Ultrasound-Guided Shoulder Injections 인제대학교일산백병원 재활의학과 임길병

Ultrasound-Guided Shoulder Injections 인제대학교일산백병원 재활의학과 임길병

How to improve needle visibility

Advantages of Ultrasound in Procedures Real-time imaging Avoids radiation exposure But, interventions without adequate needle tip visualization unintentional vascular, neural, vi sceral injury

Procedural Needle-Related Visibility Factors 1. Basic Sonography & Needle Image Interpretati on ultrasound beam : penetrate through tissue to varying degrees depending upon tissue composition(muscle, t endon, other tissue) cannot pass dense tissue such as bone

Procedural Needle-Related Visibility Factors 2. Acoustic Impedance as the Basis for Procedure Needle Visualization another essential aspect of needle visualization : acous tic impedance=> dependent on density of tissue and s peed which ultrasound beam travel marked differences in acoustic impedance between tw o tissues=> the brighter or more hyperechoic the son ographic signal of the needle

Procedural Needle-Related Visibility Factors 3. Size of the needle and echogenicity larger caliber needle : more easily visualized than a small er size diameter needle greater surface area: more si gnificant change in acoustic impedance, intercept the ultr asound beam, reflected back to the transducer

Procedural Needle-Related Visibility Factors The Skin Insertion Site Selected and Angle of Procedure Needle Passage : critical role in optimizing needle visualiza tion the angle is too steep=> shorter portion of the us beam will be reflected back perpendicular angle(90 ) of insertion us beam direction =>the transducer maximizes reception of reflected beam heel in maneuver : to press or tilt the opposite end of the ultrasound transducer-> close to 90 most optimal angle for a procedure needle to the skin s urface interface: 30 and 45

The Skin Insertion Site Selected & Angle of Procedure Needle Passage

Procedural Needle-Related Visibility Factors Echogenic Procedure Needles Small angled indentations or notches : needle shaft res ulting in an irregular surface -> increase scatter of ultr asound polymer encased procedure needle is another technol ogical advancement-> improve needle echogenicity an d ultrasound image quality

Procedural Needle-Related Visibility Factors Procedure Needle Tip procedure needle tip bevel : usually scatter the ultraso und beam d/t irregularity of the needle tip surface, less steep ang le of the needle tip procedure needle bevel up position : improved needle tip visualization

Procedure Needle Tip

Mechanical and Optical Procedure Needle Guides

Enhancement and Techniques to Improve Procedure Needle Localization Basic Sonographic Effect of Enhancement enhancement : improve the visualization of needle within a vascular structure or certain tissues(e.g., fat) that have lower acoustic impedance compared to needle

Enhancement and Techniques to Improve Procedure Needle Localization Enhancement with Priming, Insertion of Stylet or Guide Wire, & Vibration

Enhancement & Techniques to Improve Procedure Needle Localization Hydrolocalization of the Procedure Needle

Enhancement and Techniques to Improve Procedure Needle Localization Needle Visibility by Agitated Solutions or with US Contrast Agents

Ultrasound-Guided Shoulder Injection

Ultrasound (US) superficial tendons : long-head biceps, SSP, ISP-> excellent echogenicity and structural resolution visualization of soft tissue adjacent to orthopedic hardware dynamic assessment of the joint little information: interosseous structures & those shielded by bone suspicion of intra-articular pathology or osseous pathology -> plain film imaging is essential

Subacromial/Subdeltoid Bursa subacromial bursa : m/c injected structure Ix: rotator cuff pathology, impingement syndrome, & subacromial bursitis.

Subacromial/Subdeltoid Bursa Anatomy subacromial & subdeltoid bursa typically communicate location: on upper surface of supraspinatus muscle, under deep surface of deltoid functions : protect the supraspinatus

Subacromial/Subdeltoid Bursa Clinical Presentation Shoulder abduction, IR can potentially impinge : humeral head (greater tubercle) & arch of the acromio n & coracoacromial ligament Limitations of the Blind Approach : accuracy of blind injections : as low as 29%

Subacromial/Subdeltoid Bursa US-Guided Technique Transducer oriented in scapular plane, positioned just over tip of acromion SSP tendon should be visualized Bursa is seen as a thin anechoic fluid layer above the tendon Seated position with the arm hanging at their sid e Elbow flexed 90, arm supinated & palm over the ipsilateral hip Triamcinolone and local anesthetics

Biceps Tendon Sheath Anatomy long head : originates at the supraglenoid tubercle of the glenoid labrum intertubercular groove houses the bicipital tendon tendon sheath communicates proximally with the glenohumeral joint short head : originates on the coracoid process

Biceps Tendon Sheath Clinical Presentation long head : m/c injured portion of the muscle usually occur at the proximal end Bicipital tendinopathy: Speed test

Biceps Tendon Sheath US-Guided Technique short-axis approach is more common, technically easier not allow for visualization of the entire length of needle target is the small space btn the tendon & the lesser tuberosity of the humerus, just medial to the tendon inj of steroid directly into the tendon may lead to rupture longitudinal approach :more appropriate for aspiration of the fluid in the sheath triamcinolone & local anesthetic

Acromioclavicular Joint Anatomy AC joint : formed by articulation of distal end of clavicle & acromion process easy to localize because of its superficial position, often narrowed by osteophytes => US guidance is very helpful subacromial bursa & supraspinatus tendon lie directly beneath the joint

Clinical Presentation Acromioclavicular Joint Pain is reproduced with active elevation of the arm or scarf test(positioned in crossed-arm adduction) AC joint : appearance is typically a V shape covered by a thin capsule (acromioclavicular ligament) distended if effusion is present, no significant vascular or neural structures

Acromioclavicular Joint US-Guided Technique Technique : in the seated position with the arm hanging at their side V of the joint should be positioned precisely in the middle of the image needle is inserted in short-axis orientation tip of the needle is visualized as a bright dot 0.25 ml triamcinolone (40 mg/ml) & 0.75 ml of l ocal anesthetic

Anatomy Glenohumeral Joint Glenohumeral joint true articulation surface : small and shallow joi nt surface area is greatly increased by cartilaginous glenoid labrum surrounded by a thin fibrous articular capsule strengthened by three glenohumeral ligaments joint synovium extends down bicipital sheath into intertubercular groove

Glenohumeral Joint Clinical Presentation Glenohumeral pathology : painful and restricted range of motion of joint (reduced external rotation) mimic cervical radiculopathy(referred pain, paresthesias down entire upper limb)

Glenohumeral Joint Limitations of the Blind Approach 26.8% accuracy using an anterior approach 94% using us to guide glenohumeral joint injections

US-Guided Technique Glenohumeral Joint glenohumeral joint is visualized by posterior view with transducer just caudal & parallel to the spine of the scapula circular humeral head, abutting glenoid fossa with less-echogenic triangular-shaped labrum between them Inj: posterior approach with the humerus adducted across the thorax. long-axis approach, 2 cm lateral to the lateral heel of the transducer depending upon shoulder size, a 3 or 4 inch needle 1 ml of triamcinolone(40 mg/ml) & 2 ml of local anesthetic

Glenohumeral Joint The Rotator Interval Approach Anterior visualization : difficult d/t depth & overlying dense structures rotator interval : a triangular space(corocoid process, the anterior-most portion of the ssp & the superior border of the subscapularis tendon) contain : biceps tendon, glenohumeral capsule, coracohumeral ligame nt, & glenohumeral ligament Inj : arm resting at patient's side, shoulder placed in slight external rotation transducer is positioned in the transverse plane on the sup/ant shoulder Resistance to inj-> needle tip has entered tendon or ligament

Subscapularis Tendon/Subscapularis Bursa Anatomy subscapularis m : originates from subscapular fossa of the scapula inserts on the lesser tuberosity of humerus only rotator cuff muscle that acts to internally rotate subscapularis bursa lies deep to the tendon against th e neck of the scapula communicates with the shoulder joint

Subscapularis Tendon/Subscapularis Bursa Clinical Presentation Subscapularis tendinopathy : pain in the anterior shoulder provoked with active internal rotation or passive ER diffuse shoulder pain & impingement signs Strength of the subscapularis is assessed with th e Lift off test. -> subscapularis weakness, tendo n rupture, or inadequate ROM

Subscapularis Tendon/Subscapularis Bursa linear transducer is held in transverse position relative to humerus & bicipital groove subscapularis : its deep, medially located muscle belly to attach to the lesser tuberosity bursa is reached by advancing the needle through the tendon, at which time a subtle pop or give-way is detected

Sternoclavicular Joint Anatomy SC joint : formed by articulation of prox. end of clavicle with clavicular fossa in superior lateral aspect of the ster num scapular retraction -> end of the clavicle becomes more prominent great vessels of the chest & the pleura lie deep to the jo int, so care is needed

Sternoclavicular Joint Clinical Presentation SC joint pain, chest wall pain, swelling, tenderness dire ctly over the joint

Sternoclavicular Joint Tech. : placing a linear transducer in line with the clavicle small notch with clavicle projecting superficially compared to sternum covered by very thin capsule & may be distended if effusion is present needle tip is visualized as a bright dot as it enters the field of view 0.25 ml triamcinolone (40 mg/ml) & 0.75 ml of local anesthetic.

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