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Articular Block

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Authors

Brendan Tarzia, DO
Resident Physician
Creighton/Maricopa Emergency Medicine

Thomas Whiting, DO
Attending Physician
Fellowship: Ultrasound
Creighton/Maricopa Emergency Medicine

Summary

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Needle position for glenohumeral articular block
Demonstration of needle position and approach for the glenohumeral articular block.[1]Image courtesy of emra.org, “Using Point-of-Care Ultrasound to Aid Shoulder Reduction”
Demonstration of the needle approach for a glenohumeral articular block. The glenoid (left) is not articulating with the humeral head (inferior and right). The needle is seen in plane approach the joint space and capsule.[2]Video courtesy of everydayultrasound.com, “Shoulder Dislocation: Ultrasound Guided Joint Injection”
Elbow US posterior approach to articular block with demonstration of probe and needle positioning
The image on the left (A) demonstrates probe and needle position. The image on the right (B) demonstrates anticipated view with triceps (single arrow), target (multiple arrows) and needle vector (dotted line).[3]Konin GP, Nazarian LN, Walz DM. US of the elbow: indications, technique, normal anatomy, and pathologic conditions. Radiographics. 2013;33(4):E125-47. doi:10.1148/rg.334125059

Introduction

  • Joint dislocations are a common complaint seen in the Emergency Department (ED).
  • The most commonly affected joints are the shoulder (glenohumeral), elbow, interphalangeal and hip joints.
  • Radiography is typically the initial imaging modality of choice in the ED to diagnose a dislocation and confirm reduction.
    • It is often used to evaluate for fracture pre and post-reduction as well.
    • If a reduction attempt is unsuccessful, additional x-rays may be necessary, leading to incremental doses of ionizing radiation.
  • Procedural sedation is often used to facilitate reduction as well
  • Ultrasound (US) represents an extremely useful tool in the management of dislocations.
    • It offers a non-invasive, portable, low-risk, cost-effective image modality that can give a physician instantaneous information at the bedside.[4]Situ-Lacasse E, Grieger RW, Crabbe S, Waterbrook AL, Friedman L, Adhikari S. Utility of point-of-care musculoskeletal ultrasound in the evaluation of emergency department musculoskeletal pathology. … Continue reading
    • It has the added benefit of not subjecting patients to any ionizing radiation making it safe for all patients, including pregnant ones.
  • With respect to joint dislocations, ultrasound has many potential uses including diagnosing the dislocation, confirming reduction, and guiding intra-articular anesthetic injection into the joint for pain control prior to reduction attempt.
    • In an experienced user, ultrasound’s real time, dynamic imaging capabilities allow for instant confirmation of a successful or failed reduction attempt which can allow for immediate re-reduction attempt before the patient’s analgesia or sedation has worn off.[5]Gottlieb M, Holladay D, Peksa GD. Point-of-care ultrasound for the diagnosis of shoulder dislocation: A systematic review and meta-analysis. Am J Emerg Med. 2019;37(4):757-761. … Continue reading[6]Finnoff JT, Hall MM, Adams E, et al. American medical society for sports medicine position statement: Interventional musculoskeletal ultrasound in sports medicine. Clin J Sport Med. 2015;25(1):6-22. … Continue reading
    • As opposed to nerve blocks, intra-articular blocks also benefit from not impairing motor function after the procedure.[7]Raeder J, Spreng UJ. Intra-Articular and Periarticular Infiltration of Local Anesthetics.” Hadzic’s Textbook of Regional Anesthesia and Acute Pain Management. McGraw-Hill Education; 2017.
  • Note that the vast majority of research regarding articular blocks and ultrasound in the emergency department are on the glenohumeral joint, which will be discussed extensively in this chapter.

General Considerations

  • Advantages over procedural sedation
    • It is less resource intensive and does not require a “resuscitation” room equipped for sedation and less staff at bedside
    • Reduced risk of systemic side effects including respiratory depression, need for oxygen and airway support, emergence phenomenon and adverse reactions to medications
    • Unlike procedural sedation, articular blocks do not need to be re-dosed if the initial reduction attempt is unsuccessful
  • Chondrotoxicity
    • Chondrotoxicity, or damage to articular cartilage, is a known side effect of intra-articular anesthetic use which has primarily been seen in prolonged or recurrent dosing[8]Webb ST, Ghosh S. Intra-articular bupivacaine: potentially chondrotoxic? Br J Anaesth. 2009;102(4):439-441. doi:10.1093/bja/aep036[9]Gulihar A, Robati S, Twaij H, Salih A, Taylor GJS. Articular cartilage and local anaesthetic: A systematic review of the current literature. J Orthop. 2015;12(Suppl 2):S200-10. … Continue reading
    • Most of the chondrotoxicity observed has been in animal models and with higher doses and continuous infusions of bupivacaine intra-articular administration and prolonged infusions in a postoperative setting.[10]Waterbrook AL, Paul S. Intra-articular lidocaine injection for shoulder reductions: A clinical review: A clinical review. Sports Health. 2011;3(6):556-559. doi:10.1177/1941738111416777
    • In vivo studies of a single injection of bupivacaine showed decreased chondrocyte density after six months; however, no significant clinical difference was detected.[11]Chu CR, Coyle CH, Chu CT, et al. In vivo effects of single intra-articular injection of 0.5% bupivacaine on articular cartilage. J Bone Joint Surg Am. 2010;92(3):599-608. doi:10.2106/jbjs.i.00425
    • Currently, there is no evidence that a single injection of intra-articular lidocaine in the ED is harmful in the short or long term.[12]Roberts JR. Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care E-Book. Elsevier Health Sciences; 2017.
  • Choice of anesthetic
    • Lidocaine without epinephrine is the anesthetic of choice for intra-articular blocks. 
    • Lidocaine is recommended over bupivacaine given concerns of chondrotoxicity, or loss of articular cartilage, however, that seems to be with prolonged intra-articular anesthetic use 
  • Analgesia
    • Intra-articular injections appear to have an analgesic effect
    • A Cochrane review showed no statistical difference in pain control with landmark guided or ultrasound-guided intra-articular injection of glenohumeral joint when compared with IV sedation with benzodiazepines and opioids.[13]Wakai A, O’Sullivan R, McCabe A. Intra-articular lignocaine versus intravenous analgesia with or without sedation for manual reduction of acute anterior shoulder dislocation in adults. Cochrane … Continue reading
  • US vs Landmark-based approach
    • Image guided procedures, including ultrasound, have been shown to be more accurate than landmarked guided procedures.[14]Daley EL, Bajaj S, Bisson LJ, Cole BJ. Improving injection accuracy of the elbow, knee, and shoulder: does injection site and imaging make a difference? A systematic review: Does injection site and … Continue reading
    • In comparison studies, ultrasound guided injections of the glenohumeral joint are more accurate than landmark guided injections; over 97%-100% accurate in clinical case reports and studies in both adult and pediatric patients.[15]Pourcho AM, Colio SW, Hall MM. Ultrasound-guided interventional procedures about the shoulder. Phys Med Rehabil Clin N Am. 2016;27(3):555-572. doi:10.1016/j.pmr.2016.04.001[16]Breslin K, Boniface K, Cohen J. Ultrasound-guided intra-articular lidocaine block for reduction of anterior shoulder dislocation in the pediatric emergency department. Pediatr Emerg Care. … Continue reading[17]Stone MB, Sutijono D. Intraarticular injection and closed glenohumeral reduction with emergency ultrasound. Acad Emerg Med. 2009;16(12):1384-1385. doi:10.1111/j.1553-2712.2009.00568.x
    • Besides the sacroiliac joint, where further studies are needed, ultrasound guidance has been shown to improve the accuracy of other injections of major joints, including hip, ankle, elbow, and knee as well.[18]Curtiss HM, Finnoff JT, Peck E, Hollman J, Muir J, Smith J. Accuracy of ultrasound-guided and palpation-guided knee injections by an experienced and less-experienced injector using a superolateral … Continue reading[19]Levi DS. Intra-articular hip injections using ultrasound guidance: accuracy using a linear array transducer. PM R. 2013;5(2):129-134. doi:10.1016/j.pmrj.2012.08.010[20]Micu MC, Bogdan GD, Fodor D. Steroid injection for hip osteoarthritis: efficacy under ultrasound guidance. Rheumatology (Oxford). 2010;49(8):1490-1494. doi:10.1093/rheumatology/keq030[21]Daniels EW, Cole D, Jacobs B, Phillips SF. Existing evidence on ultrasound-guided injections in sports medicine. Orthop J Sports Med. 2018;6(2):232596711875657. doi:10.1177/2325967118756576[22]Cunnington J, Marshall N, Hide G, et al. A randomised, controlled, double blinded study of ultrasound guided corticosteroid joint injection in patients with inflammatory arthritis. Arthritis Rheum. … Continue reading[23]Berkoff DJ, Miller LE, Block JE. Clinical utility of ultrasound guidance for intra-articular knee injections: a review. Clin Interv Aging. 2012;7:89-95. doi:10.2147/CIA.S29265
  • Time in the emergency department
    • Pre-reduction x-ray imaging of the shoulder alone has been shown to increase time to discharge in the ED by almost 30 minutes.[24]Shuster M, Abu-Laban RB, Boyd J. Prereduction radiographs in clinically evident anterior shoulder dislocation. Am J Emerg Med. 1999;17(7):653-658. doi:10.1016/s0735-6757(99)90152-3
    • Ultrasound, conversely, has been shown to decrease both time to diagnosis and total length of stay in the ED when compared with standard radiography when IV sedation is used for reduction.[25]Abbasi S, Molaie H, Hafezimoghadam P, et al. Diagnostic accuracy of ultrasonographic examination in the management of shoulder dislocation in the emergency department. Ann Emerg Med. … Continue reading[26]Sage W, Pickup L, Smith TO, Denton ERE, Toms AP. The clinical and functional outcomes of ultrasound-guided vs landmark-guided injections for adults with shoulder pathology–a systematic review … Continue reading[27]Boswell B, Farrow R, Rosselli M, et al. Emergency medicine resident–driven point of care ultrasound for suspected shoulder dislocation. South Med J. 2019;112(12):605-609. … Continue reading
    • Both landmark guided and ultrasound-guided intra-articular glenohumeral blocks have been shown to decrease total length of stay in the ED when compared with IV sedation as well.[28]Fitch RW, Kuhn JE. Intraarticular lidocaine versus intravenous procedural sedation with narcotics and benzodiazepines for reduction of the dislocated shoulder: A systematic review. Acad Emerg Med. … Continue reading[29]Cheok CY, Mohamad JA, Ahmad TS. Pain relief for reduction of acute anterior shoulder dislocations: A prospective randomized study comparing intravenous sedation with intra-articular lidocaine. J … Continue reading[30]Miller SL, Cleeman E, Auerbach J, Flatow EL. Comparison of intra-articular lidocaine and intravenous sedation for reduction of shoulder dislocations: A randomized, prospective study. J Bone Joint … Continue reading[31]Jiang N, Hu Y-J, Zhang K-R, Zhang S, Bin Y. Intra-articular lidocaine versus intravenous analgesia and sedation for manual closed reduction of acute anterior shoulder dislocation: an updated … Continue reading[32]Matthews DE, Roberts T. Intraarticular lidocaine versus intravenous analgesic for reduction of acute anterior shoulder dislocations: A prospective randomized study. Am J Sports Med. 1995;23(1):54-58. … Continue reading
    • The average time to repeat US has been shown to be significantly less compared to time to second x-ray, allowing for further reduction attempts if necessary before analgesia (or sedation if intra-articular lidocaine wasn’t used) has worn off.[33]Seyedhosseini J, Saiidian J, Hashemi Taheri A, Vahidi E. Accuracy of point-of-care ultrasound using low frequency curvilinear transducer in the diagnosis of shoulder dislocation and confirmation of … Continue reading
    • Consideration of pre-reduction and/or post-reduction radiographs should be made within the clinical context (i.e. mechanism of injury, first time vs repeat dislocation, degree of discomfort, etc) and are at the discretion of the ED physician. 
  • Complication rate
    • Ultrasound guided intra-articular anesthetic injection has been shown to have a lower complication rate than IV sedation with systemic studies showing complication rates of 0% to 0.67% in intra-articular versus 13% to 29% with IV sedation.[34]Lippitt SB, Kennedy JP, Thompson TR. Intraarticular lidocaine versus intravenous analgesia in the reduction of dislocated shoulders. Orthop Trans. 1991;15.
    • The most common complications with IV sedation is nausea and vomiting, but respiratory depression is well documented as well and has not been shown to occur with intra-articular injections.[35]Fitch RW, Kuhn JE. Intraarticular lidocaine versus intravenous procedural sedation with narcotics and benzodiazepines for reduction of the dislocated shoulder: A systematic review. Acad Emerg Med. … Continue reading
    • Additionally, although there is a theoretical risk of septic joint or systemic lidocaine toxicity from intra-articular injection, there have been no documented cases of either of these after an injection of intra-articular lidocaine in the ED.[36]Waterbrook AL, Paul S. Intra-articular lidocaine injection for shoulder reductions: A clinical review: A clinical review. Sports Health. 2011;3(6):556-559. doi:10.1177/1941738111416777
  • Reduce cost to healthcare system 
    • There is overall less cost to the healthcare system with the associated reduction in resources, staff and time in the ED.[37]Wakai A, O’Sullivan R, McCabe A. Intra-articular lignocaine versus intravenous analgesia with or without sedation for manual reduction of acute anterior shoulder dislocation in adults. Cochrane … Continue reading
    • In a small study, Matthews et al showed a 62% reduction in cost when using intra-articular lidocaine when compared to sedation with IV morphine and versed.[38]Matthews DE, Roberts T. Intraarticular lidocaine versus intravenous analgesic for reduction of acute anterior shoulder dislocations: A prospective randomized study. Am J Sports Med. 1995;23(1):54-58. … Continue reading
  • Adjunct to standard treatment 
    • Another benefit to US guided intra-articular blocks is its ability to be used as an adjunct to standard therapy. 

Materials

  • Needle
    • 18g for drawing up medications
    • 23 – 25g for injection, 1.5 to 3.5 inch depending on body habitus
  • Syringe
    • 5-10mL
  • Sterile materials
    • Chlorhexidine or Povidone-iodine
    • Sterile drape or Sterile Towels
    • Sterile gloves
    • Sterile Ultrasound Probe Cover
    • Sterile gauze bandage
  • Medications
    • Lidocaine without epinephrine 1% 5-10mL
    • Lidocaine without epinephrine 2% 5-10mL
    • Bupivacaine 0.5% 5-8mL
  • Ultrasound
    • Linear transducer (typically 5 -15 MHz) for smaller joints
    • Curvilinear transducer (typically 2 – 5 MHz) for larger joints or patients

Glenohumeral Dislocation Block

General Discussion

  • Although articular blocks can be used in any joint, the vast majority of research has been performed in respect to glenohumeral joint dislocations.[39]Roberts JR. Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care E-Book. Elsevier Health Sciences; 2017.
    • This is due to the glenohumeral joint being the most commonly dislocated major joint in the body and thus also the most commonly encountered joint dislocation in the Emergency Department.
    • It accounts for nearly 50% of all large joint dislocations, and nearly 200,000 Emergency Department (ED) visits annually.[40]Youm T, Takemoto R, Park BK-H. Acute management of shoulder dislocations. J Am Acad Orthop Surg. 2014;22(12):761-771. doi:10.5435/JAAOS-22-12-761
  • Among shoulder dislocations, the most research has been done about anterior shoulder dislocations, which account for over 95% of all glenohumeral joint dislocations.[41]Stelter J, Malik S, Chiampas G. The emergent evaluation and treatment of shoulder, clavicle, and humerus injuries. Emerg Med Clin North Am. 2020;38(1):103-124. doi:10.1016/j.emc.2019.09.006
    • Numerous studies have shown ultrasound to be accurate at diagnosing anterior dislocation.[42]Halberg MJ, Sweeney TW, Owens WB. Bedside ultrasound for verification of shoulder reduction. Am J Emerg Med. 2009;27(1):134.e5-134.e6. doi:10.1016/j.ajem.2008.05.023[43]Akyol C, Gungor F, Akyol AJ, et al. Point-of-care ultrasonography for the management of shoulder dislocation in ED. Am J Emerg Med. 2016;34(5):866-870. doi:10.1016/j.ajem.2016.02.006[44]Lahham S, Becker B, Chiem A, et al. Pilot study to determine accuracy of posterior approach ultrasound for shoulder dislocation by novice sonographers. West J Emerg Med. 2016;17(3):377-382. … Continue reading
    • Posterior dislocations are much rarer and make up only 2-5% of shoulder dislocations and ultrasound can help diagnose these dislocations as well, which are often missed on initial patient presentation and standard anteroposterior (AP) radiography of the shoulder and ultrasound may be more sensitive.[45]Yuen CK, Chung TS, Mok KL, Kan PG, Wong YT. Dynamic ultrasonographic sign for posterior shoulder dislocation. Emerg Radiol. 2011;18(1):47-51. doi:10.1007/s10140-010-0906-7[46]Kowalsky MS, Levine WN. Traumatic posterior glenohumeral dislocation: classification, pathoanatomy, diagnosis, and treatment. Orthop Clin North Am. 2008;39(4):519-533, viii. … Continue reading[47]Mackenzie DC, Liebmann O. Point-of-care ultrasound facilitates diagnosing a posterior shoulder dislocation. J Emerg Med. 2013;44(5):976-978. doi:10.1016/j.jemermed.2012.11.080[48]Beck S, Chilstrom M. Point-of-care ultrasound diagnosis and treatment of posterior shoulder dislocation. Am J Emerg Med. 2013;31(2):449.e3-449.e5. doi:10.1016/j.ajem.2012.06.017
  • An anterior or posterior shoulder dislocation can easily be identified with the ultrasound using a posterior approach with the probe placed placed just lateral to the spine of the scapula
    • The posterior approach is highly recommended over the anterior approach as it is more accurate and provides a better window for injection.[49]Ogul H, Bayraktutan U, Ozgokce M, et al. Ultrasound-guided shoulder MR arthrography: comparison of rotator interval and posterior approach. Clin Imaging. 2014;38(1):11-17. … Continue reading
    • Absence of humeral head rotation in glenoid fossa when the arm is internally and externally rotated has been diagnostic of dislocation as well.
    • Comparison to the other shoulder is recommended if there is any uncertainty
  • Systematic reviews and meta-analyses have compared the accuracy of GHJ dislocation compared to standard radiography.[50]Gottlieb M, Russell F. Diagnostic accuracy of ultrasound for identifying shoulder dislocations and reductions: A systematic review of the literature. West J Emerg Med. 2017;18(5):937-942. … Continue reading
    • For anterior dislocations, ultrasound has shown to be nearly 100% sensitive and specific when using either the posterior or anterior approach.[51]Abbasi S, Molaie H, Hafezimoghadam P, et al. Diagnostic accuracy of ultrasonographic examination in the management of shoulder dislocation in the emergency department. Ann Emerg Med. … Continue reading
    • For posterior dislocations, US has a similar sensitivity and specificity.
  • Ultrasound can also be used to confirm reduction
    • Real-time dynamic assessment of GHJ articulation between glenoid fossa and humeral head can immediately confirm reduction after an attempt.
    • It has also been shown to be highly accurate in confirming reduction as well, with 100% specificity.
  • Ease of Reduction and Success rate
    • A couple studies have reported decreased ease and rate of reduction after articular block versus IV sedation, with one reporting a success rate of 81% with lidocaine versus 100% success rate with IV sedation.[52]Hames H, McLeod S, Millard W. Intra-articular lidocaine versus intravenous sedation for the reduction of anterior shoulder dislocations in the emergency department. CJEM. 2011;13(06):378-383. … Continue reading
    • The majority of studies, however, including a Cochrane review have shown no difference in ease of reduction or success rate when using intra-articular block compared to IV sedation for anterior or posterior dislocations, with a success rate of 90% and no significant difference when compared to IV sedation.[53]Dhinakharan SR. Intra-articular lidocaine for acute anterior shoulder dislocation reduction. Emerg Med J. 2002;19(2):142-a-143. doi:10.1136/emj.19.2.142-a[54]Wakai A, O’Sullivan R, McCabe A. Intra-articular lignocaine versus intravenous analgesia with or without sedation for manual reduction of acute anterior shoulder dislocation in adults. Cochrane … Continue reading[55]Aronson PL, Mistry RD. Intra-articular lidocaine for reduction of shoulder dislocation. Pediatr Emerg Care. 2014;30(5):358-362. doi:10.1097/pec.0000000000000131
    • There is data that shows there may be higher failure rates with intra-articular block in patients who present after 5.5 hours with dislocation.[56]Kosnik J, Shamsa F, Raphael E, Huang R, Malachias Z, Georgiadis GM. Anesthetic methods for reduction of acute shoulder dislocations: A prospective randomized study comparing intraarticular lidocaine … Continue reading

Procedure

  • Normal Glenohumeral Joint Anatomy
    • The shoulder joint is a ball and socket joint consisting of the articular surface of the humeral head and the glenoid fossa of the scapula.
    • The glenoid fossa is lined with a fibrocartilaginous layer called the glenoid labrum which helps deepen the socket, however, the glenoid fossa is still relatively shallow and only a small portion of the humeral head articulates with it.
    • Although this helps make the shoulder joint the most mobile joint in the body, it also makes it unstable and prone to dislocation.
Glenohumeral Anatomy Diagram
Illustration of the glenohumeral joint.[57]Image courtesy of wikimedia.org, “Shoulder Joint”
  • Probe position
    • Examples of both the anterior and posterior probe position are demonstrated
    • However, the posterior technique is recommended and has shown to be more effective.
    • For this reason, only the posterior approach is described
  • Normal Glenohumeral Ultrasound
    • In a normal shoulder, the humeral head should be in the glenoid fossa and adjacent to the glenoid
    • The humeral head appears as a curved bright, hyper-echoic line with black, hypoechoic circular structure under the hyperechoic curve
Clinical demonstration of probe position using the anterior approach.
Ultrasound visualization of normal shoulder using the anterior approach.
Shoulder dislocation posterior approach probe position
Clinical demonstration of probe position using the posterior approach.[58]Khallaf SF, Hussein MI, Amal M, Khouly E. Efficacy of ultrasonography-guided intra-articular steroid injection of the shoulder and exercising in patients with adhesive capsulitis: glenohumeral versus … Continue reading
Shoulder US Normal View Posterior
Ultrasound visualization of normal shoulder using the posterior approach.
  • Confirming Dislocation
    • Anterior Dislocation: The humeral head will be inferior to glenoid which will appear as deep on the screen compared to the glenoid
    • Posterior Dislocation: The humeral head will be superior to the glenoid, which will appear as more superficial on the screen compared to the glenoid.
    • Lack of rotational articulation of the humeral head in the glenoid fossa on internal and external rotation of the arm indicates dislocation as well[59]Akyol C, Gungor F, Akyol AJ, et al. Point-of-care ultrasonography for the management of shoulder dislocation in ED. Am J Emerg Med. 2016;34(5):866-870. doi:10.1016/j.ajem.2016.02.006
Ultrasound demonstrating anterior shoulder dislocation. Note the curvilinear probe posterior. The humeral head is more “anterior” relative to the glenoid fossa.
Shoulder US Posterior Dislocation Example
Ultrasound demonstrating posterior shoulder dislocation. Note the curvilinear probe is posterior. The humeral head is more “posterior” or closer to the probe relative to the glenoid fossa.[60]Image Courtesy of emdocs.net, “US Probe: Ultrasound for Shoulder Dislocation and Reduction
  • The patient is seated facing away from you
    • Alternate positioning is having the patient side-lying with affected extremity up and a bolster under the arm for comfort. Note this is the optimal position for arthrocentesis, but may not be possible with a painful shoulder dislocation
  • Proceduralist stands behind patent, ultrasound machine is in front of patient or on the unaffected side allowing a clear view of the screen during the procedure
    • Ideally, proceduralist will not have to turn head during procedure
  • Follow all sterile precautions
  • Place the probe in transverse orientation, with probe marker pointing laterally, over, and parallel to the spine of the scapula
    • Slide probe laterally and visualize the glenoid fossa and glenoid and continue laterally until the humeral head is in view.
    • You are over the posterior glenohumeral joint.
    • You should be approximately in the long axis to the infraspinatus tendon.
    • Examine contralateral shoulder if uncertain about anatomy
Needle position for glenohumeral articular block
Demonstration of needle position and approach for the glenohumeral articular block.[61]Image courtesy of emra.org, “Using Point-of-Care Ultrasound to Aid Shoulder Reduction”
  • You are encouraged to mark the skin at the likely point of entry
    • This allows for efficient reacquisition of the image after sterile preparation.
  • Make a small skin wheal with local anesthetic lateral to probe using a small-bore needle
  • Using a 20 gauge 1.5 to 3.5 inch needle, enter skin lateral to probe and advance needle from lateral to medial direction using an in-plane approach .
  • The needle should be in a parallel plane to the transducer for a linear probe, and may be at an angle with the curvilinear probe.
    • Maintain the probe in a long axis orientation with the visualized needle
  • Enter glenohumeral joint and visualize needle in the sulcus between glenoid labrum and humeral head
    • Once in GHJ, withdraw the syringe slightly to make sure the needle is not in a vessel.
    • It is common to get a flash of blood when you are in the joint as hemarthrosis is common, however continuous return of blood should not be seen and may indicate you are in a vessel.
    • Optional: Aspirate any blood in the glenohumeral joint prior to injecting the anesthetic.
  • Inject 10-20mL local anesthetic into joint space while visualizing needle at all times
  • Post-procedure
    • The patient should have pain relief within 10-20 minutes
    • Perform reduction after 10-20 minutes with preferred technique
    • Check neurovascular status prior to and post-procedure
    • Confirm reduction with ultrasound
Demonstration of the needle approach for a glenohumeral articular block. The glenoid (left) is not articulating with the humeral head (inferior and right). The needle is seen in plane approach the joint space and capsule.[62]Video courtesy of everydayultrasound.com, “Shoulder Dislocation: Ultrasound Guided Joint Injection”
Demonstration of an articular block for a glenohumeral dislocation. The glenoid (high and right) is not articulating with the humeral head (inferior). The needle is coming in lateral to medial and anesthetic can be seen flowing into the capsule.[63]Video courtesy of emdocs.net, “US Probe: Ultrasound for Shoulder Dislocation and Reduction”

Elbow Dislocation Block

General Discussion

  • General
    • The elbow joint is the second most common major joint dislocation in adults and is the most commonly dislocated joint in children.
    • Unlike the glenohumeral joint, the elbow joint, made from the articulation of the humerus and ulna, is a stable hinge joint.
    • Given its usual stability, any dislocation should prompt evaluation for fractures of surrounding structures such as radial head and coronoid process of ulna which are common associated fractures.
Elbow Anatomy
Normal osseous anatomy of the elbow.
    • There is limited research in the area of intra-articular injections for elbow dislocations, however it has been described.[64]Bullers K. Merck Manuals. J Med Libr Assoc. 2016;104(4):369-371. doi:10.3163/1536-5050.104.4.028
  • Posterior Dislocation:
    • The majority of elbow dislocations are posterior and result from fall on an outstretched hand and extended arm.
    • On physical exam, patients often hold their arms in flexion and have a prominent olecranon.
  • Anterior Dislocation:
    • Anterior dislocations are more rare than posterior and usually result from a blow directly to the olecranon of a flexed elbow.
    • Physical exam usually shows extension of arm with anterior tenting of proximal forearm and prominent distal humerus posteriorly.
    • Given the high level of force that is required to cause an anterior dislocation, associated injuries such as open fractures and neuromuscular injuries may be seen as well.

Procedure

  • General
    • Both the anterolateral and posterior approach are presented as no studies have clarified the superiority of one over the other.
    • Use standard sterile technique
    • Linear probe is recommended
    • Injectate is typically 3-5 mL of local anesthetic
    • Optional: aspirate any blood in the joint prior to reduction.
  • Anterolateral Approach[65]Sussman WI, Williams CJ, Mautner K. Ultrasound-guided elbow procedures. Phys Med Rehabil Clin N Am. 2016;27(3):573-587. doi:10.1016/j.pmr.2016.04.002
    • Position: the patient is seated or supine with elbow flexed to 90-100 degrees
      • Forearm and hand resting on a pillow
      • Pronate forearm with palm resting on table or pillow
    • Position the transducer on the dorsolateral side of joint
      • Long axis to the radiocapitellar joint and radius
Patient positioning elbow dislocation articular block anterolateral approach
Clinical image of probe position for anterolateral approach articular block elbow dislocation.[66]Collins JMP, Smithuis R, Rutten MJCM. US-guided injection of the upper and lower extremity joints. Eur J Radiol. 2012;81(10):2759-2770. doi:10.1016/j.ejrad.2011.10.025
    • Aiming distally, direct needle in line with probe into the radiocapitellar joint
    • Inject 3-5 mL of local anesthetic
Elbow US anterolateral approach articular block with anatomic illustration of needle vector
Ultrasound image of needle in plane in the radiocapitallar joint (red arrows). Also demonstrated is an illustration of the needle vector.[67]Sussman WI, Williams CJ, Mautner K. Ultrasound-guided elbow procedures. Phys Med Rehabil Clin N Am. 2016;27(3):573-587. doi:10.1016/j.pmr.2016.04.002
Elbow US Articular Block using anterolateral approach
US image of anterolateral approach to elbow dislocation articular block. Blue arrow shows needle in joint.[68]Collins JMP, Smithuis R, Rutten MJCM. US-guided injection of the upper and lower extremity joints. Eur J Radiol. 2012;81(10):2759-2770. doi:10.1016/j.ejrad.2011.10.025
  • Posterior Approach[69]Waldman SD. Atlas of Pain Management Injection Techniques E-Book. Elsevier Health Sciences; 2016
    • Position: two options
      • The patient is prone with elbow flexed 90 degrees and forearm hanging over edge of table
      • Alternative: seated with elbow flexed at 90 degrees with affected arm placed across their chest
    • Place transducer in long axis to humerus and over over posterior olecranon fossa
    • Using an in plane approach
      • Introduce the needle from a posterosuperior approach adjacent to the triceps tendon
      • Advance through the posterior fat pad and into the joint.
    • Visualize the needle entering the concave olecranon fossa of the humerus
Patient and probe position for posterior approach to articular block for elbow dislocation.[70]MacCormick LM, Baynard T, Williams BR, Vang S, Xi M, Lafferty P. Intra-articular hematoma block compared to procedural sedation for closed reduction of ankle fractures. Foot Ankle Int. … Continue reading
Elbow US posterior approach to articular block with demonstration of probe and needle positioning
The image on the left (A) demonstrates probe and needle position. The image on the right (B) demonstrates anticipated view with triceps (single arrow), target (multiple arrows) and needle vector (dotted line).[71]Konin GP, Nazarian LN, Walz DM. US of the elbow: indications, technique, normal anatomy, and pathologic conditions. Radiographics. 2013;33(4):E125-47. doi:10.1148/rg.334125059

Other Joints

  • General
    • Theoretically, intra-articular injections of anesthesia can be performed in any joint prior to reduction.
    • Both additional upper extremity (wrist, hand, fingers) and lower extremity (hip, knee and ankle) dislocations may be able to be similarly managed, but there is limited research in these areas that show its efficaciousness compared to standard treatment methods.
    • In some cases, such as the finger, a digital block may be more practical
  • Ankle
    • Data on intra-articular hematoma blocks of the ankle joint in ankle fracture-dislocations shows similar reduction of pain[72]MacCormick LM, Baynard T, Williams BR, Vang S, Xi M, Lafferty P. Intra-articular hematoma block compared to procedural sedation for closed reduction of ankle fractures. Foot Ankle Int. … Continue reading
    • One study decreased time to reduction than IV sedation.[73]White BJ, Walsh M, Egol KA, Tejwani NC. Intra-articular block compared with conscious sedation for closed reduction of ankle fracture-dislocations: A prospective randomized trial. J Bone Joint Surg … Continue reading
    • More research however is needed before conclusions and additional comparisons can be made.
  • Hip
    • As of now, using intra-articular joint injections as a sole agent for hip dislocations is not recommended given the hip joints larger surface area and concerns over adequate analgesia.

Additional Considerations

  • Absolute Contraindications:
    • Allergy to anesthetic
    • Infection overlying injection site
  • Relative Contraindications:
    • Proximal humerus fracture
    • Altered or unconscious
    • Uncooperative Patient
    • Anticoagulated
    • Poly trauma requiring additional interventions
  • Complications:
    • Damage to surrounding nerves, soft tissue
    • Local Anesthetic Systemic Toxicity (LAST): calculate the maximum dose of the anesthetic prior to injection (See: Chapter – Procedures General)
  • Troubleshooting:
    • Joint Infection: skin and joint however very unlikely when following sterile technique
    • You should be able to visualize the needle tip at all times when inserting the needle.
    • If you lose the needle tip, you should stop immediately and find the needle tip.
    • Never inject anesthetic if you can not clearly visualize where your needle tip is.
  • Charting
    • It is important to document a thorough neurovascular exam before and after the articular block, and after the reduction
  • Standardized Protocol
    • Before ultrasound can be adopted as a first line approach to diagnosing dislocation, guiding intra-articular injection and confirming reduction, more studies that standardize the approach to probe placement, dislocation diagnosis criteria, and approach to injection are needed.
  • Pediatrics
    • Although there are a few studies that looked at ultrasound’s use in dislocation and guiding intra-articular block, there is still a paucity of pediatric studies in patients under the age of 15.

Pearls & Pitfalls

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References

References[+]