FIGURE 8.3 Right anterior hip and femoral triangle. (From Tank PW, Gest TR. Lippincott Williams & Wilkins Atlas of Anatomy. Philadelphia, PA: Lippincott Williams & Wilkins, 2009.)
PATIENT POSITION
- Supine on the examination table with the head of the bed slightly elevated.
LANDMARKS
1. With the patient supine on the examination table, the clinician stands lateral to the affected hip.
2. Over the anterior aspect of the hip, identify the point at the intersection of two perpendicular lines. The first is distal and sagittal from the anterior superior iliac spine, and the second line is transverse from the proximal tip of the greater trochanter. This point will be located about 3 cm lateral to the femoral artery. Mark that spot, which is directly over the hip joint.
3. (Optional) Use ultrasound to image the hip joint.
4. At that site, press firmly on the skin with the retracted tip of a ballpoint pen. This indention represents the entry point for the needle.
5. After the landmarks are identified, the patient should not move the hip.
ANESTHESIA
- Local anesthesia of the skin using topical vapocoolant spray.
EQUIPMENT
- 20-mL syringe—for aspiration
- 3-mL syringe—for the injection of corticosteroid/local anesthetic mixture
- 25-gauge, 1½ in. needle in thin individuals. Otherwise, use a 25-gauge, 3½ in. needle (for injections only)
- 20-gauge, 1½ in. needle in thin individuals. Otherwise, use a 20-gauge, 3½ in. needle (for aspirations and injections)
- 3 mL of 1% lidocaine without epinephrine
- 1 mL of the steroid solution (40 mg of triamcinolone acetonide)
- One alcohol prep pad
- Two povidone–iodine prep pads
- Sterile gauze pads
- Sterile adhesive bandage
- Nonsterile, clean chucks pad
TECHNIQUE
1. (Optional) Use an ultrasound to image the hip joint using an adjacent but separate acoustic window. This allows imaging separate from the injection site so that there is no contamination from the ultrasound gel. Alternatively, the entire site may be prepped in an aseptic manner and sterile ultrasound gel utilized.
2. Prep the insertion site with alcohol followed by the povidone–iodine pads.
3. Achieve good local anesthesia by using topical vapocoolant spray.
4. Position the needle and syringe perpendicular to the skin with the tip of the needle directed posteriorly toward the hip joint.
5. Using the no-touch technique, introduce the needle at the insertion site (Fig. 8.4).
6. Advance the needle toward the hip joint until the needle tip contacts the junction of the femoral neck and femoral head. Back up the needle 1 to 2 mm.
7. Inject the steroid solution as a bolus into the hip joint capsule. The injected solution should flow smoothly into the space. If increased resistance is encountered, advance or withdraw the needle slightly before attempting further injection.
8. Following injection of the corticosteroid solution, withdraw the needle.
9. Apply a sterile adhesive bandage.
10. Instruct the patient to move his or her hip through its full range of motion. This movement distributes the steroid solution throughout the hip joint capsule.
11. Reexamine the hip in 5 min to confirm pain relief.
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