Steve J. Wisniewski

Sonographically guided carpal tunnel injections: the ulnar approach.

Objective. The purpose of this report is to describe a new sonographically guided technique for carpal tunnel injections using an ulnar approach. Methods. Previously published sonographically guided techniques for carpal tunnel injections were reviewed. Described approaches were noted to be technically challenging because of the need to perform long‐axis imaging of the carpal tunnel, short‐axis (out‐of‐plane) imaging of the needle, or both. Results. We developed and herein describe the ulnar approach for sonographically guided carpal tunnel injections. Advantages of this approach include transverse imaging of the carpal tunnel, long‐axis (in‐plane) imaging of the needle, and versatility in targeting structures within the carpal tunnel. Conclusions. Clinicians should consider the ulnar‐sided approach when performing sonographically guided carpal tunnel injections.

Ultrasound-guided versus nonguided tibiotalar joint and sinus tarsi injections: a cadaveric study.

To compare the relative accuracy rates of ultrasound (US)‐guided versus nonguided ankle (tibiotalar) joint and sinus tarsi injections in a cadaveric model.

Sonographically guided obturator internus injections: Techniques and validation

The primary purpose of this investigation was to describe and validate sonographically guided techniques for injecting the obturator internus (OI) muscle or bursa using a cadaveric model.

Sonographic Evaluation of the Extensor Carpi Ulnaris in Asymptomatic Tennis Players

To determine the prevalence of structural abnormalities and instability affecting the extensor carpi ulnaris (ECU) tendons of asymptomatic recreational tennis players by the use of high‐resolution ultrasonography.

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 Evaluation of Baker Cysts: Diagnosis and Management

A Baker cyst is a common finding in patients with intra-articular knee pathology, such as degenerative or inflammatory arthritis, meniscal tears, and other internal derangement of the knee [1-10]. This localized fluid collection represents distention of the gastrocnemiussemimembranosus bursa [1,2,4,8,9,11-13]. Although Baker cysts are frequently asymptomatic, patients may present with posterior knee pain, reduced knee range of motion, or a posterior knee mass [2,6,8]. The diagnosis is often made clinically or with the assistance of advanced imaging, such as magnetic resonance imaging (MRI) or ultrasound (US). Similar to other cysts, management of a Baker cyst is often aimed at treating the underlying cause, in this case, the intra-articular knee pathology [2,5,7,8]. US has previously been shown to be a reliable way to confirm the diagnosis of a Baker cyst [1,14,15]. The specific location and imaging characteristics are critical in the accurate diagnosis of a Baker cyst [1,9,11,12,14]. Other less common but significant masses may be found in the popliteal fossa, including popliteal artery aneurysms and bone and soft tissue tumors [8,9,14-16]. The following case demonstrates the use of US to confirm the diagnosis of a Baker cyst in a patient who presented with knee pain and stiffness, and to provide direct visualization of complete cyst aspiration.

Distribution Pattern of Sonographically Guided Iliopsoas Injections Cadaveric Investigation Using Coned Beam Computed Tomography

To investigate the distribution pattern of sonographically guided iliopsoas (IP) injections in an unembalmed cadaveric model.

Poster 254: Sacroiliitis Presenting as Hip Pain in an Elite Hockey Player: A Case Report

Disclosures: Katie Fast: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 22-year-old female amateur MMA fighter was scheduled to fight in the 120-pound weight division. Prior to the fight, thorough pre-fight physical examination and questionnaire were performed including a full past medical history (PMH) in which she denoted no significant PMH; her pregnancy test was also negative. The bout was stopped by the referee in the first round due to undefended strikes, with the final blow ending in profuse epistaxis. Setting: Amateur MMA Fight. Results: Immediately after the final blow, the onsite physician entered the ring to evaluate the fighter. She was alert and oriented x3 and appeared to be in no acute distress. An unprecedented amount of bleeding was noted; after 5 minutes of unmitigated bleeding 1:1000 epinephrine swab was applied directly to the nares and eventually the bleeding ceased. The physician questioned her about previous nasal fractures. She denied previous fracture but finally admitted, “I have Von Willy syndrome.” When asked why she had not disclosed this initially, she stated it was genetic and therefore nothing to be done; she also noted her primary-care provider had cleared her to fight. The physician and MMA association enacted a life-time ban on her prohibiting any future participation in their fights again. Discussion: Athletes are motivated patients, but sometimes they are more devoted to their sport than their health. The athlete in this report did not realize the potential consequences of her disease and therefore did not report it. A well-directed blow in a patient with Von Willebrand disease could result in internal or even intracranial bleeding. Event physicians must be diligent in stressing pre-participation physicals and obtaining comprehensive PMH, as the athletes may not fully appreciate the risks involved with their premorbid conditions. Conclusions: Preparticipation history and physicals, though seemingly rudimentary, provide a stop-gap for physicians to prevent serious medical consequences. Level of Evidence: Level V

Can Ultrasound Be Used to Improve the Palpation Skills of Physicians in Training? A Prospective Study

Accurate diagnosis of musculoskeletal disorders relies heavily on the physical examination, including accurate palpation of musculoskeletal structures. The literature suggests that there has been a deterioration of physical examination skills among medical students and residents, in part due to increased reliance on advanced imaging. It has been shown that knowledge of musculoskeletal anatomy and physical examination skills improve with the use of ultrasound; however, the literature is limited.

Poster 277 Metachromatic Leukodystrophy-An Unusual Diagnosis in the Setting of Usual Low Back Pain: A Case Report

Results or Clinical Course: At the TCH he was given baclofen, diazepam, and fentanyl; however, his dystonia progressed to include extreme trunk extension posturing and possible laryngospasms with secondary decline in respiratory function. He was electively intubated and transferred to the ICU for status dystonicus. Toxin screens and brain MRI were negative. He had minimal relief with tizanidine, risperdone, trihexyphenidyl, lidocaine infusion, or dexmedetomidine. A deep brain stimulator (DBS) was eventually placed at the globus pallidus pars interna with significant improvement. Genetic testing and levadopa trials were negative, and he was subsequently diagnosed with idiopathic early onset primary dystonia. Discussion: Early onset dystonia can present as focal dystonia with possible subsequent progression to a more generalized form. Progression may result in extreme posturing and laryngospasms with secondary compromise of the airway. Dystonia is the sole clinical sign with an absence of other disease or exogenous cause and onset before age 20-30 years. In the sports setting, this may be confused with muscle cramping or tremor. Initial treatment is with oral anti-spasmodics, with refractory cases treated with intrathecal baclofen, botulinum toxin chemodenervation, or DBS. Treatment by DBS restricts the athlete from contact sports. Conclusions: Sports Medicine physicians need to be aware of early onset primary dystonia, the signs of generalization, and the possibility of airway compromise.