Ultrasound (US)-guided Percutaneous Procedures to Treat Inflammatory and Degenerative Diseases of the Upper Limb: How We Do It

Transcription

1 Ultrasound (US)-guided Percutaneous Procedures to Treat Inflammatory and Degenerative Diseases of the Upper Limb: How We Do It Poster No.: C-2252 Congress: ECR 2014 Type: Educational Exhibit Authors: G. Ferrero, E. Fabbro, D. Orlandi, S. Perugin Bernardi, L. M Sconfienza, E. Silvestri, G. Garlaschi, G. Serafini ; Genova/IT, Genoa/IT, San Donato Milanese/IT, Pietra Ligure (SV)/IT Keywords: Inflammation, Puncture, Ultrasound, Musculoskeletal system DOI: /ecr2014/C-2252 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 149

2 Learning objectives The aim of this educational exhibit is to: describe the US-guided percutaneous procedures aimed to the treatment of inflammatory and degenerative diseases of the upper limb; show technical aspects, precautions, and tricks that may help to improve the outcome of such treatments; report anatomical schemes with didactic purpose and show correlations with US imaging. Page 2 of 149

3 Background Thanks to their superficial anatomical location, shoulder, elbow, wrist and hand tendons, joints and bursae represent a good target to perform treatments using ultrasound guidance. However, the knowledge of some technical aspects and tips is essential to act in the most accurate way on target tissues that can be as small as a few millimeters. Diagnostic and subsequent interventional procedures of upper limb are performed using high frequency broadband (7-15MHz) linear transducers, depending on the depth of the target and the local anatomy. Needle selection is based on the clinical question to be answered as well as the kind of drugs to be injected. All devices and drugs (Fig.1) must be prepared in full sterility before the procedure commences and all US-guided interventional procedures must be performed with an aseptic technique in order to avoid any risk of contamination by infectious organisms (bacteria, fungi, viruses). Page 3 of 149

4 Fig. 1: A well-organized tray containing all the required materials is strongly recommended and includes syringes, anesthetic, antiseptic solutions,saline solution,containers,sterile tissues,gloves and drugs. References: Radiology, Università di Genova, Azienda ospedaliera universitaria San Martino - Genova/IT Guidance of the needle under US can be performed with either the lateral or co-axial approach. In the former, the needle is kept perpendicular to the US beam and is inserted on the short side of the probe. In the latter, the needle is inserted on the long side of the probe, parallel to the US beam. The lateral approach has the advantage of excellent visibility of the needle, which, however, crosses a larger amount of tissue before reaching the target than is the case with the co-axial approach. On the other hand, the coaxial approach is burdened by a reduced needle visibility, but it can be used when the space around the target is greatly restricted. Page 4 of 149

5 However, adequate experience is needed to achieve satisfactory results (Fig.1). Fig. 2: a)in US-guided lateral approach the needle is inserted on the short side of the probe allowing for an excellent visibility.b)in US-guided coaxial approach the needle is inserted on the long side of the probe, allowing for a reduced path in soft tissues but a poor visibility. References: Radiology, Università di Genova, Azienda ospedaliera universitaria San Martino - Genova/IT After the interventional procedure the treated skin is covered with a plaster and a compressive dressing and the patient is instructed to apply an instant ice bag over the treated area. Page 5 of 149

6 Patients should be monitored for the after-effects of anesthesia for at least half an hour after the procedure. After they have been instructed regarding the management of possible complications, such as pain and skin reddening, in the following hours/days, they can be discharged from the hospital/clinic. GENERAL WORKFLOW FOR US-GUIDED INTERVENTIONAL PROCEDURES Verbal and written informed consent is obtained after the patient has received a comprehensive explanation of the risks and possible complications associated with the procedure. Local regulations may vary among different countries and hospitals. A representative of the pertinent institution should be involved in formulating an appropriate informed consent form. Pre-interventional planning should include a deep knowledge of the procedure and of the materials, as well as a preliminary US evaluation of the lesion. Patient positioning on the bed or operating table is particularly important, with the comfort of both the patient and the operator confirmed in order to avoid any sudden movements by either one. Operator sterility: accurate and effective hand hygiene is the most important component of good infection prevention and control, given that the hands are a common route of infection transmission; transient bacteria can be removed by effective hand hygiene techniques, by washing the hands with an antimicrobial liquid soap and water, or by using an alcohol-based hand rub. Sterile gloves, coats and hats are mandatory. Both the US equipment and the probe are swiped with dedicated antiseptic tissues and, if required for the procedure, a sterile probe cover is used. All devices and drugs should be prepared in full sterility before the procedure commences. The availability of an organized tray with all materials is recommended. Operating field delimitation with adhesive sterile towels should be performed by the sterile operator. Skin antisepsis should be as accurate as possible, thus we recommend a 2step antisepsis procedure: (1) the area to be treated is wiped with a brown water-based 5% povidone-iodine solution; (2) after 3-5 min (time required to let this antiseptic to act), the same area is wiped with a transparent 2% chlorhexidine-based solution, which denatures the proteins and disrupts the cell walls (this second step improves skin sterility and avoids staining of the US probe). Antiseptic solutions usually create a good coupling between the skin and the US probe. When longer procedures are performed (e.g., the treatment of calcific tendinitis), a small amount of sterile contact gel can be used. Page 6 of 149

7 Images for this section: Fig. 1: A well-organized tray containing all the required materials is strongly recommended and includes syringes, anesthetic, antiseptic solutions,saline solution,containers,sterile tissues,gloves and drugs. Radiology, Università di Genova, Azienda ospedaliera universitaria San Martino Genova/IT Page 7 of 149

8 Fig. 2: a)in US-guided lateral approach the needle is inserted on the short side of the probe allowing for an excellent visibility.b)in US-guided coaxial approach the needle is inserted on the long side of the probe, allowing for a reduced path in soft tissues but a poor visibility. Radiology, Università di Genova, Azienda ospedaliera universitaria San Martino Genova/IT Page 8 of 149

9 Findings and procedure details THE SHOULDER SUBACROMIAL-SUBDELTOID BURSA INJECTION Etiology The general term "bursitis" indicates a nonspecific inflammatory condition of the synovial walls of the bursa, an anatomical entity with the mechanical function of reducing friction between sliding structures (e.g., tendon and cortical bone, tendon and muscle). Primary bursitis commonly originates from rheumatoid arthritis, gout, tuberculosis, polymyalgia rheumatica, and other pathological conditions. The bursa may become secondarily inflamed in rotator cuff tendinopathy/tears, with or without joint effusion. Bursitis also occurs in the setting of anterosuperior impingement due to overhead activities. Isolated septic bursitis is more likely in very young infants or in elderly patients with chronic debilitating disorders, or it may derive from the accidental introduction of bacteria during nonsterile percutaneous procedures. Epidemiology Subacromial-subdeltoid (SASD) bursitis is the most common finding on US evaluation for painfulshoulder. Minor asymptomatic abnormalities of this structure can be observed in up to 78% of patients. Clinical Presentation Patients with acute SASD bursitis usually report a restriction of abduction movements without previous trauma. Pain usually worsens during the night but also when performing overhead activities, and is typically reported on the lateral and anterior aspects of the shoulder. Patients with chronic SASD bursitis often complain of a dull shoulder ache, with tenderness over the greater trochanter and beneath the deltoid muscle. Ultrasound Diagnosis Under normal conditions, the SASD bursa appears as a 2-mm-thick structure made up of an inner layer of hypoechoic fluid between two layers of hyperechoic peribursal fat. The synovial membrane of the bursa is not normally depicted on US. Since intrabursal fluid can migrate depending on gravity and arm positioning, the various portions of the SASD bursa should be systematically assessed. In subacromial impingement, the bursa has thickened walls and may contain fluid as a result of chronic inflammation. Dynamic examination with the use of longitudinal scans during abduction of the arm can underline even small intrabursal effusions, demonstrating the "notch sign" in the upper profile of the bursa at the level where it passes under the coracoacromial ligament. Care should be taken not to apply excessive pressure with the Page 9 of 149

10 probe over the bursa. An effusion in both bursal and joint synovial spaces is considered indicative of a full-thickness tear of the rotator cuff. In the case of acute bursitis, the effusion may be consistent, with findings of a hypervascular flow in the synovial walls and peribursal tissues at Doppler examination. Occasionally (synovial osteochondromatosis, rheumatoid arthritis), round hyperechoic bodies (nodules) are found within the bursal space. Septic bursitis may include a complex effusion containing debris and septations. The bursal walls may be thickened, with peribursal hypoechoic strands reflecting edema in the surrounding soft tissues as associated findings. Treatment Options Oral anti-inflammatory drugs and intrabursal steroids are usually indicated in the acute phase of the pathology. In chronic unresponsive cases, surgical removal is suggested. Interventional Procedure Indications Acute or chronic painful bursitis. Suspected or known septic bursitis can be drained but steroid injection should be avoided. Objective To deliver anti-inflammatory drugs into the bursal space. Equipment - 1 syringe (2 ml) - 20G needle - Lidocaine (2-5 ml) - Long-acting steroid (1 ml, 40 mg/ml) - Plaster - Ice pack Our Procedure Page 10 of 149

11 Fig. 3: Once the most distended bursal recess is visualized, a small amount of local aneshtetic is injected into the bursal space, with an in-plane approach. References: Radiology, Università di Genova, Azienda ospedaliera universitaria San Martino - Genova/IT STEP 1 After an accurate disinfection of both the skin and the probe, a longitudinal US scan is obtained to visualize the bursal effusion (Fig. 3). The most distended bursal recess is selected as the target. Page 11 of 149

12 Fig. 4: Needle (arrowheads) position respect to the humeral head (H) and the supraspinatus tendon (SSP), during the intrabursal local anesthetic injection (asterisks). References: Radiology, Università di Genova, Azienda ospedaliera universitaria San Martino - Genova/IT STEP 2 As shown in Fig.4a,b, the needle (arrowheads) is inserted with a lateral approach to the probe in order to reach the bursal space along a parallel path relative to the probe. A small amount of local anesthetic (asterisks) is injected into the bursal space to confirm correct positioning of the needle tip. Gently advancing the needle into the bursa while injecting can help to debride thickened and collapsed bursal walls. The anatomical scheme and the US image show the position of the needle with respect to the humeral head (H) and the supraspinatus tendon (SSP). Page 12 of 149

13 STEP 3 Once correct positioning of the needle tip has been confirmed, the steroid can be injected into the bursa, leaving the needle in place and replacing the syringe used to administer the anesthetic with one containing steroid. The needle is then removed and a plaster is applied at the puncture site together with an ice pack. POST-PROCEDURAL CARE After treatment, patients should avoid exertion and overhead movements for 5-10 days. Pain may occur after treatment and is managed with oral NSAIDs. TREATMENT OF CALCIFIC TENDINITIS OF THE ROTATOR CUFF Etiology The term "calcific tendinitis" refers to the intratendinous deposition of calcium, predominantly hydroxyapatite, that can affect every tendon in the body and especially the rotator cuff. This pathological condition is a dynamic process that evolves through four stages: pre-calcific, calcific, resorptive, and post-calcific. In the precalcific stage, microtraumatic factors associated with a local decrease in blood supply can lead to intratendinous fibrocartilaginous metaplasia, with resulting calcification. The subsequent calcific phase is considered as a resting period. Eventually, triggered by unknown factors, there is resorption of the deposit, accompanied by vascular invasion, the migration of phagocytic cells with dissolution of the calcific focus (resulting in a "toothpaste" appearance of the calcific deposit), and edema from intratendinous pressure, such that the condition becomes symptomatic. After resorption, in the post-calcific or reparative phase, fibroblasts restore the normal tendinous collagen pattern. Epidemiology Rotator cuff calcific tendinitis is a commonly seen condition, occurring in up to 20% of painful shoulders and up to 7.5% of asymptomatic shoulders. It is more frequent in women in their 40s and 50s and seems not to be related to physical activity. The supraspinatus tendon (80% of cases), followed by the infraspinatus (15% of cases) and subscapularis (5% of cases) tendons, is the most commonly affected cuff tendon. The lower third of the infraspinatus tendon, the critical zone of the supraspinatus tendon, and the preinsertional fibers of the subscapularis tendon are the most frequently affected locations. This condition is typically associated with an intact rotator cuff. Clinical Presentation The pre-calcific phase is usually asymptomatic. The typical clinical manifestation is low-grade subacute pain that usually increases at night and corresponds to the calcific stage, variably associated with mechanical symptoms according to the size of the deposit. In many cases, however, rotator cuff calcific tendinitis can be a highly disabling disorder, with sharp acute pain that limits shoulder movement and is resistant to high doses of oral anti-inflammatory drugs. This clinical presentation usually coincides with the resorptive stage; fever, reflecting rupture Page 13 of 149

14 of the calcification into the adjacent structures, is occasionally reported. However, the acute phase of calcific tendinitis of the rotator cuff is regarded as a selfhealing condition, with spontaneous resolution in 7-10 days. Ultrasound Diagnosis Three types of calcifications have been described: type I consists of a hyper-reflexive lesion with a well-circumscribed dorsal acoustic shadow; type II deposits are wellcircumscribed, homogeneous hyperechoic foci with a faint posterior shadow; type III are amorphous, inhomogeneous hyperechoic foci without posterior acoustic shadow. The consistency is solid for deposits of types I and II and semi-liquid for type III calcifications. Treatment Options Asymptomatic cases usually do not require treatment, as the process is self-healing. In patients with mild symptoms, the disease can be managed conservatively with physical therapy and a short course of oral NSAIDs. Lithotripsy is only partially effective. An alternative therapeutic approach is to extract the calcific material in an arthroscopy or imaging-guided procedure. Interventional Procedure Indications The US-guided percutaneous treatment of calcific tendinitis of the rotator cuff is always and immediately indicated in the acute phase of the pathology, with US findings of type II or III calcifications. In case of mildly symptomatic type I calcifications, elective treatment should be considered. Percutaneous treatment is not indicated if the calcification has migrated into the bursal space or is eroding the humeral cortical bone, or if it is very small (< 5 mm). Objective To dissolve and aspirate the calcific material using an US-guided, double-needle procedure. Equipment - Two 16G needles - One 10-cm 18/20G needle (optional) - Inox bowl (to collect the washing fluid) - Sterile saline solution ( ml) warmed to about C - Two syringes (20 ml and 3 ml) - Lidocaine (10 ml) - Steroid (1 ml, 40 mg/ml) - Plaster - Ice pack Our Procedure Page 14 of 149

15 Fig. 5: A small amount of local aneshtetic is injected into the bursal space, with an inplane approach. References: Radiology, Università di Genova, Azienda ospedaliera universitaria San Martino - Genova/IT Page 15 of 149

16 Fig. 6: Needle position(arrowheads) in the bursal space(asterisks);h humeral head, C calcification. References: Radiology, Università di Genova, Azienda ospedaliera universitaria San Martino - Genova/IT STEP 1 The patient is either placed in the supine position (subscapularis and supraspinatus calcifications) or is prone (infraspinatus or teres minor calcifications), as seen in Fig.5. A correct US scan should demonstrate the target calcification (C) according to its major axis (Fig.6a,b). After sterile preparation of the skin and probe, a small amount of local anesthesia is injected under US guidance and using an in-plane approach along the path of the needle (arrowheads), in the SASD bursa (asterisks), and around the calcification (C) (Figs.5,6). H humeral head. Page 16 of 149

17 Fig. 7: The first needle is inserted into the lowest portion of the calcification with a inplane approach. References: Radiology, Università di Genova, Azienda ospedaliera universitaria San Martino - Genova/IT Page 17 of 149

18 Fig. 8: The insertion of the first needle (arrowheads)into the lowest portion of the calcification (C), maintaining the bevel (arrow) open towards the probe. H, humerus. References: Radiology, Università di Genova, Azienda ospedaliera universitaria San Martino - Genova/IT STEP 2 As shown in Figs.7,8, the first needle (arrowheads) is inserted into the lowest portion of the calcification (C), maintaining the bevel (arrow) open towards the probe. H humerus. Page 18 of 149

19 Fig. 9: A second needle is inserted into the calcification parallel and superficial to the first. References: Radiology, Università di Genova, Azienda ospedaliera universitaria San Martino - Genova/IT Page 19 of 149

20 Fig. 10: A second needle (curved arrows) is inserted into the calcification (C) parallel and superficial to the first(arrowheads), and its tip is rotated 180 in order to create a correct washing circuit. Arrow, needle bevel opened upwards; circles, artifacts. References: Radiology, Università di Genova, Azienda ospedaliera universitaria San Martino - Genova/IT STEP 3 A second needle (curved arrows) is inserted into the calcification (C) parallel and superficial to the first (Figs.9,10, arrowheads), and its tip is rotated 180 in order to create a correct washing circuit. As shown in Fig.10c, the deeper needle needs to be inserted first, to avoid artifacts (circles) caused by the second, more superficial needle. Needle bevel (arrow) is opened upwards. Fig.10d shows both needles (arrowheads and curved arrows) within the calcification. H humerus. Page 20 of 149

21 Fig. 11: A 20-ml syringe filled with warm sterile water is connected to one of the needles and a gentle, intermittent pressure is applied. References: Radiology, Università di Genova, Azienda ospedaliera universitaria San Martino - Genova/IT Page 21 of 149

22 Fig. 12: A slight expansion of the calcification can be visualized during washing. Washing of the target continues until complete emptying of the calcification (C) is demonstrated. Arrowheads, first needle; curved arrow, second needle; H humerus. References: Radiology, Università di Genova, Azienda ospedaliera universitaria San Martino - Genova/IT STEP 4 A 20-ml syringe filled with warm sterile water is connected to one of the needles (arrowheads and curved arrows) and a gentle, intermittent pressure is applied. If the positioning is correct, a slight expansion of the calcification can be visualized. If no washing fluid exits and the needles are correctly positioned, an 18G spinal needle could be inserted into one or both 16G needles to slightly penetrate the target calcification, creating enough space for circulation of the fluid. The washing fluid exiting from the Page 22 of 149

23 second needle is collected in the inox bowl, positioned as shown in Fig.11. Washing of the target continues until complete emptying of the calcification (C) is demonstrated, as shown in Fig.12a,b. Arrowheads first needle, curved arrow second needle, H humerus. Fig. 13: At the end of the procedure, one needle is removed and the 1-ml syringe is connected to the remaining needle. References: Radiology, Università di Genova, Azienda ospedaliera universitaria San Martino - Genova/IT Page 23 of 149

24 Fig. 14: The needle (arrowheads) is then displaced into the SASD bursa and 1 ml of steroid is injected (asterisks). H, humerus; C, treated calcification. References: Radiology, Università di Genova, Azienda ospedaliera universitaria San Martino - Genova/IT STEP 5 At the end of the procedure, one needle is removed and the 1-ml syringe is connected to the remaining needle (Fig.13). This needle (arrowheads) is then displaced into the SASD bursa (Fig.14a,b) and 1 ml of steroid is injected (asterisks). A plaster is then applied to the skin at the puncture site and an ice pack is placed over the shoulder. H humerus, C treated calcification. POST-PROCEDURAL CARE Page 24 of 149

25 The patient is kept under observation for at least 30 min. The ice pack over the treated shoulder should be maintained for at least 2 h. Patients should avoid overhead movements and the carrying of heavy weights for up to 15 days. Pain may occur after treatment and is managed with oral NSAIDs. Post-procedural bursitis is seen in about 15% of patients within approximately 2 months after treatment. In these cases, an intrabursal steroid injection may be useful. CALCIFIC ENTHESOPATHY DRY-NEEDLING Etiology Calcific enthesopathy of the rotator cuff represents a common and mostly asymptomatic US finding. Unlike calcific tendinopathy, in which a calcification develops from fibrocartilaginous metaplasia 1-2 cm away from the insertional tendinous area, in this condition tiny calcifications are found in the insertional area of the rotator cuff tendons and are usually coupled to degenerative alterations of the pre-insertional tendinous portion. Epidemiology The exact incidence of this condition cannot be estimated because of the broad range of degenerative or inflammatory conditions that may result in calcific enthesopathy. Males and females are equally affected. Clinical Presentation Patients with symptomatic calcific enthesopathy report well-circumscribed pain at the level of the greater trochanter (supraspinatus, infraspinatus, or teres minor insertional areas) or of the lesser trochanter (subscapularis insertion). The pain is worsened by applied pressure, either by the examiner's finger or by the probe during the examination. Ultrasound Diagnosis Tiny, irregular hyperechoic insertional calcifications in a setting of degenerative tendinopathy. The calcifications are close to the humeral cortical bone and may present as an irregularity in the hyperechoic profile of the latter. Treatment Options Physiotherapy should always be considered. In symptomatic cases, a percutaneous procedure or surgical tendinous debridement is needed. Interventional Procedure Indications Symptomatic insertional calcific enthesopathy in one or more tendons of the rotator cuff. Objective Page 25 of 149

26 To fragment the tiny insertional calcifications in order to accelerate the resorption of calcific material; to produce slight intratendinous bleeding that will in turn promote healing of the tendon. Equipment - 1 syringe (5-10 ml) - 18G needle - Lidocaine (5-10 ml) - Long-acting steroid (1 ml, 40 mg/ml) - Plaster - Ice pack Our procedure Fig. 15: After sterile preparation of both the skin and the US probe, the affected area is visualized with a longitudinal scan according to the respective tendon, and the needle is inserted with a in-plane approach to reach the calcifics fragments. References: Radiology, Università di Genova, Azienda ospedaliera universitaria San Martino - Genova/IT Page 26 of 149

27 Fig. 16: Consecutive dry-needling punctures (arrowheads) are performed on the calcifications (arrows) to fragment the small calcific deposits and to produce slight bleeding into the insertional tendinous portion.h, humerus. References: Radiology, Università di Genova, Azienda ospedaliera universitaria San Martino - Genova/IT STEP 1 After sterile preparation of both the skin and the US probe, the affected area is visualized with a longitudinal scan according to the respective tendon. A small amount of local anesthetic is injected under US guidance and with an in-plane approach along the path of the needle, into the SASD bursa, and around the insertional calcifications (Figs.15,16). STEP 2 Page 27 of 149

28 As shown in Fig.16, consecutive dry-needling punctures (arrowheads) are performed on the calcifications (arrow) to fragment the small calcific deposits and to produce slight bleeding into the insertional tendinous portion. The probe should also be shifted anteriorly and posteriorly to target the treatment towards all the calcifications. H humerus. Fig. 17: At the end of the procedure, 1 ml of steroid (asterisks) is injected (arrowheads) into the SASD bursa. Arrowheads, needle; SSP, supraspinatus tendon; H, humeral head. References: Radiology, Università di Genova, Azienda ospedaliera universitaria San Martino - Genova/IT STEP 3 At the end of the procedure, 1 ml of steroid (asterisks) is injected (arrowheads) into the SASD bursa (Fig.17) and the cutaneous point of insertion is covered with a plaster. An ice pack is applied over the shoulder. Page 28 of 149

29 POST-PROCEDURAL CARE The patient is kept under observation for at least 30 min. The ice pack over the treated shouldershould be maintained for at least 2 h. Patients should avoid overhead movements and the carrying of heavy weights for up to 15 days. Pain may occur after treatment and is managed using oral NSAIDs. Post-procedural bursitis is seen in about 15% of patients within approximately 2 months after treatment. In these cases, an intrabursal steroid injection may be useful. HYALURONIC SUPPLEMENTATION OF THE SUBACROMIAL SPACE Etiology Cuff tear arthropathy is the association of a massive rotator cuff tear and shoulder osteoarthritis, with progressive superior migration of the humeral head, acetabulization of the shoulder, and collapse of the humeral head. Poor vascularity, the inferior mechanical properties of an aging rotator cuff, type III acromions, and subacromial impingement are the most outstanding factors leading to this condition. Epidemiology Most commonly, an elderly patient will present with massive rotator cuff tears altering the biomechanics of the shoulder and leading to progressive superior migration of the humeral head. The end-stage of cuff tear arthropathy is the acetabulization of the shoulder, with collapse of the humeral head. Clinical Presentation The main symptoms of cuff tear athropathy are functional limitation, weakness, and pain in the shoulder. There is an inability to perform either abduction or extra-rotation movements. Patients often complain of difficulty carrying out daily activities, such as combing their hair, clasping a bra behind their back, reaching behind their back, or sleeping on the affected shoulder. Weakness can appear during lifting or in rotating the arm. Pain while performing overhead activities and at night is common; it is usually located over the outside of the shoulder and upper arm. Crepitus or a crackling sensation may also be noted when the shoulder is moved in certain positions. Ultrasound Diagnosis A massive rotator cuff tear is diagnosed when a complete rupture of at least two tendons of the rotator cuff is identified. Treatment Options Page 29 of 149

30 Several different surgical treatment options for cuff tear arthropathy have been proposed. However, in elderly patients, surgery may be more frequently associated with complications or may be precluded due to concurrent medical conditions. Viscosupplementation can help in the conservative management of this condition. Interventional Procedure Indications Cuff tear arthropathy. Percutaneous treatment is not indicated in case of a recent history of shoulder trauma. Objective To inject a viscosupplement into the subacromialspace so as to facilitate gliding of the acromial and humeral cortical bones in the acromial-humeral articulation. Equipment - Two syringes (5 ml and 10 ml) - Lidocaine (2-5 ml) - High-molecular-weight hyaluronic acid (6 ml) - 18G needle - Plaster Our procedure Page 30 of 149

31 Fig. 18: The subacromial space is visualized on a coronal US scan and local anesthetic is injected along the path of the needle (arrowhead) with an in-plane approach and an oblique direction (lateral to medial and superior to inferior) to reach the subacromial space (asterisks), where the operator injects the drug. A acromion; H humeral head. References: Radiology, Università di Genova, Azienda ospedaliera universitaria San Martino - Genova/IT STEP 1 The subacromial space is visualized on a coronal US scan that includes the acromial superolateral cortical bone and the superior aspect of the humeral head (Fig.18a,b); A acromion, H humeral head. Local anesthetic is injected along the path of the 18G needle under US guidance with an in-plane approach and an oblique direction (lateral to medial and superior to inferior) to reach the subacromial space. STEP 2 Page 31 of 149

32 As shown in Fig.18c, once the subacromial space is reached by the needle (arrowheads), a syringe pre-filled with 6 ml of high-molecular-weight hyaluronic acid is attached to the needle, and the operator slowly and gently injects the drug into the subacromial space (asterisk). There should be no resistance against the injection; if this is not the case, a slight retraction of the needle may be necessary. A plaster is then applied to the skin at the puncture site. POST-PROCEDURAL CARE The injection should be repeated after one week. Treatment can be repeated in case of pain recurrence. INTRA-ARTICULAR INJECTIONS Intra-articular injections of the shoulder can be performed in the treatment of a variety of pathological conditions. The drugs administered in these cases may be anti-inflammatory agents, such as the use of steroids for the various forms of capsulitis, or viscosupplements such as hyaluronic acid, which are injected to decelerate the physiological process of osteoarthritis. ADHESIVE CAPSULITIS Etiology Adhesive capsulitis of the shoulder (frozen shoulder) is a common disease with unclear pathogenesis, resulting in chronic inflammation of the capsular tissues and abnormal tissue repair with fibrosis. Epidemiology Approximately 2% of the general population is affected, with a peak incidence between 40 and 60 years and a slight female predominance. Clinical Presentation This condition is classified as primary idiopathic when there is no detectable underlying causes for the symptoms, or as secondary to shoulder affections, either traumatic or non-traumatic, that determine secondary pain and stiffness. A recognized different form of secondary frozen shoulder is seen in diabetic patients and tends to be more severe and protracted. The diagnosis is essentially clinical. Patients report increasing pain, especially at night, and a progressively reduced range of motion. In most cases, adhesive capsulitis is considered as a self-limiting disorder but it lasts for years in up to 40% of patients. Treatment Options Page 32 of 149

33 Conservative treatment includes physical therapy, anti-inflammatory and analgesic medications, and oral administration or intra-articular injections of steroids. Interventional Procedure Indications Intra-articular injection of steroids: primary idiopathic or secondary adhesive capsulitis, degenerative osteoarthritis associated with articular effusion; contraindicated in diabetes-related secondary adhesive capsulitis. Intra-articular injection of hyaluronic acid: degenerative osteoarthritis without articular effusion. Objective To deliver anti-inflammatory or viscosupplement drugs within the joint space. Equipment - 1 syringe (2-5 ml) - 20G spinal needle - Long-acting steroid (1 ml, 40 mg/ml) or low molecular-weight hyaluronic acid (2 ml) - Plaster. Our Procedure Intra-articular joint injections of the shoulder can be performed with either an anterior or a posterior approach. The anterior approach suffers from the deep location of the joint with respect to the skin surface, as well as the presence of the coracoid process, which makes it extremely difficult to accurately visualize the needle tip. Thus, the posterior approach is generally more convenient. This procedure can also be used for the injection of contrast agents within the joint for purposes of arthrography. Anterior Approach Page 33 of 149

34 Fig. 19: An anterior axial US scan is performed at the level of the coracoid process and the needle is inserted with a coaxial approach. References: Radiology, Università di Genova, Azienda ospedaliera universitaria San Martino - Genova/IT STEP 1 The patient is placed in the supine position, with the forearm flexed 90 and the hand lying on the abdomen. An anterior axial US scan is performed at the level of the coracoid process. The correct scanning plane should reveal the coracoid at the middle third of its height, the subscapularis tendon on its long axis, and the humeral lesser tuberosity (Fig.19). Page 34 of 149

35 Fig. 20: The correct scanning plane should reveal the coracoid (C) at the middle third of its height, the subscapularis tendon on its long axis, and the humeral lesser tuberosity (H). G, glena; asterisk, needle tip. References: Radiology, Università di Genova, Azienda ospedaliera universitaria San Martino - Genova/IT STEP 2 The space between the coracoid and the humeral head is centered at the middle of the scanning plane and a 20G needle (arrow) is inserted perpendicular to the skin, at the middle of the probe (Fig.20a) between the humeral head (H) and the glenoid (G) and the coracoid (C). Passage of the needle tip into the glenohumeral joint is generally associated with a distinct feeling of capsular resistance followed by the sensation of a resistancefree space. STEP 3 Once correct intra-articular positioning of the needle tip has been confirmed (asterisk), the drug can be injected (Fig.20b). There should be no resistance to the injection; if this is not the case, a short retraction (1-2 mm) of the needle should be considered because the needle tip could be pointed against the humeral cartilage or into the anterior glenoid labrum. At the end of the injection, the needle can be removed and a plaster applied at the cutaneous site of approach. C coracoid, SSC subscapularis tendon, G glenoid. Posterior Approach Page 35 of 149

36 Fig. 21: A longitudinal US scan of the posterior articular recess is performed and the needle is inserted with an in-plane approach. References: Radiology, Università di Genova, Azienda ospedaliera universitaria San Martino - Genova/IT Page 36 of 149

37 Fig. 22: The posterior glenoid rim and posterior glenohumeral joint line are centered in the field of view and the needle (arrowheads) is inserted in the joint space with an inplane approach.h, humeral head; G, posterior glenoid rim. References: Radiology, Università di Genova, Azienda ospedaliera universitaria San Martino - Genova/IT Lateral Approach STEP 1 The patient is in a prone position with the upper arm not completely abducted and the forearm flexed, in order to avoid tension on the posterior joint capsule (Fig.21). A longitudinal US scan of the posterior articular recess is performed. The transducer is aligned with the long axis of the musculotendinous junction of the infraspinatus muscle, just inferior to the scapular spine, with the posterior glenoid rim and posterior glenohumeral joint line centered in the field of view (Fig.22a,b). Transducer angulation is adjusted to clearly show the contours of the posterior glenoid rim, the posterior glenoid labrum, and the humeral head. The articular cortex of the humeral head (H) appears as a spherically curved echogenic line, and the cortical surface of the posterior glenoid rim (G) as a triangular echogenic structure just medial to this line. The fibrocartilaginous posterior glenoid labrum is seen as a well-defined, triangular, and uniformly echogenic structure. Asterisks indicate the humeral cartilage. Page 37 of 149

38 Fig. 23: A longitudinal US scan of the posterior articular recess is performed and the needle is inserted with a coaxial approach. References: Radiology, Università di Genova, Azienda ospedaliera universitaria San Martino - Genova/IT Fig. 24: The posterior glenoid rim and posterior glenohumeral joint line are centered in the field of view and the needle (arrow) is inserted in the joint space (asterisk) with a coaxial approach. H, humeral head; G, posterior glenoid rim, D, deltoid muscle. References: Radiology, Università di Genova, Azienda ospedaliera universitaria San Martino - Genova/IT Co-axial Approach STEP 1 A co-axial out-of-plane approach is also possible (Figs.23,24), although the needle will be less visible. The passage of the needle tip (arrow) into the glenohumeral joint is generally associated with a distinct feeling of capsular resistance followed by the sensation of a resistance-free space. The asterisk indicates the distended posterior glenohumeral joint recess. G glenoid, H humerus, D deltoid, circles, humeral cartilage. STEP 2 Once correct intra-articular positioning of the needle tip has been confirmed, the drug can be injected. There should be no resistance to injection; if this is not the case, a short retraction (1-2 mm) of the needle should be considered because the needle tip could be pointed against the humeral cartilage or into the posterior glenoid labrum. Distension of the articular capsule is usually not visible because of the small amount of fluid injected. At the end of the injection, the needle can be removed and a plaster applied at the cutaneous site of the approach. POST-PROCEDURE CARE The patient should be kept under observation for at least 30 min after the procedure. Pain may occur after treatment and is managed with oral NSAIDs. LONG HEAD OF THE BICEPS BRACHII TENDON INJECTION Page 38 of 149

39 Etiology Pathologies of the LHBB include synovial effusion, synovial hypertrophy and, rarely, calcifications. Tenosynovitis can be found alone or, more often, associated with glenohumeral effusion since the joint space is usually in communication with the sheath of this tendon. Epidemiology A small amount of fluid within the sheath of the LHBB is a common and asymptomatic finding and is typically associated with glenohumeral joint effusion. Conspicuous effusions are usually symptomatic. Clinical Presentation Pain is usually described as originating from the anterior aspect of the shoulder and irradiating anteriorly down the humerus. The onset is typically subacute or chronic. Ultrasound Diagnosis An anechoic fluid collection around the fibrillar tendinous structure of the LHBB can be demonstrated on axial and longitudinal scans. If thickening of the synovial component of the sheath and power-doppler signs of hypervascularity are present, a rheumatic condition should be suspected. Treatment Options Physiotherapy is the treatment of choice. In the acute phase, the percutaneous injection of steroids can have a prompt effect on pain, while aspiration is usually required when a large amount of fluid is present. Interventional Procedure Indications Symptomatic effusion in the sheath of the LHBB tendon. Objective To inject a small amount of steroid in the distended sheath of the LHBB. Equipment - 1 syringe (2 ml) - 22G needle - Lidocaine (2 ml) - Long-acting steroid (1 ml, 40 mg/ml) - Plaster Our Procedure Page 39 of 149

40 Fig. 25: The LHBB tendon is seen on an axial scan and the needle is inserted with an in-plane approach lateral to the probe. References: Radiology, Università di Genova, Azienda ospedaliera universitaria San Martino - Genova/IT Page 40 of 149

41 Fig. 26: Once the needle (arrowheads) has reached the distended synovial sheath of the LHBBT (arrows), the fluid content is drained and the drug is injected (asterisks). H humerus. References: Radiology, Università di Genova, Azienda ospedaliera universitaria San Martino - Genova/IT STEP 1 The patient is placed in the supine position with his or her hand in a neutral position (Fig.25). The LHBB tendon is seen on an axial scan, starting from the bicipital groove and moving the probe caudally to identify the level of larger effusion. STEP 2 The needle is inserted with an in-plane approach lateral to the probe (Fig.26a,b) and advanced towards the tendon (arrows) while a small amount of local anesthetic is injected along the path. Once the needle (arrowheads) has reached the distended synovial sheath (Fig.26b, asterisk), the fluid content is drained (Fig.26c, asterisk). H humerus. STEP 3 The syringe with the steroid is then connected to the needle and the drug is injected (Fig.26d, asterisks), avoiding penetration of the tendon (arrows) by the needle tip (arrowheads). The needle is removed and a plaster applied on the skin. POST-PROCEDURAL CARE The patient is kept under observation for at least 10 min. Pain may occur after treatment and is managed with oral NSAIDs. After treatment, patients should avoid heavy activities and refrain from overhead movements for 5-10 days. ACROMIOCLAVICULAR JOINT INJECTION Etiology The most common AC joint pathologies that can be treated using a percutaneous approach include osteoarthritis and osteolysis of the distal clavicle. Osteoarthritis usually develops secondary to previous trauma, while osteolysis of the distal clavicle may be associated with repetitive weight training involving the shoulder. The history and physical examination are extremely important in diagnosing these conditions. Epidemiology Degeneration of the AC joint typically affects middle-aged patients and is often associated with rotator cuff disorders. However, it is also found in young athletes (20s to 30s) with repetitive falls on the shoulder. Page 41 of 149

42 Clinical Presentation Patients usually have insidious onset of pain. On physical examination, there is tenderness to palpation of the AC joint. A lump over the joint space indicates the presence of a cyst arising from the articular capsule and is usually associated with a degenerative shoulder arthropathy. Pain occurs with active or passive adduction of the shoulder and may be exacerbated by asking the patient to hold the opposite shoulder while pushing the elbow cranially against resistance. Ultrasound Diagnosis Degenerative changes of the AC joint include an irregular profile of the cortical bone surfaces of the distal clavicle and acromion, associated with an articular joint effusion and a thickened capsule. Treatment Options Physiotherapy is the preferred treatment. Steroids or hyaluronic acid can help in reducing pain and thus in facilitating rehabilitation. Interventional Procedure Indications Osteoarthritis and osteolysis of the distal clavicle. Contraindicated in the acute or subacute phase of traumatic injury. Objective To deliver steroid or hyaluronic acid in the AC joint space. Local anesthetic can be used as a diagnostic tool to assess the origin of shoulder pain. Equipment - 1 syringe (2 ml) - 23G needle - Long-acting steroid (1 ml, 40 mg/ml) and/or low-molecular-weight hyaluronic acid (1 ml) - Plaster Page 42 of 149

43 Fig. 27: A-C joint injection with a coaxial approach. References: Radiology, Università di Genova, Azienda ospedaliera universitaria San Martino - Genova/IT Page 43 of 149

44 Fig. 28: The AC joint is visualized at the middle of a coronal scan (A and C) and the needle is inserted perpendicularly to the skin at the exact half of the probe.arrow, needle tip; asterisk, distended articular space; arrowheads, joint capsule. References: Radiology, Università di Genova, Azienda ospedaliera universitaria San Martino - Genova/IT STEP 1 The patient is seated opposite the examiner in a neutral position, with the hand lying on the thigh; an out-of-plane co-axial approach is suggested (Fig.27), but an in-plane lateral approach is also possible. STEP 2 Page 44 of 149

45 With an out-of-plane co-axial approach (Fig.28a,b), the AC joint is visualized at the middle of a coronal scan (A and C) and the needle is inserted perpendicularly to the skin at the exact half of the probe. A clear sensation of resistance should be appreciated as the joint capsule is passed (arrowheads). The probe is gradually tilted towards the needle such that the needle tip (arrow) can be seen as a hyperechoic dot in the distended articular space (asterisk). There should be no resistance during the injection. With an in-plane approach, the AC joint space is visualized on a sagittal US scan. The needle is inserted lateral to the probe and advanced with a inclination. POST-PROCEDURAL CARE The patient is kept under observation for at least 10 min. An ice pack over the treated shoulder should be maintained for at least 1 h. Pain may occur after treatment and is managed using oral NSAIDs. Patients should avoid overhead movements and carrying heavy weights for up to 3 days. THE ELBOW TREATMENT OF LATERAL EPICONDYLITIS Etiology Epicondylitis is one of the most commonly diagnosed musculoskeletal disorders of the upperextremity. Lateral epicondylitis, also known as "tennis elbow," is a painful condition of the tendinous origin of the wrist extensor muscles. Anatomically, the three major components of the common extensor tendon are the extensor carpi radialis brevis, the extensor digitorum, and the extensor carpi ulnaris tendon. Injury is due to repetitive stress on the common extensor tendon around its attachment to the lateral humeral epicondyle in response to manual tasks, forceful activities, or sports that require high force combined with high repetition or awkward posture (tennis, water polo, baseball, fencing). Epidemiology Lateral epicondylitis is more common than medial epicondylitis and generally affects individuals years old, with equal prevalence among males and females. Clinical Presentation The main symptom is pain, which is localized in the lateral elbow region, corresponding to the lateral epicondyle of the humerus. It is typically related to activity and exacerbated by wrist and hand movements. Pain may radiate into the forearm and impair handgrip. Clinical tests, consisting of active and resisted movements of the extensor muscles of the forearm, provoke epicondylar pain (Cozen's sign: pain with resisted wrist extension). During clinical examination, a typical tenderness at the lateral side of the elbow will often become apparent. Symptom duration usually ranges from a few weeks to a few months. Diagnosis Page 45 of 149

46 In most cases, imaging is not necessary since the diagnosis of lateral epicondylitis is usually clinical, based on symptoms and findings during the physical examination. Imaging can be used to evaluate the extent of tissue damage, to exclude other causes of elbow pain, when the clinical presentation is atypical, or to confirm the diagnosis in patients not responding to treatment. In epicondylitis, the tendon can be thicker or thinner than normal, of poor definition, of decreased echogenicity, and accompanied by peritendinous effusion. In addition, the extensor tendon complex may show alterations in intratendinous vascularity. In severe cases, partial- or full-thickness tendon tears are seen as focal anechogenic areas with loss of the normal fibrillar pattern. Treatment Options First-line therapy usually consists of ice application, immobility of the upper limb, and NSAIDs. Shockwave therapy can reduce symptoms in the middle term. Surgical debridement is reserved for refractory cases. US-guided scarification (dry needling) can be considered as a minimally invasive option. Interventional Procedure Indications Insertional overload tendinopathy of the common extensor tendon. Contraindicated in case of traumatic lesions of the common extensor tendon. Objective To cause local hyperemia and bleeding into the tendon, thus promoting post-procedural plateletsinduced recovery phenomena. Equipment - 1 syringe (5-10 ml) - 1 syringe (1-2 ml) - 20G needle - Lidocaine (5-10 ml) - Long-acting steroid (1 ml, 40 mg/ml) - Plaster Our Procedure Page 46 of 149