Mark-Friedrich B. Hurdle

Ultrasound-Guided Intra-Articular Injection of the Trapeziometacarpal Joint: Description of Technique

OBJECTIVE To describe a new technique to perform an ultrasound-guided intra-articular injection of the trapeziometacarpal (TMC) joint. DESIGN Ultrasound-guided injection of the TMC joint was completed on fresh frozen cadaver hand specimens using diatriazoate meglumine contrast. A fluoroscopic posteroanterior image of the TMC joint was then obtained to verify intra-articular placement of the contrast. SETTING Anatomy lab in a medical college. SPECIMENS Seventeen fresh frozen cadaver hand specimens. INTERVENTIONS Not applicable. MAIN OUTCOMES MEASURE Verification of this technique was confirmed using fluoroscopy and contrast. RESULTS Sixteen (94%) of 17 joints injected showed contrast material within the TMC joint with a single cutaneous puncture. One intra-articular injection was initially misplaced into the scaphotrapeziotrapezoid joint. CONCLUSIONS Ultrasound may be used to accurately perform intra-articular TMC injections. Ultrasound provides a viable alternative to fluoroscopy when accurate injection into the TMC joint is required for diagnostic or therapeutic purposes.

Intrinsic spinal cord catheter placement: implications of new intractable pain in a patient with a spinal cord injury.

We present a case of new intractable flank pain after intrathecal infusion system placement in a 45-yr-old man with a history of a T12 spinal cord injury with dysesthetic leg pain. Pain after intrathecal infusion system placement was evaluated by magnetic resonance imaging and the catheter was found to be intraparenchymal. The patient was treated by cessation of infusion and surgical removal of the system. Before surgical removal, the pump was turned off and the patients flank pain resolved. Increased vigilance is warranted when caring for paraplegic patients. When new pain persists, intrathecal medication tapering should be considered.

Ultrasound-guided intra-articular knee injection in an obese patient.

ABSTRACT A 35-yr-old woman was referred to our outpatient clinic for a right intra-articular knee aspiration and injection. She had a medical history notable for lymphedema and morbid obesity (Fig. 1). Her body mass index was recently calculated at greater than 60 kg/m2. She had a history of four previous nonguided knee joint injections performed elsewhere that provided no significant improvement in pain. On physical examination, it was difficult to localize common knee joint bony landmarks, including the medial and lateral borders of the patella (Fig. 2). Consequently we opted to utilize ultrasound guidance for the knee joint injection via the technique described herein. FIGURE 1. Photo of patient’s right knee. FIGURE 2. Patient’s knee x-ray revealing medial compartment narrowing. The skin was palpated to localize the anterior patellar region with the knee flexed to 30 degrees. Using a Philips CX50 ultrasound machine (Philips Electronics, Andover, MA) and standard ultrasound gel, the patella was visualized using a 5-1 MHz curvilinear probe in an anatomic transverse plane. The transducer was then moved proximally until the patella was no longer visualized. As is often visualized in the knee joint of patients with osteoarthritis, a small effusion was seen in the prepatellar pouch between the femur and the quadriceps tendon (Fig. 3). Once an optimal ultrasound image was obtained in this location, the transducer position was marked on the skin. Using strict sterile technique (sterile skin prep, ultrasound probe cover, sterile ultrasound gel, etc.), the knee joint effusion in the suprapatellar pouch was revisualized in an anatomic transverse plane. Local anesthesia was obtained with lidocaine using a 25-gauge 2-in needle under live ultrasound guidance from a lateral to medial transverse approach. Afterward, following the same needle trajectory, a 22-gauge 3.5-in spinal needle was advanced into the knee joint under direct ultrasound visualization (Fig. 4). A total of 8 ml of serosanguineous fluid was aspirated from the knee joint. Afterward, a mixture of corticosteroid and local anesthetic was injected into the knee joint while observing the suprapatellar pouch filling in real time. The patient reported minimal pain during the procedure and complete pain relief immediately after the injection. FIGURE 3. Preinjection labeled ultrasound image. FIGURE 4. Postinjection ultrasound image.

Ultrasound-Guided Spinal Procedures for Pain: A Review

As the population ages, more patients are developing degenerative changes of the spine and associated pain. Although interventional procedures for axial and radicular spine pain have been available for decades, common imaging modalities have relied on ionizing radiation for guidance. Over the past decade, ultrasound has become increasingly popular to image both peripheral musculoskeletal and axial structures. This article reviews the use of ultrasound in the guidance of spine procedures, including cervical and lumbar facet injections and medial branch blocks, third occipital nerve blocks, thoracic facet and costotransverse joint injections, sacroiliac joint injections, and caudal and interlaminar epidural injections.

Poster 174 Ultrasound-Guided Costotransverse Joint Injection: A CT Controlled Feasibility Study

was given tramadol 50 mg q6h prn used in combination with acetaminophen and ice. A PRP injection was performed with ultrasound guidance of the proximal right anterior gluteus medius. 2 weeks post-injection, she had reduction of pain and an ability to gradually return to activity. She began physical therapy to restore flexibility and strength to the right gluteus medius. Patient 2 received prescription of physical therapy to restore strength and function of the left gluteus medius. Discussion: Typically, when the gluteus medius is involved in lateral hip pain it is implicated in greater trochanteric bursa syndrome. In such situations there is often insertional tendinosis or tear of the gluteus medius at the distal musculotendinous junction. However, these two cases represent very rare and previously unreported proximal gluteus medius tendon tears. Conclusions: Though very rare, proximal gluteus medius tendon tears should be considered in the differential diagnosis of lateral hip pain that lies in proximity to the iliac crest.