Ultrasound-guided interventions of the upper extremity joints

Abstract

Ultrasound guidance is valuable for performing precise joint interventions. Joint interventions may be requested for therapeutic and diagnostic pain injections, joint aspiration in the setting of suspected infection, or contrast injection for arthrography. In practice, interventions of the shoulder girdle, elbow, and hand/wrist joints may be performed without any imaging guidance. However, imaging guidance results in more accurate interventions and better patient outcomes than those performed by palpation alone. When compared to other modalities used for imaging guidance, ultrasound has many potential advantages. Radiologists should be prepared to perform ultrasound-guided upper extremity joint interventions utilizing recommended techniques to optimize clinical practice and patient outcomes. KEY POINTS: 1. Ultrasound-guided injections of the glenohumeral, acromioclavicular, sternoclavicular, elbow, and hand/wrist joints have higher accuracy than injections performed without imaging guidance. 2. Ultrasound-guided aspirations of upper extremity joints have advantages to fluoroscopic-guided aspirations because of the potential to identify effusions, soft tissue abscess, or bursitis. 3. Ultrasound-guided contrast injection prior to MR arthrography is as accurate as fluoroscopic-guided injection for upper extremity joints.

Keywords: Acromioclavicular joint; Arthrography; Aspiration; Corticosteroid injection; Elbow joint; Glenohumeral joint; Radiocarpal joint; Sternoclavicular joint; Trapeziometacarpal joint; Ultrasound.

Fig. 1

Technique for glenohumeral joint injection. a Image of a healthy volunteer shows transducer placement for anterior approach, which yields ultrasound image of the anterior glenohumeral joint space (b), showing the coracoid (C) and humeral head (HH) with expected needle trajectory (dashed arrow). c Image of a healthy volunteer shows transducer placement for posterior approach, which yields ultrasound image of the posterior glenohumeral joint space (d), showing the glenoid (G) and humeral head (HH) with the expected needle trajectory for either the medial-to-lateral or lateral-to-medial approach (dashed arrows)

Fig. 2

Ultrasound image of glenohumeral joint corticosteroid injection using posterior approach in a 46-year-old female with chronic shoulder pain and history of partial tear of the supraspinatus tendon. The humeral head (HH) and glenoid (G) are visualized posteriorly. The needle (arrows) trajectory extends medial to lateral with the tip at the humeral head, deep to the infraspinatus tendon (dashed arrow)

Fig. 3

73-year-old female with neck pain and elevated erythrocyte sedimentation rate (ESR) and c-reactive protein (CRP), as well as total shoulder arthroplasty placement one month prior. Point of care ultrasound in the emergency department described large glenohumeral joint effusion, so aspiration was requested. a Ultrasound image shows hypoechoic capsular distention (arrows) between the humeral (H) and glenoid (G) components. b Color Doppler image shows hypervascularity within the joint (arrows), consistent with synovitis. No fluid was detected, so aspiration was not performed. Subsequent cervical spine imaging identified discitis-osteomyelitis of the cervical spine as the source of infection

Fig. 4

Technique for acromioclavicular joint injection. a Image of a healthy volunteer shows transducer placement, which yields ultrasound image of the acromioclavicular joint space (b), showing the acromion (A) and clavicle (C) with expected needle trajectory for in-plane approach (dashed arrow)

Fig. 5

77-year-old female with chronic shoulder pain and tenderness to palpation over the acromioclavicular joint, for which corticosteroid injection was requested. Ultrasound image of acromioclavicular corticosteroid injection with the in-plane approach shows needle trajectory (arrows) with tip in the joint space between the acromion (A) and clavicle (C)

Fig. 6

Technique for sternoclavicular joint injection. a Image of a healthy volunteer shows transducer placement, which yields ultrasound image of the sternoclavicular joint space (b), showing the clavicle (C) and manubrium (M) with expected needle trajectory for in-plane approach (dashed arrow)

Fig. 7

66-year-old male with right sternoclavicular joint pain that worsens after playing racquetball, for which corticosteroid injection was requested. a Preprocedure ultrasound image shows the sternoclavicular joint with the manubrium (M) and clavicle (C). b Intra-procedure ultrasound image shows needle tip (arrow) at the clavicle (C) and fluid distention of the joint near the clavicle (dashed arrow)

Fig. 8

Technique for elbow joint injection. a Image of a healthy volunteer shows transducer placement for posterior approach. The transducer is oriented along the triceps tendon insertion at the olecranon (black dashed arrow) and translated laterally, which yields ultrasound image of the olecranon (O) and posterior fat pad (PF) (b). The needle trajectory (dashed arrow) is shown from proximal to distal. c Image of a healthy volunteer shows transducer placement for lateral, radiocapitellar approach. The transducer is oriented along the long axis of the radius (dashed arrow) which yields ultrasound image of the radiocapitellar joint space (d), showing the radial head (R) and capitellum (C) with expected needle trajectory for out-plane approach (dashed arrow)

Fig. 9

A 64-year-old female with a history of old elbow trauma followed by multiple elbow surgeries, including radial head resection, now with severe secondary osteoarthritis. a Lateral radiograph of the elbow shows severe joint space narrowing and osteophytosis, as well as radial head resection (arrow) and large effusion with elevation of the elbow fat pads (dashed arrows). After excluding infection of the joint, ultrasound-guided corticosteroid injection was requested for therapeutic pain relief. b Preprocedure ultrasound image at the posterior joint space shows large effusion with synovitis (dashed arrows). A posterior, transtriceps approach was used to aspirate joint fluid and inject corticosteroid and anesthetic. c Intraprocedure ultrasound shows the humerus (H) and olecranon (O) posteriorly with the needle tip (arrow) within the area of synovitis at the posterior joint space

Fig. 10

Technique for wrist or radiocarpal joint injection. a Image of a healthy volunteer shows transducer placement for radiocarpal joint approach. The transducer is oriented along the long axis of the distal radius which yields ultrasound image of the radiocarpal joint space (b), showing the distal radial epiphysis (R) and scaphoid (S) with expected needle trajectory for in-plane approach (dashed arrow)

Fig. 11

A 84-year-old male with chronic wrist pain for ten years. a Posteroanterior radiograph of the left wrist shows severe radiocarpal joint space narrowing with osteophytosis and cystic change in the radius and scaphoid. Ultrasound-guided corticosteroid injection was requested for therapeutic pain relief. b Intraprocedure ultrasound image shows the distal radius (R) at the radiocarpal joint with needle (arrows) in the dorsal joint space

Fig. 12

Technique for thumb carpometacarpal joint injection. a Image of a healthy volunteer shows the hand in a fist position with the ulna against the table. The transducer is oriented along the long axis of the thumb metacarpal base which yields ultrasound image of the joint space (b), showing the trapezium (T) and thumb metacarpal (MC) with expected needle trajectory for in-plane approach (dashed arrow)

Fig. 13

A 67-year-old male with severe thumb carpometacarpal joint osteoarthritis. a Posteroanterior radiograph of the left wrist shows severe thumb carpometacarpal joint space narrowing with large osteophytes. The patient had had prior injections by palpation, which were not effective for pain control. Ultrasound-guided corticosteroid injection was requested for pain relief. b Preprocedure ultrasound image shows obstructing ossification (arrow) at the joint. c Following pre-procedural assessment, an accessible path was found between the trapezium (T) and thumb metacarpal (MC), and intraprocedure ultrasound images shows the needle tip (arrow) in the joint space