Why use ultrasound?
Whilst it still remains more popular to inject joints using fluoroscopy across the world, one cannot deny the attractions of ultrasound being cheap, small in form and readily accessible in the clinic / office environment.
Advances in ultrasound equipment have improved needle guiding, tissue detail and penetration. Technologies such as virtual convex on linear probes and beam steering make accurately aiming of an obliquely travelling needle into deep tissue ever more straightforward.
In the hands of a skilled operator, ultrasound is actually safer than fluoroscopy. There is no radiation (for the patient and operator) and needle guidance is realtime so no nasty surprises arise.
Due to being simple and accessible it is easy to overlook the fact that a joint injection should always be a sterile procedure. The following should always be adhered to:
• The cleanest environment possible (dedicated clinic room for injection work)
• Ensure patient showers or bathes on day of procedure
• Strict aseptic technique with all sterile equipment
• Drugs used only on a per patient basis (i.e. no anaesthetic dose splitting between cases etc)
• Appropriate draping of area
• Sterile probe covers
• Follow up advice mentioning how to recognise infection and what to do
• 22 gauge spinal needle
• Lidocaine 1% for skin and subcutaneous anaesthesia
• (Levo)Bupivacaine 0.25 or 0.5% for joint injection
• Triamcinolone steroid - recommended dose 40mg
• 2 x 5mL syringes to mix:
• 5mL 1% Lidocaine
• 5mL combination of triamcinolone and (levo)bupivacaine
1. Supine position on couch with groin exposed
2. Perform diagnostic ultrasound to achieve the view shown and identify relevant anatomy (see annotations)
3. Mark the site of injection (you will not remember the spot under a drape!)
4. Take informed consent
5. Aseptic method, drape patient
6. Anaesthetise skin with spinal needle and advance into muscle - do not remove!
7. Continue to anaesthetise as you guide the needle down to the hip joint capsule under realtime control
8. Pause at the hip joint and ensure good anaesthesia, puncturing the capsule hurts
9. Puncture the capsule at the recess of the femoral head/neck junction
10. Swap syringes to the triamcinolone / (levo)bupivacaine mix
11. Inject slowly into joint capsule (over 10 secs) watching it expand in realtime
12. Remove needle and press firmly with swab to minimise bruising
13. Apply dressing and provide advice about infection signs
1. Preparation is key, do not skip the diagnostic and marking phase of this tutorial otherwise you will inevitably find yourself way off target at some point and may compromise sterility trying to change needle position
2. Needle angle should not be too steep so it is worth using a longer needle than you think. Get into a habit of measuring the distance to estimate before choosing your needle and don’t forget to compensate for the skin pressure you apply with the probe when you measure
3. Traversing muscle with a needle hurts young people but does not seem to bother older patients
4. If you are struggling with visualisation on a larger patient increase depth and decrease frequency, spatial resolution is not important in this technique
References of interest
Dr Dan Fascia works at Yorkshire Radiology, who can be found on twitter @YorkshireRad
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