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Tips and tricks in ultrasound-guided musculoskeletal interventional procedures

William R. Walter
William R. Walter
, 
Christopher J. Burke
Christopher J. Burke
 und 
Ronald S. Adler
Ronald S. Adler
   | 23. Nov. 2023
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Article Category: Review paper
Online veröffentlicht: 23. Nov. 2023
Seitenbereich: e347 - e357
Eingereicht: 05. Juni 2023
Akzeptiert: 09. Aug. 2023
DOI: https://doi.org/10.15557/jou.2023.0039
Schlüsselwörter
© 2023 William R. Walter et al., published by Sciendo
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Fig. 1.

A. Ultrasound image of the hip joint utilizing a 5MHz curvilinear transducer ideal for imaging deep, large joints such as the hip joint. The acetabulum (cross), labrum (arrow), and femoral head (double cross) are depicted prior to joint injection. The potential intra-articular space deep to the joint capsule is indicated by arrowheads, depicting no significant native joint fluid or joint effusion prior to the injection. B. Ultrasound image of the common peroneal nerve obtained using an 18 MHz hockeystick transducer to guide a perineural anesthetic injection, depicting the needle (arrow) positioned deep to the common peroneal nerve, which demonstrates fascicular enlargement indicating neuritis (arrowheads). The injectate appears as hypoechoic material distending the perineural fat plane deep to the nerve (asterisks)
A. Ultrasound image of the hip joint utilizing a 5MHz curvilinear transducer ideal for imaging deep, large joints such as the hip joint. The acetabulum (cross), labrum (arrow), and femoral head (double cross) are depicted prior to joint injection. The potential intra-articular space deep to the joint capsule is indicated by arrowheads, depicting no significant native joint fluid or joint effusion prior to the injection. B. Ultrasound image of the common peroneal nerve obtained using an 18 MHz hockeystick transducer to guide a perineural anesthetic injection, depicting the needle (arrow) positioned deep to the common peroneal nerve, which demonstrates fascicular enlargement indicating neuritis (arrowheads). The injectate appears as hypoechoic material distending the perineural fat plane deep to the nerve (asterisks)

Fig. 2.

A. Ultrasound guidance image depicting the “in-plane” approach of a 25-gauge needle (arrowheads) to the dorsal radiocarpal joint (arrow), which is depicted longitudinally at the level of the lunate (cross) and distal radius (double cross). The entire length of the needle can be seen. B. Ultrasound guidance image depicting the “out-of-plane” approach of a 25-gauge needle (arrow) within the left fourth metatarsophalangeal joint for a therapeutic intra-articular injection in a patient with rheumatoid arthritis. A native joint effusion is seen (asterisks) at the level of the metatarsal head (cross) and proximal phalanx (double cross)
A. Ultrasound guidance image depicting the “in-plane” approach of a 25-gauge needle (arrowheads) to the dorsal radiocarpal joint (arrow), which is depicted longitudinally at the level of the lunate (cross) and distal radius (double cross). The entire length of the needle can be seen. B. Ultrasound guidance image depicting the “out-of-plane” approach of a 25-gauge needle (arrow) within the left fourth metatarsophalangeal joint for a therapeutic intra-articular injection in a patient with rheumatoid arthritis. A native joint effusion is seen (asterisks) at the level of the metatarsal head (cross) and proximal phalanx (double cross)

Fig. 3.

Ultrasound guidance image depicting an “in-plane” approach to a Baker’s cyst (asterisks) in the popliteal fossa. The needle (arrowheads) is insonated at approximately 90 degrees and is therefore very well visualized with associated reverberation artifact at the deep margin of the needle
Ultrasound guidance image depicting an “in-plane” approach to a Baker’s cyst (asterisks) in the popliteal fossa. The needle (arrowheads) is insonated at approximately 90 degrees and is therefore very well visualized with associated reverberation artifact at the deep margin of the needle

Fig. 4.

Ultrasound guidance image depicting the “in-plane” approach of a 22-gauge spinal needle into the posterior glenohumeral joint. The needle (arrowheads) trajectory in this case passes from medial to lateral, over the glenoid (cross), landing on the humeral head (double cross) at a relatively acute angle, avoiding the glenoid labrum (arrow)
Ultrasound guidance image depicting the “in-plane” approach of a 22-gauge spinal needle into the posterior glenohumeral joint. The needle (arrowheads) trajectory in this case passes from medial to lateral, over the glenoid (cross), landing on the humeral head (double cross) at a relatively acute angle, avoiding the glenoid labrum (arrow)

Fig. 5.

A. Longitudinal ultrasound image of the posterior glenohumeral joint demonstrating normal findings of an intact infraspinatus tendon (arrows), articular cartilage (curved arrows) along the posterior humeral head (double cross) at the level of the glenoid (cross) and posterior glenoid labrum (asterisks). These landmarks can be used to identify appropriate trajectory for intra-articular injection, and detect pathology such as bursitis, rotator cuff tear, joint effusion, or synovitis. B. Ultrasound guidance image depicting the “in-plane” approach of a 22-gauge spinal needle into the posterior glenohumeral joint. The needle (arrowheads) trajectory in this case passes from lateral to medial, over the humeral head (double cross) toward the glenoid (cross), and landing on the humeral head (double cross) at a relatively obtuse angle
A. Longitudinal ultrasound image of the posterior glenohumeral joint demonstrating normal findings of an intact infraspinatus tendon (arrows), articular cartilage (curved arrows) along the posterior humeral head (double cross) at the level of the glenoid (cross) and posterior glenoid labrum (asterisks). These landmarks can be used to identify appropriate trajectory for intra-articular injection, and detect pathology such as bursitis, rotator cuff tear, joint effusion, or synovitis. B. Ultrasound guidance image depicting the “in-plane” approach of a 22-gauge spinal needle into the posterior glenohumeral joint. The needle (arrowheads) trajectory in this case passes from lateral to medial, over the humeral head (double cross) toward the glenoid (cross), and landing on the humeral head (double cross) at a relatively obtuse angle

Fig. 6.

A. Ultrasound guidance image of an intra-articular hip injection depicting intra-articular gas indicated by subcapsular, anti-dependent echogenic material (arrows) with typical ringdown artifact (arrowheads) at the level of the femoral head (cross). This finding indicates intra-articular position of the needle tip and injectate, but large volumes of gas may hinder visualization. B. Ultrasound guidance image depicting the “in-plane” approach of a 22-gauge spinal needle into the posterior glenohumeral joint from lateral to medial, over the humeral head (double cross). C. Ultrasound guidance image with power Doppler depicting a test injection utilizing the approach shown in Fig 6b, confirming subcapsular, intra-articular positioning of the needle tip (not directly seen) and injectate as the flow jet (arrows) from the test injection is bounded by the joint capsule
A. Ultrasound guidance image of an intra-articular hip injection depicting intra-articular gas indicated by subcapsular, anti-dependent echogenic material (arrows) with typical ringdown artifact (arrowheads) at the level of the femoral head (cross). This finding indicates intra-articular position of the needle tip and injectate, but large volumes of gas may hinder visualization. B. Ultrasound guidance image depicting the “in-plane” approach of a 22-gauge spinal needle into the posterior glenohumeral joint from lateral to medial, over the humeral head (double cross). C. Ultrasound guidance image with power Doppler depicting a test injection utilizing the approach shown in Fig 6b, confirming subcapsular, intra-articular positioning of the needle tip (not directly seen) and injectate as the flow jet (arrows) from the test injection is bounded by the joint capsule

Fig. 7.

A. Pre-injection ultrasound image of the posterosuperior glenohumeral joint in a patient with subacromial/subdeltoid bursitis, represented by complex fluid distension of the bursa (asterisks) and proliferative, hyper-vascular synovitis (arrows). B. Ultrasound guidance image demonstrates an in-plane approach of a 25-gauge needle (arrowheads) advanced into the subacromial/subdeltoid bursa (arrows) overlying the infraspinatus tendon (asterisks) at the level of the lesser tuberosity of the humerus (cross)
A. Pre-injection ultrasound image of the posterosuperior glenohumeral joint in a patient with subacromial/subdeltoid bursitis, represented by complex fluid distension of the bursa (asterisks) and proliferative, hyper-vascular synovitis (arrows). B. Ultrasound guidance image demonstrates an in-plane approach of a 25-gauge needle (arrowheads) advanced into the subacromial/subdeltoid bursa (arrows) overlying the infraspinatus tendon (asterisks) at the level of the lesser tuberosity of the humerus (cross)

Fig. 8.

Ultrasound guidance image demonstrates an in-plane approach of a 20-gauge needle (arrowheads) advanced into a calcific deposit (asterisks) along the bursal fibers of the supraspinatus tendon. The overlying bursa is displaced (arrows)
Ultrasound guidance image demonstrates an in-plane approach of a 20-gauge needle (arrowheads) advanced into a calcific deposit (asterisks) along the bursal fibers of the supraspinatus tendon. The overlying bursa is displaced (arrows)

Fig. 9.

A. Axial T1-weighted magnetic resonance image of a 47-year-old male with left buttock pain and clinical diagnosis of ischiofemoral impingement. The sciatic nerve (arrow) is well depicted between the edematous quadratus femoris muscle (asterisks) and the hamstring tendon origin (arrowhead). B. Axial T2-weighted, fat-suppressed magnetic resonance image of a 47-year-old male with left buttock pain and clinical diagnosis of ischiofemoral impingement depicting an edematous quadratus femoris muscle with adventitial bursitis (arrows). C. Ultrasound image of a 47-year-old male with left buttock pain and clinical diagnosis of ischiofemoral impingement, depicting an edematous quadratus femoris muscle (arrowheads) with associated adventitial bursitis (asterisks) in the interval between the ischium (double cross) and the femur (cross). The sciatic nerve (arrow) should be confidently identified prior to pursuing percutaneous injections in this region
A. Axial T1-weighted magnetic resonance image of a 47-year-old male with left buttock pain and clinical diagnosis of ischiofemoral impingement. The sciatic nerve (arrow) is well depicted between the edematous quadratus femoris muscle (asterisks) and the hamstring tendon origin (arrowhead). B. Axial T2-weighted, fat-suppressed magnetic resonance image of a 47-year-old male with left buttock pain and clinical diagnosis of ischiofemoral impingement depicting an edematous quadratus femoris muscle with adventitial bursitis (arrows). C. Ultrasound image of a 47-year-old male with left buttock pain and clinical diagnosis of ischiofemoral impingement, depicting an edematous quadratus femoris muscle (arrowheads) with associated adventitial bursitis (asterisks) in the interval between the ischium (double cross) and the femur (cross). The sciatic nerve (arrow) should be confidently identified prior to pursuing percutaneous injections in this region

Fig. 10.

A. Axial T1-weighted magnetic resonance image of a 33-year-old female with right buttock pain and clinical diagnosis of piriformis syndrome and muscle spasm, referred for an injection of botulinum toxin. The ultrasound transducer footprint (blue rectangle) and planned injection approach is shown (white arrow) traversing the gluteus maximus muscle (cross) into the piriformis muscle (double cross). The sacrum (arrowhead) is partially imaged and can also be a useful landmark on ultrasound. B. Ultrasound guidance image of a 33-year-old female with right buttock pain and clinical diagnosis of piriformis syndrome and muscle spasm, referred for an injection of botulinum toxin into the piriformis muscle. The patient is positioned prone. The needle (arrowheads) is seen in in-plane approach, introduced into the piriformis muscle belly (cross), just deep to the gluteus maximus muscle (double cross). The sacrum (arrowhead) provides a useful landmark medially, and the sciatic nerve (arrow) should be identified deep to the piriformis muscle
A. Axial T1-weighted magnetic resonance image of a 33-year-old female with right buttock pain and clinical diagnosis of piriformis syndrome and muscle spasm, referred for an injection of botulinum toxin. The ultrasound transducer footprint (blue rectangle) and planned injection approach is shown (white arrow) traversing the gluteus maximus muscle (cross) into the piriformis muscle (double cross). The sacrum (arrowhead) is partially imaged and can also be a useful landmark on ultrasound. B. Ultrasound guidance image of a 33-year-old female with right buttock pain and clinical diagnosis of piriformis syndrome and muscle spasm, referred for an injection of botulinum toxin into the piriformis muscle. The patient is positioned prone. The needle (arrowheads) is seen in in-plane approach, introduced into the piriformis muscle belly (cross), just deep to the gluteus maximus muscle (double cross). The sacrum (arrowhead) provides a useful landmark medially, and the sciatic nerve (arrow) should be identified deep to the piriformis muscle

Fig. 11.

Post-injection ultrasound image demonstrating a long segment of longitudinal perineural spread of injectate (arrows) along the common peroneal nerve (asterisks) following hydrodissection and subsequent steroid injection
Post-injection ultrasound image demonstrating a long segment of longitudinal perineural spread of injectate (arrows) along the common peroneal nerve (asterisks) following hydrodissection and subsequent steroid injection
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