Ultrasound Guided Shoulder Injections Final
Ultrasound Guided ShoulderInjections Lisa Pomranky, MD Marie Barton, 4th year OHSU Medical Student
Disclosure I have no financial disclosures
Objectives Review: Common guided injections in and around the shoulder Accuracy and Efficacy Indications
First Let’s go on a tour of the shoulder!
Bicep
Subscapularis
Supraspinatus
Glenohumeral
AC Joint
Glenohumeral Joint
Glenohumeral Joint – approach
Glenohumeral Joint LMGI vs USGI accuracy Patel: Cadaveric study in 2012 usingposterior approach, 40 US, 40 landmarkguided by 2 surgeons. Ultrasoundguided was more accurate (92.5% vs72.5% with p 0.02)
Glenohumeral Joint LMGI vs USGI efficacy Raeissadat: RCT of 41 patients with adhesive capsulitis sawimprovements in pain, ROM, and functional score after 1 and 4weeks that were more prominent in the US-guided group, but thedifferences were not statistically significant, except for the changesin extension where the improvements were significantly higher inthe US-guided group (11 vs 2 degrees at 1 wk and 12 vs 3 degreesat 4 wk, p 0.01) Lee: In 2009 RCT of 43 patients with adhesive capsulitis, greaterimprovement in function and pain in first 2-3 weeks in US guided,but no difference after 4 weeks. (Figure at right) Greater benefits from US-guided in the short-term butequivalent after 1 month
Glenohumeral JointIndications: GH arthritis Frozen shoulder Diagnostic purposes Cost Effectiveness A 2017 cost-effectiveness study provided simulation models whereultrasound-guided injections in adhesive capsulitis showed to be thecheapest in 44% of cases compared to palpation- (34%) andfluoroscopy-guided (22%) injections
Bicep Sheath – approach
Bicep Sheath – approachWith US probe anterior,biceps in short axis Humeral head blueline Biceps tendon greenarrow Needle pink arrows
Bicep Sheath LMGI vs USGI accuracy Hashiuchi: 30 patients with tendinitis or tenosynovitis, higher accuracy inUSG vs LMG (86.7% vs 26.7%, p 0.05) Gazzillo: A study performed at Mayo Clinic demonstrated the difficulty ofpalpating biceps brachii tendon by assessing accuracy with ultrasound.Sports medicine fellow correctly identified the tendon in 12% of cases, andPMR resident correctly identified 0%.USGI vs Fluoroscopy-guided accuracy Pestcavage-Thomas: Compared to fluoroscopy-guided biceps tendon sheathinjection, ultrasound had higher (90.6% vs 74.0%) success rates, withsimilar pain relief and complication rates
Bicep Sheath LMGI vs USGI efficacy Zhang: 98 patients with tendinitis, greater reductions in pain andincreases in quality of function in USG vs LMG using VAS score (-4.8vs -2.9, p 0.01) and Constant-Murley score (53 vs 42.1, p 0.05) Indications: Alternative for intra-articular Isolated bicep tenosynovitis
Acromioclavicular Joint – approach
Acromioclavicular Joint LMGI vs USGI accuracy Aly: Meta-analysis of three trials revealedUSG to be more accurate vs landmarkguided (93.6% vs 68.2%, p 0.0001, I 0%)LMGI vs USGI efficacy Park et al: Among 100 patients with ACosteoarthritis, USGI showed significantlygreater improvements in pain and functionat 3 and 6 months. Significant outcomepredictor was injection accuracy.
Acromioclavicular Joint Indications: ArthritisDistal Clavicle Osteolysis
Subacromial Space – approach
Subacromial Space LMGI vs USGI accuracy Dogu: In a study of 46 patients with rotator cuff pathology,accuracy of US guided was higher but not significant (70 vs 65%,p 0.05)Pain reduction LMGI vs USGI efficacy Aly: Meta-analysis of 3 studies showed significantly greaterreduction in pain (MD 1.47) and improvement in function (SMD0.70) in US group at 6 weeks. Figures at right Cole et al: No difference in pain or function at 6 weeks betweenLMG and USG groups, in a study of 56 patients with impingementsyndrome,*but accuracy was not assessedFunctional improvementAly et al 2015
Subacromial Space Indications: Isolated bursitis Impingement Hydroxyapatite deposition Diagnostic purposes
Calcific Tendinopathy/HydroxyapatiteDeposition Disease
Fenestration/BarbotageZhang 2019: Meta-analysis comparing ultrasound-guidedpercutaneous lavage (UGPL,“control”) with other “experimental”treatments (NSAID, rest, PT, extracorporeal shock-wave therapy,subacromial corticosteroid injections)Calcification disappearance rateRR 1.73 [1.44, 2.07]Constant shoulder scoreMD 10.49 [6.99, 13.98]Need for surgeryMD 10.49 [6.99, 13.98]
Pre and Post Barbotage
ultrasound-guided injections in adhesive capsulitis showed to be the cheapest in 44% of cases compared to palpation- (34%) and fluoroscopy-guided (22%) injections . injection, ultrasound had higher (90.6% vs 74.0%) success rates, with similar pain relief and complication rates. Bicep Sheath
Blind versus guided glenohumeral joint injection. A guided injection is more accurate. Patients prefer ultrasound to fluoroscopy and there is the added benefit of no radiation, no claustrophobia, lower cost and decreased procedure time. Ultrasound guided injections confer added benefit especially in the first 2 weeks.
Three-dimensional ultrasound, may be acquired and displayed over time. This is variously known as 4D ultrasound, real-time 3D ultrasound, and live 3D ultrasound. When used in conjunction with 2D ultrasound, 3D ultrasound has added diagnostic and clinical value for select indications and circumstances in obstetric and gynecologic ultrasound.
Results Ultrasound Suboptimal injections - 3 patients with mixed intra- and extra-articular injections. - 2 patients with extra-articular injection. - 1 patient with no contrast injection due to patient discomfort. - 1 patient with inadequate visualization of the hip joint. 77 23 Ultrasound Guided Procedures Successful % Suboptimal %
exercise, ultrasound-guided shoulder injection or both. 250 patients with shoulder impingement 125 USGI vs 125 blind SAB injection ( physio) Conclusions - no significant improvement SUbacromial imPingement syndrome and Pain: a randomised controlled trial Of ExeRcise and injecTion - Keele University
Australasian Society for Ultrasound in Medicine Arterial spectral Doppler waveforms Tumour angiogenesis New technologies in ultrasound Fetal ultrasound video compression algorithm Quality of compressed ultrasound video ISSN 1441-6891 ULTRASOUND BULLETIN ASUM Multidisciplinary Ultrasound Workshop 2006 Gold Coast 24-25 March 2006
However, few evidence-based guidelines for IM injections are available, and discrepancies within nursing textbooks have been noted. 10-13 In addition, current guidelines do not address administration of large-volume injections. The dorsogluteal site for IM injections is the one nurses have the most experience using, as this is what is tradi-File Size: 256KBPage Count: 6Explore furtherLarge-volume IM injections: A review of best practices .www.oncologynurseadvisor.comInjection Safety CDCwww.cdc.govGUIDELINES ON THE ADMINISTRATION OF INTRAMUSCULAR www.olchc.ieSECTION 20: PEDIATRICS: Medication: Intramuscular .www.vnhcsb.orgIntramuscular injection: Locations and administrationwww.medicalnewstoday.comRecommended to you b
ultrasound injection, whereas 1 was uncertain. The injection was successful in 202 of the first 206 patients (98%) to undergo ultrasound injection, whereas 4 patients required a second pass for a successful injection. Discussion Our data clearly show that ultrasound-guided office-based intra-articular injection of the hip is an effective
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