Linking To “Ultrasound Guided Musculoskeletal Injections” From mskultrasound.net

Today, I review, link to, and excerpt from the chapter, Ultrasound Guided Musculoskeletal Injections, from mskultrasound.net.

All that follows is from the above resource.

Table of Contents

Summary

  • Ultrasound guided musculoskeletal injections should be part of your clinical decision making for managing both acute and chronic musculoskeletal pain. It does require thought, skill and experience to determine which patients are most appropriate.
  • Know your injectates and dosing; they are different for different locations
  • Master the skill of visualizing the appropriate structures and needle (in plane or out of plane) as it’s essentially the same for every procedure
  • Increase familiarity with different types of more common injections including the Glenohumeral joint, Acromioclavicular joint, First dorsal compartment, Hip joint, Greater trochanteric bursa, Pes anserine bursa, Knee joint, Ganglion cyst

Shoulder Ultrasound: Demonstration of Needle Placement

 Sports Med Review

Jul 31, 2021

Shoulder Ultrasound: Acromioclavicular (AC) Joint Injection (out of plane)

Aug 2, 2021
Hip Ultrasound: Hip Joint Injection
Aug 2, 2021

This video demonstrates an ultrasound guided hip injection. Note that the needle tip is visualized the entire time and guided directly into the joint capsule. This is most commonly used for hip osteoarthritis, but can be used for other hip pathology.

Knee Ultrasound: Joint Injection at the Suptrapatellar Recess
Sep 17, 2021

This video demonstrates an ultrasound guided injection into the suprapatellar bursa of the knee. The needle is in plane, in short axis of the leg above the patella. Note the fluid going in with the hyperechoic bubbles. Also note that this recess is contiguous with and thus analogous to a joint injection.

Introduction

  • Therapeutic Injections are a commonly used modality to help improve patients’ musculoskeletal (MSK) pain.
  • Injectates may be used in differing doses depending on the type of injection being performed and physician preference.
  • MSK injections include intra-articular, periarticular or within soft tissue structures.
  • These injections may be performed either anatomic-based (palpation) or with ultrasound guidance.
  • We will be discussing ultrasound guided injections only in this chapter.
  • It is important when deciding to perform an injection, just like all other procedures, you must consider the indications, contraindications, and complications of the procedure that you are going to perform.
  • By reading this chapter you should understand indications, contraindications, types of injectates to use, complications, and the basic skills to perform certain injections.

General Information

Injectates

  • In general, there are many different types of injectates that may be used for MSK injections. This list includes but is not limited to: local anesthetic, corticosteroids, ketorolac, viscosupplementation, platelet rich plasma (PRP), stem cells, and saline solutions.
  • Many of these are injectates best left to the outpatient setting in the hands of more specialized physicians. For use in the emergency department (ED), we will focus solely on local anesthetic and steroid injections.
  • Corticosteroid injections are formulated in many types and doses.[1] Unfortunately, there is no consensus on which steroid should be used and at what dosages. Studies have shown equal efficacy of methylprednisolone, triamcinolone, and dexamethasone.
  • [2][3][4][5]
    • Dosing of Corticosteroid injections is equally difficult to find specific recommendations for, however in general most lower doses of steroid are equivalent to higher doses of steroid.[6][7][8][9] The lower the dose of steroid also has a reduced side effect profile. These side effects will be discussed later.
  • Local anesthetic can be injected either alone, or in conjunction with a corticosteroid. The local anesthetic can help in confirming that you have injected into the correct location, or that the location that was injected was the pain generating source.
  • Adding local anesthetic helps with both immediate pain relief and as a diagnostic tool. However, it is important to consider what local anesthetic to use.
  • Some research indicates that local anesthetic injections can lead to chondrocyte toxicity.
    • Studies seem to show that there is a dose and duration dependent component[10] to the chondrocyte toxicity indicating that a one-time small dose of local anesthetic is not likely to contribute significantly.
    • However, repeated doses can lead to long term sequelae. In studies, ropivacaine at concentrations <0.5% have been shown to have the least cytotoxicity and should be considered for use in intra-articular injections.[11]

Indications

  • Joint, tendon/ligament, or bursa injections are treatments that typically become helpful in the setting of inflammatory processes.
  • These processes include but are not limited to osteoarthritis, bursitis, tendinitis, tendinopathy, crystal arthropathy, and synovitis.[12][13]

Contraindications

  • Contraindications
    • Allergies to any medications being used
    • Local cellulitis
    • Prosthetic joint
    • Concern for active infection
    • Possibility of surgical intervention[14][15]
      • Patients who underwent CSI prior to arthroplasty or arthroscopic surgeries within three months have a two fold increase in deep joint infections following surgery.
      • Therefore if you think that the patient may require a surgical intervention in the next three months (ie. ACL tear, large meniscus tear, joint replacement) then performing an injection is not likely to be beneficial for them.
  • Relative Contraindication:
    • Acute injury
    • Uncontrolled Diabetes Mellitus or Hyperglycemia( subjective)

Complications

  • It is important to consider complications when performing any procedure.
    • Likewise, in the Emergency Department it is important to consider these complications if a patient is presenting following an outpatient joint injection.
  • Infection
    • The largest concern or complication involved in performing a joint injection is the risk of infection, which would then necesitate surgical intervention. The current data suggests that this complication is very low (0.08%) .[16]
  • Skin atrophy
    • As with any exogenous steroid, injections can cause thinning of the skin. In joint injections, this is a very rare complication and is only caused when steroids are administered close to the skin, either through back tracking along the needle path, or part of the injection still occurring within the dermis or epidermis layers.[17]
  • Hypopigmentation
    • This is also a very rare complication and is secondary to steroid exposure to the skin.[18]
Skin discoloration following corticosteroid injection

Skin discoloration or hypopigmentation following corticosteroid injection.[19]

  • Hyperglycemia in Diabetic Patients
    • Patients have been found to have a spike in blood glucose that can occur within hours of injection, and will typically last around 3-5 days, and then subsides within a week.[20]
    • In well controlled diabetics their blood glucose typically increased into the 300’s at the highest, and therefore consequences could potentially be greater in uncontrolled diabetics.
    • Editor’s note (Dr Kiel): I often tell patients their blood sugar will increase by about 100 mg/dL for about 1 week.
blood glucose levels following intra-articular tseroid injection
Blood glucose levels among 6 patients following intra-articular steroid injection (click to enlarge).[21]
  • Steroid flare (Pseudoseptic Arthritis)
    • This typically occurs within hours to 24 hours after injection.
    • This presents as a synovitis type picture and can be warm and red. It is difficult to differentiate from septic arthritis, but the timeline is typically much sooner following injection than you would expect from an infection.
    • Symptoms typically should resolve within 24 hours and can be treated symptomatically.[22]
  • Weakening or thinning of cartilage (Chondrotoxicity)
    • Several studies have shown that there is a time and dose dependent toxicity of corticosteroids to cartilage cells as well.[23]
  • Tendon Rupture
    • When performing peritendinous or tendon sheath injections there is a risk of tendon rupture. There is no good data on the rate at which this occurs, but a systematic review does turn up many case reports of this occurring.[24]
  • Other considerations to counsel patients on include:
    • Injections will help improve pain immediately following injection if a local anesthetic is used, but the increased fluid in the joint space could cause temporary increased discomfort later in the day after the local anesthetic wears off. This typically can be avoided or  improved with prophylactic NSAIDs, ice, elevation, and/or compression
    • As previously discussed, if an injection is performed and the patient’s pathology ends up requiring surgical intervention, this intervention could be delayed due to concern for post-operative infection for up to 3 months.
    • Lack of response to the procedure. This can occur either due to medication not getting to the appropriate locations or failed patient response to the medication

General Procedural Information

Equipment

  • One or two syringes
    • Size depends on joint with large 5-10 mL, small 3-5 mL
    • One with 1.0 – 5.0 mL of lidocaine (or preferred local anesthetic) if needed
    • One with 0.5 – 4.0 mL of lidocaine (or preferred local anesthetic) and 0.5 – 1.0 mL of steroid, depending on injection being performed.
  • Needle
    • 18-gauge to draw medications
    • 22 or 25-gauge needle
    • Length and size of needle varies based on joint
  • Sterile equipment
    • Sterile gloves
    • Cover can be sterile tegaderm or transducer sleeve
    • Chlorhexidine or betadine swab
    • Sterile ultrasound gel

Technique

  • Set up your equipment either completely sterilely or cleanly depending on your technique.
    • We recommend that the ultrasound machine be placed on the opposite side of the patient so you don’t have to turn your head or body during the procedure
    • Probe choice will depend on size of joint. Small joints use linear transducer with higher frequency, large joints or obese patients can require the curvilinear transducer for greater depth.
  • Have steroid and local anesthetic drawn up and needle on your syringe with ultrasound transducer prepped.
  • Place the transducer on the patient and identify notable anatomy for the specific injection that you are performing.
    • We recommend that prior to sterilizing the patient and attaching the transducer cover, you perform a sonographic evaluation to confirm your anatomy and procedural approach.
  • Insert needle with local anesthetic only syringe
    •  You can inject local as you advance the needle
    • If entering a bursa or joint capsule this can be the most uncomfortable spot and injecting extra local anesthetic just before piercing can make the procedure more comfortable.
    • Ensure that the needle is as parallel to the transducer as possible to ensure that you are able to visualize the needle.
  • Make sure to identify the needle with ultrasound as soon as you enter the skin and follow the needle the entire trajectory.
    • This can be in-plane or out-of-plane depending on the procedure.
  • Once you have entered the desired space finish injecting local anesthetic only syringe to ensure appropriate flow and location of injectate.
  • Swap syringes for the syringe with local and steroid
    • In some cases, a longer needle may be required and swapping syringes may not be possible.
  • Inject all of the steroid mixture
  • Remove the needle, clean up the skin, and place a Band-Aid.
    • Tamponade any bleeding
  • Post procedural care
    • Injection site should not be submerged in water of any kind (bath tub, pool, hot tub, etc) for approximately 48 hours.
    • Showers are okay
  • Assess the patient for the level of pain and movement of the joint that you’ve just injected, they will often have some immediate relief if injection went into pain generating location.
  • When injecting a bursa you should see a slight increase in size of the bursa, but it may not change significantly despite having good flow, this is normal.

Troubleshooting

  • If you are having difficulty seeing your needle tip, try bouncing the needle back and forth quickly and assess for motion location and/or inject a small amount of anesthetic.
  • If flow of the injectate is difficult, try rotating your needle 90 degrees and injecting again.

Specific Joint Injections

Glenohumeral Joint

Start here

 

 

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