Ultrasound visualization affords proceduralists versatile and accurate guidance for a variety of percutaneous, minimally invasive procedures in the musculoskeletal system including joint (intra-articular) injections or aspirations, intra-bursal injections, peritendinous, and perineural injections. A variety of percutaneous procedures are traditionally performed blindly, but may be more easily or more accurately performed with the real-time assistance of ultrasound guidance. Other procedures are only possible utilizing image-guidance, due to the required precision of the injection because of delicate local anatomy or depth of the injection; ultrasound is a safe, portable, and widespread modality that can be used to assist the proceduralist in localizing the needle tip in such cases, to ensure safe and accurate delivery of the medication, most frequently a solution of steroid and anesthetic. This review aims to provide a foundational approach to ultrasound-guided procedures in the musculoskeletal system, offering tips and tricks that can be employed in many different procedures including intra-articular, juxta-articular, and perineural injections for a multitude of clinical scenarios. Technical considerations regarding ultrasound transducer selection, sonographic technique, as well as common indications, contraindications, and complications of these procedures, are presented. Additionally, a variety of pharmacologic considerations for proceduralists contemplating ultrasound-guided injections are discussed.
Video 1. Ultrasound cine clip depicting real-time
sonographic guidance of an intra-articular injection of the first metatarsophalangeal joint at the
level of the metatarsal head (double cross) and the proximal phalanx base (cross). Although the
needle tip is not seen in view, intra-articular injection using an out-of-plane approach is
confirmed by the “contrast effect” of the particulate steroid and anesthetic mixture, which creates
an echogenic appearance (asterisks) and distension of the joint capsule (arrows)
Video 2. Ultrasound cine clip depicting real-time
sonographic guidance of an intra-articular injection of the first tarsometatarsal joint (curved
arrow). Although the needle tip is not seen in view, intra-articular injection using an out-of-plane
approach is confirmed by the “waterfall effect” of the echogenic particulate steroid and anesthetic
mixture (arrows)
Video 3. Ultrasound cine clip depicting real-time
sonographic guidance of an intra-articular injection of the glenohumeral joint at the level of the
posterior glenoid (cross) and humeral head (double cross). A lateral to medial in-plane approach of
the needle (arrowheads) is shown. Progressive distension of the joint by the injectate (asterisks)
and displacement of the glenoid labrum (arrow), an intra-articular structure, confirm satisfactory
intra-articular positioning of the needle tip
Video 4. Ultrasound cine clip depicting real-time
sonographic guidance of a bursal injection using an in-plane approach of a 25-gauge needle
(arrowheads). Progressive bursal distension with injectate (asterisks) confirms accurate needle
positioning
Video 5. Ultrasound cine clip depicting real-time
sonographic guidance of calcific tendinopathy barbotage. Pulsed lavage results in a dynamic
“fish-mouth” appearance of the calcific pseudocapsule (arrowheads), with the lavage needle depicted
in an out-of-plane image (arrow). As long as the pseudocapsule remains intact, little extravasation
of lavage material will be seen in the subdeltoid bursa
Video 6. Ultrasound guidance cine clip demonstrating
real-time perineural hydrodissection by a 25-gauge needle advanced into the perineural fat of the
common peroneal nerve (arrow). Multiple small-volume injections infiltrate the perineural fat with
local anesthetic, achieving a nerve block and creating potential space for subsequent steroid
injection, if desired
Video 7. Post-injection ultrasound cine clip
demonstrating a long segment of circumferential perineural spread of injectate along the common
peroneal nerve (arrow), depicted in short axis, following hydrodissection and subsequent steroid
injection
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