Elbow Procedures

KEY FACTS

• Intraarticular aspiration or injection

Posterior (trochlear-olecranon) approach (preferable)

– Position probe sagittally along posterior part of elbow

Anterolateral (radiocapitellar) approach

– Potential risk to radial neurovascular bundle

– Needle tip placed into smaller space
• Tendinosis or ligament injection

Identify abnormal hypoechoic area of tendinosis ± anechoic cleft-like intrasubstance tears within area of tendinosis

Treatment is aimed at these areas
• Dry needling: To-and-fro movement of needle within area of tendinosis for 1 minute
• Autologous blood or platelet-rich plasma injection

Platelet-rich plasma of no proven benefit over dry needling or autologous blood injection for tendinosis
• Corticosteroid injection

Inject peritendinous tissue rather than tendon substance

Reduces peritendinitis but has no therapeutic effect on tendinosis per se

– Ultimately has deleterious effect on tendon

Corticosteroids lead to increased fibroblastic senescence, reduced collagen organization, and increased collagen necrosis within tendons
• Paraarticular cyst aspiration

18-g or larger needle for more viscous content

• Intraarticular aspiration or drainage of fluid

Suspected septic arthritis or crystal arthropathy

Temporary relief of symptoms due to distension pain
• Intraarticular injection of contrast or medication

Arthrography (CT or MR)

Medication to relieve pain or inflammation

– Steroid injection to reduce inflammation in either inflammatory osteoarthritis or inflammatory arthritis, such as rheumatoid arthritis

Radiosynovectomy

– Radioactive isotope (e.g., yttrium-90) injection into joint for radioablation of synovitis in hemophiliac patients or inflammatory joint disease

– Particularly useful in hemophiliac patients to reduce frequency of joint hemarthroses

In hemophilia, synovitis leads to recurrent hemarthroses, which leads to synovial hypertrophy and synovitis; this cycle of progressive deterioration leads to end-stage arthropathy
• Paraarticular aspiration, e.g., ganglion cyst
• Paraarticular soft tissue injection

For common extensor tendon origin (CETO) or common flexor tendon origin (CFTO) tendinosis

Dry needling, steroid injection, prolotherapy, autologous blood injection, or platelet-rich plasma (PRP) injection
• Biopsy of synovium/intraarticular soft tissue mass

• Things to check

Time-out procedure (patient identity, type and side of procedure, allergy status)

Informed consent form signed and risk of procedure explained
• Medications

Local anesthetic for skin (3 mL of 1% lignocaine)

Local anesthetic for intraarticular injection

– 1-2% lignocaine or 0.25-0.50% bupivacaine (Marcaine)

Steroid

– 40 mg/mL of methylprednisolone (Depo-Medrol)

Contrast

– CT arthrogram: 10 mL of iodinated contrast (Omnipaque 300 mg/dL ± 0.1 mL of 1:1,000 epinephrine)

– MR arthrogram: 10 mL of diluted gadolinium (0.1 mL of gadolinium in 10 mL of normal saline)
• Equipment list

Sterile set, 18- to 23-g spinal needle, extension tube, syringes, coaxial needle, and biopsy needle, sterile and specimen bottles

Apr 9, 2020 | Posted by admin in MUSCULOSKELETAL IMAGING | Comments Off