Diagnostic ultrasound ( PDFDrive )

CHAPTER 25 Musculoskeletal Interventions 905
PRE-INJECTION
POST-INJECTION
N
T
ra
A
B
FIG. 25.13 Injection of First Dorsal Compartment of Wrist. This 70-year-old woman with de Quervain tendinosis had clinical symptoms of
wrist pain radiating along the extensor surface of the forearm. (A) Preinjection image shows 25-gauge needle (N) positioned in the irst dorsal
compartment tendon sheath under ultrasound guidance. The tendons (T) are inhomogeneous, with a small effusion evident (arrows) in the dependent
part of the tendon sheath. (B) After injection and needle removal, the injected material distends the sheath (arrows), producing a tenosonographic
effect; the intrinsic tendon abnormalities become more conspicuous. ra, Radial artery.
PRE-INJECTION
POST-INJECTION
N
A
bg
B
bg
FIG. 25.14 Biceps Tendon Sheath Injection. Biceps tendinosis was clinically suspected and a biceps tendon sheath injection requested for
this 41-year-old man with development of anterior shoulder pain after arthroscopic surgery for labral tear. (A) Preinjection image shows 25-gauge
needle (N) placed supericial to the long head of the biceps tendon (arrow). (B) After injection and needle removal, there is distention of the tendon
sheath by luid (arrows) containing low-level echoes caused by contrast effect. bg, Bicipital groove.
presence of luid distention of the sheath with supericially located
microbubbles helps to conirm a successful injection. A technique
to obviate the need to directly approach the tendon sheath, which
can sometimes be challenging in the absence of an efusion,
entails direct positioning of the needle within the rotator interval
adjacent to the intraarticular portion of the biceps tendon and
deep to the biceps pulley mechanism. 30 Stone and Adler reported
100% success in distending the sheath in their series. 30 herapeutic
mixture was also noted to distribute within the rotator interval
(Fig. 25.15, Video 25.2).
Iliopsoas Tendon
he iliopsoas tendon lies supericial to and along the medial
margin of the anterior capsule of the hip. he tendon inserts
onto the lesser trochanter. A bursa that frequently communicates
with the hip is present in this location and may be distended
because of underling joint pathology or a primary iliopsoas
bursitis. Alternatively, iliopsoas tendinosis may occur in the
absence of a preexisting bursitis for which a peritendinous
injection is requested. 31 A lateral approach to the tendon oten
requires use of a lower-frequency transducer and curved linear
or sector geometry. he neurovascular bundle lies medial and
supericial to the tendon, so it is advantageous to approach
from the lateral margin of the tendon and perform a small test
injection to conirm needle position. A successful injection
will show the appearance of luid or microbubbles distending
a bursa that follows the course of the long axis of the tendon
(Fig. 25.16).
Abductor and Hamstring Tendons
he most commonly requested peritendinous injections in my
experience are about the abductor tendon insertion and hamstring
tendon origin. In the irst two of these injections, the needle is
directed to the greater trochanteric bursa. hese injections can
be fairly straightforward when the bursa is distended. hey become
more challenging when there is no preexisting bursal distention.
One must then employ anatomic landmarks and test injections
with anesthetic for localization (Figs. 25.17 and 25.18). Injections
at the hamstring origin are generally peritendinous because no
true anatomic bursa exists. An adventitial bursa may be present
over the ischium. A lateral approach while scanning the tendons
in short axis is preferred for each of these injections, directing