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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5828_Библиотеки_им_академика_М_И_Перельмана.pdf
44 CHAPTER 8 Upper limb
8.1.7.A
8.1.7.C
8.1.7.B
8.1.7.D
Deltoid
Infraspinatus
Humeral
head
8.1.7.E
SSN
FIGURE 8.1.7 Injections to the SSN.
The patient can be positioned in a prone or seated position with the arm positioned
suitably for stability. The needle can be guided into the supra-scapular notch, using an IP
technique from lateral-to-medial, with the transducer in a LAX orientation. The needle tip
should be seen beneath the ligament.
FIGURE 8.1.7 cont’d.
Humeral
head
8.1.7.H
8.1 Shoulder 45
8.1.7.G
8.1.7.F
Deltoid
Infraspinatus
SSN
46 CHAPTER 8 Upper limb
Notes
(Please use this area to reflect on your procedure and how you can build on these
experiences).
8.2 Elbow 47
8.2 Elbow
Superficial structures around the elbow can be readily identified and injected under
ultrasound guidance with the patient either in a sitting or lying position. In both positions, the joint can be supported with a pillow or firm support to limit movement.
By altering the elbow position, it can help bring the structure under treatment to a
more superficial position.
Humerus
Triceps
Anterior Fat Pad
Posterior
Fat pad
Joint
Capsule
Ulnar
Olecranon
Bursa
48 CHAPTER 8 Upper limb
Joint injections
Although intra-articular aspects of the elbow joint cannot be assessed using ultrasound, superficial degenerative changes, such as osteophytes, can be seen. Guided
treatments can be performed from the lateral aspect by injections into the RadioCapitella joint (RCJ), for degenerative and pain-related symptoms, or the posterior
joint line (PJL) aspect for degenerative changes or impingement extension. If the fat
pad (PFP) is being caught, this can also be injected.
Humerus
Coronoid fossa
Medial epicondyle
Trochlea
Coronoid process
Lateral epicondyle
Capitulum
Radial head
Ulnar
Radius
8.2.1 Radio-capitella joint
8.2 Elbow 49
Patient position: In the supine position, the patient can rest their hand
Identifying the anatomy: With the transducer along the length of the elbow, the
Injections performed: CSI for pain symptoms, degenerative disease and
Recommended
transducer:
Equipment required: Equipment preparation: Set 1 for CSI or HA injections. Set
Injection technique: The injection can be performed using an IP approach,
against the body to expose the lateral elbow joint
(Fig. 8.2.1A), while in the sitting position, the shoulder is
internally rotated and the elbow is flexed (Fig. 8.2.1B). In
both positions the hand is kept in a semi-supinated
position.
radio-capitella joint (RCJ) can be seen in the LAX with the
lateral epicondyle (LE) of the humerus and the radius in
view. The common extensor tendon is seen inserting onto
the LE and the radial collateral ligament (RCL) is situated
beneath it (Fig. 8.2.1CeE).
synovitis.
PRP or HA injections for degenerative disease.
Linear 6e15 mHz.
Hockey stick 8e18 mHz.
4 for PRP injections.
Needle: 1- to 1.5-inch 23- or 25-gauge needle.
Syringes: 3 mL for CSI.
Medication: 40 mg triamcinolone (1 mL) and 1% lidocaine
(1 mL) for standard CSI.
Standard/available HA or PRP preparation.
with the transducer in a LAX oreintation, guiding the
needle from a distal to proximal position at approximately
45 degrees (Fig. 8.2.1FeH). It is important to ensure the
bevel faces down into the joint to prevent extravasation.
An OOP approach can also be used when there is
considerable degenerative disease (Fig. 8.2.1IeK), with
the transducer placed over the joint line and the needle
entry perpendicular to the skin. In the latter, the needle
can be seen passing vertically into the joint.
50 CHAPTER 8 Upper limb
8.2.1.C
8.2.1.F
8.2.1.A
8.2.1.E
8.2.1.B
8.2.1.D
CEO
RCL
LE
RCJ
Radius
8.2.1.G
LE
8.2.1.H
RCJ
Radius
FIGURE 8.2.1 Injections to the RCJ.
The patient can be lying supine or seated with the elbow slightly flexed to open the joint
and the hand placed against the body to add further stability. The injection can be
undertaken using an IP approach, from a distal-to-proximal, with the transducer in the
LAX orientation. The needle tip should be seen within the RCJ.
8.2 Elbow 51
8.2.1.I
FIGURE 8.2.1 cont’d.
8.2.1.K
8.2.1.J
LE
RCJ
Radius
52 CHAPTER 8 Upper limb
8.2.2 Posterior joint line and posterior fat pad
Patient position: In the supine position, the patient can rest their palm flat
Identifying the anatomy: In both patient positions, the triceps tendon can be
Injections performed: CSI injections for fat pad impingement.
Recommended
transducer:
Equipment required: Equipment preparation: Set 1 for CSI or HA injections. Set
Injection technique: The injection into the joint can be performed using an
on the surface of the treatment couch and with the elbow
bent, they expose and open the posterior elbow
(Fig. 8.2.2A). In the sitting position, a similar position can
be used to access the area (Fig. 8.2.2B). Although both
are somewhat awkward for the patient, by placing the
palm flat, it enhances stability for the subsequent
injection.
followed in an LAX orientation to its insertion at the
olecranon (Fig. 8.2.2CeE). Beneath this sits the posterior
fat pad (PFP) and from here the posterior joint line (PJL)
can be visualised. It can also be assessed in the SAX with
the triceps seen in cross-section (Fig. 8.2.2FeH).
PRP or HA injections for degenerative disease.
Linear 6e15 mHz.
Hockey stick 8e18 mHz.
4 for PRP injections.
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) for standard CSI.
OOP approach with the transducer in the LAX and just
adjacent to the medial border of the triceps tendon
(Fig. 8.2.2IeK). Care must be taken not to take the needle
into the substance of the TT. Alternatively, the transducer
can be placed in the SAX over the tendon and the needle
is introduced using an IP approach at approximately 45
degrees (Fig. 8.2.2LeN). The former is more suited to a
posterior joint and the latter for a fat pad injection. In both
situations it is important to be aware of the ulnar and radial
nerve positions to avoid potential injury.
8.2 Elbow 53
8.2.2.C
8.2.2.F
8.2.2.A
Olecranon
8.2.2.E
8.2.2.B
8.2.2.D
TT
PFP
PJL
8.2.2.G
Humerus
TT
PFP
8.2.2.H
Humerus
FIGURE 8.2.2 Injections to the PJL and PFP.
In both the lying and seated positions, the patient can place their hand flat on the treatment
couch, with the posterior elbow exposed, to add further stability during the procedure. The
injection can be undertaken using an IP or OOP approach with the transducer in a LAX or
SAX orientation. The needle tip should be seen within the joint or PFP.