The Pelvis, Hip, and Thigh
INJECTIONS AND ASPIRATIONS
Intra-articular Hip Injection/Aspiration
Indication
Intra-articular positioning of a needle is useful for aspirating fluid for laboratory analysis, injecting arthrogram dye, and medication delivery. In adults, a lateral or anterolateral approach is commonly used; in children, the medial approach is preferred.
Description of Procedure
LATERAL APPROACH
Position the patient supine on a bed or gurney.
Prepare a wide area of the skin at the lateral aspect of the hip with antibacterial solution.
Optional: Mark the entry site with a marking pen. Perform this step before application of antibacterial solution if a nonsterile pen is used.
The entry site is 2 cm distal to the tip of the greater trochanter on its palpable anterior border (Fig. 5-1).
Optional: Anesthetize the skin overlying the planned entry site with 2 to 3 mL of local anesthetic.
Direct the needle parallel to the floor and perpendicular to the femur until bone is felt. The needle is now at the base of the femoral neck.
Pull the needle back a few millimeters, and redirect at an angle directed approximately 10° anteriorly to match femoral anteversion and 45° superiorly to match the neck-shaft angle (Figs. 5-2 and Fig. 5-3).
Advance the needle until bone is felt.
Withdraw synovial fluid to verify intra-articular position of the needle.
Continue aspirating or inject the desired fluid.
ANTEROLATERAL APPROACH
Position the patient supine on a bed or gurney.
Prepare a wide area of the skin at the anterolateral aspect of the hip with antibacterial solution.
Optional: Mark the entry site with a marking pen. Perform this step before application of antibacterial solution if a nonsterile pen is used.
Before needle insertion, palpate and mark the femoral artery pulse and ensure that you enter lateral to this structure and the adjacent femoral nerve.
The entry site is located two fingerbreadths directly distal to the palpable anterior superior iliac spine (ASIS). If the needle is inserted perpendicular to the skin from this point, it will pierce the hip capsule at the femoral head/neck junction (Fig. 5-4).
Optional: Anesthetize the skin overlying the planned entry site with 2 to 3 mL of local anesthetic.
Pull the needle back a few millimeters and attempt aspiration.
If no fluid is obtained, direct the needle inferiorly, just below the neck and advance more posterior. Since the patient is supine, the synovial fluid has a tendency to pool posteriorly, and it may be easier to obtain fluid in this location.
Withdraw synovial fluid to verify intra-articular position of the needle.
Continue aspirating or inject the desired fluid.
 FIGURE 5-1 |
 FIGURE 5-2 |
 FIGURE 5-3 |
 FIGURE 5-4 |
 FIGURE 5-5 |
MEDIAL APPROACH
Position the patient supine with the limb in the frog-leg position (abduction and external rotation).
As this approach is typically utilized in a child, conscious sedation or general anesthesia is the preferred method of anesthesia.
Prepare a wide area of the skin at the medial aspect of the hip with antibacterial solution.
Optional: Mark the entry site with a marking pen. Perform this step before application of antibacterial solution if a nonsterile pen is used.
The entry site is just deep to the easily palpable adductor longus tendon and 2 to 4 cm inferior to the pubic symphysis (based on the size of the child) (Figs. 5-6 and 5-7).
Direct the needle parallel to the floor and toward the ASIS until bone is felt.
Withdraw synovial fluid to verify intra-articular position of the needle.
Continue aspirating or inject the desired fluid.
Tips and Other Considerations
A rough estimate for the location of the center of the femoral head is a point two fingerbreadths medial and one fingerbreadth inferior to the ASIS.
A long spinal needle should always be used. The stylet should remain inside the needle whenever the needle is moved; otherwise, a core of tissue may obstruct the needle.
When performing this procedure for the purposes of aspiration, an 18G needle is recommended, as inflammatory or septic fluid is quite viscous. For a corticosteroid solution injection, a smaller, 22G needle may be used, although the thinner needle is harder to direct.
Because the hip joint is a deep structure, fluoroscopic guidance is often helpful in locating the hip. We prefer injection of radiopaque dye to confirm intra-articular placement before the administration of medications.
 FIGURE 5-6 |
 FIGURE 5-7 |
Trochanteric Bursa Injection/Aspiration
Indication
Placement of a needle within the trochanteric bursa permits aspiration of fluid for laboratory analysis or pain relief as well as the ability to inject local anesthetic and/or corticosteroid.
Description of Procedure
Position the patient in the lateral decubitus position. Placement of the hip in slight abduction with a pillow or several towels between the legs will relax the iliotibial band.
Prepare a wide area of the skin with antibacterial solution.
Optional: Mark the entry site with a marking pen. Perform this step before application of antibacterial solution if a nonsterile pen is used.
The entry site is over the palpable greater trochanter over the point of maximal tenderness (Fig. 5-8).
Optional: Anesthetize the skin overlying the planned entry site with 2 to 3 mL of local anesthetic.
Insert the needle to the point at which it contacts bone, and pull back slightly (1 to 2 mm).
After aspirating to verify that the needle is not within a blood vessel, continue aspirating or inject the desired solution.
 FIGURE 5-8 |
Tips and Other Considerations
When performing this procedure for the purposes of aspiration, an 18G needle is recommended as inflammatory or septic fluid is quite viscous. For a corticosteroid solution injection, a smaller, 22G needle may be used.
For many patients, a standard, 1.5-inch needle will be long enough to reach the trochanteric bursa; however, in larger individuals, a spinal needle is recommended.
When injecting a corticosteroid/anesthetic solution for the treatment of trochanteric bursitis, greater pain relief may be achieved by injecting portions of the solution in slightly different positions because the bursa is septated and one injection site may not access the entire area.
CLOSED REDUCTIONS
Anterior-Posterior Compression Pelvic Fracture
Indication
The application of a pelvic binder or sheet can assist in the reduction of bony and venous hemorrhage, minimize pain, and provide provisional stabilization of pelvic fractures. Application of a pelvic binder or sheet is recommended in the setting of anterior-posterior compression (open book) pelvic fracture patterns. In a hemodynamically unstable patient with pelvic instability a pelvic binder or sheet should be placed as a life saving measure prior to radiographs. With lateral compression patterns, a theoretical risk of injury to intrapelvic structures (e.g. bladder, vaginal wall) exists; however, we feel that these risks are outweighed by the benefits of this potentially life saving intervention. In patients with a known (radiographs available) lateral compression injury, a binder is not recommended (Fig. 5-9).
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