Ultrasound and clinically guided Injection techniques on the musculoskeletal system E-Book

Giorgio Tamborrini

• Herausgeber: Books on Demand
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 85

Veröffentlichungsjahr: 2019

Beschreibung

Targeted therapeutic injections of joints, periarticular structures, tendon sheaths or bursae are among the most important treatments for inflammatory rheumatic or inflammatory activated degenerative diseases of the musculoskeletal system. Furthermore, injections of periarticular structures are also performed in post-traumatic situations or in overuse syndromes. In this publication, we discuss indications, contraindications, the clinical and ultrasound-guided techniques preferred by the authors, and possible adverse drug reactions and side effects of intraarticular and periarticular injection.

Leseprobe

Authors

KD Dr. med. Giorgio Tamborrini

Rheumatology FMH

Ultrasound QIR / SGUM / EFSUMB / EULAR

Interventional Pain Medicine SSIPM

Clinical Lecturer (KD) University of Zurich

Ultrasound Center Rheumatology Basel

University Hospital Basel, Switzerland

Assoz. Prof. Priv. Doz. Dr. med. univ. Christian Dejaco, Ph.D., MBA

Dienst für Rheumatologie | Servizio di reumatologia

Südtiroler Sanitätsbetrieb | Azienda Sanitaria dell'Alto Adige

Krankenhaus Bruneck | Ospedale di Brunico

Spitalstraße 11 | Via Ospedale 11

39031 Bruneck | Brunico, Italy

Dr. med. George Bruyn, MD, PhD

Consultant rheumatologist

MC Groep Hospitals

Lelystad, Netherlands

PD Dr. med. Andreas Siegenthaler

Anaesthesiology FMH

Interventional Pain Medicine SSIPM

Lindenhof Hospital, Berne, Switzerland

table of contents

Introduction

Technique

Needles

Drugs

Contraindications, complications and side effects

Musculoskeletal Ultrasound

Shoulder

7.1 Sternoclavicular joint

7.1.1 Ultrasound Sternoclavicular Joint

7.2 AC Joint (Acromioclavicular Joint)

7.2.1 Ultrasound AC-joint

7.3 Glenohumeral joint

7.3.1 Glenohumeral joint injection from anterior

7.3.2 Glenohumeral injection from posterior

7.3.3 Ultrasound Glenohumeral Joint

7.4 Bursa subdeltoidea

7.4.1 Injection from posterior

7.4.2 Lateral injection

7.4.3 Ultrasound Bursa subdeltoidea

7.5 Biceps tendon recess

7.5.1 Ultrasound biceps recess

7.6 Coracoid process

7.6.1 Ultrasound coracoid process

Elbow

8.1 Elbow joint

8.1.1 Lateral injection

8.1.2 Injection from posterior

8.1.3 Ultrasound elbow joint

8.2 Medial and lateral epicondyle

8.2.1 Injection lateral epicondyle

8.2.2 Injection medial epicondyle

8.2.3 Ultrasound medial and lateral epicondyle

8.3 Olecranon bursa

8.3.1 Ultrasound Olecranon bursa

8.4 Bicipitoradial bursa

8.4.1 Ultrasound of the bicipitoradial bursa

Hand

9.1 Wrist

9.1.1 Injection of distal radioulnar joint

9.1.2 Injection of the radiocarpal joint

9.1.3 Ulnocarpal joint injection

9.1.4 Injection of intercarpal joints and carpometacarpal joints

9.1.5 Ultrasound wrist

9.2 Metacarpophalangeal joint (MCP joint)

9.2.1 Ultrasound MCP joint

9.3 Proximal Interphalangeal Joint (PIP Joint)

9.3.1 Ultrasound PIP Joint

9.4 Distal Interphalangeal Joint (DIP Joint)

9.4.1 Ultrasound DIP Joint

9.5 Carpometacarpal joint I (CMC-I joint; thumb saddle joint)

9.5.1 Ultrasound CMC-1 joint

9.6 Extensor tendons

9.6.1 Ultrasound extensor tendons

9.7 Flexor tendons

9.7.1 Ultrasound flexor tendons

9.8 Carpal tunnel

9.8.1 Ultrasound carpal tunnel

Hip

10.1 Hip joint

10.1.1 Ultrasound hip joint

10.2.1 Ultrasound greater trochanter

10.3 Lateral femoral cutaneous nerve (LFCN)

10.3.1 Ultrasound LFCN

Knee

11.1 Knee joint

11.1.1 Ultrasound knee joint

11.2 Bursae at the knee

11.2.1 Ultrasound of the bursae at the knee

11.3 Pes anserine

11.3.1 Ultrasound Pes anserinus

Foot

12.1 Ankle joint (tibio-talar joint)

12.1.1 Ultrasound ankle joint

12.2 Subtalar joint

12.2.1 Ultrasound subtalar joint

12.3 Midfoot joints

12.4 Metatarsophalangeal Joint I

12.4.1 Ultrasound MTP Joint

12.5 Interphalangeal joints (IP joints)

12.5.1 Ultrasound IP-joints

12.6 Intermetatarsal space

12.6.1 Ultrasound intermetatarsal space

12.7 Tendon sheaths

12.7.1 Medial ankle tendon sheaths

12.7.2 Ultrasound medial tendon sheaths

12.7.3 Tarsal Tunnel

12.7.4 Ultrasound tarsal tunnel

12.7.5 Lateral tendon sheaths

12.7.6 Ultrasound of the lateral ankle tendon sheaths

12.7.7 Anterior ankle tendon sheaths

12.7.8 Ultrasound of anterior tendon sheaths

12.8 Bursa retrocalcanea

12.8.1 Ultrasound Bursa retrocalcanea

12.9 Plantar fascia

12.9.1 Plantar fascia ultrasound

Temporomandibular joint

13.1.1 Ultrasound of the temporomandibular joint

Spine and selected nerves

14.1. Cervical Facet Joints and Medial Branches

14.2. Lumbar Facet Joints and Medial Branches

14.3. Caudal epidural injection

14.4. Sacroiliac joint injection

14.5. Block of the Greater Occipital Nerve (GON)

14.6. Cervical Nerve Root Block

14.7. Stellate Ganglion Block

14.8. Block of the Ilioinguinal and Iliohypogastric nerve

14.9. Lateral cutaneus femoral nerve block (another variant)

Literature

1 Introduction

Targeted therapeutic injections of joints, periarticular structures, tendon sheaths or bursae are among the most important treatments for inflammatory rheumatic or inflammatory activated degenerative diseases of the musculoskeletal system. Furthermore, injections of periarticular structures are also performed in post-traumatic situations or in overuse syndromes (Table 1).

Indications for injections of the musculoskeletal system

Table 1

In the case of articular or periarticular inflammation, targeted local injection enables rapid anti-inflammatory action with few side effects, which often lasts for a long time in the case of arthritis, for example, through the use of crystalline steroid preparations.

If an effusion is present, it often makes sense to perform a diagnostic aspiration and/or therapeutic injection with determination of cell count, examination of the gram preparation, cell differentiation, crystal analysis and, depending on the clinic, culture and PCR examinations before injection. Synovial fluid analysis helps to differentiate between non-inflammatory and inflammatory arthropathy (Table 2).

Normal

non-inflammatory

inflammatory

septic

haemorrhagic

Colour

clear

clear

murky

murky

bloody

Viscosity

high

high

low

diverse

diverse

wbc/mm3

<200

≤2000

>2000

>50000

diverse

%PMN

<25

≤25

>25

>50

diverse

In this publication, we discuss indications, contraindications, the clinical and ultrasound-guided techniques preferred by the authors, and possible adverse drug reactions and side effects of intraarticular and periarticular injection.

2 Technique

The requirements for a correct injection technique are a clear (or suspected) diagnosis (if infection is suspected, no injection but only diagnostic aspiration ist done), an adequate information and informed patient consent (according to local national guidelines), musculoskeletal ultrasound and profound anatomical knowledge, the correct dosage of medication and, in particular, sufficient practical skills in carrying out injections. For injections in anatomically more difficult regions or for diagnostic injection of only small quantities of effusions, orientation through high-resolution musculoskeletal ultrasound (hrMSUS) is indispensable today. The hrMSUS can be used for pre-interventional exact localization of the injection site or for performing injection under direct view using various techniques.

A diagnostic injection or therapeutic injection should be painless or almost painless. The intervention takes place in a clean room without draughts, the patient should be comfortable and relaxed positioned.

In the clinically guided injection technique, we orient ourselves on the surface anatomy, especially using the osseous landmarks. The injection site is marked after orienting palpation by gentle pressure with an unsoiled ballpoint pen tip (no coloured marking) (Fig. 1).

Fig. 1: Marking of the injection site with a ballpoint pen

The injection site should not be in the area of a skin rash or a blood vessel. Shaving a hairy area is not necessary. The injection site is then disinfected according to the instructions of the product used. The skin can be superficially cryoanesthetized at the injection site before disinfection using sterile ice spray. A prior injection anaesthesia with a local anaesthetic is not necessary with the correct technique and doing a rapid injection. For special interventions, e.g. in the case of needling of a calcification of the rotator cuff of the shoulder, we recommend the prior application of a local anaesthetic into the subdeltoid bursa. In the case of several injections, e.g. at finger joints, a block anaesthesia can be evaluated. In children, the prior application of a local anaesthetic ointment or patch may be helpful.

Wearing a surgical mask is recommended, but the use of sterile gloves is not mandatory if a sterile no-touch technique e.g. according to the guidelines of the Swiss Society for Rheumatology (Tab. 3) is followed. The illustrations and pictures in this manual were made without wearing gloves.

Requirements for correct injection of the musculoskeletal system

* Informing the patient about the purpose of the injection and possible side effects

* Clean room

* Surgical mask

* Non-sterile gloves

* Use of disposable material

* Wipe disinfection with approved disinfectant, observe correct exposure time

* No-touch injection technique

Tab. 3.

When injecting a joint after clinical or prior sonographic orientation, the injection is usually made perpendicular to the skin surface. In paratendinous injections or directly (real-time) ultrasound-guided injections, a flatter insertion angle is selected depending on the structure to be injected. Ideally, with each "blind" intra-articular injection, synovial fluid is aspirated before an injection is performed, which proves the safe intraarticular position of the needle (not necessary with the direct ultrasound-guided injection technique). As mentioned above, aspiration of synovial fluid enables diagnostic analysis and leads to therapeutic relief in the case of large quantities of an effusion. The injection of a drug should be done without resistance and painless. After the injection, a short compression of the injection site with a sterile swab and a sterile adhesive plaster should be applied.

By following this procedure, injection will be fast, safe and efficient. In case of insufficient success, a second injection can be carried out after 2-4 weeks.

3 Needles

The suitable disposable injection needle (Fig. 2), the injection volume and the applied dose of medication depend on the size and position of the joint and are mentioned individually for each joint (Table 4