FIGURE 6.18 Posterior aspect of right elbow. (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 elevated 30 degrees.
Shoulder at 30 degrees of abduction and full external rotation.
The affected elbow is flexed at 90 degrees.
The wrist is in a neutral position.
The elbow is supported with the placement of chucks pads or towels.
Rotate the patient’s head away from the side that is being injected. This minimizes anxiety and pain perception.

LANDMARKS

1. With the patient supine on the examination table, the clinician stands lateral to the affected elbow.

2. Identify and mark the medial epicondyle of the humerus.

3. Identify and mark the course of the ulnar nerve in the ulnar groove posterior to the medial epicondyle.

4. Mark the point of maximal tenderness over the ulnar nerve. This is usually just posterior to the medical epicondyle.

5. 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.

6. After the landmarks are identified, the patient should not move the elbow.

ANESTHESIA

Local anesthesia of the skin using topical vapocoolant spray.

EQUIPMENT

3-mL syringe
25-gauge, 1-in. needle
1 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. Prep the insertion site with alcohol followed by the povidone–iodine pads.

2. Achieve good local anesthesia by using topical vapocoolant spray.

3. Position the needle and syringe at a 30-degree angle to the skin with the tip of the needle directed distally along the ulnar nerve.

4. Using the no-touch technique, introduce the needle at the insertion site (Fig. 6.19).

5. Advance the needle slowly at a shallow angle to a position just along the side of the ulnar nerve.

6. If any pain, paresthesias, or numbness is encountered, withdraw the needle slightly and redirect the needle tip using a slightly different angle.

7. When the needle is placed along the ulnar nerve, slowly deposit the steroid solution as a bolus around that structure.

8. Inject the steroid solution steadily into this area. If increased resistance is encountered, advance or withdraw the needle slightly before attempting further injection.

9. Following injection of the corticosteroid solution, withdraw the needle.

10. Apply a sterile adhesive bandage.

11. Instruct the patient to move his or her wrist and elbow through their full range of motion.

12. Reexamine the elbow in 5 min to confirm pain relief and the development of numbness in the distribution of the ulnar nerve from the local anesthetic.