Ultrasound Guided Procedures - SD

Introduction

I am Jenna Goyle.
I'm a rheumatologist in private practice.
I am associated with Ratan Bay Medical Center, Perham,
New Jersey, and Robert Wood Johnson University Medical
School in New Brunswick.
I am a practicing rheumatologist
and have an interest in musculoskeletal ultrasound.
Have been doing ultrasound
of the musculoskeletal areas for about seven years.

Topic Overview

Okay, what I'm gonna talk about today,
I'm gonna talk about some of the techniques which I use
to guide injections under ultrasound guide.

Disclosures

These Are some of my disclosures.
I'm a consultant for SCY
and also work as an instructor for Abbott.

Key References

These are some of the key references pertaining to my talk.

Ultrasound Guided Injection Techniques

Now these are some of the techniques
of ultrasound guided injections.
There are many different techniques which can be used
for joint and soft tissue injections,
but the technique selection depends upon the equipment
location of the target lesions
and also on the experience
of the physician who's performing the technique.
But for a safe
and accurate injection, you need to have a sound knowledge
of gross anatomy and surface anatomy
and also the knowledge of ultrasound beam.
This is what the ultrasound beam looks like
and this is how your image will look like.
You have ultrasound beam, which is three dimensional,
has lateral axial
and elevational dimensions, whereas you will only see
lateral and axial dimensions on your image.

Commonly Used Needle Insertion Techniques

Now these are some of the commonly used ultrasound guided
needle insertion techniques.
There are two main techniques.
One is called the direct method
and other is called an indirect method.
Again, under the direct method you could use two techniques.
One is called in plane and the other is out of plane.
And in an indirect method, you could use a technique
By marking the borders of your target lesions
or you could use a paperclip to really direct the to
to mark the point of entry for your needle.

In-Plane Needle Insertion

Here in this video clip,
you're seeing a needle being inserted
an in plane approach
and you see the needle as an echogenic band.
So here is the in plane needle insertion technique.
Here you see the relationship of my needle
to the transducer face.
And here you're seeing the needle being directed under the
transducer in a direct in plane technique.
This is what you will see in your two dimensional image,
a needle seen as an echogenic band.
And this is the relationship of your needle
to your ultrasound beam.
The needle is right in the center of your ultrasound beam.
Here is a video clip which is
demonstrating the direct technique for needle insertion.
Under ultrasound guide, here's a needle going
directly into the radiocarpal joint
and seen as an echogenic band.
So this happens to be the wrist joint being injected under
direct ultrasound technique.

Out-of-Plane Needle Insertion

Here is the out of plane needle insertion technique.
Some of the details, this is the relationship of your needle
to the transducer face.
And here is needle being inserted out of plane.
And this is what you see on your screen and echogenic dart.
And this is the relationship of your needle
to the sound beam.
Here is a video clip. This happens to be the knee joint.
Here is a needle shown as an echogenic dart
and filling the supra patellar recess of the knee joint.

Needle Versus Structure Orientation

Now relationship of needle to the structure.
So needle versus structure orientation,
you could have two kinds of orientation.
One is a long axis to the structure.
Here is the long axis to the structure.
Here is the short axis
of the structure related to the needle.

Needle Versus Sound Beam Angle

Now needle versus sound beam angle very important
for the visualization of the needle.
If the needle is parallel to the transducer face,
it'll be seen better.
But if it is perpendicular
to the sound beam, you will not see it.
So as the angle increases, the visualization
of the needle will decrease.
So you will try to keep the needle as parallel
to the transducer face as possible
to properly see the needle.

Problems with Needle Visualization

So what is the problem with this picture?
You don't see the needle. Why don't you see the needle?
The reason is needle is going almost parallel,
almost perpendicular to the transducer face.
And the sound beam will not be hitting to this needle
and you will not have any reflection from the needle
and you will not see the needle.
What you do, you adjust needle to the sound beam angle.
So increase the angle of the needle
or use a different approach.
What is a different approach you could use?
You could use a software which is helping to see the needle.
Here you see there is a needle which is going into the
glenohumeral joint and you barely see the needle,
but you could see it clearly getting into
the glenohumeral joint.
On the other side here you see a software which helps to
make needle more visible.
So you're seeing the same needle getting into the glenohumeral joint and clearly
far better visible than the needle you have
without this software.
Here is another problem with seeing the needle.
You're saying I cannot see the needle,
but if your transducer is tilted away from your needle,
then you will not be able to see the needle
because sound beam is not hitting your needle.
So in this situation, what you'll have to do,
either you will have to adjust your needle angle
to the transducer or you use a needle guide.

Tips for Needle Insertion

In a nutshell, the tips for needle insertion,
you must anchor your transducer.
To avoid sliding, you must make sure
that your transducer is very steady.
Learn to scan with a non-dominant hand penetrate skin
and insert the needle for about one centimeter.
Before you advance it, Find the needle
and pay careful attention to the needle tip.
Please do not advance the needle.
If you do not see the needle tip
and never try to move both needle
and transducer together, you will never find the needle.

Common Procedures Under Ultrasound Guidance

So let's get ready to do some procedures
and I will show you some
of the common procedures which I perform
under ultrasound guide.
I will not be showing you anatomical details,
but I will try to show you the
insertion area of injection in some of the anatomical areas.
So, but before I begin,
you must perform a full sonographic examination to identify
and define your target and choose shortest
and the safest route.
Mark the site of needle insertion
with a blunt object like the tip of a ballpoint pen.
Select a proper transducer and needle
and do not forget to maintain aseptic precautions.

Carpal Tunnel Injection

Here's a carpal tunnel injection.
This is the ultrasound view of the carpal tunnel.
Here you see this is the FCR tendon.
What I usually do, I will go over the FCR tendon
and direct my needle in a space between the median nerve
and the flexor digitorum superficialis tendon
and deposit the medication between two areas.
Here is the picture how I perform this.

Wrist Joint Injection

Here's the wrist joint injection.
You see the patient positioning here
and here you see the radius lunate and capitate.
Here is a needle which is being
directed into the radiocarpal joint under a direct method.
Here is my radiocarpal joint
and here is the needle performing the injection.

Tendon Sheath Injection of a Flexor Tendon

The tendon sheath injection of a flexor tendon.
This is the patient positioning.
Here's the needle going parallel
to the tendon right under the A one pulley.
So once I reach under the A one pulley, I inject
and you clearly see the spread of the entire
material around the tendon.

First CMC Joint Injection

The first CMC joint injection,
I usually a longitudinal in plane approach.
You could go from proximal to distal.
Here your metacarpal here is the carpal bones.
I'm going from proximal direction to distal direction
into the first CMC joint.
On the other hand, you could use a different approach.
You could go over first metacarpal from
distal to proximal.
Here I'm approaching this joint from distal to proximal
and here is a needle into the first CMC joint
and my injection into the joint.

MCP Joint Injection

Again, MCP joint injection.
Similarly, there are two approaches proximal to distal
and distal to proximal.
Here is the approach from distal to proximal.
Here is your metacarpal and here is your phalanx.
And on the other hand, this is an approach from
proximal to distal.
Here is the phalanx. Here is your metacarpal.

De Quervain's Tenosynovitis Injection

Now de Quervain's tenosynovitis you must scan
before, must make sure that you define your de Quervain's
because sometimes there could be a septum dividing these two
tendons and the pathology may be involving only
one tendon.
So you must direct your injection into that.
This is the technique I go
right under the extensor retinaculum,
right on the tendon here is my needle right under the
extensor retinaculum.
And here is the needle
carefully injecting right over the top of the tendon.

Elbow Joint Injection

The elbow joint injection.
So there are two approaches you could have elbow joint,
you could approach it from posterior
or you could approach from anterior.
And here is the approach from the posterior angle.
Usually from the posterior angle.
I would inject from lateral side, not from the medial.
The reason behind because the ulnar nerve is close right on
the medial side of the triceps.
And here is the injection getting into the lateral recess.
This is the needle proceeding into the lateral recess.
Once I reach there and carefully deposit my medication into
that lateral recess.
This is the anterior approach.
I'm approaching this anterior recess here.
Happens to be your humerus, a radial head anterior recess.
Here is the radial fossa
and here's my needle anteriorly getting into that
humero-radial joint and injecting the medication.

Tennis Elbow Injections

Tennis elbow injections.
So What I usually do,
this is the position I put the patient in
and define my extensor common tendon insertion.
I go at the insertion of the common extensor tendon.
Here is the needle getting into the common extensor tendon.
And I will inject right at the origin
of the common extensor tendon.

AC Joint Injection

AC joint injection.
The I proceed from lateral to medial in plane approach.
Here is the needle going from lateral to medial
with an in plane approach
and injecting.

Biceps Tendon Sheath Injection

Biceps tendon sheath injection.
So biceps tendon sheath injection, you could go from proximal
to distal or distal to proximal.
Here is from distal to proximal rear biceps tendon.
Here was your needle getting into the
pathological area in the tendon sheath
and injecting the medication.

Shoulder Joint Injection

The shoulder joint injection,
usually I take the posterior approach
for the shoulder joint injection.
The needle is inserted through the
myotendinous junction into the glenohumeral joint.
Here is the needle getting into the glenohumeral joint.
And this is my patient position.

Subdeltoid Subacromial Bursa Injection

Subdeltoid subacromial bursa injection.
Here is my subdeltoid subacromial bursa.
Here is the peribursal echogenic fat,
which defines my subacromial subdeltoid bursa.
And here is the acromion and here is your deltoid.
What I do is I go from lateral to medial, carefully
entering the subdeltoid bursa and injecting
and watching the whole material getting
and spreading the sub bursa.

Lower Extremity Procedures

Let's look at the lower extremity.

Hip Joint Injection

The hip joint injection.
So hip joint injection could be very challenging
and very rewarding.
And this is a anatomical image of the hip joint.
You see this, this is your anterior superior iliac spine
pubic crest, and inguinal ligament,
the hip joint usually is almost in the middle
of the inguinal ligament, about two centimeter
below the inguinal ligament.
So I will place my transducer on the femoral neck,
almost in the middle of the inguinal ligament
and then go from distal to proximal
and inject into the anterior recess
of the hip joint capsule.
As in this video
here is the iliopsoas bursa injection could be
very rewarding also.
This was the iliopsoas bursa, which was
distended in a patient with rheumatoid arthritis.
So have taken an approach from lateral to medial.
And the transducer placed in the location of the hip joint
and the needle is inserted in a in plane approach.

Trochanteric Bursa Injection

Trochanteric bursa injection.
This is my trochanteric bursa.
I see this gluteus medius tendon insertion
and the bursa underneath.
So I take my approach from medial from, sorry, from distal
to proximal or proximal to distal.
In this situation, I'm going from proximal to distal
and proximal to distal.
Here's the muscle, here's the hand.

Knee Joint Injection

The knee joint injection.
There's so many approaches for knee joint injections
that everybody use a different approach.
So the some of the approaches which I have used,
I usually use a lateral approach.
Usually a longitudinal out of plane approach is my favorite
and it transducer in plane approach.
And you could use approaches go through the rectus femoris
and medial collateral ligament.
And some people do use in lateral approach,
which I have never used.
Here is a longitudinal approach.
You see this positioning of the transducer,
but the needle is out of plane.
You're seeing that needle just as a dot.
But here is the suprapatellar recess.
You see the suprapatellar recess being filled
with the material.
Clearly this is
a transverse approach again in plane.
So I'm trying to aspirate the fluid from this SPR recess.
But if there is no fluid, I usually use
the out of plane approach.
Here is approach to the MCL.
Here is a medial collateral ligament.
Here is a medial meniscus.
So I go right under the medial meniscus at the attachment,
sorry, right under the
medial collateral ligament at the attachment of the MCL
to the capsule and inject.
So you clearly will see the material here is the needle
and you will clearly see at the junction
the medication being deposited in the knee joint.
Here is the medication.
Here is an approach from the rectus femoris.
Lateral is basically the approach which we usually use for the blind injection.
But I use my transducer
to look at the position of my needle.
And here is the needle getting into the knee joint for my proper injection.

Anserine Bursa Injection

Anserine bursa injection. First I define my anserine bursa
and go on the longitudinal plane of the anserine bursa
and direct my needle in plane into the bursa for injection.
Here's the needle in plane approach into the
bursa.

Baker's Cyst Aspiration and Injection

The baker cyst is very easy to do.
People are sometimes concerned about the vessels,
but once the baker cyst is full,
it becomes very superficial.
Just under the skin. Here is skin. Here's the baker cyst.
Here's the needle into the baker cyst.
Aspirating the entire baker cyst under ultrasound
guide blindly.
I sometimes may not be able to see where exactly it is here.
The baker cyst is completely filled.

Ankle Joint Aspiration and Injection

Is the ankle joint as aspiration
and injection, somebody had a fluid in the ankle joint.
This is my patient positioning.
And this is the needle which is being directed under
direct approach in plane into the ankle joint
Fluid.

Retrocalcaneal Bursa Injection

Retrocalcaneal bursa injection.
You could use both in plane or out of plane.
Here is the retrocalcaneal bursa being injected out of plane.
Here is a transducer. Here's the needle getting out.
Lung shown as a small dart
and injecting clearly into the retrocalcaneal bursa.

First MTP Joint Injection

The first MTP joint injection very common in my practice.
I see a lot of people with gout.
So I could go from proximal to distal, distal to proximal.
Here is an injection from distal to proximal,
getting into the recess of the joint
and depositing the medication right into the joint recess.
And make a note that in the
small joints you will see the capsule, which expands
and is distended proximally.
So you do not need to put the needle in between the bones.
Once you are in the capsule, you are at the right spot
for the injection.