Ultrasound-guided Musculoskeletal
Procedures
,UCA -ARIA 3CONFIENZA s 'IOVANNI 3ERAFINI
%NZO 3ILVESTRI
Editors
Ultrasound-guided
Musculoskeletal
Procedures
The Upper Limb
Editors
Luca Maria Sconfienza
Radiology Unit
IRCCS Policlinico San Donato
San Donato Milanese (MI), Italy
Enzo Silvestri
Radiology Unit
Ospedale Evangelico Internazionale
Genoa, Italy
Giovanni Serafini
Diagnostic Imaging Department
Ospedale S. Corona
Pietra Ligure (SV), Italy
ISBN 978-88-470-2741-1
ISBN 978-88-470-2742-8 (eBook)
DOI 10.1007/978-88-470-2742-8
Springer Milan Dordrecht Heidelberg London New York
Library of Congress Control Number: 2012939782
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Preface
Ultrasound is an emergent imaging modality that is widely used to assess
disorders affecting the musculoskeletal system. Among its many features,
it is the only imaging modality that is able to perform dynamic evaluations
of the soft tissues related to the musculoskeletal system, and without patient
exposure to ionizing radiation. Also, in expert hands, ultrasound enables the
precise guidance of needles within soft tissues and joints, for use in a wide
range of procedures.
The idea of preparing a handbook was based on the frequent requests of
our colleagues in other fields who were interested in learning ultrasoundguided procedures as applied to the musculoskeletal system. This text is extremely practical, offering point-by-point checklists for each procedure together with detailed anatomic schemes. Ultrasound images of the different
applications are provided as well.
We would also like to emphasize that this handbook is based both on
our daily experience and on data obtained from the literature. It therefore
describes different approaches for the same procedure, allowing the reader to
select the most suitable for the particular application.
Even though not all procedures are specifically included in the contents,
readers should be able to extrapolate the appropriate ultrasound-guided technique for use in other anatomic districts.
Finally, we acknowledge the work of our young colleagues, Alice Arcidiacono, Angelo Corazza, and Francesca Nosenzo, whose inputs were an
invaluable contribution to this book.
May 2012
Luca Maria Sconfienza
Giovanni Serafini
Enzo Silvestri
V
Contents
1
General Aspects of US-guided Musculoskeletal Procedures
Armando Conchiglia, Lorenzo Maria Gregori, Luigi Zugaro
and Carlo Masciocchi
1
Part I The Shoulder
2
The Shoulder: Focused US Anatomy and Examination
Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Enzo Silvestri and Davide Orlandi
13
3
Subacromial-Subdeltoid Bursa Injections . . . . . . . . . . . . . . . .
Enzo Silvestri
25
4
Treament of Calcific Tendinitis of the Rotator Cuff . . . . . . . .
Giovanni Serafini and Luca Maria Sconfienza
29
5
Calcific Enthesopathy Dry-Needling . . . . . . . . . . . . . . . . . . . .
Francesca Lacelli
37
6
Hyaluronic Supplementation of the Subacromial Space . . . .
Giovanni Serafini
41
7
Intra-articular Injections . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Francesca Lacelli
45
8
Long Head of the Biceps Brachii Tendon Injection . . . . . . . .
Luca Maria Sconfienza
51
9
Acromioclavicular Joint Injection . . . . . . . . . . . . . . . . . . . . . .
Enzo Silvestri
55
VII
VIII
Contents
Part II The Elbow
10
The Elbow: Focused US Anatomy and Examination
Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Enzo Silvestri and Emanuele Fabbro
61
11
Treatment of Lateral Epicondylitis . . . . . . . . . . . . . . . . . . . . .
Giovanni Serafini
67
12
Treatment of Medial Epicondylitis . . . . . . . . . . . . . . . . . . . . .
Enzo Silvestri
73
13
Olecranon Bursa Drainage . . . . . . . . . . . . . . . . . . . . . . . . . . .
Francesca Lacelli
79
14
Intra-articular Injections . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Luca Maria Sconfienza
83
Part III The Wrist
15
16
The Wrist: Focused US Anatomy and Examination
Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Enzo Silvestri and Giulio Ferrero
89
Treament of De Quervain’s Disease and Other Forms
of Tenosynovitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Giovanni Serafini
93
17
Articular Ganglia Drainage . . . . . . . . . . . . . . . . . . . . . . . . . . .
Leonardo Callegari
97
18
Trapeziometacarpal Joint Injection . . . . . . . . . . . . . . . . . . . .
Francesca Lacelli
101
19
Radiocarpal Joint Injections . . . . . . . . . . . . . . . . . . . . . . . . . .
Luca Maria Sconfienza
105
Contents
ix
Part IV The Hand
20
The Hand: Focused US Anatomy and Examination
Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Francesca Lacelli and Chiara Martini
111
21
Treatment of Trigger Finger . . . . . . . . . . . . . . . . . . . . . . . . . .
Leonardo Callegari
113
22
Intra-articular Injections: Metacarpophalangeal
and Interphalangeal Joints . . . . . . . . . . . . . . . . . . . . . . . . . . .
Luca Maria Sconfienza
119
Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
121
Contributors
Alice Arcidiacono Post-graduate School in Radiodiagnostics, University
of Genoa, School of Medicine, Genoa, Italy
Leonardo Callegari Radiology Unit B, Ospedale di Circolo, Fondazione
Macchi, Varese, Italy
Armando Conchiglia Radiology Department, Ospedale San Salvatore,
University of L’Aquila, L’Aquila, Italy
Angelo Corazza Post-graduate School in Radiodiagnostics, University of
Genoa, School of Medicine, Genoa, Italy
Emanuele Fabbro Post-graduate School in Radiodiagnostics, University
of Genoa, School of Medicine, Genoa, Italy
Giulio Ferrero Post-graduate School in Radiodiagnostics, University of
Genoa, School of Medicine, Genoa, Italy
Lorenzo Maria Gregori Radiology Department, Ospedale San Salvatore,
University of L’Aquila, L’Aquila, Italy
Francesca Lacelli Diagnostic Imaging Department, Ospedale S. Corona,
ASL 2 Savonese, Pietra Ligure (SV), Italy
Chiara Martini Post-graduate School in Radiodiagnostics, University of
Genoa, School of Medicine, Genoa, Italy
Carlo Masciocchi Radiology Department, Ospedale San Salvatore,
University of L’Aquila, L’Aquila, Italy
Francesca Nosenzo Post-graduate School in Radiodiagnostics, University
of Genoa, School of Medicine, Genoa, Italy
Davide Orlandi Post-graduate School in Radiodiagnostics, University of
Genoa, School of Medicine, Genoa, Italy
xi
xii
Contributors
Luca Maria Sconfienza Radiology Unit, IRCCS Policlinico San Donato,
San Donato Milanese (MI), Italy
Giovanni Serafini Diagnostic Imaging Department, Ospedale S. Corona,
ASL 2 Savonese, Pietra Ligure (SV), Italy
Enzo Silvestri
Genoa, Italy
Radiology Unit, Ospedale Evangelico Internazionale,
Luigi Zugaro Radiology Department, Ospedale San Salvatore, University
of L’Aquila, L’Aquila, Italy
1
General Aspects of US-guided
Musculoskeletal Procedures
Armando Conchiglia, Lorenzo Maria Gregori,
Luigi Zugaro and Carlo Masciocchi
Ultrasonography (US) is a quick and non-invasive imaging modality that allows for the precise
visualization of almost all soft-tissue components
of the musculoskeletal system. Moreover, this
modality also enables accurate guidance during
interventional procedures, thus reducing the risks
of complications. As US is relatively operatordependent, an effective scanning technique is
strictly correlated with the ability to delineate
US appearances. If clinical knowledge is the basic requirement for any diagnostic or therapeutic
process, then US-guided interventional procedures analogously require thorough knowledge
of the equipment being used. Also good technical skills are needed in order to extract the maximum amount of information that can be obtained
with the available equipment, while avoiding the
numerous pitfalls and artifacts of this imaging
modality.
Setting
Room
A proper setting for the room used in the interventional procedures is a prerequisite in ensur-
ing high safety standards together with a smooth
workflow.
The suggested structural requirements are the
following:
• The rooms and spaces are related to the nature and extent of the activities performed.
The minimum clearance should be 4 m, with
a 1.5-m clearance around the bed
• Chamber of observation
• Medical staff preparation area
• Storage area for clean material
• Disposal area for soiled material
• Waiting area
• Toilet and sink for patients
• Toilet and sink for medical staff.
The suggested technical requirements are the
following:
• Adjustable (height and angular adjustments)
surgical bed
• Ventilation system capable of maintaining a
constant air exchange within the room
• Adjustable lighting system illuminating the
surgical field
• Medical gas pipeline systems
• Emergency trolley
• Emergency call system.
US System
Luigi Zugaro ( )
Radiology Department
Ospedale S. Salvatore, University of l’Aquila
L’Aquila, Italy
While choosing the right US system can be extremely challenging, an informed and useful
choice is more likely if the purchaser has a clear
L.M. Sconfienza, G. Serafini, E. Silvestri (eds.), Ultrasound-guided Musculoskeletal Procedures,
DOI 10.1007/978-88-470-2741-1_1 © Springer-Verlag Italia 2012
1
2
concept of the US-guided interventional procedures that will be performed.
In general, the basic requirements for dedicated interventional US equipment are:
Ergonomics
• System dimensions and steering. The system
should be portable, allowing for transportation to remote clinics or for operating-theater
work. Machines used regularly for mobile
work should be robust and easy to move.
Hand-held portable machines are an option.
• Moveable (swivel and tilt) monitor and control panel, including height adjustment for
different operators and situations.
• Keyboard design facilitating access to the required functions, without the need for stretching or twisting.
Materials
• Long-lasting materials with high resistance to
common antiseptics
• Smooth surfaces that can be easily and quickly cleaned.
Technical Requirements
• Quick probe selection and switching process,
simultaneous connection of several probes
• Dynamic frequency capability
• Dynamic focusing control, number and pattern of focal zones
• Functions such as beam steering, sector angle
adjustment, zoom, frame rate adjustment.
Probes
• High-frequency linear-array probes, operating with frequencies of 10 MHz or more, are
mandatory
• Compatibility with US guidance devices
• Ergonomic handle shape to preserve a neutral
wrist position
• Probe design allowing use with either hand.
US-guided Procedures
Prior to any interventional procedure, a preliminary US evaluation of the affected site should be
A. Conchiglia et al.
performed in order to identify the most reliable
procedure setting and to confirm the expected
findings. This is extremely important because
the patient’s condition may have changed since
the previous examination, necessitating different
treatment.
Clinical History
It is important to have at least basic information
on the patient’s medical history. A brief preliminary talk, covering the following items, should
be held with the patient or his/her physician:
• Present complaint(s)
• History of the present complaint(s)
• Past medical history
• Drug/allergy history
• Family medical history
• Personal and social history
• Systems review.
In general, the three most urgent considerations that must be carefully assessed before any
US-guided interventional procedure are:
• The presence of blood-thinning pathologies
or the use of blood-thinning drugs that could
cause severe bleeding during and after the
procedure
• The presence of drugs allergies
• The presence of diabetes, which is a contraindication for steroid use.
Explanation of Contraindications
to the Interventional Procedure and
Informed Consent
Despite the minimal invasiveness of the interventional procedures described in this book, the
patient must be provided with an accurate explanation of the possible contraindications related to
the planned procedure. Although the complication rate associated with these procedures is extremely low, patients should be aware that their
occurrence cannot be ruled out entirely. The subjects that must be clearly explained to the patient
are the following:
• Pain/soreness during the procedure
1 General Aspects of US-guided Musculoskeletal Procedures
• Pain/soreness after the procedure and the possibility of steroid flare
• Potential risk of joint infection
• Potential risk of tendon rupture.
After receiving this information, the patient
must formally agree to the procedure by providing both verbal and written informed consent.
Antisepsis
All US-guided interventional procedures must
be performed with aseptic techniques in order
to avoid any risk of contamination by infectious
organisms (bacteria, fungi, viruses) or other disease-causing microorganisms.
The cornerstones of a safe US-guided interventional procedure are:
• Antisepsis: transient microorganisms are
removed from the skin using chemical solutions for disinfection.
• Aseptic non-touch technique: ANTT minimizes the risk of infection by ensuring that
only uncontaminated objects/fluids make
contact with sterile/susceptible sites. The
only part of sterile equipment that may be
handled is that which will not be exposed to
the susceptible site. Re-useable equipment
employed during an aseptic procedure should
be cleaned with wipes and must be fit for purpose, e.g., a steel dressing trolley for dressing changes. All packs/single-use equipment,
e.g., dressing packs, cannula packs, and syringe packs, must be intact, with a still-valid
expiration date, and without visible signs of
contamination.
• Operator sterility: accurate and effective hand
hygiene is the most important component of
good infection prevention and control, given
that the hands are a common route of infection transmission. Transient bacteria can be
removed by effective hand hygiene techniques, e.g., by washing the hands with an
antimicrobial liquid soap and water, or by using an alcohol-based hand rub. Sterile gloves,
coats and hats are mandatory.
• Probe antisepsis: the US probe and probe
wire are swiped with dedicated antiseptic tis-
3
sues; if required for the procedure, a sterile
probe cover is used.
• Patient antisepsis: the skin cannot be “sterilized” but certain chemical preparations
reduce microbial levels. Our antisepsis procedure is composed of a first step in which
a brown water-based povidone-iodine solution is used to mark the treated area and after
3–5 min (sufficient to let the antiseptic act),
in the second step, a transparent solution of
70% isopropyl alcohol and 2% chlorhexidine
is applied that disinfects by denaturing proteins and disrupting the cell wall of microorganisms in addition to being bactericidal and
long-acting. Both steps are recommended for
adequate skin decontamination prior to the
insertion of an invasive device.
• Surgical field: delimitation of the area to be
operated on is performed by the operator using sterile technique, including adhesive sterile towels.
• US contact gel: conventional US contact gel
should not be used for aseptic US-guided
procedures. However, contact gel is not generally used in short procedures (e.g., simple
injections). For longer procedures, sterile
contact gel can be applied.
Needles and Syringes
The wide range of different interventional procedures implies the use of several different kinds
of needles.
Needles of different diameters (measured in
gauges, G; the lower the number, the higher the
diameter) and lengths (measured in millimeters)
are used for all procedures:
• Superficial procedures are generally performed using thin (26–32G) and short (2–5
cm) needles.
• Procedures that require the aspiration of
dense collections, such as ganglions or calcifications, are performed using larger (14–
16G) needles. Needle length is strictly related
to the depth of the target.
• Spinal needles are used for deep locations,
such as hip joints or in obese patients. The
4
A. Conchiglia et al.
most common spinal needles used in these
procedures are 9–12 cm and 16–22G.
Syringes come with a number of designs for
the area where the blade locks to the syringe
body. Our preference is to use slip tip syringes
as they are easiest to connect to the needle for
all procedures that do not involve high pressure;
in that case, we use Luer-lock ones which assure
a screw lock mechanism by simply twisting syringe and needle together. The choice of syringe
size strictly depends on the amount of fluid to inject/drain.
For the most common upper limb procedures,
we recommend the following:
• 1–2 ml: used around the hand/wrist for very
small joint injections (MCP, PIP, DIP) and
for the treatment of trigger finger and tenosynovitis.
• 5–10 ml: used to inject sub-acromial bursa,
the drainage of small collections, and to drain
tennis/golfer’s elbow.
• 20 ml: used for calcification lavage and aspiration, or the evacuation of fluid collections.
How Is the Needle Inserted?
Guidance of the needle under US can be
performed with either the lateral or co-axial
approach. In the former, the needle is kept perpendicular to the US beam and is inserted on
the short side of the probe. In the latter, the
needle is inserted on the long side of the probe,
parallel to the US beam. The lateral approach
has the advantage of excellent visibility of
the needle, which, however, crosses a larger
amount of tissue before reaching the target
than is the case with the co-axial approach.
On the other hand, the coaxial approach is
burdened by a reduced needle visibility, but it
can be used when the space around the target
is greatly restricted. However, adequate experience is needed to achieve satisfactory results
(Fig. 1.1a-b).
a
b
Fig. 1.1 a In US-guided lateral approach the
needle is inserted on the short side of the probe
allowing for an excellent visibility. b In USguided coaxial approach the needle is inserted on
the long side of the probe, allowing for a reduced
path in soft tissues but a poor visibility
1 General Aspects of US-guided Musculoskeletal Procedures
Drugs
Local Anesthetics
The important role played by local anesthetics
is due to their ability to interrupt neural conduction, by inhibiting the influx of sodium ions. In
most cases, this inhibitory activity follows their
diffusion through the neural membrane into
the axoplasm, where they enter sodium channels. The local anesthetic molecule consists of
three components, a lipophilic aromatic ring,
an intermediate ester or amide chain, and a terminal amine, each of which confers distinct
properties to the molecule. The aromatic ring
improves the lipid solubility of the compound,
which in turn enhances diffusion through both
nerve sheaths and the neural membranes of the
individual axons comprising a nerve trunk. This
property correlates with drug power, as a greater
portion of an administered dose thereby enters
neurons.
US-guided interventional procedures usually
require local anesthesia to minimize pain and
discomfort. The type and amount of anesthetic
used depends largely on the procedure itself
and the involved anatomical location.
Fast-acting local anesthetics, such as a 100
mg/5 ml lidocaine solution (2%), are injected
with a small needle around and within the area
to be treated. Patients will initially experience a
brief stinging sensation related to the needle and
the anesthetic being introduced; bicarbonates
buffering significantly reduces this type of sensation. Within seconds, typically, the area becomes
numb. Lidocaine solutions are also an option for
US-guided diagnostic nerve blocks, with the anesthetic injected around the nerve over the level
of the suspected pathology.
Long-acting local anesthetics, such as a 25
mg/10 ml bupivacaine hydrochloride solution
(0.25%), are injected in association with corticosteroids for local relief at sites of musculoskeletal discomfort (articular and extra-articular) and
for therapeutic nerve blocks.
5
Adverse Effects
The patient may experience temporary side effects after local anesthetic administration, but persistent problems are rare. Side effects can include:
• Numbness of the tongue
• Dizziness
• Blurred vision
• Muscle twitching
Local anesthetics depress the central nervous
system in a dose-dependent manner. Convulsive
seizures are the principal life-threatening consequence of an overdose. Evidence of lidocaine
toxicity may occur at concentrations of 5 g/ml,
but convulsive seizures not until 8 g/ml. In addition to neural blockade, the peripheral actions
of most local anesthetics include varying degrees
of vasodilation, which in turn contributes to the
hypotension observed after the administration of
larger doses. It must be borne in mind that, as
central nervous system depressants, local anesthetics potentiate any respiratory depression associated with the use of sedatives and opioids.
Contrary to conventional thought, doses calculated as mg/years of age or mg/kg body weight do
not predict the systemic serum concentration of
the local anesthetic. Furthermore, considerations
of the toxicity of any drug class must include the
activity of not only the drug but also its metabolites. Local anesthetics are no exception.
It is not unusual for patients to claim that
they are allergic to local anesthetics. Upon careful questioning, however, it becomes apparent
that what they experienced was either a syncopal
episode associated with the injection or cardiac
palpitations attributed to epinephrine either contained in the solution or released endogenously.
Although rare, allergic reactions to local anesthetics have been reported in the scientific literature, but in none of these cases was there a confirmed IgE-mediated hypersensitivity reaction.
Nevertheless, patients have occasionally experienced symptoms consistent with an allergic reaction to amide local anesthetics. These episodes
generally have been attributed to the preservatives (methylparaben) or antioxidants (bisulfites)
contained in the solution.
6
Corticosteroids
Inflammation is one of the body’s first reactions to
injury. The increase in local blood flow transports
polymorphonuclear leukocytes, macrophages,
and plasma proteins to the injured area, where a redistribution of arteriolar flow produces stasis and
hypoxia at the injury site. The resulting infiltration of the affected tissues by leukocytes, plasma
proteins, and fluid causes the redness, swelling,
and pain that are characteristic of inflammation.
The causes of inflammatory muscle and joint
injuries including:
• Degenerative joint disease
• Tendinopathy
• Bursitis
• Arthritis
• Trauma.
Initially, the inflammatory reaction serves
several important purposes. For example, the
influx of leukocytes facilitates phagocytosis, allowing the removal of damaged cells and other
particulate matter.
The mechanism of corticosteroid action includes a reduction of the inflammatory reaction
by limiting capillary dilatation and the permeability of the vascular structures. These drugs
restrict the accumulation of polymorphonuclear
leukocytes and macrophages, reduce the release
of vasoactive kinins, and inhibit the release of
destructive enzymes that attack the injury debris
and destroy normal tissue indiscriminately.
Steroids have variable structures, functions,
and sites of action. In addition to the steroids
found in nature, there are many that have been
synthetically produced. These molecules differ
mostly with respect to the functional groups attached to their carbon rings.
The synthetic corticosteroids most commonly
used in radiology procedures are derivatives of
prednisolone (an analogue of cortisol). All have
anti-inflammatory potencies per dose unit that
are somewhat greater than that of cortisol.
Corticosteroid preparations can be either
soluble or insoluble. Most corticosteroid preparations contain corticosteroid esters, which are
highly insoluble in water and thus form microcrystalline suspensions.
A. Conchiglia et al.
Dexamethasone-type preparations, however,
are not esters and are freely soluble in water;
hence, the preparation is clear (i.e., non-particulate). The potential advantage of corticosteroid
ester preparations is that they require hydrolysis
by cellular esterases to release the active moiety; consequently, their actions in the joint are
longer-lasting than those of non-ester preparations. By contrast, freely water-soluble preparations, such as dexamethasone sodium phosphate
and betamethasone sodium phosphate, are taken
up rapidly by cells and thus have a quicker onset
of effect but with a concomitant reduced duration of action. Soluble preparations must be used
in all cases in which there is the risk of inadvertent intra-arterial injection, as it could result in
embolic infarction from particulate corticosteroid esters.
The duration of action of corticosteroids can
be estimated based on their biologic half-life,
pharmaceutical half-life, or duration of clinical
benefit. While the duration of clinical benefit is
the most practical assessment, it is unfortunately
the most subjective and differs widely in literature reports, without statistically significant differences. As previously explained, ester preparations of a corticosteroid would be expected to
have a longer half-life, since release of the active moiety relies on the activities of the patient’s
own hydrolytic enzymes (esterases).
Corticosteroids are sometimes administered
after admixture with other agents in the same
syringe. The potential advantages over a dualsyringe technique is the reduced chance of inadvertent needle movement during syringe exchange and a marginally reduced procedure
time.
Adverse Effects
The established adverse effects associated with
corticosteroid injections include the following:
• Infection
• Post-injection flares
• Local tissue atrophy
• Tendon rupture
• Cartilage damage
• Flushing
• Increased blood glucose levels.
1 General Aspects of US-guided Musculoskeletal Procedures
The most feared complication after steroid injection is infection. With the use of good
sterile technique, however, the incidence of
this complication is as low as 0.01–0.03%. The
most common adverse effect is the post-injection flare, which is a local increase in inflammation that develops within hours and can last 2–3
days. The prevalence of post-injection flare is
2–25% and does not predict a poor response to
therapy. The cause of the flare may be the previously described microcrystalline steroid esters,
which may incite a crystal-induced arthritis,
or possibly a chemical within the drug formulation.
Local tissue necrosis, calcification, and tendon rupture have been associated with extra-articular injections of the corticosteroid formulation triamcinolone hexacetonide. Accordingly, it
is recommended that this particular drug be administered only under US guidance, even though
it is a very effective medication, with a clinical
benefit of up to several months.
There are a number of soft-tissue adverse effects associated with the local injection of corticosteroids, namely, skin atrophy and depigmentation, as well as fat necrosis. These are most
noticeable after the injection of superficial structures (e.g., ganglia and tendon sheaths) but can
also be seen after an intra-articular injection, presumably due to the reflux of corticosteroid along
the needle track.
Corticosteroids increase protein catabolism,
and the possibility of tendon rupture associated
with intratendinous corticosteroid injection is
well recognized, implying that peritendinous injections should be performed with caution. US
guidance will increase injection accuracy.
Systemic effects do occur following softtissue or intra-articular injections but are generally believed to have minimal clinical importance. Nevertheless, it is important for the treating radiologist to be aware that intra-articular
corticosteroids do exert variable systemic effects. Patients with diabetes who are administered such injections should thus be warned to
expect a slight increase in their blood glucose
level.
7
Hyaluronic Acid
The administration of hyaluronic acid with USguided intra-articular injection, referred to as
viscosupplementation, has been demonstrated
to be effective in the treatment of moderate and
severe osteoarthritis. The aim of the procedure
is to reduce disability and pain by restoring the
physiological properties of the synovial fluid and
thereby improving articular function and the recovery of working and social activity.
The intra-articular administration of hyaluronic acid has a role not only in restoring the
viscoelastic properties of synovial fluid (pure
mechanical effect), but also in stimulating the
endogenous production of hyaluronic acid by
articular chondrocytes and synoviocytes through
the release of products based on hyaluronic acid.
Hyaluronic acid is a polysaccharide member
of the group of glycosaminoglycans. It is a polymer with a very high molecular mass and consists of repeating units of N-acetylglucosamine
and glucuronic acid linked together by glycosidic
bonds. It is present in the superficial layers of
cartilage, the intercellular matrix of the joint capsule, synovial tissue, and synovial fluid. Hyaluronic acid is highly absorbent with visco-elastic
properties: viscosity (lubrication) in case of static
compressive strength and elasticity (shock-absorbing) in response to dynamic shear and compressive forces.
Hyaluronic acid can be classified according to
its molecular mass:
• Low (up to 1000 kDa)
• Average (1000–4000 kDa)
• High (> 4000 kDa).
These differences in molecular mass translate into different effects; low molecular mass
forms have greater tissue penetration, producing
a higher concentration of the product around the
cell surface and a more powerful pharmacological response by chondrocytes. The stabilization
of aggregates at high density and high molecular
mass (> 2000 kDa) results in the reduced motility
of single hyaluronic acid molecules, preventing
their rapid degradation by synovial cells, which
take up only free molecules. The prolonged
half-life of these preparations within the joint
8
(approximately 4 weeks) allows the long-term
treatment of osteoarthritis with only a single hyaluronic acid injection.
Platelet-Rich Plasma
Autologous platelet-rich plasma (PRP) is derived
from three components (platelet concentrate,
cryoprecipitate of fibrinogen, and thrombin) of
whole blood withdrawn from the patient and
combined at the moment of administration.
The growth factors contained in the platelets,
including transforming growth factor-β (TGF-β),
platelet-derived growth factor (PDGF), fibroblastic growth factor (FGF), and insulin-like growth
factor (IGF), are physiologically involved in tissue repair mechanisms and are concentrated in
PRP, thus promoting healing of the injured tissue.
Preparations of PRP are obtained from the
transfusion medicine service of the hospital or
prepared using disposable kits. Following activation with 1–2 ml of 10% calcium gluconate solution, autologous PRP must be injected immediately to prevent gelification.
A. Conchiglia et al.
The role of PRP in oral, plastic, maxillofacial
and orthopedic surgery has been studied; for example, in the treatment of tendinosis, a fast and
durable recovery of tendon structure was demonstrated. However other studies, also conducted
on large series, concluded that PRP is no more
effective than placebo. These issues need to be
addressed before PRP can be used routinely.
Post-procedural Care
After the interventional procedure the treated
skin is covered with a plaster and a compressive
dressing and the patient is instructed to apply
an instant ice bag over the treated area. Patients
should be monitored for the after-effects of anesthesia for at least half an hour after the procedure.
After they have been instructed regarding the
management of possible complications, such as
pain and skin reddening, in the following hours/
days, they can be discharged from the hospital/
clinic.
Fig. 1.2 A well-organized tray containing all the
required materials is strongly recommended and
includes syringes, anesthetic, antiseptic solutions,
saline solution, containers, sterile tissues, gloves,
and drugs
1 General Aspects of US-guided Musculoskeletal Procedures
General Workflow for US-Guided Interventional Procedures
• Verbal and written informed consent is obtained after the patient has received a comprehensive
explanation of the risks and possible complications associated with the procedure. Local regulations may vary among different countries and hospitals. A representative of the pertinent institution should be involved in formulating an appropriate informed consent form.
• Pre-interventional planning should include a deep knowledge of the procedure and of the materials, as well as a preliminary US evaluation of the lesion.
• Patient positioning on the bed or operating table is particularly important, with the comfort of
both the patient and the operator confirmed in order to avoid any sudden movements by either one.
• Operator sterility should be performed as described above.
• Both the US equipment and the probe are swiped with dedicated antiseptic tissues and, if required for the procedure, a sterile probe cover is used.
• All devices and drugs should be prepared in full sterility before the procedure commences. The
availability of an organized tray with all materials is recommended (Fig. 1.2).
• Operating field delimitation with adhesive sterile towels should be performed by the sterile
operator.
• Skin antisepsis should be as accurate as possible. While the skin cannot be “sterilized,” certain
chemical preparations reduce microbial levels. We recommend a 2-step antisepsis procedure: (1)
the area to be treated is wiped with a brown water-based 5% povidone-iodine solution; (2) after
3–5 min (time required to let this antiseptic to act), the same area is wiped with a transparent 2%
chlorhexidine-based solution, which denatures the proteins and disrupts the cell walls of contaminating organisms, is bactericidal, and is long-acting. This second step improves skin sterility
and avoids staining of the US probe.
• Antiseptic solutions usually create a good coupling between the skin and the US probe. When
longer procedures are performed (e.g., the treatment of calcific tendinitis), a small amount of
sterile contact gel can be used.
9
Part I
The Shoulder
2
The Shoulder: Focused US Anatomy
and Examination Technique
Enzo Silvestri and Davide Orlandi
The shoulder can be subdivided into three compartments: anterior, lateral, and posterior.
Anterior Compartment
Long Head of the Biceps Brachii Tendon
Anatomy
This tendon originates from the bicipital anchor,
on the apex of the glenoid labrum. It courses
laterally and anteriorly, turning distally inside
the bicipital groove. It ends at its myotendinous
junction, located under the insertion of the pectoralis major tendon on the anterior humeral diaphysis.
Scanning Technique
The patient is seated opposite the examiner, with
his or her forearm 90° flexed and the arm resting
on the thigh, slightly internally rotated, palm facing up. The transducer is placed in a horizontal
position on the anterior aspect of the shoulder, to
localize the bicipital groove (between the lesser
and greater humeral tuberosities). Between the
two bony structures, the long head of the biceps
brachii tendon can be visualized on an axial scan
as an oval-shaped, hyperechoic structure with
a fibrillar echotexture. The probe is then glided
caudally, to evaluate the vertical part of the tendon up to the myotendinous junction, followed
by a 90° clockwise rotation to evaluate the tendon along its long axis.
Enzo Silvestri ( )
Radiology Unit
Ospedale Evangelico Internazionale
Genoa, Italy
L.M. Sconfienza, G. Serafini, E. Silvestri (eds.), Ultrasound-guided Musculoskeletal Procedures,
DOI 10.1007/978-88-470-2741-1_2 © Springer-Verlag Italia 2012
13
14
E. Silvestri and D. Orlandi
a
b
c
Fig. 2.1 Evaluation of the long head of the biceps brachii
tendon. a The probe and patient are positioned for an
evaluation of the long head of the biceps tendon on a
short-axis scan. b Anatomical scheme of the long head
of the biceps brachii tendon as seen along its short-axis
(arrowheads). GT greater tuberosity, LT lesser tuberosity.
c US short-axis scan of the long head of the biceps
brachii tendon (arrowheads). D deltoid muscle
2 The Shoulder: Focused US Anatomy and Examination Technique
15
a
b
c
Fig. 2.2 Evaluation of the long head of the biceps brachii
tendon. a The probe and patient are positioned for an
evaluation of the long head of the biceps tendon on a
long-axis scan. b Anatomical scheme of the long head
of the biceps brachii tendon as seen along its long axis
(arrowheads). H humerus. c US long-axis scan of the
long head of the biceps brachii tendon (arrowheads).
D deltoid muscle
16
E. Silvestri and D. Orlandi
Subscapularis Tendon
Anatomy
The subscapularis muscle originates from the
subscapularis fossa, on the anterior aspect of
the scapula. It runs laterally and anteriorly and
its distal tendon inserts on the anterior aspect of
the humeral head. Most fibers insert on the lesser
tuberosity, while others contribute to the stability of the biceps tendon, inserting on the greater
tuberosity and on the bicipital pulley.
Scanning Technique
With the operator holding the probe on the bicipital groove, the patient performs an extrarotation of the forearm to extract the subscapularis tendon, allowing its visualization on a longitudinal scan, while the elbow is kept as close
as possible to the thoracic wall. With the probe
turned 90° clockwise, the subscapularis tendon
can be assessed on its short axis, thus demonstrating the alternation of tendinous and muscular fibers.
a
b
c
Fig. 2.3 Evaluation of the subscapularis tendon.
a The probe and patient are positioned for an evaluation
of the subscapularis tendon on a long-axis scan.
b Anatomical scheme of the subscapularis tendon (SSC)
as seen along its long axis. H humerus. c US long-axis
scan of the SSC. D deltoid muscle
2 The Shoulder: Focused US Anatomy and Examination Technique
17
a
b
c
Fig. 2.4 Evaluation of the subscapularis tendon.
a The probe and patient are positioned for an evaluation
of the subscapularis tendon on a short-axis scan.
b Anatomical scheme of the subscapularis tendon as seen
along its short axis (arrowheads). H humerus.
c US short-axis scan of the subscapularis tendon
(arrowheads). D deltoid muscle
18
E. Silvestri and D. Orlandi
Glenohumeral Anterior Recess
The probe is placed in the same position used to
evaluate the subscapularis tendon along its long
axis and is then moved medially, which allows
visualization of the articular cortex of the humeral head. This structure appears as a spherically curved echogenic line, while the cortical
surface of the anterior glenoid rim is seen as a
triangular echogenic structure just medial to this
line. The coracoid process partially hinders the
articular space. The anterior glenoid labrum may
occasionally be seen as a well-defined, triangular,
echogenic structure.
a
b
c
Fig. 2.5 Evaluation of the glenohumeral anterior recess.
a The probe and patient are positioned for an evaluation
of the glenohumeral anterior recess. b Anatomical scheme
of the glenohumeral anterior recess (arrow). H humerus,
SSC subscapularis, C coracoid process, G glenoid.
c US scan of the glenohumeral anterior recess (arrow)
2 The Shoulder: Focused US Anatomy and Examination Technique
Lateral Compartment
Supraspinatus Tendon
Subacromial-Subdeltoid Bursa
The subacromial subdeltoid (SASD) bursa is a
wide mucous bursa covering the rotator cuff as
a cap. It acts as a local attrition attenuator and
facilitates gliding of the supraspinatus tendon
underneath the acromion during arm abduction.
This structure consists of a subacromial portion
(located between the superior face of the joint
capsule and the inferior surface of the acromion) and a subdeltoid portion (located deep to
the deltoid muscle), which may extend laterally
and inferiorly as far as 3 cm below the greater
tuberosity. In a minority of patients, a subcoracoid extension is present. When the rotator cuff is
intact, this bursa does not communicate with the
articular joint space. In normal conditions, the
SASD bursa appears as a 2-mm-thick structure
made up of a thin inner layer of hypoechoic fluid
between two layers of hyperechoic peribursal fat.
The synovial membrane of the bursa cannot be
depicted with US.
Anatomy
19
The supraspinatus muscle is located in the fossa
supraspinata of the scapula. Its tendon courses
laterally and slightly anteriorly, inserting on the
upper portion of the greater tuberosity. A few fibers are sent also to the bicipital pulley.
Scanning Technique
The patient places his or her hand on the homolateral iliac wing, with the elbow as medial
as possible. Starting from the bicipital groove,
the probe is shifted cranially and laterally in an
axial-oblique fashion along the major axis of
the supraspinatus tendon, posterior to the biceps
tendon. A correct scan is obtained when the humeral head cartilage, the anatomical neck of the
humerus, and the greater humeral tuberosity are
seen together. Anisotropy artifacts may particularly disturb the insertional area of the tendon on
the humeral neck. These artifacts can be avoided
by slightly tilting the probe laterally such that the
US beam is as perpendicular as possible to the
tendon fibers. The probe should then be rotated
90° clockwise to assess the tendon’s short axis.
20
E. Silvestri and D. Orlandi
a
b
c
Fig. 2.6 Evaluation of the supraspinatus tendon.
a The probe and patient are positioned for an evaluation
of both the supraspinatus tendon on a long-axis scan
and the SASD bursa. b Anatomical scheme of the
supraspinatus tendon (SSP) as seen along its long axis.
GT greater humeral tuberosity, arrow SASD bursa.
c US long-axis scan of the SSP. Arrow SASD bursa,
D deltoid muscle, asterisks articular cartilage. The
arrowhead indicates the critical zone of the SSP where
anisotropy artifacts may occur
2 The Shoulder: Focused US Anatomy and Examination Technique
Posterior Compartment
Infraspinatus and Teres Minor Tendons
Anatomy
The infraspinatus and teres minor muscles arise
from the fossa infraspinata of the scapula, the
former cranial to the latter. Both tendons course
laterally and cranially, inserting on the posterior
aspect of the greater tuberosity.
a
21
Scanning Technique
The patient sits opposite the examiner, elbow
flexed and palm on the opposite shoulder. The
probe should be oriented vertically to localize
the scapular spine, which separates the fossa supraspinata from the fossa infraspinata. Within the
latter, the infraspinatus and teres minor muscles
can be seen along their short axis with a sagittal
US scan. The probe should then be shifted laterally to assess both tendons on a short-axis view.
The longitudinal axis of each tendon can be studied by rotating the probe 90°.
b
c
d
Fig. 2.7 Evaluation of the extra-rotator tendons.
The patient (a) and probe (b) are positioned for an
evaluation of the extra-rotator tendons on a long-axis
scan. c Anatomical scheme of the infraspinatus tendon
(ISP) as seen along its long axis. GT greater humeral
tuberosity, MJ myotendinous junction. d US long-axis
scan of the ISP. Asterisk indicates the enthesis of the ISP,
where anisotropy artifacts may occur
22
E. Silvestri and D. Orlandi
Glenohumeral Posterior Joint Recess
The probe is placed in the same position used to
evaluate the insertional portion of the infraspinatus tendon along its long axis. It is then moved
medially to visualize the articular cortex of the
humeral head, which appears as a spherically
curved echogenic line, while the cortical surface
of the posterior glenoid rim is seen as a triangular echogenic structure just medial to this line,
and the fibrocartilaginous posterior glenoid labrum as a well-defined, triangular, echogenic
structure.
a
b
c
Fig. 2.8 Evaluation of the glenohumeral posterior recess.
a The probe and patient are positioned for an evaluation
of the glenohumeral posterior recess. b Anatomical
scheme of the glenohumeral posterior recess (arrow).
H humerus, ISP infraspinatus, asterisks humeral
cartilage, G glenoid, arrowheads glenoid labrum.
c US scan of the glenohumeral posterior recess (arrow).
D deltoid muscle
2 The Shoulder: Focused US Anatomy and Examination Technique
Acromioclavicular Joint
The patient is seated opposite the examiner and
the probe is placed on a coronal-oblique plane on
the top of his or her shoulder. The two bony struc-
23
tures of the acromion and the clavicle are demonstrated as two linear hyperechoic lines, while
the articular joint space appears as an anechoic
triangular structure between them.
a
b
c
Fig. 2.9 Evaluation of the acromioclavicular
joint. a The probe and patient are positioned for
an evaluation of the acromioclavicular joint.
b Anatomical scheme of the acromioclavicular
joint. Arrow joint space, arrowheads joint
capsule, A acromion, C clavicle. c US scan of
the acromioclavicular joint
3
Subacromial-Subdeltoid
Bursa Injections
Enzo Silvestri
Essentials
Etiology
The general term “bursitis” indicates a nonspecific inflammatory condition of the synovial
walls of the bursa, an anatomical entity with the
mechanical function of reducing friction between
sliding structures (e.g., tendon and cortical bone,
tendon and muscle). Primary bursitis commonly
originates from rheumatoid arthritis, gout, tuberculosis, polymyalgia rheumatica, and other pathological conditions. The bursa may become secondarily inflamed in rotator cuff tendinopathy/
tears, with or without joint effusion. Bursitis also
occurs in the setting of anterosuperior impingement due to overhead activities. Isolated septic
bursitis is more likely in very young infants or
in elderly patients with chronic debilitating disorders, or it may derive from the accidental introduction of bacteria during nonsterile percutaneous procedures.
Epidemiology
Subacromial-subdeltoid (SASD) bursitis is the
most common finding on US evaluation for painEnzo Silvestri ( )
Radiology Unit
Ospedale Evangelico Internazionale
Genoa, Italy
ful shoulder. Minor asymptomatic abnormalities
of this structure can be observed in up to 78% of
patients.
Clinical Presentation
Patients with acute SASD bursitis usually report
a restriction of abduction movements without
previous trauma. Pain usually worsens during the
night but also when performing overhead activities, and is typically reported on the lateral and
anterior aspects of the shoulder. Patients with
chronic SASD bursitis often complain of a dull
shoulder ache, with tenderness over the greater
trochanter and beneath the deltoid muscle.
Ultrasound Diagnosis
Under normal conditions, the SASD bursa appears as a 2-mm-thick structure made up of an
inner layer of hypoechoic fluid between two layers of hyperechoic peribursal fat. The synovial
membrane of the bursa is not normally depicted
on US.
Since intrabursal fluid can migrate depending
on gravity and arm positioning, the various portions of the SASD bursa should be systematically
assessed. In subacromial impingement, the bursa
has thickened walls and may contain fluid as
a result of chronic inflammation. Dynamic examination with the use of longitudinal scans
L.M. Sconfienza, G. Serafini, E. Silvestri (eds.), Ultrasound-guided Musculoskeletal Procedures,
DOI 10.1007/978-88-470-2741-1_3 © Springer-Verlag Italia 2012
25
26
during abduction of the arm can underline even
small intrabursal effusions, demonstrating the
“notch sign” in the upper profile of the bursa at
the level where it passes under the coracoacromial ligament. Care should be taken not to apply
excessive pressure with the probe over the bursa.
An effusion in both bursal and joint synovial
spaces is considered indicative of a full-thickness tear of the rotator cuff. In the case of acute
bursitis, the effusion may be consistent, with
findings of a hypervascular flow in the synovial
walls and peribursal tissues at Doppler examination.
Occasionally (synovial osteochondromatosis,
rheumatoid arthritis), round hyperechoic bodies
(nodules) are found within the bursal space.
Septic bursitis may include a complex effusion containing debris and septations. The bursal
walls may be thickened, with peribursal hypoechoic strands reflecting edema in the surrounding soft tissues as associated findings.
Treatment Options
Oral anti-inflammatory drugs and intrabursal
steroids are usually indicated in the acute phase
E. Silvestri
of the pathology. In chronic unresponsive cases,
surgical removal is suggested.
Interventional Procedure
Indications
Acute or chronic painful bursitis. Suspected or
known septic bursitis can be drained but steroid
injection should be avoided.
Objective
To deliver anti-inflammatory drugs into the bursal space.
Equipment
-
1 syringe (2 ml)
20G needle
Lidocaine (2–5 ml)
Long-acting steroid (1 ml, 40 mg/ml)
Plaster
Ice pack.
3 Subacromial-Subdeltoid Bursa Injections
Our Procedure
Fig. 3.1a
STEP 1
After an accurate disinfection of both the skin and the probe, a longitudinal US scan is obtained
to visualize the bursal effusion (Fig. 3.1a). The most distended bursal recess is selected as the
target.
Fig. 3.1b
Fig. 3.1c
STEP 2
As shown in Fig. 3.1b,c, the needle (arrowheads) is inserted with a lateral approach to the probe
in order to reach the bursal space along a parallel path relative to the probe. A small amount of
local anesthetic (asterisks) is injected into the bursal space to confirm correct positioning of the
needle tip. Gently advancing the needle into the bursa while injecting can help to debride thickened and collapsed bursal walls. The anatomical scheme and the US image show the position of
the needle with respect to the humeral head (H) and the supraspinatus tendon (SSP).
27
28
E. Silvestri
STEP 3
Once correct positioning of the needle tip has been confirmed, the steroid can be injected into
the bursa, leaving the needle in place and replacing the syringe used to administer the anesthetic
with one containing steroid. The needle is then removed and a plaster is applied at the puncture
site together with an ice pack.
Post-procedural Care
After treatment, patients should avoid exertion and overhead movements for 5–10 days. Pain
may occur after treatment and is managed with oral NSAIDs.
4
Treament of Calcific Tendinitis
of the Rotator Cuff
Giovanni Serafini and Luca Maria Sconfienza
Essentials
Etiology
The term “calcific tendinitis” refers to the intratendinous deposition of calcium, predominantly
hydroxyapatite, that can affect every tendon in
the body and especially the rotator cuff. This
pathological condition is a dynamic process
that evolves through four stages: pre-calcific,
calcific, resorptive, and post-calcific. In the precalcific stage, microtraumatic factors associated
with a local decrease in blood supply can lead
to intratendinous fibrocartilaginous metaplasia, with resulting calcification. The subsequent
calcific phase is considered as a resting period.
Eventually, triggered by unknown factors, there
is resorption of the deposit, accompanied by vascular invasion, the migration of phagocytic cells
with dissolution of the calcific focus (resulting
in a “toothpaste” appearance of the calcific deposit), and edema from intratendinous pressure,
such that the condition becomes symptomatic.
After resorption, in the post-calcific or reparative
phase, fibroblasts restore the normal tendinous
collagen pattern.
Giovanni Serafini ( )
Diagnostic Imaging Department
Ospedale S. Corona
Pietra Ligure (SV), Italy
Epidemiology
Rotator cuff calcific tendinitis is a commonly
seen condition, occurring in up to 20% of painful shoulders and up to 7.5% of asymptomatic
shoulders. It is more frequent in women in their
40s and 50s and seems not to be related to physical activity. The supraspinatus tendon (80% of
cases), followed by the infraspinatus (15% of
cases) and subscapularis (5% of cases) tendons,
is the most commonly affected cuff tendon. The
lower third of the infraspinatus tendon, the critical zone of the supraspinatus tendon, and the
pre-insertional fibers of the subscapularis tendon
are the most frequently affected locations. This
condition is typically associated with an intact
rotator cuff.
Clinical Presentation
The pre-calcific phase is usually asymptomatic.
The typical clinical manifestation is low-grade
subacute pain that usually increases at night and
corresponds to the calcific stage, variably associated with mechanical symptoms according to the
size of the deposit. In many cases, however, rotator cuff calcific tendinitis can be a highly disabling disorder, with sharp acute pain that limits
shoulder movement and is resistant to high doses
of oral anti-inflammatory drugs. This clinical
presentation usually coincides with the resorptive stage; fever, reflecting rupture of the calcifi-
L.M. Sconfienza, G. Serafini, E. Silvestri (eds.), Ultrasound-guided Musculoskeletal Procedures,
DOI 10.1007/978-88-470-2741-1_4 © Springer-Verlag Italia 2012
29
30
cation into the adjacent structures, is occasionally
reported. However, the acute phase of calcific
tendinitis of the rotator cuff is regarded as a selfhealing condition, with spontaneous resolution in
7–10 days.
Ultrasound Diagnosis
Three types of calcifications have been described:
type I consists of a hyper-reflexive lesion with a
well-circumscribed dorsal acoustic shadow; type
II deposits are well-circumscribed, homogeneous
hyperechoic foci with a faint posterior shadow;
type III are amorphous, inhomogeneous hyperechoic foci without posterior acoustic shadow.
The consistency is solid for deposits of types I
and II and semi-liquid for type III calcifications.
G. Serafini and L.M. Sconfienza
Interventional Procedure
Indications
The US-guided percutaneous treatment of calcific tendinitis of the rotator cuff is always and
immediately indicated in the acute phase of the
pathology, with US findings of type II or III calcifications. In case of mildly symptomatic type
I calcifications, elective treatment should be considered. Percutaneous treatment is not indicated
if the calcification has migrated into the bursal
space or is eroding the humeral cortical bone, or
if it is very small (< 5 mm).
Objective
To dissolve and aspirate the calcific material using an US-guided, double-needle procedure.
Treatment Options
Asymptomatic cases usually do not require treatment, as the process is self-healing. In patients
with mild symptoms, the disease can be managed conservatively with physical therapy and a
short course of oral NSAIDs. Lithotripsy is only
partially effective. An alternative therapeutic approach is to extract the calcific material in an arthroscopy or imaging-guided procedure.
Equipment
-
Two 16G needles
One 10-cm 18/20G needle (optional)
Inox bowl (to collect the washing fluid)
Sterile saline solution (100–200 ml) warmed to
about 38–40°C
Two syringes (20 ml and 3 ml)
Lidocaine (10 ml)
Steroid (1 ml, 40 mg/ml)
Plaster
Ice pack.
4 Treament of Calcific Tendinitis of the Rotator Cuff
Our Procedure
Fig. 4.1a
Fig. 4.1b
Fig. 4.1c
STEP 1
The patient is either placed in the supine position (subscapularis and supraspinatus calcifications) or is prone (infraspinatus or teres minor calcifications), as seen in Fig. 4.1a. A correct US
scan should demonstrate the target calcification (C) according to its major axis (Figs. 4.1b, c).
After sterile preparation of the skin and probe, a small amount of local anesthesia is injected
under US guidance and using an in-plane approach along the path of the needle (arrowheads),
in the SASD bursa (asterisks), and around the calcification (C) (Fig. 4.1a). H humeral head.
31
32
G. Serafini and L.M. Sconfienza
Fig. 4.2a
Fig. 4.2b
Fig. 4.2c
STEP 2
As shown in Fig. 4.2a–c, the first needle (arrowheads) is inserted into the lowest portion of the
calcification (C), maintaining the bevel (arrow) open towards the probe. H humerus.
4 Treament of Calcific Tendinitis of the Rotator Cuff
33
Fig. 4.3a
Fig. 4.3b
c
d
Fig. 4.3c-d
STEP 3
A second needle (curved arrows) is inserted into the calcification (C) parallel and superficial to
the first (Fig.4.3a–c, arrowheads), and its tip is rotated 180° in order to create a correct washing
circuit. As shown in Fig. 4.3c, the deeper needle needs to be inserted first, to avoid artifacts (circles) caused by the second, more superficial needle. Needle bavel (arrow) is opened upwards.
Figure 4.3d shows both needles (arrowheads and curved arrows) within the calcification.
H humerus.
34
G. Serafini and L.M. Sconfienza
Fig. 4.4a
Fig. 4.4b
Fig. 4.4c
STEP 4
A 20-ml syringe filled with warm sterile water is connected to one of the needles (arrowheads
and curved arrows) and a gentle, intermittent pressure is applied. If the positioning is correct, a
slight expansion of the calcification can be visualized. If no washing fluid exits and the needles
are correctly positioned, an 18G spinal needle could be inserted into one or both 16G needles to
slightly penetrate the target calcification, creating enough space for circulation of the fluid. The
washing fluid exiting from the second needle is collected in the inox bowl, positioned as shown
in Fig. 4.4a. Washing of the target continues until complete emptying of the calcification (C) is
demonstrated, as shown in Fig. 4.4b,c. Arrowheads first needle, curved arrow second needle,
H humerus.
4 Treament of Calcific Tendinitis of the Rotator Cuff
Fig. 4.5a
Fig. 4.5b
Fig. 4.5c
STEP 5
At the end of the procedure, one needle is removed and the 1-ml syringe is connected to the
remaining needle (Fig.4.5a). This needle (arrowheads) is then displaced into the SASD bursa
(Fig. 4.5b) and 1 ml of steroid is injected (asterisks). A plaster is then applied to the skin at the
puncture site and an ice pack is placed over the shoulder. H humerus, C treated calcification.
Post-procedural Care
The patient is kept under observation for at least 30 min. The ice pack over the treated shoulder
should be maintained for at least 2 h. Patients should avoid overhead movements and the carrying of heavy weights for up to 15 days. Pain may occur after treatment and is managed with
oral NSAIDs. Post-procedural bursitis is seen in about 15% of patients within approximately 2
months after treatment. In these cases, an intrabursal steroid injection may be useful.
35
5
Calcific Enthesopathy Dry-Needling
Francesca Lacelli
Essentials
Etiology
Calcific enthesopathy of the rotator cuff represents a common and mostly asymptomatic US
finding. Unlike calcific tendinopathy, in which
a calcification develops from fibrocartilaginous
metaplasia 1–2 cm away from the insertional tendinous area, in this condition tiny calcifications
are found in the insertional area of the rotator cuff
tendons and are usually coupled to degenerative
alterations of the pre-insertional tendinous portion.
Epidemiology
The exact incidence of this condition cannot be
estimated because of the broad range of degenerative or inflammatory conditions that may result
in calcific enthesopathy. Males and females are
equally affected.
Clinical Presentation
Patients with symptomatic calcific enthesopathy
report well-circumscribed pain at the level of the
greater trochanter (supraspinatus, infraspinatus,
or teres minor insertional areas) or of the lesser
trochanter (subscapularis insertion). The pain is
worsened by applied pressure, either by the examiner’s finger or by the probe during the examination.
Ultrasound Diagnosis
Tiny, irregular hyperechoic insertional calcifications in a setting of degenerative tendinopathy.
The calcifications are close to the humeral cortical bone and may present as an irregularity in the
hyperechoic profile of the latter.
Treatment Options
Physiotherapy should always be considered. In
symptomatic cases, a percutaneous procedure or
surgical tendinous debridement is needed.
Francesca Lacelli ( )
Diagnostic Imaging Department
Ospedale S. Corona
Pietra Ligure (SV), Italy
L.M. Sconfienza, G. Serafini, E. Silvestri (eds.), Ultrasound-guided Musculoskeletal Procedures,
DOI 10.1007/978-88-470-2741-1_5 © Springer-Verlag Italia 2012
37
38
F. Lacelli
Interventional Procedure
material; to produce slight intratendinous bleeding that will in turn promote healing of the tendon.
Indications
Symptomatic insertional calcific enthesopathy in
one or more tendons of the rotator cuff.
Objective
To fragment the tiny insertional calcifications
in order to accelerate the resorption of calcific
Equipment
-
1 syringe (5–10 ml)
18G needle
Lidocaine (5–10 ml)
Long-acting steroid (1 ml, 40 mg/ml)
Plaster
Ice pack.
Our Procedure
Fig. 5.1a
STEP 1
After sterile preparation of both the skin and the US probe, the affected area is visualized with
a longitudinal scan according to the respective tendon. A small amount of local anesthetic is
injected under US guidance and with an in-plane approach along the path of the needle, into the
SASD bursa, and around the insertional calcifications (see Fig. 3.1a–c).
5 Calcific Enthesopathy Dry-Needling
39
Fig. 5.1b
c
d
e
f
Fig. 5.1c-f
STEP 2
As shown in Fig. 5.1a–f, consecutive dry-needling punctures (arrowheads) are performed on
the calcifications (arrow) to fragment the small calcific deposits and to produce slight bleeding
into the insertional tendinous portion. The probe should also be shifted anteriorly and posteriorly to target the treatment towards all the calcifications. H humerus.
40
F. Lacelli
Fig. 5.2
STEP 3
At the end of the procedure, 1 ml of steroid (asterisks) is injected (arrowheads) into the SASD
bursa (Fig. 5.2) and the cutaneous point of insertion is covered with a plaster. An ice pack is
applied over the shoulder.
Post-procedural Care
The patient is kept under observation for at least 30 min. The ice pack over the treated shoulder
should be maintained for at least 2 h. Patients should avoid overhead movements and the carrying of heavy weights for up to 15 days. Pain may occur after treatment and is managed using
oral NSAIDs. Post-procedural bursitis is seen in about 15% of patients within approximately 2
months after treatment. In these cases, an intrabursal steroid injection may be useful.
6
Hyaluronic Supplementation
of the Subacromial Space
Giovanni Serafini
Essentials
Etiology
Cuff tear arthropathy is the association of a massive rotator cuff tear and shoulder osteoarthritis,
with progressive superior migration of the humeral head, acetabulization of the shoulder, and
collapse of the humeral head. Poor vascularity,
the inferior mechanical properties of an aging
rotator cuff, type III acromions, and subacromial
impingement are the most outstanding factors
leading to this condition.
Epidemiology
Most commonly, an elderly patient will present
with massive rotator cuff tears altering the biomechanics of the shoulder and leading to progressive superior migration of the humeral head.
The end-stage of cuff tear arthropathy is the acetabulization of the shoulder, with collapse of the
humeral head.
Giovanni Serafini ( )
Diagnostic Imaging Department
Ospedale S. Corona
Pietra Ligure (SV), Italy
Clinical Presentation
The main symptoms of cuff tear athropathy are
functional limitation, weakness, and pain in the
shoulder. There is an inability to perform either
abduction or extra-rotation movements. Patients
often complain of difficulty carrying out daily
activities, such as combing their hair, clasping a bra behind their back, reaching behind
their back, or sleeping on the affected shoulder.
Weakness can appear during lifting or in rotating
the arm. Pain while performing overhead activities
and at night is common; it is usually located over
the outside of the shoulder and upper arm. Crepitus or a crackling sensation may also be noted
when the shoulder is moved in certain positions.
Ultrasound Diagnosis
A massive rotator cuff tear is diagnosed when a
complete rupture of at least two tendons of the
rotator cuff is identified.
Treatment Options
Several different surgical treatment options for
cuff tear arthropathy have been proposed. However, in elderly patients, surgery may be more frequently associated with complications or may be
precluded due to concurrent medical conditions.
Viscosupplementation can help in the conservative management of this condition.
L.M. Sconfienza, G. Serafini, E. Silvestri (eds.), Ultrasound-guided Musculoskeletal Procedures,
DOI 10.1007/978-88-470-2741-1_6 © Springer-Verlag Italia 2012
41
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G. Serafini
Interventional Procedure
Indications
Cuff tear arthropathy. Percutaneous treatment is
not indicated in case of a recent history of shoulder trauma.
Objective
To inject a viscosupplement into the subacromial
space so as to facilitate gliding of the acromial
and humeral cortical bones in the acromial-humeral articulation.
Equipment
-
Two syringes (5 ml and 10 ml)
Lidocaine (2–5 ml)
High-molecular-weight hyaluronic acid (6 ml)
18G needle
Plaster.
Our Procedure
Fig. 6.1a
Fig. 6.1b
STEP 1
The subacromial space is visualized on a coronal US scan that includes the acromial superolateral cortical bone and the superior aspect of the humeral head (Fig. 6.1a, b); A acromion, H
humeral head. Local anesthetic is injected along the path of the 18G needle under US guidance
with an in-plane approach and an oblique direction (lateral to medial and superior to inferior) to
reach the subacromial space.
6 Hyaluronic Supplementation of the Subacromial Space
Fig. 6.1c
STEP 2
As shown in Fig. 6.1c, once the subacromial space is reached by the needle (arrowheads), a
syringe pre-filled with 6 ml of high-molecular-weight hyaluronic acid is attached to the needle,
and the operator slowly and gently injects the drug into the subacromial space (asterisk). There
should be no resistance against the injection; if this is not the case, a slight retraction of the needle may be necessary. A plaster is then applied to the skin at the puncture site.
Post-procedural Care
The injection should be repeated after one week. Treatment can be repeated in case of pain
recurrence.
43
7
Intra-articular Injections
Francesca Lacelli
Essentials
Intra-articular injections of the shoulder can be
performed in the treatment of a variety of pathological conditions. The drugs administered in
these cases may be anti-inflammatory agents,
such as the use of steroids for the various forms
of capsulitis, or viscosupplements such as hyaluronic acid, which are injected to decelerate the
physiological process of osteoarthritis.
Adhesive Capsulitis
Etiology
Adhesive capsulitis of the shoulder (frozen
shoulder) is a common disease with unclear
pathogenesis, resulting in chronic inflammation
of the capsular tissues and abnormal tissue repair
with fibrosis.
Epidemiology
Approximately 2% of the general population is
affected, with a peak incidence between 40 and
60 years and a slight female predominance.
Francesca Lacelli ( )
Diagnostic Imaging Department
Ospedale S. Corona
Pietra Ligure (SV), Italy
Clinical Presentation
This condition is classified as primary idiopathic
when there is no detectable underlying causes for
the symptoms, or as secondary to shoulder affections, either traumatic or non-traumatic, that
determine secondary pain and stiffness. A recognized different form of secondary frozen shoulder is seen in diabetic patients and tends to be
more severe and protracted. The diagnosis is essentially clinical. Patients report increasing pain,
especially at night, and a progressively reduced
range of motion. In most cases, adhesive capsulitis is considered as a self-limiting disorder but it
lasts for years in up to 40% of patients.
Treatment Options
Conservative treatment includes physical therapy, anti-inflammatory and analgesic medications,
and oral administration or intra-articular injections of steroids.
Interventional Procedure
Indications
Intra-articular injection of steroids. Primary idiopathic or secondary adhesive capsulitis, degenerative osteoarthritis associated with articular
effusion. Contraindicated in diabetes-related
secondary adhesive capsulitis.
L.M. Sconfienza, G. Serafini, E. Silvestri (eds.), Ultrasound-guided Musculoskeletal Procedures,
DOI 10.1007/978-88-470-2741-1_7 © Springer-Verlag Italia 2012
45
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F. Lacelli
Intra-articular injection of hyaluronic acid. Degenerative osteoarthritis without articular effusion.
Equipment
-
Objective
-
1 syringe (2–5 ml)
20G spinal needle
Long-acting steroid (1 ml, 40 mg/ml) or lowmolecular-weight hyaluronic acid (2 ml)
Plaster.
To deliver anti-inflammatory or viscosupplement
drugs within the joint space.
Our Procedure
Intra-articular joint injections of the shoulder can be performed with either an anterior or a posterior approach. The anterior approach suffers from the deep location of the joint with respect
to the skin surface, as well as the presence of the coracoid process, which makes it extremely
difficult to accurately visualize the needle tip. Thus, the posterior approach is generally more
convenient.
This procedure can also be used for the injection of contrast agents within the joint for purposes of arthrography.
Anterior Approach
Fig. 7.1a
STEP 1
The patient is placed in the supine position, with the forearm flexed 90° and the hand lying on
the abdomen. An anterior axial US scan is performed at the level of the coracoid process. The
correct scanning plane should reveal the coracoid at the middle third of its height, the subscapularis tendon on its long axis, and the humeral lesser tuberosity (Fig. 7.1a).
7 Intra-articular Injections
Fig. 7.1b
STEP 2
The space between the coracoid and the humeral head is centered at the middle of the scanning
plane and a 20G needle (arrow) is inserted perpendicular to the skin, at the middle of the probe
(Fig. 7.1b) between the humeral head (H) and the glenoid (G) and the coracoid (C). Passage
of the needle tip into the glenohumeral joint is generally associated with a distinct feeling of
capsular resistance followed by the sensation of a resistance-free space.
Fig. 7.1c
STEP 3
Once correct intra-articular positioning of the needle tip has been confirmed (asterisk), the drug
can be injected (Fig. 7.1c). There should be no resistance to the injection; if this is not the case,
a short retraction (1–2 mm) of the needle should be considered because the needle tip could
be pointed against the humeral cartilage or into the anterior glenoid labrum. At the end of the
injection, the needle can be removed and a plaster applied at the cutaneous site of approach.
C coracoid, SSC subscapularis tendon, G glenoid.
47
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F. Lacelli
Posterior Approach
Fig. 7.2a
Fig. 7.2b
Fig. 7.2c
Lateral Approach
STEP 1
The patient is in a prone position with the upper arm not completely abducted and the forearm
flexed, in order to avoid tension on the posterior joint capsule (Fig. 7.2a).
A longitudinal US scan of the posterior articular recess is performed. The transducer is aligned
with the long axis of the musculotendinous junction of the infraspinatus muscle, just inferior to
the scapular spine, with the posterior glenoid rim and posterior glenohumeral joint line centered
in the field of view (Fig. 7.2b,c). Transducer angulation is adjusted to clearly show the contours
of the posterior glenoid rim, the posterior glenoid labrum, and the humeral head. The articular
cortex of the humeral head appears as a spherically curved echogenic line, and the cortical surface of the posterior glenoid rim as a triangular echogenic structure just medial to this line. The
fibrocartilaginous posterior glenoid labrum is seen as a well-defined, triangular, and uniformly
echogenic structure.
7 Intra-articular Injections
Fig. 7.3a
Fig. 7.3b
Co-axial Approach
STEP 1
A co-axial out-of-plane approach is also possible (Fig. 7.3a-b), although the needle will be less
visible. The passage of the needle tip (arrow) into the glenohumeral joint is generally associated with a distinct feeling of capsular resistance followed by the sensation of a resistance-free
space. The asterisk indicates the distended posterior glenohumeral joint recess. G glenoid, H
humerus, D deltoid.
STEP 2
Once correct intra-articular positioning of the needle tip has been confirmed, the drug can be
injected. There should be no resistance to injection; if this is not the case, a short retraction
(1–2 mm) of the needle should be considered because the needle tip could be pointed against
the humeral cartilage or into the posterior glenoid labrum. Distension of the articular capsule is
usually not visible because of the small amount of fluid injected. At the end of the injection, the
needle can be removed and a plaster applied at the cutaneous site of the approach.
Post-procedural Care
The patient should be kept under observation for at least 30 min after the procedure. Pain may
occur after treatment and is managed with oral NSAIDs.
49
8
Long Head of the Biceps Brachii
Tendon Injection
Luca Maria Sconfienza
Essentials
Etiology
Pathologies of the LHBB include synovial effusion, synovial hypertrophy and, rarely, calcifications. Tenosynovitis can be found alone or, more
often, associated with glenohumeral effusion
since the joint space is usually in communication
with the sheath of this tendon.
Ultrasound Diagnosis
An anechoic fluid collection around the fibrillar
tendinous structure of the LHBB can be demonstrated on axial and longitudinal scans. If thickening of the synovial component of the sheath
and power-Doppler signs of hypervascularity are
present, a rheumatic condition should be suspected.
Treatment Options
Epidemiology
A small amount of fluid within the sheath of the
LHBB is a common and asymptomatic finding
and is typically associated with glenohumeral
joint effusion. Conspicuous effusions are usually
symptomatic.
Physiotherapy is the treatment of choice. In the
acute phase, the percutaneous injection of steroids can have a prompt effect on pain, while aspiration is usually required when a large amount
of fluid is present.
Clinical Presentation
Pain is usually described as originating from the
anterior aspect of the shoulder and irradiating anteriorly down the humerus. The onset is typically
subacute or chronic.
Luca Maria Sconfienza ( )
Radiology Unit
IRCCS Policlinico San Donato
San Donato Milanese (MI), Italy
L.M. Sconfienza, G. Serafini, E. Silvestri (eds.), Ultrasound-guided Musculoskeletal Procedures,
DOI 10.1007/978-88-470-2741-1_8 © Springer-Verlag Italia 2012
51
52
L.M. Sconfienza
Interventional Procedure
Equipment
Indications
-
Symptomatic effusion in the sheath of the LHBB
tendon.
1 syringe (2 ml)
22G needle
Lidocaine (2 ml)
Long-acting steroid (1 ml, 40 mg/ml)
Plaster.
Objective
To inject a small amount of steroid in the distended sheath of the LHBB.
Our Procedure
Fig. 8.1a
STEP 1
The patient is placed in the supine position with his or her hand in a neutral position (Fig. 8.1a).
The LHBB tendon is seen on an axial scan, starting from the bicipital groove and moving the
probe caudally to identify the level of larger effusion.
8 Long Head of the Biceps Brachii Tendon Injection
Fig. 8.1b
Fig. 8.1c
Fig. 8.1d
STEP 2
The needle is inserted with an in-plane approach lateral to the probe (Fig. 8.1b,c) and advanced
towards the tendon (arrows) while a small amount of local anesthetic is injected along the path.
Once the needle (arrowheads) has reached the distended synovial sheath (Fig. 8.1c, asterisk),
the fluid content is drained (Fig. 8.1d, asterisk). H humerus.
53
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L.M. Sconfienza
Fig. 8.1e
STEP 3
The syringe with the steroid is then connected to the needle and the drug is injected (Fig. 8.1e,
asterisks), avoiding penetration of the tendon (arrows) by the needle tip (arrowheads). The needle is removed and a plaster applied on the skin.
Post-procedural Care
The patient is kept under observation for at least 10 min. Pain may occur after treatment and is
managed with oral NSAIDs. After treatment, patients should avoid heavy activities and refrain
from overhead movements for 5–10 days.
9
Acromioclavicular Joint Injection
Enzo Silvestri
Essentials
Etiology
The most common AC joint pathologies that can
be treated using a percutaneous approach include
osteoarthritis and osteolysis of the distal clavicle. Osteoarthritis usually develops secondary
to previous trauma, while osteolysis of the distal
clavicle may be associated with repetitive weight
training involving the shoulder. The history and
physical examination are extremely important in
diagnosing these conditions.
Clinical Presentation
Patients usually have insidious onset of pain. On
physical examination, there is tenderness to palpation of the AC joint. A lump over the joint space
indicates the presence of a cyst arising from the
articular capsule and is usually associated with
a degenerative shoulder arthropathy. Pain occurs
with active or passive adduction of the shoulder
and may be exacerbated by asking the patient to
hold the opposite shoulder while pushing the elbow cranially against resistance.
Ultrasound Diagnosis
Epidemiology
Degeneration of the AC joint typically affects
middle-aged patients and is often associated with
rotator cuff disorders. However, it is also found
in young athletes (20s to 30s) with repetitive falls
on the shoulder.
Degenerative changes of the AC joint include an
irregular profile of the cortical bone surfaces of
the distal clavicle and acromion, associated with
an articular joint effusion and a thickened capsule.
Treatment Options
Physiotherapy is the preferred treatment. Steroids or hyaluronic acid can help in reducing pain
and thus in facilitating rehabilitation.
Enzo Silvestri ( )
Radiology Unit
Ospedale Evangelico Internazionale
Genoa, Italy
L.M. Sconfienza, G. Serafini, E. Silvestri (eds.), Ultrasound-guided Musculoskeletal Procedures,
DOI 10.1007/978-88-470-2741-1_9 © Springer-Verlag Italia 2012
55
56
E. Silvestri et al.
Interventional Procedure
Equipment
Indications
-
Osteoarthritis and osteolysis of the distal clavicle.
Contraindicated in the acute or subacute phase of
traumatic injury.
-
1 syringe (2 ml)
23G needle
Long-acting steroid (1 ml, 40 mg/ml) and/or
low-molecular-weight hyaluronic acid (1 ml)
Plaster.
Objective
To deliver steroid or hyaluronic acid in the AC
joint space. Local anesthetic can be used as a diagnostic tool to assess the origin of shoulder pain.
Our Procedure
Fig. 9.1
STEP 1
The patient is seated opposite the examiner in a neutral position, with the hand lying on the thigh
(Fig. 9.1). An out-of-plane co-axial approach is suggested, but an in-plane lateral approach is
also possible.
9 Acromioclavicular Joint Injection
Fig. 9.2a
Fig. 9.2b
Fig. 9.2c
STEP 2
With an out-of-plane co-axial approach (Fig. 9.2a–c), the AC joint is visualized at the middle of
a coronal scan (A and C) and the needle is inserted perpendicularly to the skin at the exact half
of the probe. A clear sensation of resistance should be appreciated as the joint capsule is passed
(arrowheads). The probe is gradually tilted towards the needle such that the needle tip (arrow)
can be seen as a hyperechoic dot in the distended articular space (asterisk). There should be no
resistance during the injection.
With an in-plane approach, the AC joint space is visualized on a sagittal US scan. The needle is
inserted lateral to the probe and advanced with a 30–45° inclination.
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E. Silvestri et al.
Post-procedural Care
The patient is kept under observation for at least 10 min. An ice pack over the treated shoulder
should be maintained for at least 1 h. Pain may occur after treatment and is managed using
oral NSAIDs. Patients should avoid overhead movements and carrying heavy weights for up
to 3 days.
Part II
The Elbow
The Elbow: Focused US Anatomy
and Examination Technique
10
Enzo Silvestri and Emanuele Fabbro
The elbow is divided into four compartments: anterior, lateral, medial, and posterior.
Anterior Compartment
Distal Tendon of the Biceps Brachii
Anatomy
The tendon originates from the distal portion of
the biceps brachii muscle. It courses obliquely
from anterior to posterior, inserting on the bicipital tuberosity of the radius and surrounded by the
bicipitoradial bursa.
Scanning Technique
The patient’s forearm is positioned as supinated
as possible on the table to improve tendon visibility. The probe must be placed longitudinally
to evaluate the tendon along its long axis up to
the insertion on the radial tuberosity. Due to the
tendon’s oblique course, which becomes deeper
as it courses distally, it is important to press the
distal edge of the probe on the patient’s skin to
avoid anisotropy artifacts.
Enzo Silvestri ( )
Radiology Unit
Ospedale Evangelico Internazionale
Genoa, Italy
L.M. Sconfienza, G. Serafini, E. Silvestri (eds.), Ultrasound-guided Musculoskeletal Procedures,
DOI 10.1007/978-88-470-2741-1_10 © Springer-Verlag Italia 2012
61
62
E. Silvestri and E. Fabbro
a
b
c
Fig. 10.1 Evaluation of the biceps brachii distal
tendon. a The probe and patient are positioned
for an evaluation of the biceps brachii distal
tendon on a long-axis scan. b Anatomical
scheme of the biceps brachii distal tendon
(arrowheads). RT radial tuberosity, RH radial
head. c US long-axis scan of the biceps brachii
distal tendon (arrowheads)
10 The Elbow: Focused US Anatomy and Examination Technique
Lateral Compartment
Common Extensor Tendon
Anatomy
The extensor tendon complex is composed of
several tendons: extensor carpi radialis brevis,
extensor carpi ulnaris, extensor digitorum communis, and extensor digiti quinti. Normally, all of
them have a fibrillar echogenic structure.
63
Scanning Technique
With the patient’s forearm slightly flexed, the
probe is placed on the lateral epicondyle to evaluate the tendon complex on a longitudinal scan.
Occasionally, it is possible to differentiate the lateral collateral ligament from the tendon, based on
their echotexture.
a
b
c
Fig. 10.2 Evaluation of the common extensor
tendon. a The probe and patient are positioned
for an evaluation of the common extensor tendon
on a long-axis scan. b Anatomical scheme of
the common extensor tendon (arrowheads).
LE lateral epicondyle, RH radial head. c US
long-axis scan of the common extensor tendon
(arrowheads)
64
E. Silvestri and E. Fabbro
Radial-Humeral Joint
Anatomy
The radial-humeral joint comprises the capitulum
humeri and the radial proximal epiphysis, each
covered by hyaline cartilage. The annular ligament accrues from the anterior edge of the radial
notch of the ulna and inserts on the posterior edge
of the radial notch. It is involved in passive stabilization of the elbow joint.
Scanning Technique
The probe is placed in the same position used to
evaluate the common extensor tendon. A longitudinal scan allows visualization of the underlying
radial-humeral synovial meniscus filling in the
gap of the lateral surface of the radial-humeral
joint. The radial head and the annular ligament
can be correctly assessed by having the patient
pronate and supinate the forearm.
a
b
c
Fig. 10.3 Evaluation of the radial-humeral joint.
a The probe and the patient are positioned for
an evaluation of the radial-humeral joint on a
long-axis scan. b Anatomical scheme of the
radial-humeral joint. c US long-axis scan of the
radial-humeral joint. The articular space (arrow)
can be seen between the capitulum humeri (CH)
and the radial head (RH). The synovial meniscus
(asterisk) is also visible
10 The Elbow: Focused US Anatomy and Examination Technique
Medial Compartment
Common Flexor Tendon
Anatomy
The common flexor tendon is composed of the
pronator teres, flexor carpi radialis, flexor digitorum superficialis, palmaris longus, and flexor
carpi ulnaris. The tendon is shorter and flatter
than the common extensor tendon.
65
Scanning Technique
With the patient’s forearm slightly flexed and externally rotated, the proximal edge of the probe is
placed over the medial epicondyle (epitrochlea)
to scan the common flexor tendon along its long
axis.
a
b
c
Fig. 10.4 Evaluation of the common flexor
tendon. a The probe and patient are positioned
for an evaluation pf the common flexor tendon
on a long-axis scan. b Anatomical scheme of
the common flexor tendon (arrowheads). ME
medial epicondyle, U ulna. c US long-axis scan
of the common flexor tendon (arrowheads)
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E. Silvestri and E. Fabbro
Posterior Compartment
Triceps Brachii Muscle and Tendon
Anatomy
The distal triceps tendon consists of the myotendinous junction of the three bellies forming the
triceps muscle (long, medial, and lateral heads);
the tendon inserts approximately 1 cm distal to
the apex of the olecranon.
Scanning Technique
The triceps brachii muscle and tendon must be
evaluated on long- and short-axis scans, positioning the elbow flexed 90°, the arm intrarotated,
and the palm placed on the table. The US beam
should be maintained as perpendicular as possible
to the tendon fibers to avoid anisotropy artifacts.
Olecranon Fossa and
Posterior Olecranon Recess
The posterior olecranon recess and the olecranic
fossa can be assessed on longitudinal scans. The
olecranon fossa appears as a wide concavity
filled with a fat pad, localized deep to the triceps
muscle and cranially to the distal humeral epicondyle. The olecranon process is visualized as
a hyperechoic curvilinear bony structure covered
by the synovial olecranon bursa. It is not visible
under normal conditions. With the patients elbow
flexed 90°, dynamic flexion and extension scans
are used to assess the presence of intra-articular
effusion.
a
b
c
Fig. 10.5 Evaluation of the posterior compartment of
the elbow. a The probe and patient are positioned for an
evaluation of the posterior compartment of the elbow on
a long-axis scan. b Anatomical scheme of the posterior
compartment of the elbow. c US long-axis scan of the
posterior compartment of the elbow. The triceps tendon
(arrowheads) inserts on the olecranon process (O).
The posterior joint recess (arrow) and the olecranic fossa
(OF) are also seen
Treatment of Lateral Epicondylitis
11
Giovanni Serafini
Essentials
Etiology
Epicondylitis is one of the most commonly diagnosed musculoskeletal disorders of the upperextremity. Lateral epicondylitis, also known
as “tennis elbow,” is a painful condition of the
tendinous origin of the wrist extensor muscles.
Anatomically, the three major components of
the common extensor tendon are the extensor
carpi radialis brevis, the extensor digitorum, and
the extensor carpi ulnaris tendon. Injury is due
to repetitive stress on the common extensor tendon around its attachment to the lateral humeral
epicondyle in response to manual tasks, forceful
activities, or sports that require high force combined with high repetition or awkward posture
(tennis, water polo, baseball, fencing).
Epidemiology
Lateral epicondylitis is more common than medial epicondylitis and generally affects individuals
40–60 years old, with equal prevalence among
males and females.
Clinical Presentation
The main symptom is pain, which is localized
in the lateral elbow region, corresponding to
the lateral epicondyle of the humerus. It is typically related to activity and exacerbated by wrist
and hand movements. Pain may radiate into the
forearm and impair handgrip. Clinical tests, consisting of active and resisted movements of the
extensor muscles of the forearm, provoke epicondylar pain (Cozen’s sign: pain with resisted wrist
extension). During clinical examination, a typical
tenderness at the lateral side of the elbow will often become apparent. Symptom duration usually
ranges from a few weeks to a few months.
Diagnosis
In most cases, imaging is not necessary since the
diagnosis of lateral epicondylitis is usually clinical, based on symptoms and findings during the
physical examination. Imaging can be used to
evaluate the extent of tissue damage, to exclude
other causes of elbow pain, when the clinical
presentation is atypical, or to confirm the diagnosis in patients not responding to treatment.
Giovanni Serafini ( )
Diagnostic Imaging Department
Ospedale S. Corona
Pietra Ligure (SV), Italy
L.M. Sconfienza, G. Serafini, E. Silvestri (eds.), Ultrasound-guided Musculoskeletal Procedures,
DOI 10.1007/978-88-470-2741-1_11 © Springer-Verlag Italia 2012
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In epicondylitis, the tendon can be thicker
or thinner than normal, of poor definition, of
decreased echogenicity, and accompanied by
peritendinous effusion. In addition, the extensor
tendon complex may show alterations in intratendinous vascularity. In severe cases, partial- or
full-thickness tendon tears are seen as focal anechogenic areas with loss of the normal fibrillar
pattern.
G. Serafini
Interventional Procedure
Indications
Insertional overload tendinopathy of the common extensor tendon. Contraindicated in case
of traumatic lesions of the common extensor
tendon.
Objective
Treatment Options
First-line therapy usually consists of ice application, immobility of the upper limb, and NSAIDs.
Shockwave therapy can reduce symptoms in the
middle term. Surgical debridement is reserved
for refractory cases. US-guided scarification (dry
needling) can be considered as a minimally invasive option.
To cause local hyperemia and bleeding into the
tendon, thus promoting post-procedural plateletsinduced recovery phenomena.
Equipment
-
1 syringe (5–10 ml)
1 syringe (1–2 ml)
20G needle
Lidocaine (5–10 ml)
Long-acting steroid (1 ml, 40 mg/ml)
Plaster.
11 Treatment of Lateral Epicondylitis
Our Procedure
Fig. 11.1a
Fig. 11.1b
Fig. 11.1c
STEP 1
The patient is seated opposite the operator. The elbow is flexed 90° and the thumb points upward
(Fig. 11.1a). The common extensor tendon is visualized by means of a longitudinal scan. The
proximal portion of the probe is placed on the hyperechoic bony line of the lateral epicondyle
(LE), while the distal part of the probe is aligned according to the common extensor tendon.
The 20G needle (arrowheads) is inserted with an in-plane approach (Fig. 11.1b), in either a
distal-proximal or a proximal-distal direction. Anesthetic (asterisks) is injected along the path
of the needle, in the peritendinous soft tissues (Fig. 11.1c), and in the degenerated portions of
the common extensor tendon (CET). RH radial head.
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Fig. 11.2a
Fig. 11.2b
STEP 2
Figure 11.2a,b shows the needle (arrowheads) during a series of 15–20 repeated punctures
(dry-needling) on the insertional portion of the tendon (CET), hitting also the periostum that
covers the lateral epicondyle (LE). The radial head (RH) is also visible.
11 Treatment of Lateral Epicondylitis
Fig. 11.3a
Fig. 11.3b
STEP 3
The end of the procedure is shown in Fig. 11.3a,b. One ml of steroid (asterisks) is injected into
the peritendinous soft tissues, superficially to the tendon enthesis (CET). The needle (arrowheads) is then removed and a plaster applied. LE lateral epicondyle, RH radial head.
Post-procedural Care
The patient is kept under observation for at least 10 min. Pain may occur after treatment and is
managed with oral NSAIDs.
Patients are advised to use an orthotic support and to reduce their manual activity, although no
systematic rest period is suggested.
71
Treatment of Medial Epicondylitis
12
Enzo Silvestri
Essentials
Etiology
Epitrochleitis, or medial epicondylitis, is the
most commonly diagnosed musculoskeletal disorder of the medial elbow. Medial epicondylitis,
also known as “golfers elbow,” is a painful condition of the tendinous origin of the wrist flexor
muscles. Anatomically, the major components of
the common flexor tendon include the pronator
teres, flexor carpi radialis, palmaris longus, flexor
carpi ulnaris, and flexor digitorum superficialis.
This condition is caused by repetitive stress
on the common flexor tendon around its attachment to the medial humeral epicondyle due to
manual tasks, forceful activities, and sports that
require high force combined with repetitive valgus stress on the elbow joint (golf, baseball, goalkeeper).
Epidemiology
Medial epicondylitis is less common than lateral epicondylitis, with males slightly more often
affected than females. The typical age range is
from 30 to 50 years.
Enzo Silvestri ( )
Radiology Unit
Ospedale Evangelico Internazionale
Genoa, Italy
Clinical Presentation
The main symptom is pain, which is localized
in the medial elbow region, corresponding to
the medial epicondyle of the humerus. Pain is
typically related to activity and is exacerbated
by wrist and hand movements. Moreover, it may
radiate into the forearm and impair handgrip.
Clinical tests, consisting of active and resisted
movements of the flexor muscles of the forearm,
provoke epitrochlear pain with resisted wrist
flexion. During clinical examination, a typical
tenderness at the medial side of the elbow will
become apparent. The duration of epitrochleitis
symptoms usually ranges from a few weeks to a
few months.
Diagnosis
In most cases, imaging is not needed since the
diagnose of medial epicondylitis is usually clinical, based on symptoms and findings during the
physical examination. Diagnostic imaging can
be used to evaluate the extent of tissue damage,
to exclude other causes of elbow pain, when the
clinical presentation is atypical, or to confirm the
diagnosis in patients not responding to treatment.
Ultrasound can demonstrate thinning or
thickening of the tendon, sometimes associated
with a peritendinous effusion. Also, tendon vascularity, evaluated using power Doppler, may be
increased. More rarely, partial tears are seen.
L.M. Sconfienza, G. Serafini, E. Silvestri (eds.), Ultrasound-guided Musculoskeletal Procedures,
DOI 10.1007/978-88-470-2741-1_12 © Springer-Verlag Italia 2012
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E. Silvestri
Treatment Options
Objective
First-line therapy usually consists of ice application, immobility of the upper limb, the use of orthotic devices, and NSAIDs. Shockwave therapy
can reduce symptoms in the middle term. Surgical debridement is reserved for refractory cases.
US-guided scarification (dry needling) can be
considered as a minimally invasive option.
To cause local hyperemia and bleeding into the
tendon, thus promoting relevant post-procedural
platelets-induced recovery phenomena.
Interventional Procedure
Indications
Equipment
-
1 syringe (5–10 ml)
1 syringe (1–2 ml)
20G needle
Lidocaine (5–10 ml)
Long-acting steroid (1 ml, 40 mg/ml)
Plaster.
Insertional overload tendinopathy of the common flexor tendon. Contraindicated in case of
traumatic lesions of the common flexor tendon.
Our Procedure
Fig. 12.1a
STEP 1
The patient is seated opposite the operator. The elbow is flexed 90° and the thumb points laterally (see Fig. 10.4a). The common flexor tendon (CFT) is visualized by means of a longitudinal
scan. The proximal portion of the probe is placed on the hyperechoic bony line of the medial
epicondyle (ME), while the distal part of the probe is aligned according to the common flexor
tendon (see Fig. 10.4b,c).
12 Treatment of Medial Epicondylitis
Fig. 12.1b
Fig. 12.1c
STEP 2
A 20G needle (arrowheads) is inserted with an in-plane approach, in either a distal-proximal
or a proximal-distal direction (Fig. 12.1a–c), while a small amount of anesthetic (asterisks) is
injected along the path of the needle, in the peritendinous soft tissues, and in the degenerated
portions of the common flexor tendon (CFT). ME medial epicondyle.
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E. Silvestri
Fig. 12.2a
Fig. 12.2b
STEP 3
A series of 15–20 repeated punctures (dry needling, arrowheads) are performed in the insertional degenerated portions of the tendon (CFT), hitting also the periostium covering the medial
epicondyle (Fig. 12.2a,b). ME medial epicondyle, arrow needle tip.
12 Treatment of Medial Epicondylitis
Fig. 12.3a
Fig. 12.3b
STEP 4
At the end of the procedure, 1 ml of steroid (asterisks) is injected in the peritendinous soft tissues superficially to the tendinous insertion (CFT) (Fig. 12.3a,b). The needle (arrowheads) is
then removed and a plaster applied. ME medial epicondyle, U ulna.
Post-procedural Care
The patient is kept under observation for at least 10 min. Pain may occur after treatment and is
managed with oral NSAIDs.
Patients are advised to use an orthotic support and to reduce their manual activity, although no
systematic rest period is suggested.
77
Olecranon Bursa Drainage
13
Francesca Lacelli
Essentials
Epidemiology
Olecranon bursitis is a relatively common condition that typically affects men between the ages
of 30 and 60 years. It is characterized by an inflammatory process with fluid distension or hypertrophy of the synovial membrane.
Clinical Presentation
Patients usually complain of swelling in the olecranon region. Pain can vary from a subtle discomfort to an intense symptomatology. Pressure
or active and passive movements may result in a
worsening of symptoms. If fever is present, the
diagnosis of septic bursitis must be considered.
Ultrasound Diagnosis
Etiology
The most common cause of olecranon bursitis is
local contusion: 66% of cases are aseptic and usually occur when trauma or repeated small injuries
lead to bleeding into the bursa or the release of inflammatory mediators (student’s elbow, miner’s
elbow). Bursitis can also develop secondary to
calcific enthesopathy of the distal triceps tendon,
systemic disorders such as rheumatoid arthritis,
gout, hydroxyapatite and calcium pyrophosphate
deposition diseases, septic conditions, or chronic
hemodialysis.
Francesca Lacelli ( )
Diagnostic Imaging Department
Ospedale S. Corona
Pietra Ligure (SV), Italy
Olecranon bursitis is seen as a localized fluid collection and synovial wall hypertrophy. Color- and
power-Doppler imaging demonstrate soft-tissue
hyperemia. Both edema of the surrounding soft
tissues and cellulitis are frequently associated
with hemorrhagic and septic bursitis. In patients
with chronic renal failure, it is common to identify a calcified bursitis. The presence of synovial
proliferation and fibrosis suggests a differential
diagnosis that includes solid tumor and chronic
bursitis. In patients with rheumatoid arthritis,
subcutaneous nodules can be seen in the olecranon region and along the proximal ulna. Fluid
collection can lead to bursal rupture dissecting
the superficial soft tissues.
Treatment Options
Most patients respond to conservative management, including ice, activity modification, and
L.M. Sconfienza, G. Serafini, E. Silvestri (eds.), Ultrasound-guided Musculoskeletal Procedures,
DOI 10.1007/978-88-470-2741-1_13 © Springer-Verlag Italia 2012
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F. Lacelli
NSAIDs. In cases of septic bursitis, oral antibiotics may be administered. Drainage in the acute
phases usually relieves swelling and discomfort,
while steroid injection is performed in chronic or
recurrent bursitis.
Objective
To drain distended olecranic bursa. To deliver
anti-inflammatory drugs into the bursal space.
Equipment
Interventional Procedure
Indications
-
Chronic or recurrent bursitis non-responsive to
conservative treatment. Septic bursitis can be
drained but steroid should not be injected.
-
1 syringe (1 ml)
1 syringe to drain the bursal effusion (up to
20 ml)
14G–20G simple needle or shielded cannula
Long-acting steroid (1 ml, 40 mg/ml)
Plaster.
Our Procedure
Fig. 13.1a
Fig. 13.1b
STEP 1
The patient is positioned prone, with the forearm flexed and the hand lying on the examination
table (Fig. 13.1a). This position can help to squeeze the bursa in case of a drainage procedure
to address a consistent effusion. A longitudinal US scan is performed on the olecranic region
(O) to assess the anatomical extension of the bursa and to identify the enlarged bursa (asterisks)
(Fig. 13.1b).
13 Olecranon Bursa Drainage
Fig. 13.2a
Fig. 13.2b
Fig. 13.2c
STEP 2
A needle connected to a syringe is inserted with an in-plane approach until the tip enters the
bursa (Fig. 13.2a). In some patients the bursal content is very dense, such that drainage is extremely challenging. In these cases, a larger shielded cannula (Fig. 13.2b,c, arrowheads) and the
application of manual compression over the bursa (asterisks) may be helpful. A biopsy handle
may also be used to obtain a more effective vacuum. T triceps tendon, O olecranon.
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F. Lacelli
Fig. 13.3
STEP 3
When the bursa (asterisks) has been completely drained, a small amount of steroid (circles) is
injected (Fig. 13.3). In case of infection, lavage using warm saline solution may help. In these
cases, however, steroid injections are to be avoided. The needle is then removed and a plaster
applied at the cutaneous puncture site. T triceps tendon, O olecranon.
Post-procedural Care
The patient is kept under observation for at least 10 min. Pain may occur after treatment and is
managed with oral NSAIDs.
The patient is advised to avoid stressing the olecranon region on hard surfaces for a few days.
Intra-articular Injections
14
Luca Maria Sconfienza
Essentials
Interventional Procedure
Treatment Options
Indications
Intra-articular injections of the elbow can be performed in the treatment of a variety of pathological conditions.
The drugs administered in these cases may be
an anti-inflammatory agent, such as the use of
steroids for rheumatoid arthritis or crystal-induced arthropathies, or a viscosupplement, such
as hyaluronic acid, which is injected in joints involved by osteoarthritis. Local anesthetic can be
injected to assess the intra-articular relevance of
referred pain or as short-term analgesia. In traumatic fractures of the radial head, aspiration and
analgesic injection are an option.
This procedure can also be used to inject contrast agent within the joint for arthrography.
Intra-articular injection of steroids: rheumatoid
arthritis, crystal arthropathies, degenerative osteoarthritis with articular effusion.
Intra-articular injection of hyaluronic acid:
degenerative osteoarthritis without articular effusion.
Intra-articular injection of local anesthetic:
assessment of intra-articular relevance of pain,
traumatic fractures of the radial head.
Objective
To deliver anti-inflammatory or viscosupplement
agents into the intra-articular joint space.
Equipment
-
1 syringe (2–5 ml)
21G needle
Long-acting steroid (1 ml, 40 mg/ml) or lowmolecular-weight hyaluronic acid (2 ml)
Plaster.
Luca Maria Sconfienza ( )
Radiology Unit
IRCCS Policlinico San Donato
San Donato Milanese (MI), Italy
L.M. Sconfienza, G. Serafini, E. Silvestri (eds.), Ultrasound-guided Musculoskeletal Procedures,
DOI 10.1007/978-88-470-2741-1_14 © Springer-Verlag Italia 2012
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L. M. Sconfienza
Our Procedure
Fig. 14.1a
STEP 1
The patient is seated facing the operator with the elbow flexed 90° and the hand in a neutral position. The transducer is aligned longitudinally to visualize the humeral-radial joint (Fig. 14.1a). A
longitudinal US scan of the lateral articular recess is performed, examining the cortical bone of
the capitulum humeri, the synovial meniscus, and the proximal radial epiphisis covered with hyaline cartilage. The humeral-radial joint line is then centered in the field of view (see Fig. 10.3).
14 Intra-articular Injections
Fig. 14.1b
Fig. 14.1c
STEP 2
A 20G needle is inserted perpendicularly to the skin at the center of the probe, with an out-ofplane (coaxial) approach (Fig. 14.1b). Passage of the needle tip into the joint is generally associated with a distinct feeling of capsular resistance followed by the sensation of a resistance-free
space. When the needle tip (arrow) reaches the US scanning plane (Fig. 14.1c), it is visualized
as a hyperechoic dot appearing in the anechoic articular space between the capitulum humeri
(CH) and the radial head (RH), underlying the common extensor tendon (CET). The injection
should be made slowly but with consistent pressure. At the end of the injection, the needle can
be removed and a plaster applied on the skin.
Post-procedural Care
The patient should be kept under observation for at least 30 min after the procedure. Pain may
occur after treatment and is managed with oral NSAIDs.
A short resting period of 1 or 2 days should be recommended.
85
Part III
The Wrist
The Wrist: Focused US Anatomy and
Examination Technique
15
Enzo Silvestri and Giulio Ferrero
Extensor Tendons
Anatomy
On the dorsal side of the wrist, the extensor tendons run within six compartments, numbered
from 1 to 6, from the radial to the ulnar side. The
first compartment consists of the abductor pollicis longus and extensor pollicis brevis tendons.
The second comprises the extensor carpi radialis
longus and brevis tendons. The third, separated
from the second by the Lister tubercle, contains
the extensor pollicis longus tendon. The fourth
compartment is the widest, as it must accommodate the extensor indici and the four extensor digitorum tendons. The fifth consists of the extensor
digiti quinti tendon, and the sixth the extensor
carpi ulnaris tendon.
Scanning Technique
To evaluate the first compartment, the wrist must
be kept in an intermediate position between pronation and supination and the probe must be
placed on the lateral side of the radial styloid.
The second to fifth compartments are evaluated
with the palm facing down in a neutral position.
The sixth compartment is assessed with the hand
slightly bent on the radial side. Long- and shortaxis scans of each tendon up to its distal insertion
must be obtained, also during finger flexion and
extension.
Enzo Silvestri ( )
Radiology Unit
Ospedale Evangelico Internazionale
Genoa, Italy
L.M. Sconfienza, G. Serafini, E. Silvestri (eds.), Ultrasound-guided Musculoskeletal Procedures,
DOI 10.1007/978-88-470-2741-1_14 © Springer-Verlag Italia 2012
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E. Silvestri and G. Ferrero
a
b
c
d
e
f
Fig. 15.1 a Overview of the extensor compartments of
the wrist. b Abductor pollicis longus (APL) and extensor
pollicis brevis (EPB) tendons. R radius. c Extensor carpi
radialis longus (ECRL) and brevis (ECRB) tendons.
d The extensor pollicis longus tendon (EPL) is separated
from the second compartment by the Lister tubercle (L).
The extensor digiti secundi (EDS) and the extensor
digitorum communis (EDC) tendons are contained in the
fourth compartment. e Extensor digitorum communis
(EDC) and extensor digiti quinti (EDQ) within the fourth
compartment. f Extensor carpi (ECU) tendon overlying
the ulna (U). All tendons are stabilized by the extensor
retinacula (arrowheads)
15 The Wrist: Focused US Anatomy and Examination Technique
Carpal Joints
91
carpal joint. The trapezium also articulates with
the first metacarpal bone.
Anatomy
The radiocarpal joint is formed by the radius, the
radioulnar capsule recess, and three bones of the
proximal carpal row: scaphoid, lunate, and triquetrum. Between the scaphoid and the lunate
and between the lunate and the triquetrum there
are two important ligaments that act as passive
wrist stabilizers, the scapho-lunate and lunatetriquetrum. The integrity or interruption of these
structures defines the distribution of drugs inside
the compartments and their spread into the mid-
Scanning Technique
The radiocarpal joint can be assessed by placing the probe on the dorsal side of the wrist on
a longitudinal scan. A small amount of effusion
will stretch the proximal side of the capsule.
The trapezium-metacarpal joint is scanned with
the wrist kept in the same position used for the
first dorsal compartment, with the probe aligned
along a longitudinal axis.
a
b
Fig. 15.2a,b Sagittal scan over the radio-midcarpal joints. The distal radius (R), lunate (L),
and capitate (C) are seen. The radiocarpal
(arrow) and the mid-carpal (arrowhead) joints
are visible
92
E. Silvestri and G. Ferrero
a
b
Fig. 15.3a,b Trapeziometacarpal joint. The
articular space (arrow) can be seen between the
trapezium (T) and the metacarpal base (M). The
joint capsule (arrowheads) is visible as well
Treament of De Quervain’s Disease
and Other Forms of Tenosynovitis
16
Giovanni Serafini
Essentials
Epidemiology
De Quervain’s disease occurs in 0.5% of males
and 1.3% of females; in the latter, it is often associated with pregnancy and nursing. The prevalence and incidence of De Quervain’s tenosynovitis in primary care are not known. This disease
has a considerable impact on daily activities.
Etiology
De Quervain’s disease is a chronic tenosynovitis of the first dorsal compartment of the wrist,
caused by a thickening of the retinaculum. This
impairs the normal sliding of the extensor pollicis brevis and abductor pollicis longus tendons.
Retinaculum thickening reflects degenerative
changes, such as myxoid degeneration, fibrocartilaginous metaplasia, and mucopolysaccharide
deposition. This condition should be not confused with acute tenosynovitis, in which inflammation and synovial effusion within the tendon
sheath are seen.
Clinical Presentation
Typical symptoms include pain or tenderness
over the radial styloid, sometimes radiating to
the thumb, forearm, or shoulder. On physical examination, swelling over the radial styloid with
tenderness and crepitations on palpation may be
noted. There may also be associated functional
limitations. Finkelstein’s test (deviating the wrist
to the ulnar side while grasping the thumb, resulting in pain) is typically positive.
Ultrasound Diagnosis
Retinaculum thickening in the extensor compartment can be seen on US. Power Doppler can be
used to detect hypervascularity. A dynamic US
evaluation may demonstrate the impaired mobility of the tendons within the compartment. In
some cases, an accessory tendon or a fibrous hyperechoic septum separating the two tendons is
seen. The detection of these findings is important
as they imply an improvement or worsening of
the disease.
Treatment Options
Giovanni Serafini ( )
Diagnostic Imaging Department
Ospedale S. Corona
Pietra Ligure (SV), Italy
Therapy initially consists of resting the thumb
and wrist with or without splinting and ice application. An intracompartmental injection can provide the complete relief of symptoms. In some
L.M. Sconfienza, G. Serafini, E. Silvestri (eds.), Ultrasound-guided Musculoskeletal Procedures,
DOI 10.1007/978-88-470-2741-1_16 © Springer-Verlag Italia 2012
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cases, however, surgery is needed to release the
retinaculum or to remove the accessory tendon or
the fibrous septum.
Interventional Procedure
Indications
If the condition is symptomatic and limits daily life activities, then US-guided percutaneous
treatment is indicated. There are no specific contraindications to this procedure.
Objective
Early or subacute De Quervain’s disease responds well to corticosteroid injection, with the
G. Serafini
anti-inflammatory effects possibly resulting in
relief from both pain and swelling. Advanced disease stages, characterized by a severe stenosis of
the compartment due to retinaculum thickening,
may benefit from a first injection of steroid, followed by 1–2 weeks of delayed hyaluronic acid
injection. This second step has the advantage of
both improving tendon sliding and stretching the
thickened retinaculum.
Equipment
-
25G or smaller needle
1 syringe (1–2 ml)
Long-acting steroid (1 ml, 40 mg/ml)
Low-molecular-weight hyaluronic acid (2 ml,
optional)
Plaster.
16 Treament of De Quervain’s Disease and Other Forms of Tenosynovitis
Our Procedure
Fig. 16.1a
Fig. 16.1b
Fig. 16.1c
Lateral Approach
The wrist must be placed in an intermediate position between pronation and supination (Fig.
16.1a). The probe is then positioned on the lateral side of the radial styloid to assess the first
compartment along its short axis (Fig. 16.1b). APL abductor pollicis longus, EPB extensor pollicis brevis.
We prefer to use a lateral approach to treat De Quervain’s disease (Fig. 16.1c). The needle
(arrowheads) is inserted within the thickened retinaculum (arrows) and the drug (asterisks) is
injected. The abductor pollicis longus (APL), extensor pollicis brevis (EPB), and extensor carpi
radialis longus (ECRL, second compartment) can be seen.
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G. Serafini
Fig. 16.2a
Fig. 16.2b
Longitudinal Approach
Note that a long-axis approach is also possible (Fig. 16.2a). In Fig. 16.2b, the needle (arrowheads) is inserted within the thickened retinaculum (arrows). The abductor pollicis longus
(APL) is seen overlying the radius (R).
Post-procedural Care
The patient is kept under observation for at least 10 min. Pain may occur after treatment and is
managed with oral NSAIDs.
Patients are advised to reduce their manual activity, although no systematic rest period is suggested.
Other Forms of Tenosynovitis of the
Dorsal Compartments
Not just the first compartment but also other extensor compartments can be affected by acute or
chronic tenosynovitis, which can similarly cause
pain and functional limitations. Acute tenosynovitis is characterized by a fluid effusion within
the compartment or the tendon sheath, while in
chronic tenosynovitis there is synovial thickening or proliferation. The sixth extensor compart-
ment differs from the other five in that sheath effusion frequently occurs in conjunction with joint
effusion, due to the physiological communication
between the two structures. In this case, sheath
effusion should not be treated.
Also in these cases, steroid injection is a valid
option, as it is able to reduce pain and effusion.
Sometimes, hyaluronic acid is injected to improve tendon sliding and to stretch a retinaculum
stenosis. The injection technique is similar to that
described for De Quervain’s disease.
Articular Ganglia Drainage
17
Leonardo Callegari
Essentials
Epidemiology
Ganglion cysts are the most common benign
soft-tissue lesions of the wrist. They occur three
times more often in women than in men, are predominantly seen in young adults, and are rare in
children. In 60–70% of affected individuals, the
ganglion cyst is localized in the dorsal aspect of
the wrist and communicates with the synovial
joint via a pedicle that usually originates at the
scapholunate ligament but also may arise from a
number of other sites over the dorsal aspect of the
wrist capsule. In 13–20% of the cases, ganglia
are found on the volar side of the wrist.
Etiology
Ganglia are articular cysts that originate from the
articular cavity. The exact mechanism of ganglion formation remains unknown.
Clinical Presentation
On examination, wrist ganglia are usually 1- to
2-cm lumps, but they are rarely accompanied by
Leonardo Callegari ( )
Radiology Unit B
Ospedale di Circolo, Fondazione Macchi
Varese, Italy
signs of inflammation. On palpation, they are a
firm swelling well tethered in place by an attachment to the underlying joint capsule or tendon
sheath.
While ganglia are frequently asymptomatic,
symptoms may include general wrist pain, especially during activities, functional limitation, or a
decrease in grip strength. In some cases, ganglia
may cause pain by compressing small branches
of the peripheral nerves.
Ultrasound Diagnosis
Wrist ganglia have a typical cystic pattern on US,
i.e., roundish or oval hypo/anechoic findings and
well delimited by a thin and regular wall. When
the cyst content is not exactly hypo/anechoic,
the presence of a well-defined pedicle may help
to differentiate a ganglia from other pathological
conditions.
Treatment Options
Ganglion cyst can be treated conservatively, by
percutaneous drainage, or surgically. Bandaging
is the most common conservative treatment and
is aimed at limiting wrist mobility. Percutaneous
drainage is the second treatment option but about
50% of these treated ganglion cysts will relapse.
However, as this procedure is relatively non-invasive, it can be repeated several times. In case
of recurrent cysts, surgery, performed using an
L.M. Sconfienza, G. Serafini, E. Silvestri (eds.), Ultrasound-guided Musculoskeletal Procedures,
DOI 10.1007/978-88-470-2741-1_17 © Springer-Verlag Italia 2012
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L. Callegari
arthroscopic or open-air approach, is the last option. It is associated with a 35% recurrence rate,
especially in patients with a longer history and a
larger ganglion cyst.
Objective
Interventional Procedure
Equipment
Indications
-
Articular ganglia can be treated to reduce pain or
other symptoms. Asymptomatic ganglia can be
drained also for aesthetic reasons.
Ganglia drainage is aimed at reducing lesion volume. Steroid injection after drainage may help to
keep the ganglia wall collapsed.
18G needle
1 syringe (10 ml)
Lidocaine (2–4 ml)
Long-acting steroid (1 ml, 40 mg/ml).
Our Procedure
Fig. 17.1a
Fig. 17.1b
STEP 1
The wrist should be positioned according to the ganglion’s location (Fig. 17.1a). Ganglia more
commonly occur on the dorsal side of the wrist. The probe is usually positioned along the major axis of the ganglion. As seen in Fig. 17.1b, the ganglion (G) should be assessed also with
respect to the other structures of the wrist. Particular attention should be paid to avoid injury of
the radial artery (A) that frequently surrounds the ganglion.
17 Articular Ganglia Drainage
Fig. 17.2a
Fig. 17.2b
STEP 2
Using an in-plane lateral approach (see Fig. 17.1a), a small amount of anesthesia is injected
into the subcutaneous tissues around the ganglion (G). Then, a large-bore needle (arrowheads)
is advanced within the ganglion (Fig. 17.2a,b), with care taken to avoid surrounding structures,
such as the radial artery (A). R radius, S scaphoid.
Fig. 17.3
STEP 3
The ganglion’s content is completely drained using a syringe (Fig. 17.3). Continuous US monitoring of the needle (arrowheads) is mandatory. This procedure is usually quite slow, as the
material contained in the ganglion is often very dense. In these cases, a larger shielded cannula
and the application of manual compression over the ganglion may be helpful. A biopsy handle
may also be used to obtain a more effective vacuum.
99
100
L. Callegari
Fig. 17.4
STEP 4
At the end of the procedure, a small amount of steroid (asterisks) is injected into the ganglion
cavity (Fig. 17.4).
Post-procedural Care
A compressive bandage is applied to the involved site for 5-10 days in order to keep the ganglion
wall collapsed and to minimize the probability of recurrence.
Trapeziometacarpal
Joint Injection
18
Francesca Lacelli
Essentials
Epidemiology
Trapeziometacarpal osteoarthritis occurs most
often in women over the age of 40. In approximately 80% of cases, it is associated with osteoarthritis between the trapezium and the base
of the second metacarpal, and in 40% of cases
with osteoarthritis between the trapezium and the
scaphoid.
Etiology
The trapeziometacarpal joint may be involved by
different kinds of arthritis. The most common is
osteoarthritis, also known as rhizarthrosis, and it
is a result of natural joint aging. As the degenerative process continues, the cartilage becomes increasingly thinner, and eventually disappears. At
later stages, the articular space may be lost and
osteophytes are frequently seen. There may also
be progressive subluxation of the base of the first
metacarpal bone.
Clinical Presentation
The typical symptom is pain that occurs either
after prolonged activities or as a result of simple
anteposition and opposition movements of the
thumb. Pain is mostly reported over the volar side
of the thumb base.
Ultrasound Diagnosis
The trapeziometacarpal joint is easily evaluated
by placing the probe on the volar side of the carpus and detecting the joint along its long axis. US
signs of rhizarthrosis are joint effusion, a reduction of the articular space, erosive phenomena,
and osteophytes.
Treatment Options
Conservative treatment of trapeziometacarpal arthritis includes physiotherapy, orthopedic splinting, and drug injection. The aim is to control
symptoms and to delay or avoid surgery.
In case of severe arthritis or persisting symptoms
despite conservative therapy, surgery is an option.
Francesca Lacelli ( )
Diagnostic Imaging Department
Ospedale S. Corona
Pietra Ligure (SV), Italy
L.M. Sconfienza, G. Serafini, E. Silvestri (eds.), Ultrasound-guided Musculoskeletal Procedures,
DOI 10.1007/978-88-470-2741-1_18 © Springer-Verlag Italia 2012
101
102
Interventional Procedure
Indications
US-guided percutaneous treatment is indicated
if the patient complains of pain and functional
limitation. This form of therapy has been shown
to delay surgery and in some cases to allow the
patient to completely avoid it.
Objective
Steroid injection is useful in reducing both the inflammatory component of osteoarthritis and pain.
Hyaluronic acid is injected 10–15 days later and
improves joint mobility. The injection should be
F. Lacelli
repeated weekly, three times. This cycle can be
repeated in case of pain recurrence.
Early stages of the disease respond well to
this form of treatment. In patients with later-stage
disease, the outcome is worse and there is earlier
symptom recurrence.
Equipment
-
25G or smaller needle
1 syringe (1–2 ml)
Local anesthetic (0.5 ml)
Long-lasting steroid (0.5 ml, 40 mg/ml)
Low-molecular-weight hyaluronic acid (0.5–
1 ml)
Plaster.
Our Procedure
Fig. 18.1a
Co-axial Approach
STEP 1
The wrist must be positioned in an intermediate position between pronation and supination. The
probe is placed on the lateral side of the wrist along its long axis, visualizing the trapeziometacarpal joint along its long axis. The needle is inserted with a co-axial out-of-plane approach
(Fig. 18.1a).
18 Trapeziometacarpal Joint Injection
103
Fig. 18.1b
Fig. 18.1c
STEP 2
The articular space (arrow) can be seen between the trapezium (T) and the metacarpal base (M).
As shown in Fig. 18.1b,c, the needle is inserted in the joint space, where it is seen as a small
hyperechoic dot (arrow). Steroid (asterisk) is then injected into the joint, distending the capsule
(arrowheads). After 10–15 days, hyaluronic acid is injected according to the same technique.
104
F. Lacelli
Fig. 18.2a
Fig. 18.2b
Fig. 18.2c
Longitudinal Approach
The procedure can also be performed using a lateral approach (Fig. 18.2a). The needle (arrowheads) is inserted in the joint space (Fig. 18.2b,c) and drug (asterisk) is then injected in the
joint, distending the capsule (arrows). Delayed hyaluronic acid injection is performed as above.
M metacarpal base, T trapezium.
Post-procedural Care
After treatment, patients should avoid heavy activities for 5–10 days. Pain may occur after treatment and is managed with oral NSAIDs.
Radiocarpal Joint Injections
19
Luca Maria Sconfienza
Similar to the other joints discussed thus far,
intra-articular injections of the wrist can be performed to address a variety of pathological conditions. The drug of choice will depend on the
condition and the treatment goals. The technique
can also be used in the injection of intra-articular
contrast agent for arthrography.
Equipment
-
21G–23G needle
1 syringe (3–5 ml)
Local anesthetic (5 ml) and/or
Long-lasting steroid (1 ml, 40 mg/ml) and/or
Medium-molecular-weight hyaluronic acid
(2 ml)
Plaster.
Indications
Intra-articular injection of steroids: rheumatoid
arthritis, crystal arthropathies, degenerative osteoarthritis with articular effusion.
Intra-articular injection of hyaluronic acid:
degenerative osteoarthritis without articular effusion.
Intra-articular injection of local anesthetic:
assessment of intra-articular relevance of pain,
traumatic fractures of the radial head, short-term
analgesia.
Luca Maria Sconfienza ( )
Radiology Unit
IRCCS Policlinico San Donato
San Donato Milanese (MI), Italy
L.M. Sconfienza, G. Serafini, E. Silvestri (eds.), Ultrasound-guided Musculoskeletal Procedures,
DOI 10.1007/978-88-470-2741-1_19 © Springer-Verlag Italia 2012
105
106
L.M. Sconfienza
Our Procedure
Fig. 19.1a
STEP 1
The hand is positioned on the table with the palm facing down (Fig. 19.1a). The probe is placed
over the relevant joint to be injected. To inject the radiocarpal joint, the probe is positioned on
the dorsal side of the wrist along its long axis (see Fig. 15.2a); this also allows visualization of
the distal radial epiphysis and the first carpal row (see Fig. 15.2b).
19 Radiocarpal Joint Injections
107
Fig. 19.1b
Fig. 19.1c
STEP 2
The needle is inserted into the joint using an out-of-plane co-axial approach (Fig. 19.1b).
Fig. 19.1c shows the injection of steroid in a patient with rheumatoid arthritis accompanied by
synovial proliferation. The needle (arrows) can be seen as a small hyperechoic dot within the
synovial proliferation (asterisks). The latter arises between the carpal bones (CB). The extensor
tendons (ET), radius (R), and metacarpal bone (M) are also seen.
Post-procedural Care
Patients should avoid heavy activities for 5–10 days. Pain may occur after treatment and is managed with oral NSAIDs.
Part IV
The Hand
The Hand: Focused US Anatomy
and Examination Technique
20
Francesca Lacelli and Chiara Martini
Flexor Digitorum Tendons
Anatomy
There are nine flexor tendons for each hand, a
flexor digitorum superficialis and a flexor digitorum profundus for each finger, from the second
to the fifth. The thumb is provided with a single
flexor tendon only. The flexor digitorum profundus tendon originates from the anterior and medial aspects of the ulna, while the flexor digitorum
superficialis tendon has two heads: humero-ulnar
and radial. Both muscles originate from long
tendons that proximally enter the carpal tunnel
and then insert on the fingers. Deep tendons run
straight up to the bases of the distal phalanges,
where they insert. Superficial tendons run up
to the middle of the proximal phalanges, where
they split into two branches that surround the
deep tendons and insert on the head of the middle phalanges. The superficial and deep tendons
have common tendon sheaths. Flexor tendons are
kept in place by several fibrous bands referred to
as pulleys. These structures are very thin and are
occasionally seen US as thin hypoechoic bundles
that overhang the tendons.
Scanning Technique
With the patient’s hand placed on the table with
the palmar side facing up, the probe is placed at
the carpal tunnel level and then is moved distally
to follow the tendons until their insertions. Axial
scans allow the changing relationship between
superficial and deep flexor tendons to be assessed; longitudinal scans are useful for passive
dynamic evaluation, e.g., in patients with tendon
impingement under the pulleys.
Metacarpophalangeal and
Interphalangeal Joints
Scanning Technique
With the patient’s palm facing up, the probe is
placed along the longitudinal axis over the pertinent joint. Each joint is renforced by a capsule
and a palmar plate, which together form a capsuloligamentous complex that is located on the
ventral side. A small amount of intra-articular
fluid can be seen under normal conditions.
Francesca Lacelli ( )
Diagnostic Imaging Department
Ospedale S. Corona
Pietra Ligure (SV), Italy
L.M. Sconfienza, G. Serafini, E. Silvestri (eds.), Ultrasound-guided Musculoskeletal Procedures,
DOI 10.1007/978-88-470-2741-1_20 © Springer-Verlag Italia 2012
111
112
F. Lacelli and C. Martini
a
b
Fig. 20.1 a The probe position and b a long-axis
scan of the flexor tendons. The flexor digitorum
superficialis (FDS) and flexor digitorum
profundus (FDP) can be seen. The A1 reflection
pulley is indicated (arrowheads). MH metacarpal
head, PP proximal phalanx
Fig. 20.2 Long-axis lateral scan of the second
metacarpophalangeal joint. The joint space
(arrow) is located between the metacarpal
head (MH) and the proximal phalanx (PP) and
surrounded by the joint capsule (arrowheads)
Treatment of Trigger Finger
21
Leonardo Callegari
Essentials
Etiology
Trigger finger is a stenosing tenosynovitis that
originates from a thickening of the first annular
(A1) pulley of the flexor tendons. In order of frequency, the thumb, annular, middle, little, and
index fingers are affected.
Most cases of trigger finger are idiopathic. In
some patients, high pressures on the A1 pulley
during maximum flexion may cause changes in
the pulley itself, with hypertrophy and fibrocartilaginous metaplasia. It is thought that chronic,
repetitive friction causes a nodule in the tendon
as the fibers lose their normal arrangement.
Clinical Presentation
Symptoms include triggering or catching of the
finger during movement, pain on passive extension, and locking. Clinically, finger clicking
can be clearly perceived. Sometimes, a palpable
nodule may be appreciated over the metacarpophalangeal joint.
Ultrasound Diagnosis
Hypoechoic thickening of the A1 pulley and
nodular thickening of the flexor tendon can be
demonstrated using US. Dynamic US scans can
confirm the diagnosis of trigger finger when
thickening of the pulley or the tendon cannot otherwise be detected.
Epidemiology
Trigger finger is one of the most common pathologies of the upper limb (28 cases per 100,000 per
year). It is more frequent in women, with a peak
of incidence between the age of 50 and 60. There
may be an associated clinical condition (diabetes
mellitus, rheumatoid arthritis, hypothyroidism,
obesity). In other patients it is due to repetitive
activities (work, sport).
Alternative Treatments
Alternative treatments of trigger finger include:
splintage, if the symptoms are mild: simply resting the finger may be enough to relieve the problem; pharmacological therapy with NSAIDs; and
surgical release of the A1 pulley by open or percutaneous techniques.
Leonardo Callegari ( )
Radiology Unit B
Ospedale di Circolo, Fondazione Macchi
Varese, Italy
L.M. Sconfienza, G. Serafini, E. Silvestri (eds.), Ultrasound-guided Musculoskeletal Procedures,
DOI 10.1007/978-88-470-2741-1_21 © Springer-Verlag Italia 2012
113
114
Interventional Procedure
Indications
The US-guided percutaneous treatment of trigger
finger is indicated when the patient complains
of pain or functional limitation (presence of discomfort or blockage during movements of the
finger, or an inability to actively achieve flexion).
Objective
The aim of steroid injection is to reduce pain and
inflammation. A 10- to 15-day delayed injection
L. Callegari
of hyaluronic acid into the sheath is performed
to improve tendon sliding under the pulley by
stretching the A1 pulley fibrosis.
Equipment
-
25G needle
Two syringes (2 ml)
Lidocaine (0.5 ml)
Long-acting steroid (1 ml, 40 mg/ml)
Low-molecular-weight hyaluronic acid (1 ml)
Plaster.
21 Treatment of Trigger Finger
115
Our Procedure
Fig. 21.1a
Fig. 21.1b
Fig. 21.1c
STEP 1
The patient is seated opposite the examiner with his or her hand placed on the table and the palm
facing up (Fig. 21.1a). The probe is placed at the level of the metacarpophalangeal joint, along
the major axis of the flexor tendons (Fig. 21.1b,c). Note the thickened pulley (arrows) and the
chronic tenosynovitis (arrowheads). FDS flexor digitorum superficialis, FDP flexor digitorum
profundus, MH metacarpophalangeal head, PP proximal phalanx.
116
L. Callegari
Fig. 21.2a
Fig. 21.2b
Fig. 21.2c
Fig. 21.3
Longitudinal Approach
STEP 2
As seen in Fig. 21.2a–c, the needle (arrowheads) is inserted along a longitudinal axis with a distal-proximal approach and the anesthetic is injected within the tendon sheath (arrows indicate
the A1 pulley), avoiding the tendons. FDS flexor digitorum superficialis, FDP flexor digitorum
profundus. Then, with the needle (arrowhead) kept in place, steroid (asterisks) is injected within
the sheath (Fig. 21.3), avoiding the tendons.
21 Treatment of Trigger Finger
117
Fig. 21.4a
Fig. 21.4b
Fig. 21.4c
Lateral Approach
STEP 2
A short-axis approach is also possible, as shown in Fig. 21.4a-c. In this case, the probe is oriented on the short axis of the tendons (FT) and the needle (arrowheads) is inserted laterally.
Steroid (asterisk) is then injected.
118
L. Callegari
Fig. 21.5
STEP 3
After 10–15 days, hyaluronic acid (asterisks) is injected using the same longitudinal or lateral
injection technique (Fig. 21.5), avoiding the tendons. FDS flexor digitorum superficialis, FDP
flexor digitorum profundus. Arrowheads indicate the needle.
Post-procedural Care
After hyaluronic acid has been injected into the sheath, passive flexion- extension movements
of the treated finger should be performed in order to favor the homogeneous spreading of hyaluronic acid within the sheath.
Intra-articular Injections:
Metacarpophalangeal
and Interphalangeal Joints
22
Luca Maria Sconfienza
Essentials
Intra-articular injections of drugs are an option
also for the metacarpophalangeal and interphalangeal joints. They are administered as described for the others joints of the upper limb.
Interventional Procedures
Indications
Intra-articular injection of steroids: rheumatoid
arthritis, degenerative osteoarthritis with articular effusion.
Intra-articular injection of hyaluronic acid:
degenerative osteoarthritis without articular effusion.
Intra-articular injection of local anesthetic:
assessment of the intra-articular relevancy of
pain, short-term analgesia.
Objective
The aim of injecting intra-articular steroids and
anesthetic is to reduce inflammation and pain,
improving joint functionality. The intra-articular
injection of hyaluronic acid improves joint lubrication.
Equipment
-
23–35G or smaller needle
1 syringe (3–5 ml)
Local anesthetic (1 ml)
Steroid (0.5–1 ml, 40 mg/ml)
Low-molecular-weight hyaluronic acid (1 ml)
Plaster.
Luca Maria Sconfienza ( )
Radiology Unit
IRCCS Policlinico San Donato
San Donato Milanese (MI), Italy
L.M. Sconfienza, G. Serafini, E. Silvestri (eds.), Ultrasound-guided Musculoskeletal Procedures,
DOI 10.1007/978-88-470-2741-1_22 © Springer-Verlag Italia 2012
119
120
L.M. Sconfienza
Our Procedure
Fig. 22.1a
STEP 1
The patient is seated in front of the table, opposite the examiner, with his or her hand placed on
the table, palm facing down (Fig. 22.1a). The probe is positioned on the dorsal side of the joint
for treatment along the longitudinal axis.
Fig. 22.1b
Fig. 22.1c
STEP 2
The needle is inserted out-of-plane in the ulnar or radial (Fig. 22.1b,c) side of the joint. Insertion of the needle is easier on the less degenerated side of the joint. A small amount of anesthetic is injected. In the next step, with the needle kept in place, steroid and then hyaluronic acid
are injected within the joint capsule. MH metacarpophalangeal head, PP proximal phalanx. Arrowheads indicate the joint capsule, the arrow the needle tip, and asterisks the drugs. A similar
approach can be used for the interphalangeal joints. although caution is needed to avoid injury
to the interdigital neurovascular bundle. A palmar approach is also possible.
Post-procedural Care
After treatment, patients should avoid heavy activities for 5–10 days. Pain may occur after
treatment and is managed with oral NSAIDs.
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Suggested Reading
Salim N, Abdullah S, Sapuan J, Haflah NH (2012)
Outcome of corticosteroid injection versus
physiotherapy in the treatment of mild trigger
fingers. J Hand Surg Eur 37(1):27-34
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WM, Faloppa F (2012) Treatment of trigger finger:
randomized clinical trial comparing the methods of
corticosteroid injection, percutaneous release and
open surgery. Rheumatology (Oxford) 51(1):93-9