Hand and Wrist Procedures
Transverse US-guided injection of Botox alongside the digital neurovascular bundle 
on ulnar side base of the little finger is shown. A 25-g needle 
is positioned alongside the neurovascular bundle and Botox is injected 
. The flexor tendons 
of the little finger are seen alongside the neurovascular bundle.
Ten target point injections (yellow dots) are performed alongside the radial and ulnar neurovascular bundles at the base of the 5 fingers (7 injection points) and also in the midpalm region (3 injection points).
Clinical photograph of a patient with Raynaud phenomenon before Botox injection is shown. There is dry gangrene 
of the index finger tip and a generalized dusky discoloration of the fingers, particularly the little finger.
Clinical photograph of the same patient with Raynaud phenomenon several months after Botox injection is shown. The dry gangrene 
of the index finger tip has healed. The skin coloration is now normal.
PREPROCEDURE
Indications
PROCEDURE
Joint Aspiration or Injection
Sterile technique: Skin and underlying soft tissues anesthetized at puncture site
Avoid injection of bubbles by 1st flushing syringe and tubing
US assessment preprocedure planning best approach that will avoid neurovascular or tendon injury
Use free-hand technique to advance 25-g needle into joint space using continuous US guidance
Can use long-axis (preferable) or short-axis approach
Use smallest needle possible (23- to 27-g) that will comfortably reach joint
Ensure on real-time imaging that needle tip is within joint space and directed toward any joint fluid
Free flow of fluid with low-pressure injection helps confirm intraarticular position of needle tip
If free-fluid flow is not present, rotate or slightly realign needle
Continue monitoring joint on real-time imaging during procedure with realignment of needle if necessary
Post injection, apply local pressure and avoid active exercise for 10 minutes to prevent leakage of solution along needle track
25-g intravenous or spinal needle is used
Radiocarpal joint
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Hand and Wrist Procedures
