Ultrasound Guided Injection Techniques
Metacarpophalangeal, Interphalangeal, Proximal Interphalangeal, Distal Interphalangeal Joint Injections
- •
Out-of-plane relative to transducer or short axis to the joint approaches maybe easier for these superficial joints
- •
A gel stand-off may improve joint and needle visualization
- •
Understanding and identification of at-risk anatomy is required prior to injection
- •
A hockey stick transducer may improve ability to do injections.
- •
Joints often hold relatively small volumes of injectate; therefore, practitioner will often have to limit anesthetic in favor of therapeutic injectate when performing the procedure.
- •
Use of particulate corticosteroids increases the risk of skin depigmentation, especially in the case of superficial injections
Pertinent Anatomy
- •
The metacarpophalangeal (MCP), interphalangeal (IP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints are small synovial joints that allow for flexion and extension of the fingers and thumb.
- •
Neurovascular structures run along the relative volar side of each digit ( Figs. 19.1 and 19.2B ).
Fig. 19.1
Hand Pulley System Anatomy.
Note enlarged view of the A1 pully.
Fig. 19.2
Transducer placement and sonographic appearance of volar and dorsal targets for hand injections. (A) Axial position of the transducer (black rectangle) overlying the volar proximal hand with corresponding sonographic (B) sonographic appearance of the anatomy at this level. Note the neurovascular structures (arrowheads) adjacent to the flexor digitorum superficialis (FS) and profundus (FP) . (C and D) Sagittal position of the transducer (black rectangle) overlying the dorsal metacarpal phalangeal joint with correlative sonographic image at this level. Note proximal extension of the dorsal recess (open arrows) . MC, Metacarpal; PP, proximal phalanx.
- •
Dorsal recess of the joints extends proximal to each joint allowing for relatively easier access than volar to joint (see Fig. 19.2C and D ).
Common Pathology
- •
Osteoarthritis commonly effects the joints of the hand.
- •
The MCP and IP joints are commonly affected by disorders of the hand, including dislocations, sprains, fractures, and both osteoarthritis and inflammatory arthropathies.
- •
The PIP joint is a commonly injured finger joint, often resulting in fractures, collateral ligament injuries, palmar plate injuries, and subsequent post-traumatic osteoarthritis.
- •
Inflammatory arthritis, such as rheumatoid arthritis, can have a predilection for the joints of the hand
- •
Common findings of joint space narrowing, osteophyte formation, effusion, joint subluxation or deformity, and erosive changes, in the case of inflammatory arthritis can occur.
Equipment
- •
High frequency linear array transducer
- •
Smaller footprint or hockey stick probes maybe easier to use over regions with noncompliant tissue.
Common Injectates
- •
Local anesthetics for diagnostics, corticosteroids intra-articular (IA) only
- •
Prolotherapy
- •
Orthobiologics (PRP, bone marrow concentrate, etc.)
- •
Corticosteroid should not be injected directly into capsular ligaments
Injectate Volume
- •
0.5 to 1.5 mL
Authors Preferred Injection Technique
Patient Position
- •
Seated or supine on table with forearm pronated ( Fig. 19.3A )
Fig. 19.3
Metacarpal or Interphalangeal Joint Injections.
(A) Transducer (black rectangle) placement along the dorsal recess of the target joint. Black arrow , trajectory of the needle. (B) Sonographic image of the needle tip (arrowhead) within the dorsal joint recess. Note reverberation artifact deep to the needle. MC, Metacarpal, PP, proximal phalanx.
Clinical Position
- •
Standing or seated ipsilateral side of the patient
Transducer Position
- •
The transducer is placed in the anatomic sagittal plane with the desired target joint centered on the transducer, for out-of-plane approach (see Fig. 19.3A ).
- •
Alternatively, this can be done in the anatomic axial plane for the in-plane approach.
Needle Position
- •
Needle is introduced in short axis from an ulnar to radial or radial to ulnar direction into the joint (see Fig. 19.3A and B ).
Targets
- •
The desired joint
- •
Watch distention of the capsule or slight separation of the bones with ultrasound during the injection.
- •
Can also inject the overlying capsular ligaments (with prolotherapy or orthobiologics) for each joint in the same position with the needle in short axis or in long axis ( Fig. 19.4A and B )
Fig. 19.4
Metacarpal Phalangeal Joint and Ulnar Capsular Ligament Injection.
(A) Transducer placement (black rectangle) for in plane technique with needle traversing from distal to proximal direction (black arrow) . (B) Sonographic image of needle (arrowheads ) injecting along the ulnar capsular ligament, note joint distension (asterisk) .
- •
A dorsal approach to the joint effectively avoids the neurovascular bundles, which are volar.
- •
Needle depth can also be confirmed by turning the transducer 90 degrees to show an in-plane view of the needle.
- •
When injecting the ulnar collateral ligament of the first MCP joint, it may be helpful to have the patient hold onto a rolled- up towel or other cylindrical object to help position and stabilize the joint during the injection (see Fig. 19.4A ).
Carpometacarpal and Scaphotrapeziotrapezoid Joints and Carpometacarpal Capsular Ligaments
- •
When using orthobiologics it is recommended to address the joint instability/mechanical symptoms in addition to the condition being treated.
Pertinent Anatomy
- •
The carpometacarpal (CMC) joint is a saddle shaped synovial joint between the trapezium and first metacarpal.
- •
The scaphotrapeziotrapezoid (STT) joint is a dome-shaped articulation composed of scaphotrapezial and/or scaphotrapezoidal articulation
- •
The terminal SR2 and SR3 branches of the superficial radial nerve border the volar and dorsal sides of the STT and CMC joints.
- •
Also just proximal to the STT and CMC joints the radial artery branches into superficial and deep palmar arteries ( Fig. 19.5A and B ).
Fig. 19.5
Carpometacarpal (CMC) and/or Scaphotrapziotrapezoidal (STT) Joint Injection.
(A) Visualization of the CMC or STT joint can be optimized by placement of the transducer ( black rectangle) sagittal to the hand along the dorsal surface. (B) Sonographic image showing the location of the radial artery (open arrow) relative to the STT and CMC joints. (C and D) Sonographic images of the needle (arrowhead) within the STT and CMC joints respectively. MC, metacarpal; R, radius; S, scaphoid; T, trapezium.
- •
The flexor carpi radialis (FCR) tendon is just palmar and ulnar to the CMC and STT joints.
- •
The palmar cutaneous nerve usual resides between the FCR tendon and the palmaris on the palmar side of the wrist.
Common Pathology
- •
Observed in up to 15% of radiographic studies and 83.3% of cadaveric specimens, degenerative arthritis of the CMC and STT joint are the first and second most common cause of degenerative changes in the wrist.
- •
Injuries to the scaphotrapezial ligament, the major anatomic stabilizer of the STT joint, can lead to post-traumatic arthritic changes.
- •
Other theories for injury to the STT joint include disruption of the scapholunate interosseous ligament and cartilage erosion in the STT joint.
- •
Common pathologic US findings include joint effusions, synovitis, loss of articular space, cortical irregularities, and osteophyte formation.
- •
STT and CMC arthropathy have been associated with tendinopathy of the FCR tendon which lies anatomically just palmar and ulnar to the STT joint.
Equipment
- •
Injections can be performed using a high-frequency linear array transducer. If available, a hockey stick or shorter foot-print transducer may also be helpful.
- •
30 to 25-gauge 1 to 1.5 inch needle
Common Injectates
- •
Local anesthetics for diagnostics, corticosteroids IA only
- •
Prolotherapy
- •
Orthobiologics (PRP, bone marrow concentrate, etc.)
- •
Corticosteroid should not be injected directly into capsular ligaments
Injectate Volume
- •
1 to 2 mL
Technique: CMC and STT Joints Intra-Articular
Patient Position
- •
Supine ( Fig. 19.5A )
- •
For both joints, wrist supinated supported by towels
- •
For dorsal approach to the CMC joint, the wrist can be in neutral position.
Clinician Position
- •
Standing or seated ipsilateral side of the patient
Transducer Position
- •
Identify CMC joint in the transverse plane palmer aspect
- •
Transducer angled near parallel with the metacarpal bone
- •
Scaphotrapeziotrapezoid joint set up similar except the transducer is positioned more proximal
Needle Position
- •
Short-axis injection
Targets
- •
The desired joint (see Fig. 19.5A, C and D )
- •
Watch distention of the capsule or slight separation of the bones with ultrasound during the injection.
- •
Can also inject the overlying palmer capsular ligaments for both joints in the same position
Related posts:
Autologous Orthobiologics
Autologous Tissue Harvesting Techniques: Platelet-Rich Plasma
Sclerosing Agents
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
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
