Ultrasound-Guided Techniques
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A hockey stick transducer or small linear/shorter footprint transducer may be beneficial in areas about the hand and wrist due to the nature of the smaller anatomy.
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A gel standoff can be beneficial when doing procedures about the wrist to facilitate better needle visualization.
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As with any procedure, a knowledge of the at-risk structures and common anatomic variants with sonographic identification prior to any procedure is recommended.
Wrist Joint Injections
Pertinent Anatomy
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The wrist region is composed of three noncommunicating synovial joints: the radiocarpal joint, the midcarpal joint, and the distal radioulnar joint (DRUJ) ( Fig. 18.1 ).
Fig. 18.1
Drawing of The Wrist Joint.
Note the radiocarpal joint (green) between the radius and ulna proximally and proximal carpal row distally. Mid carpal joint (blue) lies between the proximal and distal carpal row. The distal radioulnar joint (yellow) is the articulation between the distal radius and ulna. The triangular fibrocartilage complex is the fibroligamentous construct between the distal ulna and proximal carpal row.
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The triangular fibrocartilage complex (TFCC) is a construct between the distal ulna and proximal carpal row. The TFCC is composed of fibrocartilage (meniscal homolog), flexor carpi ulnaris tendon sheath, and radioulnar ligaments, which stabilize the DRUJ. ,
Common Pathology
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Injuries to the wrist include dislocations, chronic instability/ligamentous laxity, inflammatory arthritis, and osteoarthritis.
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Prior scaphoid fractures, scapholunate or lunotriquetral ligament (LTL), and TFCC injuries may predispose to post-traumatic arthritis. , ,
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The anatomic variation of positive ulnar variance may cause abutment of the cartilage and subsequent attritional tearing/degeneration of the TFCC. ,
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Pathologic signs include osteophyte formation, cortical irregularities, articular space narrowing, joint effusions, or thickening of the synovium/synovitis. ,
Equipment
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Injections can be performed using a high-frequency linear array transducer. If available, a hockey stick or shorter footprint transducer may also be helpful.
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30 to 22 gauge, 1 to 2 inch needle.
Common Injectates
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Local anesthetics for diagnostics, corticosteroids
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Prolotherapy
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Orthobiologics (platelet-rich plasma [PRP], bone marrow concentrate, etc.)
Injectate Volume
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1 to 3 cc
Technique
Wrist Joint Injections (Radiocarpal, Midcarpal, and Distal Radioulnar Joints)
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Patient position
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A supine or seated position with the forearm fully pronated and wrist in slight flexion ( Fig. 18.2A ).
Fig. 18.2
Wrist Joint (Radiocarpal Joint [RC]).
(A) Transducer placed along the anatomic sagittal plane to optimize visualization of the RC and midcarpal joint. Black arrow represents the direction of needle when using an in plane approach from a distal to proximal direction. White arrow represents path of needle when performing an out of plane injection from ulnar to radial. (B) Needle (arrowheads) placed in plane with transducer from distal to proximal direction (black arrow 2A) . Asterisk denotes location of joint space. (C) Needle is placed out of plane with transducer from radial to ulnar direction (white arrow 2A.) , asterisk denotes location of joint space. R , Radius, S , scaphoid.
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Place the wrist on a rolled-up towel; slight wrist flexion opens up the dorsal joint recess. ,
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Clinician position
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Seated facing the wrist and ultrasound machine monitor.
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Transducer orientation
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Placing the transducer in the anatomic sagittal plane optimizes visualization of most of the wrist joints, with the exception of the DRUJ, which is best visualized in the anatomic axial plane due to its orientation (see Fig. 18.2 ).
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Radiocarpal Joint (Proximal Carpal Row)
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Transducer orientation: radiocarpal joint
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The anatomic axial plane over the dorsal radius at the level of Lister’s tubercle.
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Center the transducer over Lister’s tubercle; then visualize the radiocarpal joint by rotating the transducer 90 degrees to the anatomic sagittal plane on the longitudinal axis (see Fig. 18.2A ).
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Needle orientation
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A needle can then be inserted via an in-plane distal-to-proximal trajectory toward the joint (see Fig. 18.2B ).
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The transducer (Td) can be rotated and translated slightly to create a tendon-free region through which the needle will traverse (see Fig. 18.2B ).
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This can also be performed via an out-of-plane technique with the transducer placed in the anatomic sagittal plane centered over the radioscaphoid joint (see Fig. 18.2A and C ).
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Target
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Due to the paucity of overlying neurovascular structures and ease of access to the joint space, the radioscaphoid joint is the preferred target in an in-plane approach. ,
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Important to note that the articular hypoechoic scaphoid cartilage may not be easily visualized given the orientation.
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Midcarpal Joint Injection
The technique is like the radiocarpal joint, with the exception being the target is the dorsal recess of the midcarpal joint.
Distal Radioulnar Joint Injection
Transducer Orientation
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Centered over the DRUJ and overlying extensor digiti minimi tendon in anatomic axial orientation ( Fig. 18.3A ).
Fig. 18.3
Distal Radioulnar Joint (DRUJ) Injection.
(A) Transducer is placed along the anatomic axial plane to optimize visualization of the DRUJ. (B) Ultrasound image with needle placed (arrowheads) in plane with transducer from ulnar to radial direction (black arrow [3A]) into the dorsal recess of the joint. (C) Ultrasound image with needle placed (arrowhead) out of plane with transducer from distal to proximal ( white arrow [3A]). ECRB , Extensor carpi radialis brevis; ECRL , extensor carpi radialis longus; EDC , extensor digitorum communis; EDM , extensor digiti minimi; EPL , extensor pollicis longus; white oval encircles the posterior interosseous nerve; R , radius; U , ulna.
Needle Orientation
In plane with ulnar-to-radial approach with the tip placed in the dorsal recess of the joint (see Fig. 18.3B ).
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Alternatively, an out-of-plane technique can be used when the needle is introduced from a distal-to-proximal direction into the joint (see Fig. 18.3A ).
Target
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Joint recess.
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A slight oblique pathway of the needle may be needed to avoid placement of the needle through the overlying extensor digiti minimi tendon or the posterior interosseous nerve (PIN) (see Fig. 18.3C ).
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The location of the PIN in the fourth dorsal compartment should be identified and monitored during the injection.
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Joint aspiration may help to further delineate pathology and direct treatment for diseases such as inflammatory and crystalline arthropathies. , If one prefers to initially aspirate the joint, a larger-gauge needle, such as an 18 gauge, would be recommended.
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Reported accuracy rates of palpation-guided and ultrasound-guided injections for these regions range from 25% to 97% and 79% to 94%, respectively.
Scapholunate Ligament, Lunotriquetral Ligament, and TFCC Injections
Pertinent Anatomy
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Scapholunate ligament (SLL) and lunotriquetral ligament LTL are both composed of 3 structurally distinct parts (volar, membranous, and dorsal). The dorsal SLL is the strongest component, while the volar portion is the strongest portion in the LTL.
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The TFCC can be difficult to see in its entirety as the ulnar styloid process blocks the view. Adjacent structures include wrist ulnar collateral ligament (UCL), extensor carpi ulnaris (ECU) tendon, and sheath.
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Easily visualized structures associated with the complex include the UCL and the overlying ECU tendon sheath. , ,
Common Pathology
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There are Twenty individual ligaments in the wrist, but the SLL and TFCC are more prone to injury.
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SLL and LTL injuries occur with a fall onto an outstretched hand. This can lead to altered arthrokinematics and subsequent development of arthritis. Total disruption of the SLL and LTL can lead to instability and result in a scapholunate advanced collapse of the wrist. Acute total SLL injuries should be treated surgically.
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TFCC injuries may occur as a result of direct trauma from falls or chronic attrition associated with ulnar abutment syndrome.
Equipment
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Injections can be performed using a high-frequency linear array transducer. If available, a hockey stick or shorter footprint transducer may also be helpful.
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30 to 22 gauge, 1 to 2 inch needle
Common Injectates
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Local anesthetics for diagnostics
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Prolotherapy
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Orthobiologics (PRP, bone marrow concentrate, etc.)
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Corticosteroids should not be injected directly into a ligament or tendon.
Injectate Volume
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1 to 3 cc
Technique
Patient Position
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Supine or seated with forearm pronated and resting on table with a towel under the wrist to induce slight wrist flexion ( Fig. 18.4A ).
Fig. 18.4
Dorsal Wrist Ligament and Triangular Fibrocartilage Complex (TFCC) Injection:
(A) Transducer orientation ( black rectangle for SL and TFCC) ( dashed rectangle for lunotriquetral ligament [LTL]) axial to dorsal wrist. Black arrow, direction of needle placement from ulnar to radial. White arrow, out-of-plane needle trajectory for LTL injection. (B) Needle (arrowheads) placed into the dorsal TFCC (open arrow) . (C) Needle (arrowheads) placed into the dorsal scapholunate ligament (curved arrow) . Placement of the forearm and wrist in preparation for the dorsal wrist joint injections. Hint: A rolled towel placed under the distal forearm to cause slight wrist flexion aides in visualization of the target and needle. EDC , Extensor digitorum communis; EDM , extensor digiti minimi; L , lunate; open oval , posterior interosseous nerve; S , scaphoid; U , ulna.
Clinician Position
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Standing or seated facing the wrist and ultrasound machine monitor.
TFCC Injection
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Transducer orientation
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Anatomic axial plane over the distal ulna and radius.
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Slide the transducer distally to view the ulnar attachment of the TFCC. The transducer may need to be rotated clockwise/counterclockwise to improve visualization of the ligament (see Fig. 18.4A ).
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Needle orientation
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Use an ulnar gel standoff
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In plane
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Ulnar-to-radial direction
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Target
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Dorsal aspect of the TFCC and UCL (see Fig. 18.4B )
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Scapholunate and Lunotriquetral Ligament Injection
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Transducer Orientation
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The SLL is identified by placing the transducer in the anatomic axial plane over the distal radius and sliding the transducer distally (see Fig. 18.4A ).
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The dorsal aspect of the LTL is identified by placing the transducer in the anatomic axial plane over the distal ulna and radius and sliding distally to view the LTL.
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Needle Position
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Using an ulnar gel standoff, the SLL injection is performed via an in-plane ulnar-to-radial direction with the goal of placing the injectate in the ligament (see Fig. 18.4C ).
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The LTL injection is performed using an out-of-plane distal-to-proximal approach.
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Caution should be taken to identify and avoid the PIN located on the radial side of the fourth dorsal compartment (see Fig. 18.4C ).
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Target
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Hypoechoic or pathologic areas of the scapholunate or LTL.
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Fewer dorsal neurovascular structures are present compared to the volar wrist, but the location of the PIN on the radial side of the fourth dorsal compartment should be noted prior to any procedure using the dorsal approach.
Volar Ligaments: Radioscaphocapitate, Long Radiotriquetral, Short Radiolunate, Radioscapholunate
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This is an advanced injection that requires excellent needle visualization skills.
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Must clearly identify and avoid the median nerve, radial, and ulnar arteries.
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One does not have to specifically identify each individual ligament for injection.
Pertinent Anatomy
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The wrist ligaments are generally grouped into the intrinsic (ligaments between the carpal bones) and extrinsic (connecting carpal bone to distal radius or ulna). The volar ligaments can generally be called the palmar extrinsic capsular wrist ligaments, and specific ligaments are named for the bones they originate and insert onto. ,
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Four ligaments originate from the distal radius and attach to the carpal bones.
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The radioscaphocapitate ligament (RSCL) originates from the volar aspect of the radial styloid to approximately the middle of the scaphoid fossa.
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The long radiotriquetral ligament (LRLL), which also is known as the palmar radiolunotriquetral or the radiotriquetral ligament, originates from the volar rim of the distal radius, ulnar to the RSCL and spans the remaining part of the scaphoid fossa.
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The short radiolunate ligament (SRLL) originates from the volar ulnar aspect of the distal radius across the entire width of the lunate fossa and attaches to the radial half of the palmar cortex of the lunate.
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The radioscapholunate ligament (RSLL) (ligament of Testut and Kuenz) is located just ulnar to the LRLL and radial to the SRLL.
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Common Pathology
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Hyperextension of the wrist is a common mechanism.
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While the TFCC and SLL are the most commonly injured structure, any of the 20 wrist ligaments can be injured.
Equipment
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Injections can be performed using a high-frequency linear array transducer. If available, a hockey stick or shorter footprint transducer may also be helpful.
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30 to 25 gauge, 1 to 2 inch needle.
Common Injectates
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Local anesthetics for diagnostics
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Prolotherapy
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Orthobiologics (PRP, bone marrow concentrate, etc.)
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Corticosteroids should not be injected directly into a ligament or tendon.
Injectate Volume
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1 to 3 cc
Technique
Patient Position
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Supine, wrist supinated ( Fig. 18.5A ).
Fig. 18.5
Sonographic Images of Volar Wrist Ligament Injections.
(A) Transducer placement (black rectangle) along the volar wrist. (B) Needle placement along the volar wrist ligaments (blue rectangles) , needle (white arrows) traversing radial to ulnar. (C) Needle placement (white arrows) along the volar wrist ligaments, needle traversing ulnar to radial. FCR , Flexor carpi radialis; PL, palmar ligament; R , radius; U , ulna.
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May have a small towel roll under the wrist for slight extension to “open” the space.
Clinician Position
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Seated or standing on the side of the patient’s wrist.
Transducer Orientation
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Short axis to the wrist and carpal tunnel structures.
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Take care to angulate parallel or perpendicular to avoid anisotropy.
Needle Orientation
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The radial and ulnar approaches are necessary to target the desired ligaments.
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Radial approach: the needle will enter medial to the radial artery and radial to the median nerve (see Fig. 18.5B ).
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Ulnar approach: the needle will enter radial to ulnar neurovascular structures and medially to the median nerve (see Fig. 18.5C ).
Target
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Target the bands overlying (extrinsic ligaments) and between (intrinsic ligaments) the carpal bones.
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Redirect the needle as needed, targeting the ligaments with care to avoid the neurovascular bundle.
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Redirect proximal to target ligaments over the first proximal row and between the first carpal row and the distal radius and ulna as well.
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Be sure to always visualize needle tips and avoid the neurovascular structures.
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Variances in anatomy will determine how many of the ligaments will be accessible
Dorsal Compartments of the Wrist (1 to 6) Injection
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The first and sixth compartments are most commonly clinically involved.
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The first compartment tendons may have a separate sheath that may require separate injections to adequately resolve pain in this region.
Pertinent Anatomy
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Six compartments on the dorsal side of the wrist house the extensor tendons, and the tendons are held in place by the overlying extensor retinaculum ( Fig. 18.6 ). The compartments are numbered from lateral to medial, and contents include:
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First–abductor pollicis longus (APL) and extensor pollicis brevis (EPB)
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Second–extensor carpi radialis longus and brevis (ECRL/ECRB)
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Third–extensor pollicis longus (EPL)
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Forth–extensor digitorum and extensor indices (lies deep to digitorum) (EDC, EIP)
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Fifth–extensor digiti minimi/quinti (EDM/EDQ)
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Sixth–extensor carpi ulnaris (ECU)
Fig. 18.6
The Six Dorsal Compartments of the Wrist. (A) Transverse wrist.
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The superficial radial nerve traverses over the first dorsal compartment and divides into the SR3 and SR2 branches just proximal to the extensor retinaculum ( Fig. 18.7A and B ). The SR2 branch courses from volar to dorsal over the first compartment, often just proximal to the proximal edge of the retinaculum (see Fig. 18.7A and B ).
Fig. 18.7
Anatomy of the First Dorsal Compartment.
(A and B) Cadaveric dissection of the compartment showing the abductor pollicis longus (A) , extensor pollicis brevis (E) , retinaculum (open star) , the bifurcation of the superficial radial nerve (curved arrow) and the SR2 (open arrow) and SR3 (white arrow) branches. (C and D) Sonographic axial images of the first dorsal compartment. Note the SR2 (white oval) and SR3 (yellow oval) . R, Radius; V, adjacent cephalic vein.
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The cephalic vein has a branch that is typically located over or slightly dorsal to the first dorsal compartment (see Fig. 18.7D ).
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The first compartment can be divided into separate synovial sheaths and compartments for the APL and EPB tendons by an intra-compartment septum in up to 33% of patients. Implications include isolated tenosynovitis of the EPB or APL and may be clinically significant for the treatment of de Quervain’s syndrome (see Fig. 18.7B and C ).
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The APL tendon often has multiple slips, which can be mistaken as longitudinal split tearing. ,
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Anatomic variations may also be seen in the second dorsal compartment, such as the extensor carpi radialis intermedius, which should not be mistaken for a longitudinal split tear.
Common Pathology
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Stenosing tenosynovitis most commonly involves the first (de Quervain’s syndrome) and sixth dorsal compartments. ,
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The mechanism of action is believed to be repetitive microtrauma related to occupation or sporting activities at the distal radial styloid, causing degeneration and inflammation in the APL and EPB tendons. ,
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Tenosynovitis is seen more commonly in those with diabetes mellitus or autoimmune conditions such as rheumatoid arthritis. , ,
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The first compartment crossing over the second (proximal intersection syndrome) and the third compartment crossing over the second (distal intersection syndrome) can be other areas of pathology.
Equipment
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High-frequency linear array transducer.
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Smaller footprint or hockey stick probes may be easier to use.
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30 to 25 gauge, 1 to 2 inch needle.
Common Injectates
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Local anesthetics for diagnostics, corticosteroids into tendon sheaths only
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Prolotherapy
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Orthobiologics (PRP, bone marrow concentrate, etc.)
Injectate Volume
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1 to 2 cc
Technique
Patient Position
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First to second compartments: Seated or supine on the table with the forearm in neutral position (thumb pointed upward) for ( Fig. 18.8A and B ).
Fig. 18.8
Transducer Placement and Sonographic Images of The Six Dorsal Compartments.
(A and B) Compartments 1–3, (C and D) Compartments 3–5, (E and F) 6th compartment. A, abductor pollicis longus; E, extensor pollicis brevis; EM, extensor digiti minimi; ECU, extensor carpi ulnaris; EDC , Extensor digitorum; EPL , extensor pollicis longus; R , radius.
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Third and fifth compartments: Seated or supine on the table with the forearm pronated (see Fig. 18.8C and D ).
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Sixth compartment: Supine with the forearm pronated over a pillow on the chest (see Fig. 18.8E and F ).
Clinician Position
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Seated or standing on the side of the patient’s wrist.
Transducer Orientation
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The anatomic axial plane, short axis relative to the desired tendon (in-plane technique) ( Fig. 18.9A and B ).
Fig. 18.9
Injection Technique for First Dorsal Compartment.
(A) Transducer placement (black rectangle) ; in-plane approach, black arrow , out-of-plane approach, white arrow . (B) Sonographic image of in-plane injection, needle (arrowheads) placed deep to the abductor pollicis longus (A) and extensor pollicis brevis (E ) tendons. (C) Sonographic image of out-of plane approach; note hyperechoic needle tip (arrowhead) superficial to the tendons. Yellow oval, SR2; white oval, SR3; V, cephalic vein; I , radius.
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Alternative position: sagittal to the long axis of the distal forearm/tendon (in or out-of-plane technique) (see Fig. 18.9A and C ).
Needle Orientation
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The needle is introduced via an ulnar-to-radial, radial-to-ulnar, or in the case of the ECU tendon volar-to-dorsal or dorsal-to volar direction.
Target
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Tendon sheath of EPB/APL
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If using prolotherapy or orthobiologics, inject directly into the tendon
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