Ultrasound joint injections

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BobBarker

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Any good resources for shoulders? I think I have knees figured out and am planning to keep doing the hips and sij's with fluoro. Got zero training with joint injections in fellowship but do around 5 blind shoulders and knees daily in clinic. I think I understand the different cpt codes and have access to an old ultrasound machine. I am looking for the ultrasound technique that corresponds with a posterior subacromial approach.

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I think 20611 (major joint with US), is pretty close to 20610+77002 but I do have a lot more nursing assistance on my fluoro day and probably should be doing more glenohumeral injections anyways. I have turned into ortho triage it seems, so learning as I go out of necessity. Would you propose doing all knee and shoulders under fluoro?
 
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Not a fan of US for GHJ except in younger patients who probably don't need it. I just can't make out the anatomy in elderly patients with totally destroyed shoulders. Fluoro is much more reliable. I like US for the AC, and for all the tendons.
 
Not all shoulder injections are created equal, your target depends on why you are injecting. The GH joint doesn't communicate with every bursa reliably. (http://radsource.us/subcoracoid-bursa). Below are a couple OK videos showing the concepts.

Rotator cuff tear - subacromial subdelt bursa in a decent target...
OA of GH joint - need to inject the joint or a communicating bursa...
(I was also taught a biceps tendon sheath technique which does reliably communicate with the GH joint and is very straight forward. Just don't inject the tendon itself, it may lead to weakening and ultimate rupture.)

I find ultrasound is quicker for me doing shoulders and knees. Hips and SIJI are faster with flouro (ultrasound is more limited by patient habitus with these two as well).
 
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Also, you can see after using ultrasound that most blind injections are probably intramuscular or into a tendon.
 
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Don't use ultrasound for SIJ, it won't be reimbursed unless you're billing it as a TPI.
 
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Right. Because by default they must have surgery if PT fails. So how do you pick your subset. Retrospectively, I presume.

Couple ways I think about this:
1) If patient has synovitis/capsular inflammation (on MRI or US), I absolutely inject into and around the joint and generally see decent lasting results (2 months +)
2) If just degenerative changes at the joint, and some bright marrow signal at distal end of the joint there is a shorter response.
3) If degenerative changes and NO increased marrow signal, then I don't expect much of a response - I usually don't bother injecting.
4) If there is distal osteolysis of the clavicle, then I don't inject since I consider that more of a fracture than arthritis. http://radiopaedia.org/cases/post-traumatic-osteolysis-of-outer-end-of-clavicle

- You'll note a lot of this prognosticating is based on MRI and not plain film. You'll also note I'm not posting any reference (so take this all with a grain of salt) because as of my knowledge, no one has published on MRI findings correlating to injection response - doubt we'll ever see something like that either (although hundreds of these injections are done every day - you'd think someone would have made that a small resident project).

If I want to inject both the AC joint and subacromial space as targets, there are occasions where the capsule is ruptured or there is an easy path trans-AC joint to inject the medication subacromial (contrast confirms under fluoro or with color doppler flow of medication on US - probably requires another hand). That's called a "geyser" sign through the ACJ. http://radiopaedia.org/articles/geyser-sign

For the OP, US landmarks for subacromial is fairly simple. Find the distal acromion (shadowing) and inject beneath, HOWEVER, the doesn't guarantee bursa. To get bursa, image deep to the deltoid, locate the bursa, place a needle there and distend with medication.
 
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Probably came across a little strong. Its a $75ish dollar injection with us. Just saying the cost and risk benefit is pretty favorable even if 1:10 work versus several PT visits or surgery
 
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