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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5828_Библиотеки_им_академика_М_И_Перельмана.pdf
54 CHAPTER 8 Upper limb
8.2.2.I
8.2.2.L
Olecranon
8.2.2.K
8.2.2.J
TT
PFP
PJL
8.2.2.M
Triceps
PFP
Humerus
FIGURE 8.2.2 cont’d.
8.2.2.N
Humerus
8.2 Elbow 55
Tendon injections
Tendons commonly causing pain or functional symptoms around the elbow include
the common extensor origin (CEO) or common flexor origin (CFO) and less often
the triceps tendon (TT).
Brachioradialis
Extensor carpi
Triceps
tendon
radialis brevis
Aconeus
Extensor carpi
radialis longus
Flexor Carpi
Ulnaris
Olecranon
Extensor
digitorum
Extensor carpi
ulnaris
56 CHAPTER 8 Upper limb
8.2.3 Common extensor origin
Patient position: In the supine position, the patient can rest their arm flat
Identifying the anatomy: In the LAX orientation, the lateral epicondyle (LE) of the
Injections performed: CSI for pain (although this is not generally advocated).
Recommended
transducer:
Equipment required: Equipment preparation: Set 1 for CSI. Set 2 for HVI. Set
Injection technique: The injection can be performed using an IP approach
on the treatment couch, with the elbow bent and the
hand in a semi-supinated position (Fig. 8.2.3A). Resting
the hand against the body adds further stability. A
similar position can be taken in the seated position with
the arm resting atop of the treatment couch (F 8.2.3B).
Both will enable access to the common extensor origin
(CEO).
humerus and radial head can be identified, with the
common extensor tendon inserting onto the LE and the
radial collateral ligament beneath (Fig. 8.2.3CeE). It
should also be visualised in an SAX view and also care
should be taken to look out for the radial nerve and its
branches.
HVI (tendon stripping) for tendinopathy with
neovascularity.
PRP for degenerative tendinopathy with intrasubstance
tears.
Linear 6e15 mHz.
Hockey stick 8e18 mHz.
4 for PRP.
Needle: 1- to 1.5-inch 25- or 27-gauge needle.
Syringes: 3 mL for CSI, 10 mL for HVI.
Medication: 20 mg triamcinolone (0.5 mL) and 1%
lidocaine (1 mL) for standard CSI. Normal saline (20
e30 mL) can be added for HVI.
(Fig. 8.2.3FeH), guiding the needle from a distal to
proximal direction at approximately 15 degrees. It is
important to ensure the bevel faces down and it can be
brought to rest upon the tendon before injecting a small
volume to separate this from the overlying tissue. Once
this separation is noted, the needle can be withdrawn
and the HVI (tendon stripping) can be undertaken or the
CSI can be delivered to this space.
In situations where a PRP injection is undertaken for the
tendon, the needle is introduced into the tendon and a
fenestration technique is used to deliver it into the
structure. Care must be taken to avoid injury to the
Radial nerve.
8.2.3.A
8.2 Elbow 57
8.2.3.B
8.2.3.C
CEO
LE
8.2.3.E
8.2.3.F
CEO
LE
8.2.3.H
8.2.3.D
Radius
8.2.3.G
Radius
FIGURE 8.2.3 Injections to the CEO.
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 above or within the CEO.
58 CHAPTER 8 Upper limb
8.2.4 Common flexor origin
Patient position: In the sitting position, the arm can be placed in a supinated
Identifying the
anatomy:
Injections performed: CSI for pain (although this is not generally advocated).
Recommended
transducer:
Equipment required: Equipment preparation: Set 1 for CSI. Set 2 for HVI. Set 4
Injection technique: The injection can be performed using an IP approach
and externally rotated position to expose the common
flexor origin (CFO) (Fig. 8.2.4A). Supine, the patient can
have the arm supinated and slightly abducted (Fig. 8.2.4B).
In the prone position, the patient can rest their arm flat on
their back with the elbow flexed to 90 degrees and the hand
in a semi-pronated position (Fig. 8.2.4C). The latter tends to
be a more stable position to perform a procedure.
With the transducer in the LAX orientation, the medial
epicondyle (ME) of the humerus and ulnar can be identified,
with the CFO inserting onto the ME. The ulnar collateral
ligament is located beneath (Fig. 8.2.4DeG). This can be
seen in all three patient positions. An SAX view can help to
visualise the ulnar nerve prior to undertaking the injection.
HVI (tendon stripping) for neovascularity.
PRP for degenerative tendinopathy with intrasubstance
tears.
Linear 6e15 mHz.
Hockey stick 8e18 mHz.
for PRP.
Needle: 1- to 1.5-inch 25- or 27-gauge needle.
Syringes: 3 mL for CSI, 10 mL(s) for HVI.
Medication: 20 mg triamcinolone (0.5 mL) and 1%
lidocaine (1 mL) for standard CSI. Normal saline (20
e30 mL) can be added for HVI.
(Fig. 8.2.4HeK), guiding the needle from a distal to proximal
direction at an approximately 15 degrees. It is important to
ensure the bevel faces down and it can be brought to rest
upon the tendon before injecting a small volume to separate
this from the overlying tissue. Once this separation is noted,
the needle can be withdrawn and the HVI (tendon stripping)
is undertaken or the CSI can be delivered to this space.
If a PRP injection is being undertaken for the tendon, the
needle is passed into the tendon and a fenestration
technique is used to distribute the solution within the
structure.
8.2.4.A
8.2 Elbow 59
8.2.4.B 8.2.4.C
8.2.4.F
8.2.4.D
CFO
8.2.4.G
8.2.4.H 8.2.4.J8.2.4.I
CFO
8.2.4.E
ME
ME
Ulnar
Ulnar
8.2.4.K
FIGURE 8.2.4 Injections to the CFO.
The patient can be seated or lying supine with elbow slightly flexed and shoulder
externally rotated, or prone with the shoulder internally rotated and the arm on the back.
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 above or within the CFO.
60 CHAPTER 8 Upper limb
8.2.5 Triceps Tendon
Patient position: In the supine position, the patient can rest their palm flat on
Identifying the
anatomy:
Injections performed: PRP tendon pathologies such as tendinopathy with
Recommended
transducer:
Equipment required: Equipment preparation: Set 4 for PRP injections.
Injection technique: The injection into the TT can be performed using an IP
the surface of the treatment couch and keep the elbow
bent. This position exposes the posterior elbow and the
triceps tendon (TT) (Fig. 8.2.5.A). In the sitting position, a
similar position can be used to access the area
(Fig. 8.2.5.B). Although both are somewhat awkward for
the patient, but by placing the palm flat, it enhances stability
for the subsequent injection.
In both patient positions, the TT can be followed in an LAX
orientation to its insertion at the Olecranon (Fig. 8.2.5.C, D
and E). It can also be assessed in the SAX by rotating the
transducer 90
degenerative changes.
Linear 6e15mHz.
Hockey stick 8e18mHz.
Needle: 1-1.5-inch 25- or 27-gauge needle.
Standard/available PRP preparation.
approach with the transducer in the LAX (Fig. 8.2.5.F, G
and H) or SAX (Fig. 8.2.5.L, M and N). In both, the needle is
introduced at approximately 20
using a fenestration technique. In both orientations it is
important to be aware of the ulnar and radial nerve
positions to avoid potential injury.
(Fig. 8.2.5.F, G and H).
and the solution is injected
TT
8.2.5.A
8.2.5.B
8.2.5.C
Olecranon
PFP
PJL
Humerus
8.2.5.D
8.2.5.E
8.2.5.F
8.2.5.G
TT
PFP
Humerus
8.2.5.H
8.2 Elbow 61
FIGURE 8.2.5 Injections to the TT.
In both the side-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 TT.
62 CHAPTER 8 Upper limb
8.2.5.I
8.2.5.L
Olecranon
8.2.5.K
8.2.5.J
TT
PFP
PJL
8.2.5.M
Triceps
PFP
Humerus
FIGURE 8.2.5 cont’d.
8.2.5.N
Humerus
8.2 Elbow 63
Ligament injection
The two most commonly injected ligaments in the elbow include the laterally placed
radial collateral (RCL) or the medially situated ulnar collateral (UCL). These may
cause pain and stability issues around the elbow, particularly with repeated throwing
activities or a sudden trauma.
Humerus
Arcular capsule
Radial collateral
Ulnar collateral
ligament (anterior)
ligament
Ulnar
Annular ligament
Radial tuberosity
Radius