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MSK Procedures:

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Shoulder Injection, Fluoro-Guided (YE Method):

 

Patient Set-up

 

  1. Pt. should be on the table supine

  2. YE prefers anterior approach.  For AA, the target is the rotator interval or the supero-medial HH.  

  3. While pt. supine, externally rotate arm to open up shoulder joint

  4. Use fluoro with intermittent pulsing

  5. find region of interest, collimate and place in center of field

  6. Mark area using hemostat and surgical marking pen

 

Table Set-up

 

  1. Set up table:

  2. Have RN help with drawing up meds

  3. Draw up 5-10 ml of lidocaine for skin anesthesia

  4. Draw up 1 ml of kenalog and 4 ml of lidocaine for injectate solution

  5. Draw up 10-20 ml of contrast, attach tubing and make sure tubing is full of contrast and no bubbles

 

Procedure:

 

  1. Prep area with iodine or chloraprep

  2. Drape area

  3. Use 22 G needle to begin advancement

  4. Advance needle at marked site

  5. Ensure perpendicular to beam, check with intermittent fluoro

  6. According to YE, should go in a couple inches

  7. Will sort of feel a loss of resistance at the joint, also you want to go until you feel bone (the HH, superomedial aspect)

  8. When in joint, remove inner stylet, inject lidocaine to ensure no resistance to flow

  9. If fairly certain in joint, injection the contrast from the tubing

  10. Now take images, check to ensure intraarticular pattern, SAVE IMAGE

  11. Now take injectate (4 ml lido and 1 ml kenalog) and inject entire mixture into the joint

  12. Check under fluoro, should see the contrast DILUTING because its mixing with the injectate in the joint

  13. *If joint infected or has effusion, remove 5-10 cc of fluid before injecting mixture to avoid pressurizing the joint acc. to YE

  14. When injectate injected, replace stylet, and then remove the needle quickly

  15. Apply pressure with gauze

 

Procedure complete

 

Addt'l Help:

Good website detailing procedure with pics

 

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Knee Injection, US-Guided (YE Method):

 

Patient Set-up

 

  1. Pt. should be on bed supine

  2. Knee can be fully extended, sometimes helps to bend slightly by placing pillows or wedge underneath knee

  3. Make sure bed height is up so don't have to bend

  4. YE prefers lateral approach


US Scanning:

 

  1. Use linear tranducer, 10 Mhz or so

  2. Scan the suprapatellar region, scan along long axis of quad tendon

  3. There should be fluid just lateral to the tendon, in the lateral pouch / gutter

  4. The fluid will have a triangular appearance

  5. Check with doppler to exclude vascularity along needle path

  6. Optimize settings with respect to gain, focal zone, depth

  7. Want to have tranducer transverse to long axis of quad tendon, so can visualize needle entering from lateral and going along long axis of probe

  8. Mark spot with surgical pen


Procedure:

 

  1. Prep and drape area

  2. Numb with lidocaine

  3. Set up probe cover

  4. Set up probe for real time guidance, transverse to long axis of quad tendon, want to enter needle from lateral along long axis of probe

  5. Use 20 or 22 G spinal needle

  6. Visualize needle entering into fluid

  7. When intra-articular, remove inner stylet, inject injectate (variety of injectates but often hyaluronic acid)

  8. Replace stylet, and remove needle

  9. Apply pressure and small dressing if nesc.

 

Procedure complete

 

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Hip Injection, US-Guided (YE Method):

 

Patient Set-up

 

  1. Pt. should be on bed supine

  2. Make sure bed height is up so don't have to bend over


US Scanning:

 

  1. Use linear tranducer, 10 Mhz or so

  2. Scan the groin region, identify femoral vessels (SFA and SFV) which are medial, make sure to stay lateral of this area

  3. Want to scan both longitudinal to iliopsoas tendon and transverse

  4. The approach will be longitudinal

  5. Should see femoral neck to head junction

  6. Should be able to see IP tendon superficially and should see thickening where the capsule is

  7. Goal is to advance neede to head / neck junction or head region, where you will be under the capsule

  8. Mark spot with surgical pen


Procedure:

 

  1. Prep and drape area

  2. Numb with lidocaine

  3. Set up probe cover

  4. Set up probe for real time guidance, longitudinal orient probe to long axis of iliospoas tendon, want to enter needle from lateral along long axis of probe

  5. Use 20 or 22 G spinal needle

  6. Visualize needle touching femoral head

  7. When intra-articular, remove inner stylet, inject lidocaine to see if flows freely (no resistance).  Then inject injectate (same as shoulder, 1 ml of steroid, 4 ml of lidocaine)

  8. Replace stylet, and remove needle

  9. Apply pressure and small dressing if nesc.  Take post procedure US image

 

Procedure complete

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