Musculoskeletal Procedures


Fig. 8.1

Subacromial subdeltoid bursa (bounded by arrows) in coronal plane. The humerus, deltoid muscle, and acromion (Acr) are visible as well





Hip


The trochanteric bursa (also referred to as the subgluteus maximus bursa) is located lateral to the proximal femur, between the insertion of the gluteus medius and gluteus minimus muscles into the greater trochanter of the femur (Fig. 8.2).

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Fig. 8.2

Subgluteus maximus bursa (trochanteric bursa) indicated by white arrow. Purple indicates gluteus minimus attaching to anterior facet. Orange indicates gluteus medius attaching to lateral facet. Black arrow indicates iliotibial tract



Elbow


The olecranon bursa is located over the extensor surface of the proximal ulna and extending over the tip of the bony olecranon process itself (Fig. 8.3).

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Fig. 8.3

Inflamed olecranon bursa (∗); color power Doppler demonstrates surrounding hyperemia


Indications






  • Aspiration of fluid from an inflamed bursa for analysis



  • Injection if anti-inflammatory medications into the bursa


Contraindications






  • Cellulitis overlying the needle entry site (relative contraindication)


Preparation


Equipment setup for bursa aspiration is the same as standard landmark-guided approaches. When ultrasound is used, a sterile ultrasound sheath (probe cover) and sterile gel should be used.


Procedure





  1. 1.

    Patient positioning is the same as landmark-guided approaches.


     

  2. 2.

    Longitudinal and transverse views of the bursa should be obtained sonographically to confirm the location of the bursa and that hypoechoic fluid exists within it (Figs. 8.4 and 8.5).


     

  3. 3.

    An in-plane needle visualization approach can be used to visualize the needle path from the skin to the bursa, as well as fluid injection if that is performed (Figs. 8.6, 8.7, and 8.8).


     

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Fig. 8.4

Setup for subacromial subdeltoid bursa aspiration or injection


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Fig. 8.5

Setup for olecranon bursa aspiration or injection


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Fig. 8.6

Sonographic guidance of subacromial subdeltoid needle bursa aspiration or injection. In the left image, white arrow highlights needle position, white arrowhead (needle tip), black arrows (bursa) and supraspinatus tendon (asterisk). In the right image, anechoic anti-inflammatory bursal injection (black arrows) is visible along with the needle tip (white arrowhead) and supraspinatus tendon (asterisk) (Acr-acromion)


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Fig. 8.7

Sonographic guidance of needle into the olecranon bursa (asterisk). Arrowhead is needle tip


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Fig. 8.8

Injection into the trochanteric bursa. The needle tip path is marked by the arrow, and anechoic anti-inflammatory injection is visible


Complications






  • Infection



  • Bleeding



  • Hematoma



  • Injury to neurovascular structures


Pearls






  • For olecranon bursa aspiration, elbow flexion can put some pressure on the bursa which aids drainage.



  • The subacromial, subdeltoid bursa should be examined through a range of shoulder abduction to highlight its position.



  • Hip rotation can make subgluteus maximus bursitis more evident.


Pitfalls






  • The olecranon bursa is a frequent site of septic bursitis; confirm a sterile (aseptic) bursitis prior to steroid injection.


Integration into Clinical Practice


Ultrasound can be used to confirm the location and appearance of the bursa in cases of suspected bursitis. Then under appropriate sterile real-time guidance, a needle can be directed into the bursa for fluid analysis or injection.


Evidence


A review of studies comparing the two approaches found subacromial-subdeltoid bursa injection was 63% successful in cases where palpation was used; ultrasound guidance increased the success rate to 100% [1].


A recent Cochrane review of 290 patients in five studies found that image guidance provided no outcome benefit (pain, function, or adverse events) for patients compared to blind glucocorticoid injection for shoulder pain. Thus, the authors concluded that despite the fact that ultrasound may improve accuracy of injection into the shoulder, there was no added outcome benefit to ultrasound use [2].



Key Point






  • Examine bursae through the joint’s full range of motion.


Arthrocentesis and Joint Injection


Arthrocentesis is commonly performed for diagnostic and therapeutic indications in multiple joints throughout the body. The procedure has traditionally been landmark guided, but there is a range of difficulty in accessing certain joints, and patient body habitus or acute discomfort may make the procedure more challenging. Thus, ultrasound can be used to confirm an effusion is present and to guide needle placement into the synovial joint for fluid aspiration or injection of analgesic or anti-inflammatory medications.


Anatomy


The sonographic appearance of a joint space is comprised of bright, hyperechoic cartilage and bony interfaces creating a “seagull sign” (Fig. 8.9). Depending on the joint and pathology, tendon origins and insertions may be visible, and anechoic or hypoechoic synovial fluid may be visible.

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Fig. 8.9

The “seagull sign” created by two adjacent cartilage interfaces curving in toward each other and suggesting a seagull’s wings



Knee


The distal femur, proximal tibia, and patella are often easily visualized sonographically, though not always in the same view (Fig. 8.10). The patellar tendon will be visible as well and can serve as a landmark for underlying effusion.

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Fig. 8.10

Knee joint – the distal femur, patella, and effusion are visible



Ankle


Following the distal tibia distally, the joint space with the talus will become visible (Fig. 8.11).

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Fig. 8.11

Normal ankle joint (left), including the distal tibia and talus. Effusion (star) on the right



Hip


With the probe orientated obliquely along the anterior hip along the axis of the femoral neck, the acetabulum, femoral neck, and femoral head will be visible (Fig. 8.12).

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Fig. 8.12

Hip effusion (∗), with underlying femoral head (FH) and femoral neck (FN)



MTP joint


The joint space between the metatarsal and proximal phalanxes is readily visible; a water bath can be helpful if the structures are too superficial (Fig. 8.13).

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Fig. 8.13

Metatarsal (M)-phalangeal (P) joint



Elbow


Effusion may be visualized in several locations, including the annular recess, coronoid fossa, or olecranon fossa (Fig. 8.14).

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Fig. 8.14

The olecranon fossa (arrows) with joint capsule (horizontal line). Left is normal; capsule does not extend past fossa. On the right, effusion (in this case hematoma) extends past the fossa



Shoulder


The glenohumeral joint may be visualized and from an anterior or posterior approach and several different approaches toward needle guidance have been described. From the anterior approach, the humeral head is visible deep and lateral to the coracoid process. From the posterior approach, the glenoid fossa is visible medial to the humeral head (Fig. 8.15).

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Fig. 8.15

Glenohumeral joint from anterior approach (a) Humeral head (H) and coracoid (C) are visible. Posterior approach (b) demonstrating the glenoid (G) and humeral head (H)



AC joint


The acromioclavicular joint is very superficial, located at the lateral edge of the clavicle (Fig. 8.16).

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Fig. 8.16

Acromion (A)-clavicular (C) joint, demonstrating needle guidance for injection



Wrist


Following the distal radius to its distal edge, the radiocarpal joint will become visible (Fig. 8.17).

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Fig. 8.17

Joint space between the radius (R) and scaphoid (S)


Indications






  • Fluid analysis for diagnostic evaluation of a new effusion



  • Evaluation of possible septic joint



  • Aspiration of fluid to relieve pain and pressure of an effusion or fluid collection



  • Injection of anesthetic or anti-inflammatory medication


Contraindications






  • Cellulitis overlying the needle entry site (relative contraindication)



  • Mass or vessel overlying the needle entry site


Preparation


Standard preparation for arthrocentesis should be maintained, including creating a sterile prep site and assembling appropriate anesthesia, syringes, needles, drapes, and other equipment. In order to visualize needle entry in real time, a sterile probe sheath and sterile gel should be used.


Procedure





  1. 1.

    The ultrasound probe should be placed over the joint of interest, and the typical appearance of a joint space should be confirmed.


     

  2. 2.

    The presence of joint effusion should be confirmed by noting an anechoic space without Doppler flow above the joint cartilage.


     

  3. 3.

    At this point, the needle should be directed in the plane of the ultrasound beam toward the joint space. The needle progress may be observed in real time until joint fluid is aspirated.


     

  4. 4.

    In some cases, ultrasound may be used to confirm the presence and location of joint fluid, at which point the proper location and trajectory of needle placement will be noted but performed without direct ultrasound visualization. This technique is more feasible for larger joints where the procedure itself is less challenging and there is less benefit to holding the ultrasound probe for the duration of the procedure.


     

Complications






  • Infection



  • Bleeding



  • Hematoma



  • Injury to nerves, vessels, and tendons


Pearls






  • Joint effusion may be hypoechoic instead of anechoic in the presence of debris, immune reaction, infection, or other causes.



  • Joint effusions should compress under probe pressure.


Pitfalls






  • It is quite feasible to perform a sterile joint aspiration using real-time ultrasound guidance. Do not let the introduction of the ultrasound probe alter the sterility of the procedure.


Integration into Clinical Practice


Ultrasound can rapidly confirm the presence of joint effusion prior to considering arthrocentesis or joint injection. Local anatomy can be assessed, including the presence of any vessels, nerves, or other structures to be avoided with your needle.


Evidence


Glenohumeral joint and knee joint injection were each 79% successful with landmark technique; ultrasound guidance increased success to 95% for the shoulder and 99% for the knee [1]. An emergency department-based study of ultrasound-guided knee arthrocentesis demonstrated the technique had equal success compared with a landmark-based approach. However, ultrasound guidance yielded less pain for patients and shorter procedure time and was less technically difficult for emergency providers [3].



Key Points






  • Ultrasound may be especially useful in confirming effusions in smaller or deeper joints.



  • Sonographic guidance for needle approach can assist in avoiding vessels, nerves, and other sensitive structures en route to the effusion.


Fracture Reduction


Distal radius fractures are one of the most commonly encountered fractures in both the adult and pediatric population. Ultrasound has been shown to be accurate compared to radiography for detecting distal radius fractures. Ultrasound can show the amount of fracture displacement and can also be used to determine adequate reduction. Traditionally, adequacy of reduction is assessed blindly. Once the clinician determines that reduction is successful, the wrist is splinted, and the patient is sent for post-reduction x-rays. If the alignment is inadequate, then the splint must be removed and a second reduction attempt performed. This may include additional procedural sedation and increases the patient’s length of stay. Some settings have access to fluoroscopy, where reduction can be assessed immediately at the bedside. While fluoroscopy is accurate, purchase and maintenance of the machine add additional costs. It also adds radiation, a concern especially in pediatric patients. Ultrasound has advantages over both these techniques, allowing real-time objective assessment of fracture reduction similar to fluoroscopy, without the additional cost and radiation.


While ultrasound can theoretically be used to reduce any fracture, it has been most extensively described in distal radius fractures, and therefore this section will focus specifically on distal radius fractures. In particular, it will focus only on the use of ultrasound to guide the procedure, as the reduction technique is described in other procedural texts.


Anatomy


Distal radius fractures can be easily visualized on ultrasound. The radius has the appearance of a linear bright hyperechoic line with shadow in the far field when viewed in longitudinal plane (Fig. 8.18). The radiocarpal joint and lunate can be seen at the distal end of the radius. The radius can also be scanned in short axis and can be followed distally to the joint line. The long-axis view is the highest yield when assessing for fractures.

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Fig. 8.18

Normal radius, shown in longitudinal plane. Arrows highlight bright echogenic bony cortex


A fracture is diagnosed by visualizing a disruption of the radial bony cortex. The amount of displacement can be estimated by noting the distance between the proximal and distal bony fragments (Fig. 8.19). Angulation of the bone may also be noted. Associated hematoma can be seen.

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Fig. 8.19

Minimally displaced fracture (left) and significantly displaced fracture (right). Arrows highlight the cortex; asterisks denote fracture site


Indications






  • Any fracture that may be clearly visualized on ultrasound, most commonly distal radius, with or without associated ulnar fractures


Contraindications






  • Open fracture, such that the ultrasound gel would come into contact with tissue


Preparation


The fracture should first be interrogated with ultrasound. Multiple orthogonal views should be used, similar to the orthogonal views taken with x-ray. The following three images should be taken in long axis (Fig. 8.20):


  1. (a)

    Posteroanterior view from the dorsal surface


     

  2. (b)

    Anteroposterior view from the volar surface


     

  3. (c)

    Lateral view


     

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Oct 20, 2020 | Posted by in ANESTHESIA | Comments Off on Musculoskeletal Procedures

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