Assessing and treating upper limb structures are commonly undertaken in musculoskeletal medicine, particularly as these tend to be superficial and readily identified with ultrasound. These tend to become more amenable as you progress distally in the upper limb.
8.1
Shoulder
Superficial structures such as the rotator cuff, bursa and supra-scapular nerve can be evaluated using ultrasound. These and others, such as the acromioclavicular and glenohumeral joint, can be injected under ultrasound guidance. The key with shoulder injections is stability and limiting movement. If you have been trained in imaging and performing procedures in the seated position, it may be best to continue to do so; nevertheless, positioning the patient in a supine or prone position can optimise stability.
Joint injections
The glenohumeral (GHJ), acromioclavicular (ACJ) and sternoclavicular (SCJ) joints are commonly injected under ultrasound guidance for pain symptoms or limitation in movement. Positioning of the patient to aid the clinician can be an important consideration and this might need to be adapted to suit an individual basis.
8.1.1
Glenohumeral joint
| Patient position: | For the glenohumeral joint (GHJ), the patient can be positioned in a prone ( Fig. 8.1.1A ) or upright position ( Fig. 8.1.1B ). In the former, the arm hangs off the bed and gravity can be used to help open the GHJ. In the latter, the hand should rest on the opposite shoulder to optimise position and open the joint. |
| Identifying the anatomy: | In both patient positions, the GHJ can be traced back in LAX from the infraspinatus tendon insertion and along the curve of the humeral head ( Fig. 8.1.1C–E ). The posterior labrum may be identified and in degenerative shoulders, narrowing of the joint space or an effusion might be seen. |
| Injections performed: | CSI, PRP or HA injections into the shoulder for degenerative disease. With additional volume, a hydro can be performed for frozen shoulders. |
| Recommended transducer: | Curvilinear 3–5 mHz. |
| Equipment suggested: | Equipment preparation: Set 1 for CSI or HA injections. Set 3 for hydrodilatations. Set 4 for PRP injections. Needle: 2-inch 21- or 23-gauge needle. Syringes: 3 mL for cortisone injection or 10 mL(s) for a hydrodilatation. Medication: 40 mg triamcinolone (1 mL) and 1% lidocaine (5 mL). Add normal saline (110 mL) for hydrodilatations. Standard/available HA or PRP preparation. |
| Injection technique: | Using the humeral head as a guide, the needle can be inserted IP at approximately 45 degrees. With the bevel facing down, it can be guided into the posterior of the GHJ ( Fig. 8.1.1F–H ). As the joint capsule is breached, the patient may experience discomfort and if successfully placed, the injected solution should be seen flowing around the humeral head. A clampable extension tubing can help prevent fluid from escaping during a hydrodilatation. In situations where the needle is incorrectly placed, extravasation into the infraspinatus or surrounding tissue may be witnessed. |
Injections to the GHJ.
The patient can be positioned in a prone or seated position with the arm positioned appropriately to open the joint. The injection can be undertaken IP, using the humeral head to guide the needle from lateral-to-medial. The needle tip should be seen within the GHJ.
8.1.2
Acromio-clavicular joint
| Patient position: | For the acromio-clavicular joint (ACJ), consider positioning the patient in a sitting ( Fig. 8.1.2A ) or supine position ( Fig. 8.1.2B ) with the arm by their side and the hand in a supinated position. The orientation may differ according to the side being injected and the clinician’s hand dominance. |
| Identifying the anatomy: | The ACJ is readily identified by following the biceps tendon in the SAX proximally until the joint is visualised, or by palpating the clavicle and placing the transducer directly over the joint ( Fig. 8.12C–E ). Both enable the ACJ to be visualised in the LAX, where degenerative changes or synovial hypertrophy can be witnessed. |
| Injections performed: | CSI for pain, degenerative disease or synovitis. PRP or HA injections for degenerative disease. |
| Recommended transducer: | Linear 6–15 mHz. Hockey stick 8–18 mHz. |
| Equipment suggested: | Equipment preparation: Set 1 for CSI or HA injections. Set 4 for PRP. Needle: 1-inch 25- or 27-gauge needle. Syringes: 3 mL for CSI. Medication: 40 mg triamcinolone (1 mL) and 1% lidocaine (1 mL). Standard/available HA or PRP preparation. |
| Injection technique: | Maintaining the transducer in the LAX orientation, an IP technique can be used from a lateral approach to perform the injection with the needle at approximately 20 degrees ( Fig. 8.1.2F–H ). In situations where there is considerable degenerative change in the joint, an OOP approach can be used to access the joint by positioning the midline of the transducer over the joint and introducing the needle perpendicular to the skin ( Fig. 8.1.2I–K ). |
Injections to the ACJ.
The patient can be in a seated or supine position with the forearm also supine. The injection can be performed using an IP or OOP approach with the transducer in the LAX orientation. The needle tip should be seen within the ACJ.
8.1.3
Sternoclavicular joint
| Patient position: | For the sternoclavicular joint (SCJ), consider positioning the patient in a sitting ( Fig. 8.1.3A ) or supine position ( Fig. 8.1.3B ) with the arm by their side and the hand in a supinated position. |
| Identifying the anatomy: | The SCJ is readily identified by following the clavicle from lateral to medial or the sternum from an inferior to superior position. The joint can be identified in an LAX view as a gap between the clavicle and sternum ( Fig. 8.1.3C–E ). |
| Injections performed: | CSI for pain symptoms, degenerative disease or synovitis. PRP or HA injections for degenerative disease. |
| Recommended transducer: | Linear 6–15 mHz. Hockey stick 8–18 mHz. |
| Equipment suggested: | Equipment preparation: Set 1 for CSI or HA injections. Set 4 for PRP. Needle: 1-inch 25- or 27-gauge needle. Syringes: 3 mL for CSI. Medication: 40 mg triamcinolone (1 mL) and 1% lidocaine (1 mL). Standard/available HA or PRP preparation. |
| Injection technique: | Maintaining the transducer in the LAX, an IP technique can be used to perform the injection from a medial or lateral approach with the needle at 20 degrees and the bevel facing down ( Fig. 8.1.3F–H ). In situations where there is considerable degenerative change in the joint, an OOP approach can be used to access the joint by positioning the midline of the transducer over the joint and introducing the needle perpendicular to the skin ( Fig. 8.1.3.I–K ). |
Injections to the SCJ.
The patient can be in a seated or supine position with the forearm also supine. The injection is undertaken using an IP (medial or lateral) or OOP approach with the transducer in the LAX orientation. The needle tip should be seen within the SCJ.
Tendons
With tendons around the shoulder readily visible using ultrasound, the commonest one requiring a direct procedure is the Long Head of the Biceps (LHBT) tendon when treating a tenosynovitis or tendinopathy. While pain in the others are more commonly treated through injection in to the Subacromial Subdeltoid Bursa, tears of the Supraspinatus can sometimes be amenable to a PRP injection.
8.1.4
Long head biceps tendon
| Patient position: | For the long head biceps tendon (LHBT), the patient can be placed in a sitting ( Fig. 8.1.4A ) or supine position ( Fig. 8.1.4B ) with the hand supinated and the elbow flexed or extended respectively. |
| Identifying the anatomy: | Placing the transducer in transverse orientation the LHBT can be identified in the SAX within the bicipital groove. It should be traced distally to the pectoralis insertion, to check for integrity, prior to performing the injection ( Fig. 8.1.4C–E ). Fluid may be identified in the tendon sheath or tendinopathy might be noted. A further evaluation can be undertaken in an LAX view ( Fig. 8.1.4F and G ). |
| Injections performed: | CSI for tenosynovitis and pain. PRP for degenerative tendinopathy into the LHBT itself. |
| Recommended transducer: | Linear 6–15 mHz. |
| Equipment required: | Equipment preparation: Set 1 for CSI. Set 4 for PRP. Needle: 1.5- to 2-inch 25- or 27-gauge needle. Syringes: 3 mL for CSI. Medication: 20 mg triamcinolone (0.5 mL) and 1% lidocaine (1 mL). Standard/available PRP preparation. |
| Injection technique: | Using a lateral approach and the LHBT in an SAX orientation, the needle is introduced IP at approximately a 45-degree with the bevel facing down. Once the tip penetrates the LHBT sheath and the needle can be advanced until it makes contact with the bicipital groove ( Fig. 8.1.4H–J ). At this point the solution can be slowly injected and should be seen to flow around the LHBT, but if there is a resistance or flow into the tendon the needle tip must be readjusted. An alternative approach is in the LAX with the needle also in IP but this time at a 30–45 degrees ( Fig. 8.1.4K and L ). Once in the sheath, the fluid should be seen tracking along the length of the tendon. For PRP injections, it is important to identify the level of the injection and follow a similar technique, but in this situation the needle is inserted into the tendon itself before the solution is injected using a fenestration technique. |
Injections to the LHBT.
The patient can be in a seated or supine position, with the hand also supine and the elbow flexed or extended. The injection is undertaken using an IP approach, with the transducer in a SAX or LAX orientation. The needle tip should be seen within the tendon and its sheath.
8.1.5
Supraspinatus
| Patient position: | For the supraspinatus (SSP), consider positioning the patient in a supine but slightly side-rotated position with their hand in a back-pocket position (Fig. 8.1.5.A). A towel can be used to help the patient maintain this position. Alternatively, the patient can be sat upright, with the hand also in the back-pocket position (Fig. 8.1.5.B). |
| Identifying the anatomy: | Placing the transducer with one edge pointing towards the umbilicus (Fig. 8.1.5.C, D and E), the rotator interval can be identified with the long head of biceps tendon in SAX. Moving the transducer laterally will bring the SSP into view, also in an SAX orientation with the SASDB overlying. In this position SSP tears or tendinopathy can be identified, but must be subsequently confirmed in the LAX view. |
| Injections performed: | PRP for acute tears or degenerative tendinopathy with intrasubstance change. |
| Recommended transducer: | Linear 6–15mHz. |
| Equipment required: | Equipment preparation: Set 4 for PRP. Needle: 1.5-inch 23- or 25-gauge needle. Standard/available PRP preparation. |
| Injection technique: | Using a lateral approach with the transducer in the SAX, the needle is guided IP into the body of the SSP and into the tear (Fig. 8.1.5.F, G and H). With the bevel down, the injection is undertaken using a fenestration technique to suitably distribute the PRP. Care should be taken not to overly traumatise the intact tissue. |
Bursal injections
The subacromial subdeltoid bursa (SASDB) is a common site for shoulder injections when patients report pain with abduction or for impingement. It can also be helpful with generalised pain, limited movement or supraspinatus (SSP) tendinopathy. With chronic pain, there may be adhesions in the SASDB and a HVI can be useful to release these.
8.1.6
Subacromial subdeltoid bursa
| Patient position: | For the subacromial subdeltoid bursa (SASDB), consider positioning the patient in a supine but slightly rotated position with the hand on the back pocket ( Fig. 8.1.5A ). A towel can be used to support the patient. Alternatively, the patient can be sitting, with the hand also in the back pocket position ( Fig. 8.1.5B ). |
| Identifying the anatomy: | Placing the transducer with one edge pointing toward the umbilicus ( Fig. 8.1.5C–E ), the rotator interval can be identified with the long head of biceps tendon in SAX. Moving the transducer laterally will be bring the SSP into view in the SAX with the SASDB overlying. In this position tears or tendinopathy can be identified and subsequently confirmed in an LAX. The bursa is identified and it can be assessed for thickening, bursitis or impingement. |
| Injections performed: | CSI for pain and impingement symptoms. HVI in chronic pain with adhesions. |
| Recommended transducer: | Linear 6–15 mHz. |
| Equipment required: | Equipment preparation: Set 1 for CSI. Set 2 for HVI. Needle: 1.5-inch 21- or 23-gauge needle. Syringes: 5 mL for CSI and 10 mls for HVI. Medication: 40 mg triamcinolone (1 mL) and 1% lidocaine (5–10 mL) for CSI and additional saline (20–30 mL) for HVI. |
| Injection technique: | Using a lateral approach with the transducer in the SAX, the needle is guided IP as horizontally as possible so that it can be visualised in its entirety ( Fig. 8.1.5.F, G and H ). With the bevel down, once the needle rests against the SSP a small amount of fluid can be injected to lift off the SASDB. Once separation is seen, the needle can be withdrawn slightly and the remainder of the solution can be injected into the SASDB. If there is pressure or it appears that the solution if being injected into the upper fibres of the tendon, the tip should be pulled back and repositioned. A clampable extension tubing can help prevent fluid from escaping during the HVI. |
Injections to the SSP.
The patient can be in a seated or supine (side-lying) position with the hand on the back pocket. The injection can be undertaken using an IP approach, with the transducer in a SAX or LAX orientation. The needle tip should be seen within the SSP tendon itself.
Nerve injections
Injection to the supra-scapular nerve (SSN) can be helpful during glenohumeral injections and for analgesia in chronic shoulder pain. A similar approach to glenohumeral joint injections can be undertaken but aiming more medial for the nerve in the supra-scapular notch.
8.1.7
Supra-scapular nerve
| Patient position: | For the supra-scapular nerve (SSN), consider asking the patient to lie prone with the arm over the edge of the couch ( Fig. 8.1.6A ) or to be in a seated position with the hand resting on the opposite shoulder ( Fig. 8.1.6B ). |
| Identifying the anatomy: | Placing the transducer along with the spine of the scapula, this can be followed until the supra-scapular notch is identified with SSN sitting within it in a SAX orientation ( Fig. 8.1.6C–E ). The vascular supply can be identified using the power Doppler and this should be avoided if possible. |
| Injections performed: | LA for diagnostic uncertainty or to relieve pain during shoulder procedures such as hydrodilatations. CSI for shoulder pain. |
| Recommended transducer: | Curvilinear 3–5 mHz. |
| Equipment required: | Equipment preparation: Set 1 for CSI or LA injection. Needle: 2- to 2.5-inch 23- or 25-gauge needle. Syringes: 3 mL for CSI or LA injections. Medication: 20 mg triamcinolone (0.5 mL) and 1% lidocaine (0.5 mL) for standard CSI and 1% lidocaine (1 mL) only for LA injections. |
| Injection technique: | Approaching from the lateral aspect, with the nerve in the SAX, the needle can be guided to the SSN within the supra-scapular notch using an IP approach. The needle is aimed at approximately 45 degrees with the bevel pointing down to limit spilling of the solution. ( Fig. 8.1.6F–H ). Once the ligament is breached, and not blood flow is confirmed on aspiration, the solution can then be injected around the nerve. |
Injections to the SASDB.
The patient can be in a seated or side-lying position with the hand on the back pocket to add stability. The injection can be undertaken using an IP approach, with the transducer in a SAX or LAX orientation. The needle tip should be seen within the SASDB.
Injections to the SSN.
The patient can be positioned in a prone or seated position with the arm positioned suitably for stability. The needle can be guided into the supra-scapular notch, using an IP technique from lateral-to-medial, with the transducer in a LAX orientation. The needle tip should be seen beneath the ligament.
Notes
(Please use this area to reflect on your procedure and how you can build on these experiences).
8.2
Elbow
Superficial structures around the elbow can be readily identified and injected under ultrasound guidance with the patient either in a sitting or lying position. In both positions, the joint can be supported with a pillow or firm support to limit movement. By altering the elbow position, it can help bring the structure under treatment to a more superficial position.
Joint injections
Although intra-articular aspects of the elbow joint cannot be assessed using ultrasound, superficial degenerative changes, such as osteophytes, can be seen. Guided treatments can be performed from the lateral aspect by injections into the Radio-Capitella joint (RCJ), for degenerative and pain-related symptoms, or the posterior joint line (PJL) aspect for degenerative changes or impingement extension. If the fat pad (PFP) is being caught, this can also be injected.
8.2.1
Radio-capitella joint
| Patient position: | In the supine position, the patient can rest their hand against the body to expose the lateral elbow joint ( Fig. 8.2.1A ), while in the sitting position, the shoulder is internally rotated and the elbow is flexed ( Fig. 8.2.1B ). In both positions the hand is kept in a semi-supinated position. |
| Identifying the anatomy: | With the transducer along the length of the elbow, the radio-capitella joint (RCJ) can be seen in the LAX with the lateral epicondyle (LE) of the humerus and the radius in view. The common extensor tendon is seen inserting onto the LE and the radial collateral ligament (RCL) is situated beneath it ( Fig. 8.2.1C–E ). |
| Injections performed: | CSI for pain symptoms, degenerative disease and synovitis. PRP or HA injections for degenerative disease. |
| Recommended transducer: | Linear 6–15 mHz. Hockey stick 8–18 mHz. |
| Equipment required: | Equipment preparation: Set 1 for CSI or HA injections. Set 4 for PRP injections. Needle: 1- to 1.5-inch 23- or 25-gauge needle. Syringes: 3 mL for CSI. Medication: 40 mg triamcinolone (1 mL) and 1% lidocaine (1 mL) for standard CSI. Standard/available HA or PRP preparation. |
| Injection technique: | The injection can be performed using an IP approach, with the transducer in a LAX oreintation, guiding the needle from a distal to proximal position at approximately 45 degrees ( Fig. 8.2.1F–H ). It is important to ensure the bevel faces down into the joint to prevent extravasation. An OOP approach can also be used when there is considerable degenerative disease ( Fig. 8.2.1I–K ), with the transducer placed over the joint line and the needle entry perpendicular to the skin. In the latter, the needle can be seen passing vertically into the joint. |
Injections to the RCJ.
The patient can be lying supine or seated with the elbow slightly flexed to open the joint and the hand placed against the body to add further stability. The injection can be undertaken using an IP approach, from a distal-to-proximal, with the transducer in the LAX orientation. The needle tip should be seen within the RCJ.
8.2.2
Posterior joint line and posterior fat pad
| Patient position: | In the supine position, the patient can rest their palm flat on the surface of the treatment couch and with the elbow bent, they expose and open the posterior elbow ( Fig. 8.2.2A ). In the sitting position, a similar position can be used to access the area ( Fig. 8.2.2B ). Although both are somewhat awkward for the patient, by placing the palm flat, it enhances stability for the subsequent injection. |
| Identifying the anatomy: | In both patient positions, the triceps tendon can be followed in an LAX orientation to its insertion at the olecranon ( Fig. 8.2.2C–E ). Beneath this sits the posterior fat pad (PFP) and from here the posterior joint line (PJL) can be visualised. It can also be assessed in the SAX with the triceps seen in cross-section ( Fig. 8.2.2F–H ). |
| Injections performed: | CSI injections for fat pad impingement. PRP or HA injections for degenerative disease. |
| Recommended transducer: | Linear 6–15 mHz. Hockey stick 8–18 mHz. |
| Equipment required: | Equipment preparation: Set 1 for CSI or HA injections. Set 4 for PRP injections. Needle: 1- to 1.5-inch 25- or 27-gauge needle. Syringes: 3 mL for CSI. Medication: 20 mg triamcinolone (0.5 mL) and 1% lidocaine (1 mL) for standard CSI. |
| Injection technique: | The injection into the joint can be performed using an OOP approach with the transducer in the LAX and just adjacent to the medial border of the triceps tendon ( Fig. 8.2.2I–K ). Care must be taken not to take the needle into the substance of the TT. Alternatively, the transducer can be placed in the SAX over the tendon and the needle is introduced using an IP approach at approximately 45 degrees ( Fig. 8.2.2L–N ). The former is more suited to a posterior joint and the latter for a fat pad injection. In both situations it is important to be aware of the ulnar and radial nerve positions to avoid potential injury. |
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