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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5828_Библиотеки_им_академика_М_И_Перельмана.pdf
144 CHAPTER 10 Lower limb
10.1.8 Lateral femoral cutaneous nerve
Patient position: For the lateral femoral cutaneous nerve (LFCN), the patient should
Identifying the
anatomy:
Injections
performed:
Recommended
transducer:
Equipment
suggested:
Injection
technique:
be placed in a supine position with the hip slightly extended by
moving the end of the treatment couch downwards (Fig. 10.1.8A).
In this position, the patient can be asked to perform a straight leg
raise and a hollow between the rectus femoris (RF) and sartorius
(SRT) can be seen. This is where the LCFN is located.
The transducer can be placed in a SAX oreintation over the
anatomical position for the LFCN and it can be seen running in this
channel (Fig. 10.1.8B and C). The nerve can be followed
proximally to the inguinal ligament where compression normally
occurs.
CSI for meralgia paraesthetica.
Linear 6e15 mHz.
Hockey stick 8e18 mHz.
Equipment preparation: Set 1 for CSI.
Needle: 1- to 1.5-inch 25- or 27-gauge needle.
Syringes: 3 mL for CSI.
Medication: 20 mg triamcinolone (0.5 mL) and 1% lidocaine
(1 mL).
Viewing the LFCN in the SAX oreintation, the needle can be
introduced with the bevel facing down using an IP technique at
10e15 degrees from the lateral aspect so that it rests above the
nerve (Fig. 10.1.8D and E). A small amount of solution can be
injected to separate the layers and open the space and once the
anatomy is more clearly defined, the remainder can be injected
around the nerve. Care must be taken not to inject into the nerve
directly.
10.1.8.A
10.1 Hip 145
10.1.8.B 10.1.8.C
10.1.8.D
10.1.8.E
RF
RF
LFCN
LFCN
SRT
SRT
FIGURE 10.1.8 Injections to the LFCN.
In the supine position, the hip can be opened further by lowering the end of the couch.
The injection can be undertaken using an IP technique from a lateral approach, with the
transducer in a SAX orientation. The needle tip should be seen above the LFCN.
146 CHAPTER 10 Lower limb
Muscle
Although not commonly undertaken, an intramuscular injection can be performed
into the piriformis muscle (PM) for patients experiencing sign ificant radicular
pain from sciatic nerve compression as it passes near the PM.
Gluteus medius
Gluteus maximus
Tensor fasciae
latae
Piriformis
10.1.9 Piriformis muscle
10.1 Hip 147
Patient position: For the piriformis muscle (PM), the patient can be
Identifying the anatomy: The transducer can be placed in a SAX orientation
Injections performed: CSI for pain symptoms.
Recommended
transducer:
Equipment suggested: Equipment preparation: Set 1 for CSI.
Injection technique: Viewing the PM in the LAX orientation, the needle
placed in a prone position (Fig. 10.1.9A). To put the
area on stretch, the hip can be slightly flexed by
lowering the end of the examination couch, thereby
taking the PM into a more superficial position.
over the ischial tuberosity and moved proximally
and laterally. The PM should then be seen in a LAX
view, moving towards the greater trochanter (GT)
of the femur beneath the gluteus maximus (GMax)
(Fig. 10.1.9B and C). The sciatic nerve can be seen
running in close proximity to the PM.
Linear 6e15 mHz.
Curvilinear 2e5mhz.
Needle: 2- to 2.5-inch 23- or 25-gauge needle.
Syringes: 5 mL for CSI.
Medication: 40 mg triamcinolone (0.5 mL) and 1%
lidocaine (3 mL).
can be introduced using an IP technique at an
angle of approximately 45 degrees (Fig. 10.1.9D
and E). This may need to be altered according to
patient habitus or muscle bulk. With the bevel
facing down, the needle tip can be inserted into the
muscle and provided there is no blood flow on
aspiration, the CSI can be distributed using a
fenestration technique. Care should be taken to
avoid the sciatic nerve.
148 CHAPTER 10 Lower limb
10.1.9.A
GMax
GT
PM
SN
10.1.9.B
10.1.9.D 10.1.9.E
10.1.9.C
GT
GMax
PM
SN
FIGURE 10.1.9 Injections to the PM.
In the prone position, the PM can be made more superficial by flexing the hip. The
injection can be undertaken using an IP technique with the transducer in a LAX
orientation over the PM. The needle tip should be taken into the PM before the injection is
undertaken.
10.1 Hip 149
Notes
(Please use this area to reflect on your procedure and how you can build on these
experiences).
150 CHAPTER 10 Lower limb
10.2 Knee
With many superficial structures around the knee that can be injured, several can be
treated with ultrasound guided interventions. The key with knee injections is stability, sufficient exposure and ease of access to the structure of interest. As such the
prone, supine or side-lying position is most suited for knee injections and an appropriate support can help with stability.
Femur
Quadriceps tendon
Joint capsule
Lateral patella-
femoral ligament
Lateral collateral
ligament
Lateral patella
renaculum
Tibia
Patella tendon
Fibula
Interosseous
ligament
Medial patella
renaculum
Pre-patella
bursa
Pes anserine
bursa
10.2 Knee 151
Joint injections
The common joint injections around the knee include the main knee joint (KJ) itself,
proximal tibio-fibular joint (PTJF) and posteriorly into a Baker’s cyst (BC).
Femur
Patella-femoral
joint
Tibia
Fibula
Patella
152 CHAPTER 10 Lower limb
10.2.1 Knee joint
Patient position: For the knee joint (KJ), the patient can be
Identifying the anatomy: The KJ can be accessed via the suprapatellar
Injections performed: CSI for pain or degenerative disease.
Recommended
transducer:
Equipment suggested: Equipment preparation: Set 1 for CSI and HA
Injection technique: Viewing the SPB in a SAX orientation, the needle
positioned in a supine position with the knee
flexed to approximately 45 degrees. Using a
stable support limits movement and eases the
guidance of injections (Fig. 10.2.1A and B).
bursa (SPB) or patello-femoral joint (PFJ). For the
former, the transducer is best placed in a SAX
orientation over the quadriceps tendon and SPB
can be seen beneath it (Fig. 10.2.1C and D). For
the PFJ, the transducer can be placed over the
medial or lateral border of the patella and medial
or lateral femoral condyle (MFC or LFC); the joint
space should be seen between the two bony
prominences (Fig. 10.2.1E and F).
HA or PRP injections for degenerative disease.
Linear 6e15 mHz (SPB).
Hockey stick 8e18 mHz (PFJ).
injections. Set 4 for PRP injections.
Needle: 2- to 2.5-inch 21- or 23-gauge needle.
Syringes: 5 mL for CSI.
Medication: 40 mg triamcinolone (1 mL) and 1%
lidocaine (4 mL).
Standard/available HA or PRP preparation.
can be introduced with the bevel down, using an
IP technique from the lateral aspect
(Fig. 10.2.1G and H). It is often good to start a
few centimetres below the transducer so that the
needle can be brought in parallel to the field of
view. Accessing from the PFJ, the transducer
can be placed in a SAX orientation over it and the
needle can be introduced using either an IP
(Fig. 10.2.1I and J) or OOP technique
(Fig. 10.2.1K and L). In the former, the needle
may be less visible once in the joint, while with
the latter, only the needle tip will be seen in the
joint space.
10.2 Knee 153
10.2.1.A
10.2.1.C
10.2.1.E
10.2.1.B
10.2.1.D
Patella
10.2.1.F
Quadriceps
tendon
Synovium
Femur
PFJ
Vastus
medialis
LFC
10.2.1.G
10.2.1.I
10.2.1.H
Patella
10.2.1.J
Quadriceps
tendon
Synovium
Femur
PFJ
Vastus
medialis
LFC
FIGURE 10.2.1 Injections to the KJ.
In the supine position the knee can be flexed to 45 degrees. The injection can be
undertaken with the transducer in a SAX orientation over the SPB (IP approach) or PFJ
(OOP approach). The needle tip should be seen in the bursa or joint before the injection is
undertaken.