Ultrasound and clinically guided Injection techniques on the musculoskeletal system

By Giorgio Tamborrini, Christian Dejaco, George A. W. Bruyn and Andreas Siegenthaler

Targeted therapeutic injections of joints, periarticular structures, tendon sheaths or bursae are among the most important treatments for inflammatory rheumatic or inflammatory activated degenerative diseases of the musculoskeletal system. Furthermore, injections of periarticular structures are also performed in post-traumatic situations or in overuse syndromes.
In this publication, we discuss indications, contraindications, the clinical and ultrasound-guided techniques preferred by the authors, and possible adverse drug reactions and side effects of intraarticular and periarticular injection.

• Language: English
• Publisher: Books on Demand
• Release date: Apr 1, 2019
• ISBN: 9783749404063

Giorgio Tamborrini

Ultraschallzentrum Rheumatologie Basel uzrbasel.ch and irheuma.com Rheumatologist and Sonographer. EULAR teacher. EFSUMB Level III.

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Literature

1 Introduction

Targeted therapeutic injections of joints, periarticular structures, tendon sheaths or bursae are among the most important treatments for inflammatory rheumatic or inflammatory activated degenerative diseases of the musculoskeletal system. Furthermore, injections of periarticular structures are also performed in post-traumatic situations or in overuse syndromes (Table 1).

Indications for injections of the musculoskeletal system

Table 1

In the case of articular or periarticular inflammation, targeted local injection enables rapid anti-inflammatory action with few side effects, which often lasts for a long time in the case of arthritis, for example, through the use of crystalline steroid preparations.

If an effusion is present, it often makes sense to perform a diagnostic aspiration and/or therapeutic injection with determination of cell count, examination of the gram preparation, cell differentiation, crystal analysis and, depending on the clinic, culture and PCR examinations before injection. Synovial fluid analysis helps to differentiate between non-inflammatory and inflammatory arthropathy (Table 2).

Table 2: Synovial fluid analysis, wbc/mm3 = granulocytes per mm3, PMN = polynuclear neutrophilic granulocytes

In this publication, we discuss indications, contraindications, the clinical and ultrasound-guided techniques preferred by the authors, and possible adverse drug reactions and side effects of intraarticular and periarticular injection.

2 Technique

The requirements for a correct injection technique are a clear (or suspected) diagnosis (if infection is suspected, no injection but only diagnostic aspiration ist done), an adequate information and informed patient consent (according to local national guidelines), musculoskeletal ultrasound and profound anatomical knowledge, the correct dosage of medication and, in particular, sufficient practical skills in carrying out injections. For injections in anatomically more difficult regions or for diagnostic injection of only small quantities of effusions, orientation through high-resolution musculoskeletal ultrasound (hrMSUS) is indispensable today. The hrMSUS can be used for pre-interventional exact localization of the injection site or for performing injection under direct view using various techniques.

A diagnostic injection or therapeutic injection should be painless or almost painless. The intervention takes place in a clean room without draughts, the patient should be comfortable and relaxed positioned.

In the clinically guided injection technique, we orient ourselves on the surface anatomy, especially using the osseous landmarks. The injection site is marked after orienting palpation by gentle pressure with an unsoiled ballpoint pen tip (no coloured marking) (Fig. 1).

Fig. 1: Marking of the injection site with a ballpoint pen

The injection site should not be in the area of a skin rash or a blood vessel. Shaving a hairy area is not necessary. The injection site is then disinfected according to the instructions of the product used. The skin can be superficially cryoanesthetized at the injection site before disinfection using sterile ice spray. A prior injection anaesthesia with a local anaesthetic is not necessary with the correct technique and doing a rapid injection. For special interventions, e.g. in the case of needling of a calcification of the rotator cuff of the shoulder, we recommend the prior application of a local anaesthetic into the subdeltoid bursa. In the case of several injections, e.g. at finger joints, a block anaesthesia can be evaluated. In children, the prior application of a local anaesthetic ointment or patch may be helpful.

Wearing a surgical mask is recommended, but the use of sterile gloves is not mandatory if a sterile no-touch technique e.g. according to the guidelines of the Swiss Society for Rheumatology (Tab. 3) is followed. The illustrations and pictures in this manual were made without wearing gloves.

Tab. 3.

When injecting a joint after clinical or prior sonographic orientation, the injection is usually made perpendicular to the skin surface. In paratendinous injections or directly (real-time) ultrasound-guided injections, a flatter insertion angle is selected depending on the structure to be injected. Ideally, with each blind intra-articular injection, synovial fluid is aspirated before an injection is performed, which proves the safe intraarticular position of the needle (not necessary with the direct ultrasound-guided injection technique). As mentioned above, aspiration of synovial fluid enables diagnostic analysis and leads to therapeutic relief in the case of large quantities of an effusion. The injection of a drug should be done without resistance and painless. After the injection, a short compression of the injection site with a sterile swab and a sterile adhesive plaster should be applied.

By following this procedure, injection will be fast, safe and efficient. In case of insufficient success, a second injection can