Diagnostic ultrasound ( PDFDrive )

CHAPTER
25
Musculoskeletal Interventions
Ronald S. Adler
SUMMARY OF KEY POINTS
• Choose transducer geometry and entry site to visualize the
needle as a specular relector.
• Orient transducer to maximize tendon echogenicity
(anisotropy).
• Injected corticosteroid/anesthetic suspension often displays
a contrast effect, which can help localize injected mixture.
• Patients with diabetes should be cautioned that they may
develop a transient hyperglycemia that may last up to 5
days following therapeutic injection.
• Most small joints and supericial tendon sheaths of hand
and foot can be injected using a short-axis approach.
• Shoulder and hip joints can be injected using long-axis
approach.
• Ganglion and paralabral cyst luid can be very viscous or
gelatinous and may require a large-bore needle.
• Choose needle trajectory to avoid neurovascular
structures.
• Intratendinous injections of platelet-rich plasma (PRP)
should be performed in combination with intratendinous
fenestration to promote bleeding and initiate an
inlammatory response. The patient should avoid
nonsteroidal antiinlammatory drugs (NSAIDs) for 1 week
before and 2 weeks after the procedure.
• Use of coaxial technique can be of value in performing
ablative therapy and core biopsies to minimize
extralesional soft tissue damage.
CHAPTER OUTLINE
TECHNICAL CONSIDERATIONS
INJECTION TECHNIQUE
INJECTION MATERIALS
INJECTION OF JOINTS
SUPERFICIAL PERITENDINOUS AND
PERIARTICULAR INJECTIONS
Foot and Ankle
Hand and Wrist
INJECTION OF DEEP TENDONS
Biceps Tendon
Iliopsoas Tendon
Abductor and Hamstring Tendons
BURSAL, GANGLION CYST, AND
PARALABRAL INJECTIONS
Calciic Tendinitis
INTRATENDINOUS INJECTIONS:
PERCUTANEOUS TENOTOMY
PERINEURAL INJECTIONS
CONCLUSION
The real-time nature of ultrasound makes it ideally suited to
provide guidance for a variety of musculoskeletal interventional
procedures. 1-10 Continuous observation of needle position
ensures proper placement and allows continuous monitoring of
the distribution of injected and aspirated material. he adverse
efects of improper needle placement during corticosteroid
administration are well documented. 11-16 Likewise, decompression
of luid-illed lesions and fragmentation of calciic deposits may
be performed.
he current generation of high-frequency transducers for
sonography of small parts allows excellent depiction of sot tissue
detail and articular surfaces, particularly in the hand, wrist, foot,
and ankle. 17 his allows needle placement in nonluid-distended
structures, such as a nondistended joint, tendon sheath, or bursa.
he injected agent also produces a contrast efect, which can
improve delineation of surrounding structures (e.g., labral
morphology) and provide additional information regarding the
agent’s distribution. 18,19 Ultrasound guidance has broad appeal
because it does not involve ionizing radiation; this feature is
particularly advantageous in the pediatric population and during
pregnancy.
Ultrasound-guided injections in the musculoskeletal system
include injection of joints, tendon sheaths, bursae, and ganglion
cysts. he chapter emphasizes the most common injections
performed at my institution, an orthopedic and rheumatology
specialty hospital. he most common clinical indication for
ultrasound-guided injections generally relates to pain that does
not respond to other conservative measures, regardless of the
anatomic site. he pain may result from a chronic repetitive injury
in the work environment, a sports-related injury, or an underlying
inlammatory disorder, such as rheumatoid arthritis.
TECHNICAL CONSIDERATIONS
Diagnostic and subsequent interventional examinations are oten
performed using either linear or curved, phased array transducers,
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