Basic Joint Injection “How to do it”

1. Basic Joint Injection“How to do it” Steven R. Urbanski, M.D. Jefferson Radiology Hartford, Connecticut

2. Notice: • THESE INSTRUCTIONS ARE JUST ONE APPROACH • OTHER METHODS WILL WORK JUST AS WELL • USE THE PHOTOS TO ASSIST IN POSITIONING • AND TO DETERMINE IF YOU’RE IN THE CAPSULE • (Most photos are taken from conventional arthrograms which • are generally performed with a greater volume of contrast. • For pre-MRI injection you will only be injecting a small • amount of iodinated contrast to validate that your needle • tip is within the joint or joint capsule).

3. Shoulder -supine; neutral or externally rotate shoulder (sandbag) -22g spinal needle -10-15cc contrast (10cc is fine) -Landmark: inferomedial aspect humeral head Hip -supine; pad behind knee; foot up (sandbag) -22g spinal needle -10-15cc contrast (10cc is fine) -mark femoral pulse; rotate C-arm away if necessary -Landmark: proximal-mid femoral neck, lateral to artery Knee -supine; pad behind knee -any routine short needle (20g, 21g, 22g, 23g) -10-20cc contrast (10cc is fine) -Landmark: at lateral patello-femoral joint (by feel) Elbow -prone; elbow over head flexed 90° -25g butterfly if available -5-10cc contrast (5cc is fine) -Landmark: radial-capitellum joint Wrist -dealer’s choice; supine, prone, sitting (least favored-as patient may become vasovagal) -wrist should be flexed over a soft pad (see photo) -25g butterfly if available -several cc contrast (watch on fluoro-don’t overfill) -Landmark: Radiocarpal compartment at mid navicular Ankle -First mark dorsalis pedis pulse -Turn decubitus; side of interest side down -25g butterfly if available -5-10cc contrast (5cc is fine) -Landmark: AP needle at tibio-talar joint while watching fluoro from a lateral view Summary

4. Basic Procedure: all joints 1. PROPERLY POSITION THE PATIENT to optimize needle placement 2. Use Kelly clamp/sharpie to mark your site 3. Local anesthesia (carbonated lido: 10% sodium bicarbonate) 4. Insert needle, intermittently check with fluoro 5. Validate needle position with small amount iodinated contrast (I use connecting tube…except in the knee; butterfly for wrist and elbow) 6. Inject Dilute Gad (see next slide…. Use 0.5%) 7. Have patient exercise joint prior to imaging to distribute gad

5. What about Gad? I prefer to first inject a small amount of full strength iodinated contrast into joint capsule prior to giving the dilute gad to validate my needle placement. Use photos in this presentation to see what the joint capsules look like. Mixing a “pinch” of Gad (DDM recommends 0.5% solution) Will need a TUBERCULIN Syringe to measure the “pinch” If you have a 10cc NS bottle, then inject 0.05cc Gd into saline If you have a 30cc NS bottle, then inject 0.15cc Gd into saline Shake bottle to mix, draw into syringe

6. THE SHOULDER

7. Shoulder: Patient Positioning NO GOOD !!!! Internal Rotation ↓ ↓ Do NOT position with shoulder internally rotated

8. Shoulder: Patient Positioning ↓ ↓ YES!! Neutral – External Rotation YES, POSITION WITH ARM IN NEUTRAL or EXTERNAL ROTATION SANDBAG HELPS TO KEEP ARM IN POSITION WHILE YOU WORK.

9. Shoulder: Mark site Mark site overlying lower inner aspect of Humeral head (stay below the “equator”) NEEDLE: 22 g Spinal Needle (protects cartilage/will bend) INJECT: 10cc is fine for MRI

10. EXAMPLE Case: • Contrast should flow away from the needle • Often fills below coracoid process before filling the axillary recess • Only inject small amount of contrast to see if “in”; then Gd

11. Shoulder: normal capsule Axillary Recess Subscapular recess Biceps Tendon (usually stops at neck)

12. Another Example:

13. Diagnostic Arthrography: EXERCISE Joint!! Exercise (passive or active) distributes the contrast Post exercise Rotator Cuff Tear easily seen.

14. Another example: Needle no higher than this “stay below the equator” POST Exercise

15. Bursal injection!! Inadvertent injection of Subscapularis Bursa Usually from needle not in deep enough (“go to bone”) Contrast is in bursa (not around humeral head cartilage) Subscp burse may communicate with subacromial bursa

16. Shoulder: “the final product”

17. THE HIP

18. HIP: Patient Positioning Relaxed Leg Position (use cushion behind the knee) Foot straight up (internal rotation; sandbag helps to maintain position) CHECK Pulse/MARK Femoral Artery (AVOID Injecting here) Landmark → ANYWHERE at Prox-Mid FEMORAL NECK

19. The Native Hip: You don’t need to be in the “joint”. You only have to place the needle tip in the joint capsule. See how large the capsule is. Placing the needle anywhere the capsule is will result in success. The depth is easy… contact bone.

20. Hip: (oblique entrance to avoid femoral artery) ↑ Femoral Pulse is here Here, C-arm rotated 5-10° laterally Now my approach (circle) is away from the femoral artery. (if no C-arm, just turn patient 5-10° away)

21. Example: injection at lateral side of femoral neck NEEDLE: 22g spinal needle INJECT: Test injection, then 10cc dilute Gd

22. Example: Injection near center of femoral neck ↑ Femoral Artery

23. Another example:

24. Another example: Test Injection POST final injection 3-5cc contrast

25. Hip: “the final product”

26. THE KNEE

27. The Knee: POSITIONING Patient Supine Knee relaxed, slightly flexed Palpate patella Set landmark at Lat PF joint This injection is done by “feel” not directed by fluoro

28. Needle placed by palpation (no imaging) • Needle: short regular 20-23g drawing needle • Inject: 10-15cc (10cc should be fine) • Contrast injected during fluoro (validate within capsule)

29. Knee Injection: Watch contrast flow away from needle into joint capsule After injection exercise the joint

30. Needle placed by Palpation (w/o fluoro) Contrast flows away From the needle tip

31. MR-Gad Injection: prior meniscetomy

32. THE ELBOW

33. Elbow: approach Most patients will turn head away!!

34. NEEDLE: 23 or 25g butterfly Inject: 5 – 10cc (5cc Gad likely enough)

35. Continued injection Contrast 5 – 10cc volume Needle: 23 or 25g butterfly ↑ Space for Annular Lig

37. Conventional Arthrogram

38. radial head partially absent

39. THE WRIST

40. Wrist injection: what NOT to do ↓↓ DO NOT INJECT at the ligament Need to first flex wrist (next slide)

41. Wrist: Patient positioning (your choice!!) Note that wrist is flexed over The pad (easier access) Sitting position not favored (vasovagal)

42. Wrist arthro • Keep away from TFC & Ligaments (SLL, LTL) • Needle best at Mid-Navicular • Cushion under wrist mandatory!!!

43. Wrist Injection: • 25g Butterfly works well • Image during injection!! • (only a few cc necessary) • Exercise post injection

44. Normal: If difficult to inject, it may be from the small size of the wrist joint → bevel may be obstructed by the articular cartilage. Rotating the needle bevel may allow injection

45. THE ANKLE

46. Feel Pulse and mark with sharpie AVOID INJECTING AT PULSE Turn patient lateral for injection

47. Ankle: injection approach → If try to inject from AP view will hit bone Use lateral projection with needle entering from AP side

48. Ankle: injection approach 25g needle (butterfly works well) Capsular Volume = 5 -10cc Initial filling Articular surfaces and Anterior/Posterior recesses

49. Conventional arthrogram

50. Normal filling: Medial side tendons 15% -flexor digitorum longus - flexor hallucus longus Subtalar Joint 10% ABNORMAL (peroneal tendons) → calcaneofibular lig tear Ankle Arthro: tendon communication