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Ultrasound Guided Musculoskeletal Injections

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Authors

Alex Tomesch, MD
Assistant Clinical Professor of Emergency Medicine
Department of Emergency Medicine
University of Missouri

Anna Waterbrook, MD, FACEP, CAQ-SM
Department of Emergency Medicine
University of Arizona

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
US video showing the commonly accepted posterior approach to a glenohumeral joint injection. Needle is visualized in plane.
US video of AC joint injection, needle out of plane and joint in long axis.
Video demonstrating standard approach to an ultrasound guided hip injection. The needle is in plane and capsular distension is demonstrated.
Ultrasound guided suprapatellar recess (joint) injection. The needle is in plane, the view is short axis of the suprapatellar recess. The injectate can be seen swirling around the needle.

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]Cushman DM, Bruno B, Christiansen J, Schultz A, McCormick ZL. Efficacy of injected corticosteroid type, dose, and volume for pain in large joints: A narrative review. PM R. 2018;10(7):748-757 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]Cushman DM, Bruno B, Christiansen J, Schultz A, McCormick ZL. Efficacy of injected corticosteroid type, dose, and volume for pain in large joints: A narrative review. PM R. 2018;10(7):748-757[3]Chávez-López MA, Navarro-Soltero LA, Rosas-Cabral A, Gallaga A, Huerta-Yáñez G. Methylprednisolone versus triamcinolone in painful shoulder using ultrasound-guided injection. Mod Rheumatol. … Continue reading[4]Sakeni RA, Al-Nimer MSM. Comparison between intraarticular triamcinolone acetonide and methylprednisolone acetate injections in treatment of frozen shoulder. Saudi Med J. 2007;28(5):707-712.[5]Plafki C, Steffen R, Willburger RE, Wittenberg RH. Local anaesthetic injection with and without corticosteroids for subacromial impingement syndrome. Int Orthop. 2000;24(1):40-42.
    • 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]Cushman DM, Bruno B, Christiansen J, Schultz A, McCormick ZL. Efficacy of injected corticosteroid type, dose, and volume for pain in large joints: A narrative review. PM R. 2018;10(7):748-757[7]de Jong BA, Dahmen R, Hogeweg JA, Marti RK. Intra-articular triamcinolone acetonide injection in patients with capsulitis of the shoulder: a comparative study of two dose regimens. Clin Rehabil. … Continue reading[8]Hong JY, Yoon S-H, Moon DJ, Kwack K-S, Joen B, Lee HY. Comparison of high- and low-dose corticosteroid in subacromial injection for periarticular shoulder disorder: a randomized, triple-blind, … Continue reading[9]Robinson P, Keenan A-M, Conaghan PG. Clinical effectiveness and dose response of image-guided intra-articular corticosteroid injection for hip osteoarthritis. Rheumatology (Oxford). … Continue reading 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]Jayaram P, Kennedy DJ, Yeh P, Dragoo J. Chondrotoxic effects of local anesthetics on human knee articular cartilage: A systematic review. PM R. 2019;11(4):379-400. 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]Jayaram P, Kennedy DJ, Yeh P, Dragoo J. Chondrotoxic effects of local anesthetics on human knee articular cartilage: A systematic review. PM R. 2019;11(4):379-400.

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]Mellor R, Bennell K, Grimaldi A, et al. Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, … Continue reading[13]Werner BC, Cancienne JM, Browne JA. The timing of total hip arthroplasty after intraarticular hip injection affects postoperative infection risk. J Arthroplasty. 2016;31(4):820-823.

Contraindications

  • Contraindications
    • Allergies to any medications being used
    • Local cellulitis
    • Prosthetic joint
    • Concern for active infection
    • Possibility of surgical intervention[14]Werner BC, Cancienne JM, Browne JA. The timing of total hip arthroplasty after intraarticular hip injection affects postoperative infection risk. J Arthroplasty. 2016;31(4):820-823.[15]Xing D, Yang Y, Ma X, Ma J, Ma B, Chen Y. Dose intraarticular steroid injection increase the rate of infection in subsequent arthroplasty: grading the evidence through a meta-analysis. J Orthop Surg … Continue reading
      • 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]Petersen SK, Hansen I, Andreasen RA. Low frequency of septic arthritis after arthrocentesis and intra-articular glucocorticoid injection. Scand J Rheumatol. 2019;48(5):393-397.
  • 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]Habib GS, Saliba W, Nashashibi M. Local effects of intra-articular corticosteroids. Clin Rheumatol. 2010;29(4):347-356.
  • Hypopigmentation
    • This is also a very rare complication and is secondary to steroid exposure to the skin.[18]Habib GS, Saliba W, Nashashibi M. Local effects of intra-articular corticosteroids. Clin Rheumatol. 2010;29(4):347-356.
Skin discoloration following corticosteroid injection

Skin discoloration or hypopigmentation following corticosteroid injection.[19]Gupta A, Garg M, Johnson N, Vignesh P. Hypopigmentation after intra-articular corticosteroid injection. BMJ Case Rep. 2019;12(3):e228921.

  • 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]Habib GS, Bashir M, Jabbour A. Increased blood glucose levels following intra-articular injection of methylprednisolone acetate in patients with controlled diabetes and symptomatic osteoarthritis of … Continue reading
    • 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]Habib GS, Bashir M, Jabbour A. Increased blood glucose levels following intra-articular injection of methylprednisolone acetate in patients with controlled diabetes and symptomatic osteoarthritis of … Continue reading
  • 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]Berger RG, Yount WJ. Immediate “steroid flare” from intraarticular triamcinolone hexacetonide injection: Case report and review of the literature. Arthritis Rheum. 2010;33(8):1284-1286.
  • 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]Wernecke C, Braun HJ, Dragoo JL. The effect of intra-articular corticosteroids on articular cartilage: A systematic review: A systematic review. Orthop J Sports Med. 2015;3(5):2325967115581163.
  • 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]Brinks A, Koes BW, Volkers ACW, Verhaar JAN, Bierma-Zeinstra SMA. Adverse effects of extra-articular corticosteroid injections: a systematic review. BMC Musculoskelet Disord. 2010;11(1):206.
  • 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

  • Potential indications in the ED
    • Adhesive capsulitis
    • Severe glenohumeral osteoarthritis
    • Shoulder dislocation
  • Equipment
    • One 10 mL syringe with medication(s) for joint
    • Optional: second syringe with local anesthetic only
    • 21-25 gauge, 1.5 – 2 inch needle
    • Probe: curvilinear or linear
  • Positioning
    • Place the patient in a lateral decubitus position, ipsilateral or affected arm is up.
    • Alternative position: if necessary based on the clinical picture, this procedure can be performed with the patient seated
    • Position yourself in front of the patient with the ultrasound machine positioned behind the patient so you, the injection, and the ultrasound are in-line
Shoulder US Glenohumeral Joint with Curvilinear Probe
Posterior view of glenohumeral joint using curvilinear probe.
Shoulder US Glenohumeral Joint Injection with Linear Probe, Needle in Plane
Posterior view of glenohumeral joint using linear probe, needle is visualized in plane in the joint.
  • Pre-procedure
    • Identify the glenohumeral joint (GHJ) posteriorly
    • Find the suprascapular notch and following laterally to the GHJ
    • Once this is identified you will want to position your transducer so the joint is as far laterally on your probe as possible.
    • Optional: build up a large ‘mound’ or ‘step off’ of sterile ultrasound gel to rock the transducer up on the medial side.
Video showing needle placement and advancement using curvilinear probe.
Video showing large volume joint injection for adhesive capsulitis. The needle is visualized at an angle from left to right. The capsule is quite distended and injectate can be seen swirling within the hypoechoic fluid in the capsule.
  • Procedure
    • Insert needle with lidocaine attached at a near 90 degree angle immediately adjacent to the curvilinear transducer.
    • Optional: inject local anesthetic as you go, especially prior to entering the joint capsule.
    • Direct the needle into the GHJ
    • Once in the joint capsule, confirm location by injecting 1-2 mL
    • After confirmation, inject the rest of the injectate
  • Pearls
    • Note that the GHJ capsule can be fairly resistant to flow and it may take a few seconds to adequately distend the capsule to accept the total volume of injectate. To get around this, a larger gauge (i.e. 21-22) needle can be used.
    • If using the two syringe technique, when switching syringes for the injectate, push the entire syringe contents into the joint space and remove the needle.
Video showing advancement of needle and injection. Note the injectate can be seen entering the joint with capsular distension.

Acromioclavicular Joint

  • Potential Indications in the ED
    • Acromioclavicular (AC) Joint Arthritis
    • AC Joint Sprain
  • Equipment
    • Syringe: 2-3 mL
    • Needle: 25-gauge, 0.5 – 1 inch
    • Injectate: 0.5 – 1 mL anesthetic, 0.5 – 1 mL corticosteroid (1-2 mL max)
    • Linear probe
    • There is no local anesthetic injection for this procedure.
Normal Acromioclavicular Joint seen in long axis.[25]Case courtesy of Dr Dai Roberts, Radiopaedia.org, rID: 76776
  • Positioning
    • Have the patient seated at the side of the bed or gurney
    • Stand behind or next to the patient so the AC joint, patient, and ultrasound are in line.
  • Pre-Procedure
    • Palpate the shoulder to determine the location of the A/C joint.
    • Place the linear transducer directly over the A/C joint and identify it on ultrasound.
  • Approach 1 (In Plane)
    • Identify the joint in long axis
    • Once the joint is located on ultrasound, move the transducer so that the joint is located all the way laterally on the screen.
    • Insert needle just lateral to the edge of the transducer at a 30-45 degree angle and go directly to the AC joint
Shoulder US AC Joint Injection, Long Axis, In Plane
AC Joint Injection with needle in plane, long axis to the joint.
Video showing AC Joint Injection with needle in plane, long axis to the joint. Capsular distension is demonstrated.
Video showing AC Joint Injection with needle in plane, long axis to the joint. Capsular distension is demonstrated. Note the AC Joint is slightly abnormal appearing suggesting an injury.
  • Approach 2 (Out of Plane)
    • Place the probe over the joint in long axis, centering the joint on the screen
    • Insert the needle at the center point and use a step-wise approach, track the needle down into the joint space
Shoulder US AC Joint Injection Long Axis, Needle Out of Plane
AC Joint Injection with needle out of plane (arrow) and the joint is visualized in long axis.
AC Joint Injection with needle out of plane and the joint is visualized in long axis.
Video demonstrating AC Joint injection with needle out of plane and joint visualized in long axis. You can see the injectate flowing into the joint space.
  • Pearls
    • There is no extra-articular component, do not inject as you go
    • This is a small joint and it can be extremely difficult to push injectate
    • Try rotating the needle 90 degrees if you are having difficulty injecting
    • Also try to advance further into the joint if having issues pushing the injectate.

First Dorsal Compartment (DeQuarvain's Tenosynovitis)

  • Potential indications in the ED
    • Known or new diagnosis of De Quervain’s Tenosynovitis
  • Equipment
    • Syringe: 1 – 3 mL
    • Injectate: 0.5 – 1 mL corticosteroid, 0.5 – 1 mL anesthetic
    • Needle: 1 – 1.5 inch, 25 gauge
    • Probe: linear transducer
  • Positioning
    • Patient is seated, facing proceduralist
    • Hand placed on examination table
Dorsal compartments of the wrist illustration
Illustration of the dorsal compartments of the wrist. The first compartment contains both the Extensor Pollicis Brevis and Abductor Pollicis Longus (Labled 1).[26]Patel KR, Tadisina KK, Gonzalez MH. De quervain’s disease. Eplasty. 2013;13:ic52.
Ultrasound view of the first dorsal compartment with peritendinous fluid, especially around the APL. Note the radial artery to the left.[27]Image courtesy of Dr Taco Geerstma, ultrasoundcases.info, “Extensor tendons dorsal side of the wrist: First compartment”
Ultrasound of the first dorsal compartment showing an anatomic varient where there is septation between the EPB and APL (white arrow). EPB is noted to have peritendinous fluid and the radial styloid process is labaled (RST).[28]Choi S-J, Ahn JH, Lee Y-J, et al. de Quervain disease: US identification of anatomic variations in the first extensor compartment with an emphasis on subcompartmentalization. Radiology. … Continue reading
  • Pre-Procedure
    • Evaluate the 1st dorsal compartment to identify the anatomy
    • The optimal approach may be medial or lateral
    • Be sure to identify the radial artery
  • Procedure
    • In short axis, Identify the first dorsal compartment, containing extensor pollicis brevis (EPB) and the abductor pollicis longus (APL).
    • Slide the probe laterally so that the EPB is all the way on the medial side of the probe.
    • On the medial side of the probe, insert the needle just below (3-5 mm) below the probe edge and insert into the EPB tendon sheath.
    • Reverse the directions above if the lateral approach is more optimal
Ultrasound guided injection of the 1st dorsal compartment performed in short axis with the needle in plane. Note the proceduralist is optomizing needle position in the hypoechoic fluid prior to injection.
Ultrasound guided injection of the 1st dorsal compartment in long axis with the needle in plane.
Ultrasound guided injection of the 1st dorsal compartment performed in short axis with the needle out of plane. The needle tip is visualized between the APL and EPB.
Increased signal and vascularity with color doppler of the first dorsal compartment suggesting tenosynovitis.
  • Pearls
    • Can be performed in long axis if desired
    • Considered first line treatment for De Quervain’s

Hip Joint

  • Potential indications in the ED
    • Severe or symptomatic hip osteoarthritis
  • Equipment
    • Syringe: Two 10 mL
    • Injectate 1: 5 – 10 cc anesthetic in one syringe for local anesthesia,
    • Needle 1: 1.5 – 2 inch, 25 gauge for local anesthetic
    • Injectate 2: 2 mL lidocaine and 2 mL corticosteroid for joint space
    • Needle 2: 3.5 inch, 22-25 gauge needle for steroid injection
    • Probe: curvilinear
Illustration of the hip joint capsule.[29]Image courtesy of Dave Klemm, aafp.org, “Hip Impingement: Identifying and Treating a Common Cause of Hip Pain”.
Hip US Normal view long axis
Normal ultrasound demonstration of hip joint showing acetabulum, femoral head and neck, capsule
Ultrasound guided hip injection with needle in plane. Before (left) and after (right).[30]Gao G, Fu Q, Wu R, Liu R, Cui L, Xu Y. Ultrasound and ultrasound-guided hip injection have high accuracy in the diagnosis of femoroacetabular impingement with atypical symptoms. Arthroscopy. … Continue reading
  • Pre-Procedure
    • Identify femoral shaft in short axis
    • Move transducer cranial until you identify the greater trochanter (contour of bone will change)
    • Rotate the probe to midline along the axis of femoral neck and head
    • Slide the probe medial until the capsule and acetabulum are also visualized
  • Procedure
    • Target for injection is the femoral head or neck within the capsule, and not directly into the femoroacetabular joint space
    • Slide the probe medial to move the target closer to the lateral part of the probe
    • Insert the shorter needle in a vector towards your target and inject local anesthetic to create a track as you back out
    • In the same track, insert the longer needle until it is visualized in the joint space
    • Inject the corticosteroid and withdraw the needle.
Ultrasound guided hip injection using the single needle technique. The needle is in plane and capsular distension is well demonsrated.
A second video showing an ultrasound guided hip injection. The needle is in plane and capsular distension is demonstrated.
  • Pearls
    • Performed identical to hip arthrocentesis
    • The flow of injectate into the joint should flow freely. If there is resistance, consider repositioning the needle.
    • In patients with a small frame and body habitus, the linear probe can be considered
    • In patients with a large body habitus, an assistant may need to retract the panus to optimize view.

Greater Trochanteric Bursa

  • Potential indications in the ED
    • New or known diagnosis of greater trochanteric pain syndrome (trochanteric bursitis)
  • Equipment
    • Probe: linear or curvilinear depending patients body habitus
    • Needle: 1.5 – 3.5 inch, 22 gauge needle. Will need longer needle for larger patient
    • Syringe: 5 – 10 cc syringe
    • Injectate: 5 mL local anesthetic, 1 – 2 mL corticosteroid
Anatomic illustration of the trochanteric bursa, sometimes referred to as the subglute max bursa.
  • Positioning
    • Patient is laying in lateral decubitus position with affected hip pointed up
    • Stand behind patient, with ultrasound machine on the opposite side
Hip US Demonstration of the trochanteric bursea labeled
Ultrasound identification of the trochanteric bursa (labeled) as well as the other relevant anatomy.[31]Mitchell WG, Kettwich SC, Sibbitt WL Jr, et al. Outcomes and cost-effectiveness of ultrasound-guided injection of the trochanteric bursa. Rheumatol Int. 2018;38(3):393-401.
Hip US Demonstration of ultrasound guided trochanteric bursa injection
In plane ultrasound guided approach with distension of the bursa.[32]Case courtesy of Dr James Harvey, Radiopaedia.org, rID: 82181
  • Pre-Procedure
    • Identify the greater trochanter with the probe
    • The trochanteric bursa is just a few millimeters above the bone
    • Sometimes a hypoechoic stripe can be seen within the bursa
  • Procedure
    • Once the target is identified, insert from posterior to anterior with needle in plane
    • The target is between the gluteus medius and gluteus minimus muscle tendons as they insert on the greater trochanter
    • Inject your medications, which should flow freely into the bursa
Video using internal and external rotation of the hip to help identify the bursa.
In plane ultrasound guided trochanteric bursa injection.

Pes Anserine Bursa

  • Potential indications in the ED
    • Known or newly diagnosed Pes Anserine Bursitis
  • Equipment
    • Syringe: 1 – 3 mL
    • Injectate: 1 – 2 mL corticosteroid, 0.5 – 1 mL anesthetic
    • Needle: 1 – 1.5 inch, 25 gauge
    • Probe: linear transducer
Knee anatomy Pes Anserine Bursa
Illustration of the Pes Anserine Bursa (black) below the three muscles that make up the Pes Anserinus (Red) on the medial knee.
  • Positioning
    • Patient is supine
    • Affected leg is externally rotated, exposing the medial knee
    • Stand at patients side, ultrasound machine on opposite side
  • Pre-Procedure
    • Scan to identify the bursa, located on the medial side of the tibia
    • It is inferior to the insertion of sartorious, gracilis and semitendinosis muscles
Ultrasound of an inflammed pes anserine bursa (PAB) below the tendons of the pes anserinus (PAT) over the tibia (T).[33]Imani F, Rahimzadeh P, Abolhasan Gharehdag F, Faiz SHR. Sonoanatomic variation of pes anserine bursa. Korean J Pain. 2013;26(3):249-254.
Coronal oblique image of needle in the pes anserine bursa (asterisk) between the MCL (black arrows) and the pes anserinus (PES).[34]Finnoff JT, Nutz DJ, Henning PT, Hollman JH, Smith J. Accuracy of ultrasound-guided versus unguided pes anserinus bursa injections. PM R. 2010;2(8):732-739.
  • Procedure
    • Center your target on the screen
    • Insert your needle on the side closest to the bursa in plane
    • Push the entire injectate into bursa and withdraw the needle.
Video demonstration of ultrasound guided pes anserine bursa injecction with needle in plane and bursal distension.
  • Pearls
    • If not certain of bursa, you can consider using an anesthetic only syringe to hydrodissect the area, confirm anatomy and create a window for the steroid

Knee Joint

  • Potential indications in the ED
    • Severe knee osteoarthritis
    • Gout
  • Equipment
    • Syringe: 5 – 10 mL
    • Injectate: 1 – 2 mL corticosteroid, 5 mL anesthetic
    • Needle 1: 1 – 1.5 inch, 25 gauge for local anesthetic
    • Needle 2: 1.5 – 3.5 inch, 22-25 gauge needle for steroid injection
    • Probe: curvilinear or linear transducer depending on body habitus
Anatomic illustration of the suprapatellar recess
Clinical illustration of the knee anatomy, highlighting the suprapatellar recess or ‘bursa’. Note that this space is contiguous with the rest of the joint space.
  • Positioning
    • Patient is supine
    • Physician stands on side of affected knee with ultrasound machine on contralateral side
    • Optional: pillow or folded blanket under knee to flex to 20 – 30 degrees
Clinical demonstration of ultrasound guided suprapatellar knee injection
Demonstration of probe and needle position for ultrasound guided injection (and arthrocentesis).[35]Na K-S. Ultrasound-guided intra-articular injections. Korean J Med. 2015;89(6):654-662.
Knee US Showing needle in suprapatellar recess
Knee ultrasound in short axis above the suprapatellar recess showing needle in plane in the recess. Note there is a slight amount of fluid suggesting active injection.
  • Pre-Procedure
    • The probe is placed above the patella over the suprapatellar recess in short axis
    • Identify the suprapatellar recess. A tissue plane between the prefemoral fat pad and suprapatellar fat pad
    • If effusion present, there will be a hypoechoic black stripe
    • If no effusion, push on the side of the knee to identify the appropriate tissue plane
  • Procedure
    • Identify if your point of injection on the lateral knee
    • Optional: create a wheel of local anesthetic
    • Advance the needle into the suprapatellar recess and hydrodissect with your injectate
    • Optional: if using two syringe technique, switch syringes and inject the corticosteroid into the recess
Video showing needle insertion into the suprapatellar recess from lateral to medial. Note there is a small amount of hypoechoic fluid in the recess, suggesting either a trace effusion or injectate.
Video demonstration of both the needle injection simultaneously with the ultrasound screen showing the needle in plane.
  • Pearls
    • Performed identical to knee arthrocentesis
    • In smaller patients, a shorter needle and linear probe is appropriate
    • In larger patients, a spinal needle and curvilinear probe is often required
    • Note this procedure can be safely and accurately performed without ultrasound guidance, but that technique is not reviewed here.

Ganglion Cyst

  • Potential indications in the ED
    • Painful or symptomatic ganglion cyst
    • Most commonly located on the dorsal wrist (aka bible cyst)
    • Can occur in any joint
  • Equipment
    • Syringe: 1 – 3 mL, 5 – 10 mL
    • Injectate: 1 – 2 mL corticosteroid, 0.5 – 1 mL anesthetic
    • Needle 1: 1 – 1.5 inch, 18 gauge for aspiration
    • Needle 2: If needed, a 1 – 1.5 inch, 25 gauge needle for steroid injection
    • Probe: linear transducer
Clinical example of a large ganglion cyst of the wrist.[36]Sbai MA, Benzarti S, Msek H, Boussen M, Khorbi A. Pseudotumoral form of soft-tissue tuberculosis of the wrist. Int J Mycobacteriol. 2016;5(1):99-101.
  • Positioning
    • Patient is seated, hand on examination table
    • Physician is positioned so they are in a straight line with the patients wrist and ultrasound machine
Wrist US Large dorsal ganglion cyst
Ultrasound of large ganglion cyst of the dorsal wrist.[37]Case courtesy of Dr Martin Perez Romagnoli, Radiopaedia.org, rID: 64953
Wrist US aspiration of ganglion cyst
Demonstration of aspiration of a ganglion cyst with needle in plane.[38]Dilek B, Capkin E, Karkucak M. Contribution of ultrasounography to diagnosis and fast symptomatic recovery: A ganglion cyst causing compression in the neighborhood ulnar nerve. J Neurol Res. … Continue reading
  • Pre-Procedure
    • Identify the cyst with ultrasound, it should appear hypoechoic with fairly clear borders
    • Use doppler to confirm there is flow or vascular component
  • Procedure
    • Identify best point of entry, create wheel of anesthetized skin using a small gauge needle
    • Under ultrasound guidance, insert the 18 gauge needle into the cyst and aspirate as much of the cyst as possible
    • Switch syringes and attach the injectate syringe with a small amount of anesthetic and corticosteroid
Quick scan through a small dorsal ganglion cyst.
Aspiration of cyst seen on the left.
  • Pearls
    • Note that the ganglion cyst fluid is typically very thick and viscous
    • Decompression of the cyst should be the sonographic end point
    • If necessary, remove the large gauge needle and re-insert a smaller needle into the cyst with the corticosteroids

Pearls and Pitfalls

  • Be sure to resource to quickly review dosing of medications, needle sizes and technique prior to starting any procedure
  • Become comfortable with the straightforward injections, e.g. knee and subacromial bursa, before progressing to harder injection locations
  • When in doubt of needle location you can always inject a little lidocaine or gently bounce needle up and down to help determine location
  • Remember that the more parallel your needle is to the transducer the easier it is to see it.
  • Maintain visualization of your needle tip at all times
  • Review your anatomy! This makes interpreting the ultrasound much easier

References

References[+]