ultrasound-guided joint injection€¦ · structures- shoulder, knee, ... • ultrasound guided...
TRANSCRIPT
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Ultrasound-Guided Joint Injection
Jason Matuszak, MD, FAAFP
Mark Mirabelli, MD, FAAFP
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ACTIVITY DISCLAIMERThe material presented here is being made available by the American Academy of Family Physicians
for educational purposes only. Please note that medical information is constantly changing; the
information contained in this activity was accurate at the time of publication. This material is not
intended to represent the only, nor necessarily best, methods or procedures appropriate for the
medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion
of the faculty, which may be helpful to others who face similar situations.
The AAFP disclaims any and all liability for injury or other damages resulting to any individual using
this material and for all claims that might arise out of the use of the techniques demonstrated therein
by such individuals, whether these claims shall be asserted by a physician or any other person.
Physicians may care to check specific details such as drug doses and contraindications, etc., in
standard sources prior to clinical application. This material might contain recommendations/guidelines
developed by other organizations. Please note that although these guidelines might be included, this
does not necessarily imply the endorsement by the AAFP.
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DISCLOSUREIt is the policy of the AAFP that all individuals in a position to control content disclose any relationships with
commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential
conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those
participants who had no conflict of interest or who agreed to an identified resolution process prior to their
participation were involved in this CME activity.
The following individual(s) in a position to control content for this session have disclosed the following relevant
financial relationships
Mark Mirabelli, MD, FAAFP
• Consultant or Advisory Board: Fidia Pharma USA (OA treatment - (Hymovis)
All other individuals in a position to control content for this session have indicated they have no relevant financial
relationships to disclose.
The content of my material/presentation in this CME activity will not include discussion of unapproved or
investigational uses of products or devices.
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Jason Matuszak, MD, FAAFPChief, Division of Sports Medicine, Excelsior Orthopaedics, Amherst, New York; Clinical Assistant Professor,
University at Buffalo Jacobs School of Medicine and Biomedical Sciences, New York
Dr. Matuszak earned his medical degree at the State University of New York (SUNY) Upstate Medical
University in Syracuse. He completed his family medicine residency at St. Joseph’s Hospital in Syracuse
and a sports medicine fellowship at the University of Hawaii at Manoa, Honolulu. A family physician and
sports medicine physician who is board certified in clinical informatics, he is the founder and director of The
Sports Concussion Center at Excelsior Orthopaedics, Excelsior Sports Medicine’s STRIDES program for
running and endurance medicine, and a musculoskeletal ultrasound program. He serves as a school
physician for Williamsville Central School District and a team physician for 12 local high schools. He has
also worked as a team physician for the Buffalo Bisons (AAA affiliate of the Toronto Blue Jays) and the
Western New York Flash of the National Women’s Soccer League, and as a volunteer physician for the
Ironman World Championship, the U.S. Olympic Committee, and USA Hockey. In addition, he has helped
develop team physician consensus conference guidelines and clinical practice guidelines for
musculoskeletal conditions. Dr. Matuszak is speaker of the Congress of Delegates for the New York State
Academy of Family Physicians and chair of the Physicians Advisory Council to the P2 Collaborative of
Western New York and HEALTHeLINK, western New York’s regional health information organization.
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Mark Mirabelli, MD, FAAFP
Team Physician, St. John Fisher College (Rochester, N.Y), the Rochester Knighthawks, and
the State University of New York, Geneseo; Ringside Physician, New York Athletic
Commission
Dr. Mark Mirabelli completed the Primary Care Sports Medicine Fellowship at the Cleveland
Clinic Foundation, where he was a team physician for the Cleveland Browns, Cavaliers, and
Indians as well as treating collegiate athletes at Cleveland State University, John Carroll
University, and several high schools. He completed his family medicine residency at the
University of Michigan, where he served as Chief Resident, and graduated from Cornell
University and New York Medical College. He lectures regularly on sports medicine and has
written several journal articles and textbook chapters focusing on men's health, sports
medicine, and office-based musculoskeletal procedures. Dr. Mirabelli also maintains a small
primary-care practice at Highland Family Medicine in addition to managing the entire spectrum
of musculoskeletal problems in his practice at University Orthopedics Associates, Rochester.
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Learning Objectives
1. Discuss the basic principles of ultrasound imaging, equipment,
functionality, aseptic technique and injectate selection for ultrasound-
guided pain procedures.
2. Develop scanning techniques to optimize musculoskeletal windows for
ultrasound guided injections.
3. Practice joint injection techniques using models.
4. Establish appropriate billing and coding protocols for performing
billable injections.
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Class outline
• Knobology/Reading ultrasound basics
• Injection applications
• Knee
• Shoulder
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“Orthopedic” Uses of Point of Care
Ultrasound (POCUS)
• Diagnostic
• Guidance for procedures
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“Orthopedic” Uses of Point of Care
Ultrasound (POCUS)• Diagnostic
– Assess acute or chronic injuries or diseases• Muscle/Tendon – Strain/tear, tendonopathy
• Ligament – Sprain/tear, laxity/instability
• Bone – Fracture, cortical thickening/callus
• Nerve – Laceration, entrapment, neuroma
• Joint/capsules/synovium – Effusion, Avulsion, hypertrophy/hyperplasia (+rheumatic)
– Masses – solid/cystic
• Guidance for procedures
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“Orthopedic” Uses of Point of Care
Ultrasound (POCUS)• Diagnostic
• Guidance for procedures– Injections/aspirations
• Joint –
• Tendon sheath -
• Bursae
• Nerve
– Novel procedures• Needle tenotomy
• ?Surgical interventions
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What’s the data?
• Across the board – All are more accurate• AMSSM Position: USGIs are more accurate than LMGIs (SORT A).
– Major joint• Glenohumeral, Femoral-acetabular, Knee, Sacroiliac
– Intermediate joint• Sternoclavicular, Acromioclavicular, Elbow, Wrist, Ankle, Midfoot
– Small joint• Intercarpal/carpometacarpal, Interphalyngeal
– Tendon Sheath
– Nerve
Finnoff, CJSM 2015
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What’s the data?
• Across the board – Some are more Efficacious• AMSSM Position: USGIs are more efficacious than LMGIs (SORT B)
– Major joint• Glenohumeral, Femoral-acetabular, Knee, Sacroiliac
– Intermediate joint• Sternoclavicular, Acromioclavicular, Elbow, Wrist, Ankle, Midfoot
– Small joint• Intercarpal/carpometacarpal, Interphalyngeal
– Tendon Sheath
– Nerve
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What’s the data?
• Some might… Save a surgery?
– Paralabral cyst aspiration
– Calcific tendonitis debridement
– Platelet Rich Plasma
– Adhesive capsulitis
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What’s the data?
• May be better than fluoroscopy?– Radiation
– Contrast
– Accuracy
– Time for procedure
– Patient comfort
– Cost
– Location (office vs radiology facility or hospital)
– Diagnostic information in addition to location
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Knobology/Reading Ultrasound
Jason M Matuszak, MD FAAFP
Chief of Sports Medicine, Excelsior Orthopaedics, Buffalo, NY
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Principles of ultrasound
Infrasound<20 Hz
Audible range20 Hz to 20 kHz
Ultrasound>20 kHz
Whales, elephants, Rhinoceros
Humans Dogs, dolphins, bats, mice
https://commons.wikimedia.org/wiki/File:Sonar_Principle_EN.svghttps://commons.wikimedia.org/wiki/File:UsMachTxPhoto.jpg
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Machine controls
• On-Off
• Presets
• Depth
• Focus
• Gain – overall
• Time Gain Compensation
• Freeze
• Frequency
• Measuring tools
• Color Doppler
• Power Doppler
• Spectral Doppler
• M Mode
• Save/Clips
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Science of Ultrasound
• Reflection of Sound
– Angles make a difference –anisotropy
– Signal attenuates as tissue bends away
– Direction of the probe
– Contact and fluid transmission
• Frequency / Penetration –probe selection
Graphics and pictures this page: Matuszak 2018
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Focal Zone
• Multi-beam technology
• Focal depth is sometimes
adjustable
Focal Zone
Near Zone
Far Zone
Graphics and pictures this page: Matuszak 2018
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Probe Basics
Graphics and pictures this page: Matuszak 2018
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Scanning Planes
• To body axis or to target structure
– Transverse
– Longitudinal
– Sagittal
– Coronal
– Oblique
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Probe Maneuvers
Heel-Toe ToggleGraphics and pictures this page: Matuszak 2018
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Probe Maneuvers
Long axis slide Short axis slideGraphics and pictures this page: Matuszak 2018
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Terminology
• Anechoic
• Hypoechoic
• Isoechoic
• Hyperechoic
Graphics and pictures this page: Matuszak 2018
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Ultrasound Interpretation
Bone Tissue FluidGraphics and pictures this page: Matuszak 2018
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How to look at an ultrasound picture
Muscle
Tendon
Subcutaneous fatSkin
Bone
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Transition Slide
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Equipment
• Gloves (sterile vs semi vs clean)
• Needles
• Antiseptic
• Povidone-iodine or chlorhexadine or alcohol
• Syringes
• Collection tubes (if aspirating) /cap
• Gauze and Bandages
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Needle and Syringe• Small joint / trigger point : 1 cc
• Medium joint: 3 cc
• Large joint : 5-10 cc
• Aspiration: 20-60 cc
• Use appropriate gauge
• 18 gauge for aspiration
• 27 gauge for skin anesthesia and fingers
• Use needle long enough (minimum length)
• 5/8 inch- finger
• 1 inch - elbow
• 1 1/2 inch - Shoulder, knee
• 3 inch spinal - Hip trochanter
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Needle Selection
• Better to have a slightly longer needle than needed
than one that is too short
• Consider blunt or minimal bevel for nerve injections
• Echogenic needles can be used (higher cost, better
reflectivity)
– Modern US needle guidance packages may make
unnecessary
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What to inject?
• Anesthetic
• Corticosteroid
• Hyaluronic acid
• Prolotherapy / sclerosing solutions (dextrose, etc)
• Other: PRP / autologous blood / BMAC / Adipose
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Probe specifications
• A 12 MHz transducer has very good resolution, but cannot penetrate
very deep into the body
– Use high frequency probe / linear (8-18 MHz) for more superficial
structures- shoulder, knee, elbow
• A 3 MHz transducer can penetrate deep into the body, but the
resolution is not as good
– Use low frequency probe / curvilinear (1.5 -5 Mhz) for deeper
structures – hip, sacroiliac
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Patient and examiner positioning
• Patient, examiner and screen all in line
• Patient problem area maximally exposed –patient may be supine,
prone, seated in chair or rotating stool
• Examiner standing, seated in chair or stool - don’t bend or squat
• Use proper ergonomics
– Rest hand on patient
– Neck and back of examiner upright
– Relax hand and wrist
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Process of Injection
• Use adequate sterile gel- try gel standoff if needed
• Place transducer on skin and find “home” anatomy
• Subtle hand motions translate to significant changes on screen
• Adjust frequency, depth, gain, focus (not all settings may be available)
• Obtain optimal image of injection site BEFORE introducing the needle
• Use image guidance mode /software if available
• Introduce needle at appropriate angle and adjust image guidance software
(shallow, medium, steep angle)
• Make further adjustments with probe position or needle- not both at same
time
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Needle Positioning
• Needle Position:
In plane
-needle parallel and in plane with
transducer
-entire needle shaft and tip as
well as target structure are
visualized throughout
interventionMalanga et al, Atlas of Ultrasound-Guided Musculoskeletal Injections. 2-6
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Needle positioning
• Needle position:
Out of plane
- transducer oriented
perpendicular to needle
- needle only visualized when
in the field of view
Out of plane approach
Malanga et al, Atlas of Ultrasound-Guided Musculoskeletal Injections. 2-6
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Can’t find the needle?
• Advance needle slowly
• Wiggle the needle
• Inject small amount of fluid
• Pull back and reposition or reangle
• Hold needle and sweep the probe
• Still problems? Start over or abort
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Summary Practice
Recommendation Slide
• Ultrasound guided injection or aspiration of various soft tissues and joints is
more accurate than clinically guided injections and may reduce
complications
• Imaging tool – Must have the knowledge to understand how the image is
formed
• Obtain and use supplies and instruments that fit the purpose
• Optimize the best image of the injection site first – know the anatomy
• Make fine adjustments of the probe OR needle separately to improve the
image
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Questions
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Selected References
European Society for MSK Radiology, Technical Guidelines V Knee. 2010. Available at
https://essr.org/content-essr/uploads/2016/10/knee.pdf
The association for medical ultrasound (AIUM) – AIUM Practice Parameter for the Performance of a
MSK US Exam. 2017. Available at https://www.aium.org/resources/guidelines/musculoskeletal.pdf
Fundamentals of MSK Ultrasound 3rd Ed. Jacobson, Jon. A. 2017
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Ultrasound-Guided Shoulder
InjectionsJason M Matuszak, MD FAAFP
Chief of Sports Medicine
Excelsior Orthopaedics
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Matuszak Rule to Ultrasound-Guided
Injections
• There are only 2 injections to learn – the in-
plane (long axis) injection and the out-of-plane
(short axis) injection – then the only thing that
changes is the target structure.
– If you can find the target, and a safe path to it, you
can inject it
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Matuszak Rule to Ultrasound-Guided
Injections
Graphics and pictures this page: Matuszak 2018
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Injection basics
• Overall risk-benefit of local corticosteroid injection for long
term outcomes remains unclear
• Effect of local anesthetic on tissue is unclear
• Other injectates (PRP, prolotherapy, MSC) remain
experimental
• Using ultrasound for guidance does not change sterility level
of technique
• Injections into spaces or potential spaces should always flow
easily!
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Injection basics
• Make sure you can reach your target structure
• Many different approaches to every injection
– We’ll teach one, but you can experiment
• All injections are more accurate with imaging guidance (Finnoff CJSM 2015)
– Not all may be more efficacious
– Average change in cost is about $40
– Procedures with guidance may take longer
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Clinical Case #1
• Hey Doc – “I was raking my leaves for about 2 hours on Friday and by Sunday, I could lift my arm over my head. Can you inject me or something?”– 44 year old male with right shoulder pain
– Started after raking
– Pain is reproduced with abduction
– No strength deficit
– Negative drop-arm test
– Positive Neer and Hawkins
– X-rays are negative
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Subacromial/Subdeltoid Bursa
• Indications for injection
– Subacromial “bursitis”
– Subacromial impingement
– Rotator cuff tendonitis
– Calcific tendonitis or bursitis
• Calcium Pyrophophate
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Subacromial/Subdeltoid Bursa
• Evidence– Cochrane review 2012 – no added benefit from
image-guided injections• no difference at 1 or 2 weeks
• Discounted benefit at 6 weeks due to heterogeneity
– Wu 2015 – Meta-analysis showed improvement at 6 weeks of:
• Pain
• Functional Scores
• Abduction degrees
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Subacromial/Subdeltoid Bursa
• Is ultrasound-guidance indicated?
– +/-
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Subacromial/Subdeltoid Bursa
• Positioning and Landmarks
– Lateral approach
• Seated
• Palpate lateral aspect distal acromion
https://commons.wikimedia.org/wiki/File:Shoulder_joint_back-en.svg
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Subacromial/Subdeltoid Bursa
• Pertinent ultrasound landmarks– Lateral
approach• Biceps
tendon
• Greater tuberosity
• AcromionGraphics and pictures this page: Matuszak 2018
Gre
ater
Tu
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sity
Less
er
Tube
rosi
ty
Supraspinatus Subscapularis
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Subacromial/Subdeltoid Bursa
• Pertinent ultrasound landmarks– Lateral
approach• Biceps
tendon
• Greater tuberosity
• AcromionGraphics and pictures this page: Matuszak 2018
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Subacromial/Subdeltoid Bursa
• Pertinent ultrasound landmarks– Lateral
approach• Biceps
tendon
• Greater tuberosity
• AcromionGraphics and pictures this page: Matuszak 2018
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Subacromial/Subdeltoid Bursa
• Confirmation
– Should see fluid motion effect filling bursal sac
– Injection should flow easily
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Clinical Case #2
Hey Doc – “My shoulder hurts every time it’s cold and damp and it’s really stiff in the morning when I wake up. Can you inject me or something?”
– 84 year old female with right shoulder pain
– Progressively worse over several years
– Pain is reproduced with all active range of motion
– Palpable grinding and crepitus with motion
– Negative drop-arm test
– X-rays are show severe GH arthritis
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Glenohumeral Joint `
• Indications for
injection
– GH arthritis
– Frozen
Shoulder
– Labral tearBlausen.com staff (2014). "Medical gallery of Blausen Medical 2014". WikiJournal of
Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436
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Glenohumeral Joint
• Evidence
– More accurate (Finnoff CJSM 2015)• US guided GH injection 91-100% accurate
• Landmark guided GH injection – 64-73% accurate
– More effective (Lee Arch Phys Med Rehabil2009)
• Pain intensity, range of motion, and shoulder function score
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Glenohumeral joint
• Is ultrasound-guidance indicated?
– YES
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Glenohumeral Joint
• Positioning and
Landmarks
– Seated facing
away
– Palpate
scapular spinehttps://commons.wikimedia.org/wiki/File:Shoulder_joint_back-en.svg
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Glenohumeral joint
• Pertinent ultrasound landmarks– Posterior
approach• Scapular Spine
– Posterior RC MTJ
• GlenohumeralJoint
Graphics and pictures this page: Matuszak 2018
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Glenohumeral joint
• Pertinent ultrasound landmarks– Posterior
approach• Scapular
Spine
• GlenohumeralJoint
Graphics and pictures this page: Matuszak 2018
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Glenohumeral joint
• Pertinent ultrasound landmarks– Posterior
approach• Scapular Spine
• GlenohumeralJoint
– Humeral head/capsule
Graphics and pictures this page: Matuszak 2018
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Glenohumeral Arthritis
• Confirmation
– Should see fluid motion in the space under
the joint capsule and around humeral head
– Injection should flow easily
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Clinical Case #3
• Hey Doc – “I’ve noticed that I have this lump at the point of my shoulder that aches and it’s worse when I carry my purse on this side. Can you inject me or something?”– 46 year old transgender female with right shoulder pain
– Notices with changes in weather and carrying purse on this side
– Pain is reproduced with abduction and overhead weightlifting
– Feels crepitus and grinding when reaching across chest to the opposite shoulder
– No strength deficit
– Negative drop-arm test
– X-rays show ac joint arthritis
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Acromioclavicular Joint
• Indications for
injection
– AC joint
arthritis
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Acromioclavicular Joint
• Evidence– More accurate
• 93.6% USGI versus 68.2% LMGI (Aly BJSM 2015)
– More effective• +/- one small study (20 participants) showed no benefit
(Sabeti-Aschraf Eur J Rad 2010)
• + benefit in another study of 100 patients (Park Pain Phys 2015)
– Better pain
– Better function
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Acromioclavicular Joint
• Is ultrasound-guidance indicated?
– YES
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Acromioclavicular Joint
• Positioning and Landmarks
– Superior or Anterior approach
– Short Axis usually By OpenStax College [CC-BY-3.0
(http://creativecommons.org/licenses/by/3.0)], via Wikimedia Commons
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Acromioclavicular Joint
• Pertinent ultrasound landmarks– Cranial from
Bicipital Groove
– Lateral from the clavicle
Graphics and pictures this page: Matuszak 2018 Gre
ater
Tu
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sity
Less
er
Tube
rosi
ty
Supraspinatus Subscapularis
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Acromioclavicular Joint
• Pertinent ultrasound landmarks– Cranial from
Bicipital Groove
– Lateral from the clavicle
Graphics and pictures this page: Matuszak 2018
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Acromioclavicular Joint
• Confirmation
– Fluid motion signal deep to the joint capsule
– Ease of injection
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Selective References
• http://www.aium.org/usinteractive/index.ht
ml#
• https://www.essr.org/subcommittees/ultras
ound/
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Ultrasound Evaluation of the Knee
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Audience Response #1
A 57 year old male has fallen on his knee and is seen the same day. Examination reveals decreased range of motion and 2/5 quadriceps strength. Moderate tenderness is present in the suprapatellar knee, a small effusion is noted . No other abnormaltiesare noted. Initial xrays are negative. Ultrasound imaging of which structure will be diagnostic?
1. Quadriceps tendon
2. MCL
3. ACL
4. Hamstring tendon
5. Pes Anserine
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Audience Response #2:A 28 year recreational basketball player twists her knee during a game. She feels a pop and has limited ability to walk with significant swelling. Which of the following could NOT be seen on diagnostic US of this knee?
1. Loose body in joint
2. LCL sprain
3. Knee effusion
4. Medial meniscal root tear
5. Patellar tendon tear
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Audience Response #3:A 56 year old female is complaining of worsening knee osteoarthritis. You recommend an injection of the knee. Which of the following injuries is not an indication to perform an ultrasound guided injection of the knee?
1. Morbid obesity
2. Failed previous clinically guided attempt
3. Decreased pain
4. Increased aspirate amount
5. Clinically inaccessible joint
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Knee Anatomy
• Sprains – ligament
• Strains – musculotendonous
• Fractures
• Dislocations / subluxations
• Cartilage injuries – meniscal vs
chondralBy Kari Stammen, via Wikimedia Commons
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Illustration from Anatomy & Physiology, ConnexionsWeb site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013via WikiMediaCommons
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Differential Diagnosis
• Meniscal tears
• Fractures• Supracondylar femur• Patellar• Tibial plateau
• Chondral / Osteochondral lesions
• Dislocations / subluxations• Tibio-femoral• Patello-femoral
• Soft tissue Contusions / hematomas
• Lacerations, abrasions
• Ligament or capsular sprains• ACL, PCL, LCL, MCL
• Bursitis• Pre-, Infra- patellar • IT band, pes anserine
• Muscle and tendon strains• Quadriceps• Hamstring• Pes anserine
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By Hellerhoff (Own work) [CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons
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MSK US Knee Protocol
• Patient in supine position with bolster
– Scan long and short axes suprapatellar
– Trochlear view
– Infrapatellar long axis
– Medial and Lateral joint lines long axis
• Patient in prone position
– posterior knee long and short axes
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Anterior Knee Long Axis
MSK US Knee, Mark H. Mirabelli, MD
European Society of MSK Radiology, MSK US Technical Guidelines, V. Knee
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Anterior Knee Short Axis
MSK US Knee, Mark H. Mirabelli, MD
European Society of MSK Radiology, MSK US Technical Guidelines, V. Knee
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Trochlear View
European Society of MSK Radiology, MSK US Technical Guidelines, V. Knee
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Infrapatellar Long axis
MSK US Knee, Mark H. Mirabelli, MD
European Society of MSK Radiology, MSK US Technical Guidelines, V. Knee
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Medial joint line – long axis
MSK US Knee, Mark H. Mirabelli, MD
European Society of MSK Radiology, MSK US Technical Guidelines, V. Knee
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Lateral joint line – long axis
European Society of MSK Radiology, MSK US Technical Guidelines, V. Knee
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Posterior knee
European Society of MSK Radiology, MSK US Technical Guidelines, V. Knee
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Ultrasound Guided Injection
• Lateral suprapatellar approach
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Summary Practice
Recommendation Slide
• MSK US of the knee is a useful adjunct for
diagnosing many conditions
• Assessment of effusion, tendons and ligaments
can be rapidly performed
• Ultrasound guided injection or aspiration of the
knee can be done at the suprapatellar lateral
portal, the pes anserine and the posterior knee
(Baker’s cyst)
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Questions
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Selected ReferencesEuropean Society for MSK Radiology, Technical Guidelines V Knee.
2010. Available at https://essr.org/content-
essr/uploads/2016/10/knee.pdf
The association for medical ultrasound (AIUM) – AIUM Practice
Parameter for the Performance of a MSK US Exam. 2017.
Available at
https://www.aium.org/resources/guidelines/musculoskeletal.pdf
Fundamentals of MSK Ultrasound 3rd Ed. Jacobson, Jon. A. 2017