procedure. Overhead athletes should start a progressive throwing program after the period of rest.
- •
The ulnar nerve should be visualized before the procedure to avoid accidental nerve injury ( Fig. 17.5 ).
Fig. 17.5
Intraligamentous injection of the ulnar collateral ligament (UCL) using a 25-gauge needle. (A) Elbow position, needle position, and transducer placement. (B) Needle (open arrow) approaching the UCL.
Tendon Injections
Common Extensor Tendon
- •
Most injections can be accomplished using a high-frequency linear ultrasound transducer.
Pertinent Anatomy
- •
The tendon originates from the lateral epicondyle of the humerus.
- •
Deep to the common flexor tendon, the radial collateral ligament occupies approximately 50% of the footprint at the lateral epicondyle ( Fig. 17.6 ).
Fig. 17.6
Pertinent muscular anatomy of the elbow demonstrating the extensor muscles on the dorsal surface of the forearm and their attachment on the lateral epicondyle of the humerus.
Common Pathology
- •
Lateral epicondylitis is the most common cause of lateral elbow pain.
- •
Typically an overuse syndrome.
- •
Degenerative changes include tendon thickening, intratendinous calcifications, or partial and complete tearing.
Equipment
- •
Needle size: 25- or 27-gauge 1- or 1.5-inch needle.
- •
High-frequency linear ultrasound transducer.
Common Injectates
- •
Local anesthetic plus or minus corticosteroids peritendinous.
- •
Orthobiologics (PRP, bone marrow concentrate, etc.).
- •
Avoid intratendinous corticosteroids.
Injectate Volume
- •
2 to 3 cc.
Technique
Patient Position
- •
Seated or supine position.
- •
Elbow is flexed approximately 90 degrees and the forearm is prone ( Fig. 17.7 ).
Fig. 17.7
Intratendinous injection of the common extensor tendon using a 25-gauge needle. (A) Elbow position, needle position, and transducer placement. (B) Needle (open arrow) approaching intratendinous defect.
Clinician Position
- •
Seated or standing directly next to the elbow being injected.
Transducer Position
- •
Long-axis or longitudinal to the tendon.
Needle Position
- •
Long-axis to the tendon and in-plane to the transducer from a distal to proximal orientation.
Target
- •
Areas of hypoechogenicity and cortical irregularities.
- •
Fenestration of tendon and mild excoriation at sites of cortical irregularities until achieve change in the tissue texture.
- •
Regenerative injection (PRP, ADSC, BMAC) should target areas of hypoechogenicity filling interstitial tears with injectate.
- •
The needle should also be repositioned, moving in a medial to lateral fashion for complete coverage of the enthesis and targeting all areas of hypoechogenicity.
- •
Examine for associated varus instability of lateral collateral complex as associated ligament injuries have been reported in up to 20% of cases of lateral epicondylitis.
- •
Long-term studies have shown that corticosteroid injections are no more beneficial than observation alone and may even have an inferior outcome with higher recurrence rates at 1 year. ,
- •
Avoid intratendinous injection of local anesthetics, especially bupivacaine and lidocaine, as these have been shown to have deleterious effects on progenitor cells. If intratendinous anesthesia is required, then a small amount of 0.125% ropivacaine is preferred.
Related posts:
Autologous Orthobiologics
Autologous Tissue Harvesting Techniques: Platelet-Rich Plasma
Ultrasound Basics
Therapeutic Dextrose Injection : Prolotherapy, Perineural Injection Therapy, and Hydrodissection
Ultrasound-Guided Needle Tenotomy and Ultrasound-Guided Tenotomy and Debridement With Tenex Health TX System
Calcific Tendonitis Barbotage/Lavage
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
