Ultrasound-Guided Musculoskeletal Procedures - The Upper Limb

Ultrasound-guided Musculoskeletal
Procedures
,UCA-ARIA3CONFIENZAs'IOVANNI3ERAFINI
%NZO3ILVESTRI
Editors
Ultrasound-guided
Musculoskeletal
Procedures
The Upper Limb
Editors
Luca Maria Sconfienza Enzo Silvestri
Radiology Unit Radiology Unit
IRCCS Policlinico San Donato Ospedale Evangelico Internazionale
San Donato Milanese (MI), Italy Genoa, Italy
Giovanni Serafini
Diagnostic Imaging Department
Ospedale S. Corona
Pietra Ligure (SV), Italy
ISBN 978-88-470-2741-1 ISBN 978-88-470-2742-8 (eBook)

DOI 10.1007/978-88-470-2742-8
Springer Milan Dordrecht Heidelberg London New York
Library of Congress Control Number: 2012939782
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Preface
Ultrasound is an emergent imaging modality that is widely used to assess

disorders affecting the musculoskeletal system. Among its many features,
it is the only imaging modality that is able to perform dynamic evaluations
of the soft tissues related to the musculoskeletal system, and without patient
exposure to ionizing radiation. Also, in expert hands, ultrasound enables the
precise guidance of needles within soft tissues and joints, for use in a wide
range of procedures.
The idea of preparing a handbook was based on the frequent requests of
our colleagues in other fields who were interested in learning ultrasound-
guided procedures as applied to the musculoskeletal system. This text is ex-
tremely practical, offering point-by-point checklists for each procedure to-
gether with detailed anatomic schemes. Ultrasound images of the different
applications are provided as well.
We would also like to emphasize that this handbook is based both on
our daily experience and on data obtained from the literature. It therefore
describes different approaches for the same procedure, allowing the reader to
select the most suitable for the particular application.
Even though not all procedures are specifically included in the contents,
readers should be able to extrapolate the appropriate ultrasound-guided tech-
nique for use in other anatomic districts.
Finally, we acknowledge the work of our young colleagues, Alice Ar-
cidiacono, Angelo Corazza, and Francesca Nosenzo, whose inputs were an
invaluable contribution to this book.
May 2012 Luca Maria Sconfienza

Giovanni Serafini
Enzo Silvestri
V
Contents
1 General Aspects of US-guided Musculoskeletal Procedures 1

Armando Conchiglia, Lorenzo Maria Gregori, Luigi Zugaro
and Carlo Masciocchi
Part I The Shoulder
2 The Shoulder: Focused US Anatomy and Examination

Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Enzo Silvestri and Davide Orlandi
3 Subacromial-Subdeltoid Bursa Injections . . . . . . . . . . . . . . . . 25

Enzo Silvestri
4 Treament of Calcific Tendinitis of the Rotator Cuff . . . . . . . . 29

Giovanni Serafini and Luca Maria Sconfienza
5 Calcific Enthesopathy Dry-Needling . . . . . . . . . . . . . . . . . . . . 37

Francesca Lacelli
6 Hyaluronic Supplementation of the Subacromial Space . . . . 41

Giovanni Serafini
7 Intra-articular Injections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Francesca Lacelli
8 Long Head of the Biceps Brachii Tendon Injection . . . . . . . . 51

Luca Maria Sconfienza
9 Acromioclavicular Joint Injection . . . . . . . . . . . . . . . . . . . . . . 55

Enzo Silvestri
VII
VIII Contents
Part II The Elbow
10 The Elbow: Focused US Anatomy and Examination

Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Enzo Silvestri and Emanuele Fabbro
11 Treatment of Lateral Epicondylitis . . . . . . . . . . . . . . . . . . . . . 67

Giovanni Serafini
12 Treatment of Medial Epicondylitis . . . . . . . . . . . . . . . . . . . . . 73

Enzo Silvestri
13 Olecranon Bursa Drainage . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

Francesca Lacelli
14 Intra-articular Injections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Part III The Wrist
15 The Wrist: Focused US Anatomy and Examination

Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Enzo Silvestri and Giulio Ferrero
16 Treament of De Quervain’s Disease and Other Forms

of Tenosynovitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Giovanni Serafini
17 Articular Ganglia Drainage . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

Leonardo Callegari
18 Trapeziometacarpal Joint Injection . . . . . . . . . . . . . . . . . . . . 101

Francesca Lacelli
19 Radiocarpal Joint Injections . . . . . . . . . . . . . . . . . . . . . . . . . . 105

Contents ix
Part IV The Hand
20 The Hand: Focused US Anatomy and Examination

Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Francesca Lacelli and Chiara Martini
21 Treatment of Trigger Finger . . . . . . . . . . . . . . . . . . . . . . . . . . 113

Leonardo Callegari
22 Intra-articular Injections: Metacarpophalangeal

and Interphalangeal Joints . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121

Contributors
Alice Arcidiacono Post-graduate School in Radiodiagnostics, University

of Genoa, School of Medicine, Genoa, Italy
Leonardo Callegari Radiology Unit B, Ospedale di Circolo, Fondazione

Macchi, Varese, Italy
Armando Conchiglia Radiology Department, Ospedale San Salvatore,

University of L’Aquila, L’Aquila, Italy
Angelo Corazza Post-graduate School in Radiodiagnostics, University of

Genoa, School of Medicine, Genoa, Italy
Emanuele Fabbro Post-graduate School in Radiodiagnostics, University

Giulio Ferrero Post-graduate School in Radiodiagnostics, University of

Lorenzo Maria Gregori Radiology Department, Ospedale San Salvatore,

Francesca Lacelli Diagnostic Imaging Department, Ospedale S. Corona,

ASL 2 Savonese, Pietra Ligure (SV), Italy
Chiara Martini Post-graduate School in Radiodiagnostics, University of

Carlo Masciocchi Radiology Department, Ospedale San Salvatore,

Francesca Nosenzo Post-graduate School in Radiodiagnostics, University

Davide Orlandi Post-graduate School in Radiodiagnostics, University of

xi
xii Contributors
Luca Maria Sconfienza Radiology Unit, IRCCS Policlinico San Donato,

San Donato Milanese (MI), Italy
Giovanni Serafini Diagnostic Imaging Department, Ospedale S. Corona,

ASL 2 Savonese, Pietra Ligure (SV), Italy
Enzo Silvestri Radiology Unit, Ospedale Evangelico Internazionale,

Genoa, Italy
Luigi Zugaro Radiology Department, Ospedale San Salvatore, University

of L’Aquila, L’Aquila, Italy
General Aspects of US-guided
Musculoskeletal Procedures 1
Armando Conchiglia, Lorenzo Maria Gregori,
Luigi Zugaro and Carlo Masciocchi
Ultrasonography (US) is a quick and non-inva- ing high safety standards together with a smooth
sive imaging modality that allows for the precise workflow.
visualization of almost all soft-tissue components The suggested structural requirements are the
of the musculoskeletal system. Moreover, this following:
modality also enables accurate guidance during • The rooms and spaces are related to the na-
interventional procedures, thus reducing the risks ture and extent of the activities performed.
of complications. As US is relatively operator- The minimum clearance should be 4 m, with
dependent, an effective scanning technique is a 1.5-m clearance around the bed
strictly correlated with the ability to delineate • Chamber of observation
US appearances. If clinical knowledge is the ba- • Medical staff preparation area
sic requirement for any diagnostic or therapeutic • Storage area for clean material
process, then US-guided interventional proce- • Disposal area for soiled material
dures analogously require thorough knowledge • Waiting area
of the equipment being used. Also good techni- • Toilet and sink for patients
cal skills are needed in order to extract the maxi- • Toilet and sink for medical staff.
mum amount of information that can be obtained
with the available equipment, while avoiding the The suggested technical requirements are the
numerous pitfalls and artifacts of this imaging following:
modality. • Adjustable (height and angular adjustments)
surgical bed
• Ventilation system capable of maintaining a
Setting constant air exchange within the room
• Adjustable lighting system illuminating the
Room surgical field
• Medical gas pipeline systems
A proper setting for the room used in the inter- • Emergency trolley
ventional procedures is a prerequisite in ensur- • Emergency call system.
US System
Luigi Zugaro ( )
Radiology Department
While choosing the right US system can be ex-
Ospedale S. Salvatore, University of l’Aquila tremely challenging, an informed and useful
L’Aquila, Italy choice is more likely if the purchaser has a clear
L.M. Sconfienza, G. Serafini, E. Silvestri (eds.), Ultrasound-guided Musculoskeletal Procedures, 1

DOI 10.1007/978-88-470-2741-1_1 © Springer-Verlag Italia 2012
2 A. Conchiglia et al.
concept of the US-guided interventional proce- performed in order to identify the most reliable
dures that will be performed. procedure setting and to confirm the expected
In general, the basic requirements for dedi- findings. This is extremely important because
cated interventional US equipment are: the patient’s condition may have changed since
the previous examination, necessitating different
Ergonomics treatment.
• System dimensions and steering. The system
should be portable, allowing for transporta-
tion to remote clinics or for operating-theater Clinical History
work. Machines used regularly for mobile
work should be robust and easy to move. It is important to have at least basic information
Hand-held portable machines are an option. on the patient’s medical history. A brief prelimi-
• Moveable (swivel and tilt) monitor and con- nary talk, covering the following items, should
trol panel, including height adjustment for be held with the patient or his/her physician:
different operators and situations. • Present complaint(s)
• Keyboard design facilitating access to the re- • History of the present complaint(s)
quired functions, without the need for stretch- • Past medical history
ing or twisting. • Drug/allergy history
• Family medical history
Materials • Personal and social history
• Long-lasting materials with high resistance to • Systems review.
common antiseptics In general, the three most urgent considera-
• Smooth surfaces that can be easily and quick- tions that must be carefully assessed before any
ly cleaned. US-guided interventional procedure are:
• The presence of blood-thinning pathologies
Technical Requirements or the use of blood-thinning drugs that could
• Quick probe selection and switching process, cause severe bleeding during and after the
simultaneous connection of several probes procedure
• Dynamic frequency capability • The presence of drugs allergies
• Dynamic focusing control, number and pat- • The presence of diabetes, which is a contrain-
tern of focal zones dication for steroid use.
• Functions such as beam steering, sector angle
adjustment, zoom, frame rate adjustment.
Explanation of Contraindications
Probes to the Interventional Procedure and
• High-frequency linear-array probes, operat- Informed Consent
ing with frequencies of 10 MHz or more, are
mandatory Despite the minimal invasiveness of the inter-
• Compatibility with US guidance devices ventional procedures described in this book, the
• Ergonomic handle shape to preserve a neutral patient must be provided with an accurate expla-
wrist position nation of the possible contraindications related to
• Probe design allowing use with either hand. the planned procedure. Although the complica-
tion rate associated with these procedures is ex-
tremely low, patients should be aware that their
US-guided Procedures occurrence cannot be ruled out entirely. The sub-
jects that must be clearly explained to the patient
Prior to any interventional procedure, a prelimi- are the following:
nary US evaluation of the affected site should be • Pain/soreness during the procedure
• Pain/soreness after the procedure and the pos- sues; if required for the procedure, a sterile
sibility of steroid flare probe cover is used.
• Potential risk of joint infection • Patient antisepsis: the skin cannot be “steri-
• Potential risk of tendon rupture. lized” but certain chemical preparations
After receiving this information, the patient reduce microbial levels. Our antisepsis pro-
must formally agree to the procedure by provid- cedure is composed of a first step in which
ing both verbal and written informed consent. a brown water-based povidone-iodine solu-
tion is used to mark the treated area and after
3–5 min (sufficient to let the antiseptic act),
Antisepsis in the second step, a transparent solution of
70% isopropyl alcohol and 2% chlorhexidine
All US-guided interventional procedures must is applied that disinfects by denaturing pro-
be performed with aseptic techniques in order teins and disrupting the cell wall of microor-
to avoid any risk of contamination by infectious ganisms in addition to being bactericidal and
organisms (bacteria, fungi, viruses) or other dis- long-acting. Both steps are recommended for
ease-causing microorganisms. adequate skin decontamination prior to the
The cornerstones of a safe US-guided inter- insertion of an invasive device.
ventional procedure are: • Surgical field: delimitation of the area to be
• Antisepsis: transient microorganisms are operated on is performed by the operator us-
removed from the skin using chemical solu- ing sterile technique, including adhesive ster-
tions for disinfection. ile towels.
• Aseptic non-touch technique: ANTT mini- • US contact gel: conventional US contact gel
mizes the risk of infection by ensuring that should not be used for aseptic US-guided
only uncontaminated objects/fluids make procedures. However, contact gel is not gen-
contact with sterile/susceptible sites. The erally used in short procedures (e.g., simple
only part of sterile equipment that may be injections). For longer procedures, sterile
handled is that which will not be exposed to contact gel can be applied.
the susceptible site. Re-useable equipment
employed during an aseptic procedure should
be cleaned with wipes and must be fit for pur- Needles and Syringes
pose, e.g., a steel dressing trolley for dress-
ing changes. All packs/single-use equipment, The wide range of different interventional pro-
e.g., dressing packs, cannula packs, and sy- cedures implies the use of several different kinds
ringe packs, must be intact, with a still-valid of needles.
expiration date, and without visible signs of Needles of different diameters (measured in
contamination. gauges, G; the lower the number, the higher the
• Operator sterility: accurate and effective hand diameter) and lengths (measured in millimeters)
hygiene is the most important component of are used for all procedures:
good infection prevention and control, given • Superficial procedures are generally per-
that the hands are a common route of infec- formed using thin (26–32G) and short (2–5
tion transmission. Transient bacteria can be cm) needles.
removed by effective hand hygiene tech- • Procedures that require the aspiration of
niques, e.g., by washing the hands with an dense collections, such as ganglions or cal-
antimicrobial liquid soap and water, or by us- cifications, are performed using larger (14–
ing an alcohol-based hand rub. Sterile gloves, 16G) needles. Needle length is strictly related
coats and hats are mandatory. to the depth of the target.
• Probe antisepsis: the US probe and probe • Spinal needles are used for deep locations,
wire are swiped with dedicated antiseptic tis- such as hip joints or in obese patients. The
most common spinal needles used in these How Is the Needle Inserted?
procedures are 9–12 cm and 16–22G.
Syringes come with a number of designs for Guidance of the needle under US can be
the area where the blade locks to the syringe performed with either the lateral or co-axial
body. Our preference is to use slip tip syringes approach. In the former, the needle is kept per-
as they are easiest to connect to the needle for pendicular to the US beam and is inserted on
all procedures that do not involve high pressure; the short side of the probe. In the latter, the
in that case, we use Luer-lock ones which assure needle is inserted on the long side of the probe,
a screw lock mechanism by simply twisting sy- parallel to the US beam. The lateral approach
ringe and needle together. The choice of syringe has the advantage of excellent visibility of
size strictly depends on the amount of fluid to in- the needle, which, however, crosses a larger
ject/drain. amount of tissue before reaching the target
For the most common upper limb procedures, than is the case with the co-axial approach.
we recommend the following: On the other hand, the coaxial approach is
• 1–2 ml: used around the hand/wrist for very burdened by a reduced needle visibility, but it
small joint injections (MCP, PIP, DIP) and can be used when the space around the target
for the treatment of trigger finger and teno- is greatly restricted. However, adequate expe-
synovitis. rience is needed to achieve satisfactory results
• 5–10 ml: used to inject sub-acromial bursa, (Fig. 1.1a-b).
the drainage of small collections, and to drain
tennis/golfer’s elbow.
• 20 ml: used for calcification lavage and aspi-
ration, or the evacuation of fluid collections.
Fig. 1.1 a In US-guided lateral approach the

needle is inserted on the short side of the probe
allowing for an excellent visibility. b In US-
guided coaxial approach the needle is inserted on
the long side of the probe, allowing for a reduced
path in soft tissues but a poor visibility
Drugs Adverse Effects

The patient may experience temporary side ef-
Local Anesthetics fects after local anesthetic administration, but per-
sistent problems are rare. Side effects can include:
The important role played by local anesthetics • Numbness of the tongue
is due to their ability to interrupt neural conduc- • Dizziness
tion, by inhibiting the influx of sodium ions. In • Blurred vision
most cases, this inhibitory activity follows their • Muscle twitching
diffusion through the neural membrane into Local anesthetics depress the central nervous
the axoplasm, where they enter sodium chan- system in a dose-dependent manner. Convulsive
nels. The local anesthetic molecule consists of seizures are the principal life-threatening con-
three components, a lipophilic aromatic ring, sequence of an overdose. Evidence of lidocaine
an intermediate ester or amide chain, and a ter- toxicity may occur at concentrations of 5 g/ml,
minal amine, each of which confers distinct but convulsive seizures not until 8 g/ml. In ad-
properties to the molecule. The aromatic ring dition to neural blockade, the peripheral actions
improves the lipid solubility of the compound, of most local anesthetics include varying degrees
which in turn enhances diffusion through both of vasodilation, which in turn contributes to the
nerve sheaths and the neural membranes of the hypotension observed after the administration of
individual axons comprising a nerve trunk. This larger doses. It must be borne in mind that, as
property correlates with drug power, as a greater central nervous system depressants, local anes-
portion of an administered dose thereby enters thetics potentiate any respiratory depression as-
neurons. sociated with the use of sedatives and opioids.
US-guided interventional procedures usually Contrary to conventional thought, doses calculat-
require local anesthesia to minimize pain and ed as mg/years of age or mg/kg body weight do
discomfort. The type and amount of anesthetic not predict the systemic serum concentration of
used depends largely on the procedure itself the local anesthetic. Furthermore, considerations
and the involved anatomical location. of the toxicity of any drug class must include the
Fast-acting local anesthetics, such as a 100 activity of not only the drug but also its metabo-
mg/5 ml lidocaine solution (2%), are injected lites. Local anesthetics are no exception.
with a small needle around and within the area It is not unusual for patients to claim that
to be treated. Patients will initially experience a they are allergic to local anesthetics. Upon care-
brief stinging sensation related to the needle and ful questioning, however, it becomes apparent
the anesthetic being introduced; bicarbonates that what they experienced was either a syncopal
buffering significantly reduces this type of sensa- episode associated with the injection or cardiac
tion. Within seconds, typically, the area becomes palpitations attributed to epinephrine either con-
numb. Lidocaine solutions are also an option for tained in the solution or released endogenously.
US-guided diagnostic nerve blocks, with the an- Although rare, allergic reactions to local anes-
esthetic injected around the nerve over the level thetics have been reported in the scientific litera-
of the suspected pathology. ture, but in none of these cases was there a con-
Long-acting local anesthetics, such as a 25 firmed IgE-mediated hypersensitivity reaction.
mg/10 ml bupivacaine hydrochloride solution Nevertheless, patients have occasionally experi-
(0.25%), are injected in association with corti- enced symptoms consistent with an allergic reac-
costeroids for local relief at sites of musculoskel- tion to amide local anesthetics. These episodes
etal discomfort (articular and extra-articular) and generally have been attributed to the preserva-
for therapeutic nerve blocks. tives (methylparaben) or antioxidants (bisulfites)
contained in the solution.
Corticosteroids Dexamethasone-type preparations, however,

are not esters and are freely soluble in water;
Inflammation is one of the body’s first reactions to hence, the preparation is clear (i.e., non-partic-
injury. The increase in local blood flow transports ulate). The potential advantage of corticosteroid
polymorphonuclear leukocytes, macrophages, ester preparations is that they require hydrolysis
and plasma proteins to the injured area, where a re- by cellular esterases to release the active moi-
distribution of arteriolar flow produces stasis and ety; consequently, their actions in the joint are
hypoxia at the injury site. The resulting infiltra- longer-lasting than those of non-ester prepara-
tion of the affected tissues by leukocytes, plasma tions. By contrast, freely water-soluble prepara-
proteins, and fluid causes the redness, swelling, tions, such as dexamethasone sodium phosphate
and pain that are characteristic of inflammation. and betamethasone sodium phosphate, are taken
The causes of inflammatory muscle and joint up rapidly by cells and thus have a quicker onset
injuries including: of effect but with a concomitant reduced dura-
• Degenerative joint disease tion of action. Soluble preparations must be used
• Tendinopathy in all cases in which there is the risk of inadvert-
• Bursitis ent intra-arterial injection, as it could result in
• Arthritis embolic infarction from particulate corticoster-
• Trauma. oid esters.
Initially, the inflammatory reaction serves The duration of action of corticosteroids can
several important purposes. For example, the be estimated based on their biologic half-life,
influx of leukocytes facilitates phagocytosis, al- pharmaceutical half-life, or duration of clinical
lowing the removal of damaged cells and other benefit. While the duration of clinical benefit is
particulate matter. the most practical assessment, it is unfortunately
The mechanism of corticosteroid action in- the most subjective and differs widely in litera-
cludes a reduction of the inflammatory reaction ture reports, without statistically significant dif-
by limiting capillary dilatation and the perme- ferences. As previously explained, ester prepa-
ability of the vascular structures. These drugs rations of a corticosteroid would be expected to
restrict the accumulation of polymorphonuclear have a longer half-life, since release of the ac-
leukocytes and macrophages, reduce the release tive moiety relies on the activities of the patient’s
of vasoactive kinins, and inhibit the release of own hydrolytic enzymes (esterases).
destructive enzymes that attack the injury debris Corticosteroids are sometimes administered
and destroy normal tissue indiscriminately. after admixture with other agents in the same
Steroids have variable structures, functions, syringe. The potential advantages over a dual-
and sites of action. In addition to the steroids syringe technique is the reduced chance of in-
found in nature, there are many that have been advertent needle movement during syringe ex-
synthetically produced. These molecules differ change and a marginally reduced procedure
mostly with respect to the functional groups at- time.
tached to their carbon rings.
The synthetic corticosteroids most commonly Adverse Effects
used in radiology procedures are derivatives of The established adverse effects associated with
prednisolone (an analogue of cortisol). All have corticosteroid injections include the following:
anti-inflammatory potencies per dose unit that • Infection
are somewhat greater than that of cortisol. • Post-injection flares
Corticosteroid preparations can be either • Local tissue atrophy
soluble or insoluble. Most corticosteroid prepa- • Tendon rupture
rations contain corticosteroid esters, which are • Cartilage damage
highly insoluble in water and thus form micro- • Flushing
crystalline suspensions. • Increased blood glucose levels.
The most feared complication after ster- Hyaluronic Acid

oid injection is infection. With the use of good
sterile technique, however, the incidence of The administration of hyaluronic acid with US-
this complication is as low as 0.01–0.03%. The guided intra-articular injection, referred to as
most common adverse effect is the post-injec- viscosupplementation, has been demonstrated
tion flare, which is a local increase in inflamma- to be effective in the treatment of moderate and
tion that develops within hours and can last 2–3 severe osteoarthritis. The aim of the procedure
days. The prevalence of post-injection flare is is to reduce disability and pain by restoring the
2–25% and does not predict a poor response to physiological properties of the synovial fluid and
therapy. The cause of the flare may be the previ- thereby improving articular function and the re-
ously described microcrystalline steroid esters, covery of working and social activity.
which may incite a crystal-induced arthritis, The intra-articular administration of hya-
or possibly a chemical within the drug formula- luronic acid has a role not only in restoring the
tion. viscoelastic properties of synovial fluid (pure
Local tissue necrosis, calcification, and ten- mechanical effect), but also in stimulating the
don rupture have been associated with extra-ar- endogenous production of hyaluronic acid by
ticular injections of the corticosteroid formula- articular chondrocytes and synoviocytes through
tion triamcinolone hexacetonide. Accordingly, it the release of products based on hyaluronic acid.
is recommended that this particular drug be ad- Hyaluronic acid is a polysaccharide member
ministered only under US guidance, even though of the group of glycosaminoglycans. It is a poly-
it is a very effective medication, with a clinical mer with a very high molecular mass and con-
benefit of up to several months. sists of repeating units of N-acetylglucosamine
There are a number of soft-tissue adverse ef- and glucuronic acid linked together by glycosidic
fects associated with the local injection of corti- bonds. It is present in the superficial layers of
costeroids, namely, skin atrophy and depigmen- cartilage, the intercellular matrix of the joint cap-
tation, as well as fat necrosis. These are most sule, synovial tissue, and synovial fluid. Hyalu-
noticeable after the injection of superficial struc- ronic acid is highly absorbent with visco-elastic
tures (e.g., ganglia and tendon sheaths) but can properties: viscosity (lubrication) in case of static
also be seen after an intra-articular injection, pre- compressive strength and elasticity (shock-ab-
sumably due to the reflux of corticosteroid along sorbing) in response to dynamic shear and com-
the needle track. pressive forces.
Corticosteroids increase protein catabolism, Hyaluronic acid can be classified according to
and the possibility of tendon rupture associated its molecular mass:
with intratendinous corticosteroid injection is • Low (up to 1000 kDa)
well recognized, implying that peritendinous in- • Average (1000–4000 kDa)
jections should be performed with caution. US • High (> 4000 kDa).
guidance will increase injection accuracy. These differences in molecular mass trans-
Systemic effects do occur following soft- late into different effects; low molecular mass
tissue or intra-articular injections but are gen- forms have greater tissue penetration, producing
erally believed to have minimal clinical impor- a higher concentration of the product around the
tance. Nevertheless, it is important for the treat- cell surface and a more powerful pharmacologi-
ing radiologist to be aware that intra-articular cal response by chondrocytes. The stabilization
corticosteroids do exert variable systemic ef- of aggregates at high density and high molecular
fects. Patients with diabetes who are adminis- mass (> 2000 kDa) results in the reduced motility
tered such injections should thus be warned to of single hyaluronic acid molecules, preventing
expect a slight increase in their blood glucose their rapid degradation by synovial cells, which
level. take up only free molecules. The prolonged
half-life of these preparations within the joint
(approximately 4 weeks) allows the long-term The role of PRP in oral, plastic, maxillofacial
treatment of osteoarthritis with only a single hya- and orthopedic surgery has been studied; for ex-
luronic acid injection. ample, in the treatment of tendinosis, a fast and
durable recovery of tendon structure was demon-
strated. However other studies, also conducted
Platelet-Rich Plasma on large series, concluded that PRP is no more
effective than placebo. These issues need to be
Autologous platelet-rich plasma (PRP) is derived addressed before PRP can be used routinely.
from three components (platelet concentrate,
cryoprecipitate of fibrinogen, and thrombin) of
whole blood withdrawn from the patient and Post-procedural Care
combined at the moment of administration.
The growth factors contained in the platelets, After the interventional procedure the treated
including transforming growth factor-β (TGF-β), skin is covered with a plaster and a compressive
platelet-derived growth factor (PDGF), fibroblas- dressing and the patient is instructed to apply
tic growth factor (FGF), and insulin-like growth an instant ice bag over the treated area. Patients
factor (IGF), are physiologically involved in tis- should be monitored for the after-effects of anes-
sue repair mechanisms and are concentrated in thesia for at least half an hour after the procedure.
PRP, thus promoting healing of the injured tissue. After they have been instructed regarding the
Preparations of PRP are obtained from the management of possible complications, such as
transfusion medicine service of the hospital or pain and skin reddening, in the following hours/
prepared using disposable kits. Following activa- days, they can be discharged from the hospital/
tion with 1–2 ml of 10% calcium gluconate solu- clinic.
tion, autologous PRP must be injected immedi-
ately to prevent gelification.
Fig. 1.2 A well-organized tray containing all the

required materials is strongly recommended and
includes syringes, anesthetic, antiseptic solutions,
saline solution, containers, sterile tissues, gloves,
and drugs
General Workflow for US-Guided Interventional Procedures
• Verbal and written informed consent is obtained after the patient has received a comprehensive
explanation of the risks and possible complications associated with the procedure. Local regula-
tions may vary among different countries and hospitals. A representative of the pertinent institu-
tion should be involved in formulating an appropriate informed consent form.
• Pre-interventional planning should include a deep knowledge of the procedure and of the materi-
als, as well as a preliminary US evaluation of the lesion.
• Patient positioning on the bed or operating table is particularly important, with the comfort of
both the patient and the operator confirmed in order to avoid any sudden movements by either one.
• Operator sterility should be performed as described above.
• Both the US equipment and the probe are swiped with dedicated antiseptic tissues and, if re-
quired for the procedure, a sterile probe cover is used.
• All devices and drugs should be prepared in full sterility before the procedure commences. The
availability of an organized tray with all materials is recommended (Fig. 1.2).
• Operating field delimitation with adhesive sterile towels should be performed by the sterile
operator.
• Skin antisepsis should be as accurate as possible. While the skin cannot be “sterilized,” certain
chemical preparations reduce microbial levels. We recommend a 2-step antisepsis procedure: (1)
the area to be treated is wiped with a brown water-based 5% povidone-iodine solution; (2) after
3–5 min (time required to let this antiseptic to act), the same area is wiped with a transparent 2%
chlorhexidine-based solution, which denatures the proteins and disrupts the cell walls of con-
taminating organisms, is bactericidal, and is long-acting. This second step improves skin sterility
and avoids staining of the US probe.
• Antiseptic solutions usually create a good coupling between the skin and the US probe. When
longer procedures are performed (e.g., the treatment of calcific tendinitis), a small amount of
sterile contact gel can be used.
Part I
The Shoulder
The Shoulder: Focused US Anatomy
and Examination Technique 2
Enzo Silvestri and Davide Orlandi
The shoulder can be subdivided into three com- Scanning Technique

partments: anterior, lateral, and posterior. The patient is seated opposite the examiner, with
his or her forearm 90° flexed and the arm resting
on the thigh, slightly internally rotated, palm fac-
Anterior Compartment ing up. The transducer is placed in a horizontal
position on the anterior aspect of the shoulder, to
Long Head of the Biceps Brachii Tendon localize the bicipital groove (between the lesser
and greater humeral tuberosities). Between the
Anatomy two bony structures, the long head of the biceps
This tendon originates from the bicipital anchor, brachii tendon can be visualized on an axial scan
on the apex of the glenoid labrum. It courses as an oval-shaped, hyperechoic structure with
laterally and anteriorly, turning distally inside a fibrillar echotexture. The probe is then glided
the bicipital groove. It ends at its myotendinous caudally, to evaluate the vertical part of the ten-
junction, located under the insertion of the pec- don up to the myotendinous junction, followed
toralis major tendon on the anterior humeral dia- by a 90° clockwise rotation to evaluate the ten-
physis. don along its long axis.
Enzo Silvestri ( )
Radiology Unit
Ospedale Evangelico Internazionale
Genoa, Italy

14 E. Silvestri and D. Orlandi
Fig. 2.1 Evaluation of the long head of the biceps brachii

tendon. a The probe and patient are positioned for an
evaluation of the long head of the biceps tendon on a
short-axis scan. b Anatomical scheme of the long head
of the biceps brachii tendon as seen along its short-axis
(arrowheads). GT greater tuberosity, LT lesser tuberosity.
c US short-axis scan of the long head of the biceps
brachii tendon (arrowheads). D deltoid muscle
2 The Shoulder: Focused US Anatomy and Examination Technique 15
Fig. 2.2 Evaluation of the long head of the biceps brachii

tendon. a The probe and patient are positioned for an
evaluation of the long head of the biceps tendon on a
long-axis scan. b Anatomical scheme of the long head
of the biceps brachii tendon as seen along its long axis
(arrowheads). H humerus. c US long-axis scan of the
long head of the biceps brachii tendon (arrowheads).
D deltoid muscle
Subscapularis Tendon Scanning Technique

With the operator holding the probe on the bi-
Anatomy cipital groove, the patient performs an extra-
The subscapularis muscle originates from the rotation of the forearm to extract the subscapu-
subscapularis fossa, on the anterior aspect of laris tendon, allowing its visualization on a lon-
the scapula. It runs laterally and anteriorly and gitudinal scan, while the elbow is kept as close
its distal tendon inserts on the anterior aspect of as possible to the thoracic wall. With the probe
the humeral head. Most fibers insert on the lesser turned 90° clockwise, the subscapularis tendon
tuberosity, while others contribute to the stabil- can be assessed on its short axis, thus demon-
ity of the biceps tendon, inserting on the greater strating the alternation of tendinous and muscu-
tuberosity and on the bicipital pulley. lar fibers.
Fig. 2.3 Evaluation of the subscapularis tendon.

a The probe and patient are positioned for an evaluation
of the subscapularis tendon on a long-axis scan.
b Anatomical scheme of the subscapularis tendon (SSC)
as seen along its long axis. H humerus. c US long-axis
scan of the SSC. D deltoid muscle
Fig. 2.4 Evaluation of the subscapularis tendon.

of the subscapularis tendon on a short-axis scan.
b Anatomical scheme of the subscapularis tendon as seen
along its short axis (arrowheads). H humerus.
c US short-axis scan of the subscapularis tendon
(arrowheads). D deltoid muscle
Glenohumeral Anterior Recess surface of the anterior glenoid rim is seen as a

The probe is placed in the same position used to triangular echogenic structure just medial to this
evaluate the subscapularis tendon along its long line. The coracoid process partially hinders the
axis and is then moved medially, which allows articular space. The anterior glenoid labrum may
visualization of the articular cortex of the hu- occasionally be seen as a well-defined, triangular,
meral head. This structure appears as a spheri- echogenic structure.
cally curved echogenic line, while the cortical
Fig. 2.5 Evaluation of the glenohumeral anterior recess.

of the glenohumeral anterior recess. b Anatomical scheme
of the glenohumeral anterior recess (arrow). H humerus,
SSC subscapularis, C coracoid process, G glenoid.
c US scan of the glenohumeral anterior recess (arrow)
Lateral Compartment Supraspinatus Tendon
Subacromial-Subdeltoid Bursa Anatomy

The subacromial subdeltoid (SASD) bursa is a The supraspinatus muscle is located in the fossa
wide mucous bursa covering the rotator cuff as supraspinata of the scapula. Its tendon courses
a cap. It acts as a local attrition attenuator and laterally and slightly anteriorly, inserting on the
facilitates gliding of the supraspinatus tendon upper portion of the greater tuberosity. A few fib-
underneath the acromion during arm abduction. ers are sent also to the bicipital pulley.
This structure consists of a subacromial portion
(located between the superior face of the joint Scanning Technique
capsule and the inferior surface of the acro- The patient places his or her hand on the ho-
mion) and a subdeltoid portion (located deep to molateral iliac wing, with the elbow as medial
the deltoid muscle), which may extend laterally as possible. Starting from the bicipital groove,
and inferiorly as far as 3 cm below the greater the probe is shifted cranially and laterally in an
tuberosity. In a minority of patients, a subcora- axial-oblique fashion along the major axis of
coid extension is present. When the rotator cuff is the supraspinatus tendon, posterior to the biceps
intact, this bursa does not communicate with the tendon. A correct scan is obtained when the hu-
articular joint space. In normal conditions, the meral head cartilage, the anatomical neck of the
SASD bursa appears as a 2-mm-thick structure humerus, and the greater humeral tuberosity are
made up of a thin inner layer of hypoechoic fluid seen together. Anisotropy artifacts may particu-
between two layers of hyperechoic peribursal fat. larly disturb the insertional area of the tendon on
The synovial membrane of the bursa cannot be the humeral neck. These artifacts can be avoided
depicted with US. by slightly tilting the probe laterally such that the
US beam is as perpendicular as possible to the
tendon fibers. The probe should then be rotated
90° clockwise to assess the tendon’s short axis.
Fig. 2.6 Evaluation of the supraspinatus tendon.

of both the supraspinatus tendon on a long-axis scan
and the SASD bursa. b Anatomical scheme of the
supraspinatus tendon (SSP) as seen along its long axis.
GT greater humeral tuberosity, arrow SASD bursa.
c US long-axis scan of the SSP. Arrow SASD bursa,
D deltoid muscle, asterisks articular cartilage. The
arrowhead indicates the critical zone of the SSP where
anisotropy artifacts may occur
Posterior Compartment Scanning Technique

The patient sits opposite the examiner, elbow
Infraspinatus and Teres Minor Tendons flexed and palm on the opposite shoulder. The
probe should be oriented vertically to localize
Anatomy the scapular spine, which separates the fossa su-
The infraspinatus and teres minor muscles arise praspinata from the fossa infraspinata. Within the
from the fossa infraspinata of the scapula, the latter, the infraspinatus and teres minor muscles
former cranial to the latter. Both tendons course can be seen along their short axis with a sagittal
laterally and cranially, inserting on the posterior US scan. The probe should then be shifted later-
aspect of the greater tuberosity. ally to assess both tendons on a short-axis view.
The longitudinal axis of each tendon can be stud-
ied by rotating the probe 90°.
a b
Fig. 2.7 Evaluation of the extra-rotator tendons.

The patient (a) and probe (b) are positioned for an
evaluation of the extra-rotator tendons on a long-axis
scan. c Anatomical scheme of the infraspinatus tendon
(ISP) as seen along its long axis. GT greater humeral
tuberosity, MJ myotendinous junction. d US long-axis
scan of the ISP. Asterisk indicates the enthesis of the ISP,
where anisotropy artifacts may occur
Glenohumeral Posterior Joint Recess curved echogenic line, while the cortical surface
The probe is placed in the same position used to of the posterior glenoid rim is seen as a triangu-
evaluate the insertional portion of the infraspina- lar echogenic structure just medial to this line,
tus tendon along its long axis. It is then moved and the fibrocartilaginous posterior glenoid la-
medially to visualize the articular cortex of the brum as a well-defined, triangular, echogenic
humeral head, which appears as a spherically structure.
Fig. 2.8 Evaluation of the glenohumeral posterior recess.

of the glenohumeral posterior recess. b Anatomical
scheme of the glenohumeral posterior recess (arrow).
H humerus, ISP infraspinatus, asterisks humeral
cartilage, G glenoid, arrowheads glenoid labrum.
c US scan of the glenohumeral posterior recess (arrow).
D deltoid muscle
Acromioclavicular Joint tures of the acromion and the clavicle are dem-
The patient is seated opposite the examiner and onstrated as two linear hyperechoic lines, while
the probe is placed on a coronal-oblique plane on the articular joint space appears as an anechoic
the top of his or her shoulder. The two bony struc- triangular structure between them.
Fig. 2.9 Evaluation of the acromioclavicular

joint. a The probe and patient are positioned for
an evaluation of the acromioclavicular joint.
b Anatomical scheme of the acromioclavicular
joint. Arrow joint space, arrowheads joint
capsule, A acromion, C clavicle. c US scan of
the acromioclavicular joint
Subacromial-Subdeltoid
Bursa Injections 3
Enzo Silvestri
ful shoulder. Minor asymptomatic abnormalities

Essentials of this structure can be observed in up to 78% of
patients.
Etiology
The general term “bursitis” indicates a nonspe-

Clinical Presentation
cific inflammatory condition of the synovial
walls of the bursa, an anatomical entity with the
Patients with acute SASD bursitis usually report
mechanical function of reducing friction between
a restriction of abduction movements without
sliding structures (e.g., tendon and cortical bone,
previous trauma. Pain usually worsens during the
tendon and muscle). Primary bursitis commonly
night but also when performing overhead activi-
originates from rheumatoid arthritis, gout, tuber-
ties, and is typically reported on the lateral and
culosis, polymyalgia rheumatica, and other path-
anterior aspects of the shoulder. Patients with
ological conditions. The bursa may become sec-
chronic SASD bursitis often complain of a dull
ondarily inflamed in rotator cuff tendinopathy/
shoulder ache, with tenderness over the greater
tears, with or without joint effusion. Bursitis also
trochanter and beneath the deltoid muscle.
occurs in the setting of anterosuperior impinge-
ment due to overhead activities. Isolated septic
bursitis is more likely in very young infants or
Ultrasound Diagnosis
in elderly patients with chronic debilitating dis-
orders, or it may derive from the accidental intro-
Under normal conditions, the SASD bursa ap-
duction of bacteria during nonsterile percutane-
pears as a 2-mm-thick structure made up of an
ous procedures.
inner layer of hypoechoic fluid between two lay-
ers of hyperechoic peribursal fat. The synovial
Epidemiology membrane of the bursa is not normally depicted
on US.
Subacromial-subdeltoid (SASD) bursitis is the Since intrabursal fluid can migrate depending
most common finding on US evaluation for pain- on gravity and arm positioning, the various por-
tions of the SASD bursa should be systematically
assessed. In subacromial impingement, the bursa
Enzo Silvestri ( )
Radiology Unit
has thickened walls and may contain fluid as
Ospedale Evangelico Internazionale a result of chronic inflammation. Dynamic ex-
Genoa, Italy amination with the use of longitudinal scans

26 E. Silvestri
during abduction of the arm can underline even of the pathology. In chronic unresponsive cases,
small intrabursal effusions, demonstrating the surgical removal is suggested.
“notch sign” in the upper profile of the bursa at
the level where it passes under the coracoacro-
mial ligament. Care should be taken not to apply Interventional Procedure
excessive pressure with the probe over the bursa.
An effusion in both bursal and joint synovial Indications
spaces is considered indicative of a full-thick-
ness tear of the rotator cuff. In the case of acute Acute or chronic painful bursitis. Suspected or
bursitis, the effusion may be consistent, with known septic bursitis can be drained but steroid
findings of a hypervascular flow in the synovial injection should be avoided.
walls and peribursal tissues at Doppler examina-
tion.
Occasionally (synovial osteochondromatosis, Objective
rheumatoid arthritis), round hyperechoic bodies
(nodules) are found within the bursal space. To deliver anti-inflammatory drugs into the bur-
Septic bursitis may include a complex effu- sal space.
sion containing debris and septations. The bursal
walls may be thickened, with peribursal hypo-
echoic strands reflecting edema in the surround- Equipment
ing soft tissues as associated findings.
- 1 syringe (2 ml)
- 20G needle
Treatment Options - Lidocaine (2–5 ml)
- Long-acting steroid (1 ml, 40 mg/ml)
Oral anti-inflammatory drugs and intrabursal - Plaster
steroids are usually indicated in the acute phase - Ice pack.
3 Subacromial-Subdeltoid Bursa Injections 27
Our Procedure
Fig. 3.1a
STEP 1
After an accurate disinfection of both the skin and the probe, a longitudinal US scan is obtained
to visualize the bursal effusion (Fig. 3.1a). The most distended bursal recess is selected as the
target.
Fig. 3.1b
Fig. 3.1c
STEP 2
As shown in Fig. 3.1b,c, the needle (arrowheads) is inserted with a lateral approach to the probe
in order to reach the bursal space along a parallel path relative to the probe. A small amount of
local anesthetic (asterisks) is injected into the bursal space to confirm correct positioning of the
needle tip. Gently advancing the needle into the bursa while injecting can help to debride thick-
ened and collapsed bursal walls. The anatomical scheme and the US image show the position of
the needle with respect to the humeral head (H) and the supraspinatus tendon (SSP).
28 E. Silvestri
STEP 3
Once correct positioning of the needle tip has been confirmed, the steroid can be injected into
the bursa, leaving the needle in place and replacing the syringe used to administer the anesthetic
with one containing steroid. The needle is then removed and a plaster is applied at the puncture
site together with an ice pack.
Post-procedural Care
After treatment, patients should avoid exertion and overhead movements for 5–10 days. Pain
may occur after treatment and is managed with oral NSAIDs.
Treament of Calcific Tendinitis
of the Rotator Cuff 4
Giovanni Serafini and Luca Maria Sconfienza
Epidemiology
Essentials
Rotator cuff calcific tendinitis is a commonly
Etiology
seen condition, occurring in up to 20% of pain-
ful shoulders and up to 7.5% of asymptomatic
The term “calcific tendinitis” refers to the intra-
shoulders. It is more frequent in women in their
tendinous deposition of calcium, predominantly
40s and 50s and seems not to be related to physi-
hydroxyapatite, that can affect every tendon in
cal activity. The supraspinatus tendon (80% of
the body and especially the rotator cuff. This
cases), followed by the infraspinatus (15% of
pathological condition is a dynamic process
cases) and subscapularis (5% of cases) tendons,
that evolves through four stages: pre-calcific,
is the most commonly affected cuff tendon. The
calcific, resorptive, and post-calcific. In the pre-
lower third of the infraspinatus tendon, the criti-
calcific stage, microtraumatic factors associated
cal zone of the supraspinatus tendon, and the
with a local decrease in blood supply can lead
pre-insertional fibers of the subscapularis tendon
to intratendinous fibrocartilaginous metapla-
are the most frequently affected locations. This
sia, with resulting calcification. The subsequent
condition is typically associated with an intact
calcific phase is considered as a resting period.
rotator cuff.
Eventually, triggered by unknown factors, there
is resorption of the deposit, accompanied by vas-
cular invasion, the migration of phagocytic cells
with dissolution of the calcific focus (resulting
in a “toothpaste” appearance of the calcific de-
The pre-calcific phase is usually asymptomatic.
posit), and edema from intratendinous pressure,
The typical clinical manifestation is low-grade
such that the condition becomes symptomatic.
subacute pain that usually increases at night and
After resorption, in the post-calcific or reparative
corresponds to the calcific stage, variably associ-
phase, fibroblasts restore the normal tendinous
ated with mechanical symptoms according to the
collagen pattern.
size of the deposit. In many cases, however, rota-
tor cuff calcific tendinitis can be a highly disa-
bling disorder, with sharp acute pain that limits
shoulder movement and is resistant to high doses
Giovanni Serafini ( )
of oral anti-inflammatory drugs. This clinical
Ospedale S. Corona presentation usually coincides with the resorp-
Pietra Ligure (SV), Italy tive stage; fever, reflecting rupture of the calcifi-

30 G. Serafini and L.M. Sconfienza
cation into the adjacent structures, is occasionally Interventional Procedure

reported. However, the acute phase of calcific
tendinitis of the rotator cuff is regarded as a self- Indications
healing condition, with spontaneous resolution in
7–10 days. The US-guided percutaneous treatment of cal-
cific tendinitis of the rotator cuff is always and
immediately indicated in the acute phase of the
Ultrasound Diagnosis pathology, with US findings of type II or III cal-
cifications. In case of mildly symptomatic type
Three types of calcifications have been described: I calcifications, elective treatment should be con-
type I consists of a hyper-reflexive lesion with a sidered. Percutaneous treatment is not indicated
well-circumscribed dorsal acoustic shadow; type if the calcification has migrated into the bursal
II deposits are well-circumscribed, homogeneous space or is eroding the humeral cortical bone, or
hyperechoic foci with a faint posterior shadow; if it is very small (< 5 mm).
type III are amorphous, inhomogeneous hyper-
echoic foci without posterior acoustic shadow.
The consistency is solid for deposits of types I Objective
and II and semi-liquid for type III calcifications.
To dissolve and aspirate the calcific material us-
ing an US-guided, double-needle procedure.
Treatment Options
Asymptomatic cases usually do not require treat- Equipment

ment, as the process is self-healing. In patients
with mild symptoms, the disease can be man- - Two 16G needles
aged conservatively with physical therapy and a - One 10-cm 18/20G needle (optional)
short course of oral NSAIDs. Lithotripsy is only - Inox bowl (to collect the washing fluid)
partially effective. An alternative therapeutic ap- - Sterile saline solution (100–200 ml) warmed to
proach is to extract the calcific material in an ar- about 38–40°C
throscopy or imaging-guided procedure. - Two syringes (20 ml and 3 ml)
- Lidocaine (10 ml)
- Steroid (1 ml, 40 mg/ml)
- Plaster
- Ice pack.
4 Treament of Calcific Tendinitis of the Rotator Cuff 31
Our Procedure
Fig. 4.1a
Fig. 4.1b
Fig. 4.1c
STEP 1
The patient is either placed in the supine position (subscapularis and supraspinatus calcifica-
tions) or is prone (infraspinatus or teres minor calcifications), as seen in Fig. 4.1a. A correct US
scan should demonstrate the target calcification (C) according to its major axis (Figs. 4.1b, c).
After sterile preparation of the skin and probe, a small amount of local anesthesia is injected
under US guidance and using an in-plane approach along the path of the needle (arrowheads),
in the SASD bursa (asterisks), and around the calcification (C) (Fig. 4.1a). H humeral head.
Fig. 4.2a
Fig. 4.2b
Fig. 4.2c
STEP 2
As shown in Fig. 4.2a–c, the first needle (arrowheads) is inserted into the lowest portion of the
calcification (C), maintaining the bevel (arrow) open towards the probe. H humerus.
Fig. 4.3a
Fig. 4.3b
c d
Fig. 4.3c-d
STEP 3
A second needle (curved arrows) is inserted into the calcification (C) parallel and superficial to
the first (Fig.4.3a–c, arrowheads), and its tip is rotated 180° in order to create a correct washing
circuit. As shown in Fig. 4.3c, the deeper needle needs to be inserted first, to avoid artifacts (cir-
cles) caused by the second, more superficial needle. Needle bavel (arrow) is opened upwards.
Figure 4.3d shows both needles (arrowheads and curved arrows) within the calcification.
H humerus.
Fig. 4.4a
Fig. 4.4b
Fig. 4.4c
STEP 4
A 20-ml syringe filled with warm sterile water is connected to one of the needles (arrowheads
and curved arrows) and a gentle, intermittent pressure is applied. If the positioning is correct, a
slight expansion of the calcification can be visualized. If no washing fluid exits and the needles
are correctly positioned, an 18G spinal needle could be inserted into one or both 16G needles to
slightly penetrate the target calcification, creating enough space for circulation of the fluid. The
washing fluid exiting from the second needle is collected in the inox bowl, positioned as shown
in Fig. 4.4a. Washing of the target continues until complete emptying of the calcification (C) is
demonstrated, as shown in Fig. 4.4b,c. Arrowheads first needle, curved arrow second needle,
H humerus.
Fig. 4.5a
Fig. 4.5b
Fig. 4.5c
STEP 5
At the end of the procedure, one needle is removed and the 1-ml syringe is connected to the
remaining needle (Fig.4.5a). This needle (arrowheads) is then displaced into the SASD bursa
(Fig. 4.5b) and 1 ml of steroid is injected (asterisks). A plaster is then applied to the skin at the
puncture site and an ice pack is placed over the shoulder. H humerus, C treated calcification.
The patient is kept under observation for at least 30 min. The ice pack over the treated shoulder
should be maintained for at least 2 h. Patients should avoid overhead movements and the car-
rying of heavy weights for up to 15 days. Pain may occur after treatment and is managed with
oral NSAIDs. Post-procedural bursitis is seen in about 15% of patients within approximately 2
months after treatment. In these cases, an intrabursal steroid injection may be useful.
Calcific Enthesopathy Dry-Needling
5
Francesca Lacelli
Essentials
Patients with symptomatic calcific enthesopathy
Etiology
report well-circumscribed pain at the level of the
greater trochanter (supraspinatus, infraspinatus,
Calcific enthesopathy of the rotator cuff repre-
or teres minor insertional areas) or of the lesser
sents a common and mostly asymptomatic US
trochanter (subscapularis insertion). The pain is
finding. Unlike calcific tendinopathy, in which
worsened by applied pressure, either by the ex-
a calcification develops from fibrocartilaginous
aminer’s finger or by the probe during the exami-
metaplasia 1–2 cm away from the insertional ten-
nation.
dinous area, in this condition tiny calcifications
are found in the insertional area of the rotator cuff
tendons and are usually coupled to degenerative
alterations of the pre-insertional tendinous por-
tion.
Tiny, irregular hyperechoic insertional calcifica-
tions in a setting of degenerative tendinopathy.
The calcifications are close to the humeral corti-
Epidemiology
cal bone and may present as an irregularity in the
hyperechoic profile of the latter.
The exact incidence of this condition cannot be
estimated because of the broad range of degener-
ative or inflammatory conditions that may result
Treatment Options
in calcific enthesopathy. Males and females are
equally affected.
Physiotherapy should always be considered. In
symptomatic cases, a percutaneous procedure or
surgical tendinous debridement is needed.
Francesca Lacelli ( )
Ospedale S. Corona

38 F. Lacelli
Interventional Procedure material; to produce slight intratendinous bleed-

ing that will in turn promote healing of the tendon.
Indications
Symptomatic insertional calcific enthesopathy in Equipment

one or more tendons of the rotator cuff.
- 1 syringe (5–10 ml)
- 18G needle
Objective - Lidocaine (5–10 ml)
To fragment the tiny insertional calcifications - Plaster
in order to accelerate the resorption of calcific - Ice pack.
Our Procedure
Fig. 5.1a
STEP 1
After sterile preparation of both the skin and the US probe, the affected area is visualized with
a longitudinal scan according to the respective tendon. A small amount of local anesthetic is
injected under US guidance and with an in-plane approach along the path of the needle, into the
SASD bursa, and around the insertional calcifications (see Fig. 3.1a–c).
5 Calcific Enthesopathy Dry-Needling 39
Fig. 5.1b
c d
e f
Fig. 5.1c-f
STEP 2
As shown in Fig. 5.1a–f, consecutive dry-needling punctures (arrowheads) are performed on
the calcifications (arrow) to fragment the small calcific deposits and to produce slight bleeding
into the insertional tendinous portion. The probe should also be shifted anteriorly and posteri-
orly to target the treatment towards all the calcifications. H humerus.
40 F. Lacelli
Fig. 5.2
STEP 3
At the end of the procedure, 1 ml of steroid (asterisks) is injected (arrowheads) into the SASD
bursa (Fig. 5.2) and the cutaneous point of insertion is covered with a plaster. An ice pack is
applied over the shoulder.
The patient is kept under observation for at least 30 min. The ice pack over the treated shoulder
should be maintained for at least 2 h. Patients should avoid overhead movements and the car-
rying of heavy weights for up to 15 days. Pain may occur after treatment and is managed using
oral NSAIDs. Post-procedural bursitis is seen in about 15% of patients within approximately 2
months after treatment. In these cases, an intrabursal steroid injection may be useful.
Hyaluronic Supplementation
of the Subacromial Space 6
Giovanni Serafini
Essentials
The main symptoms of cuff tear athropathy are
Etiology
functional limitation, weakness, and pain in the
shoulder. There is an inability to perform either
Cuff tear arthropathy is the association of a mas-
abduction or extra-rotation movements. Patients
sive rotator cuff tear and shoulder osteoarthritis,
often complain of difficulty carrying out daily
with progressive superior migration of the hu-
activities, such as combing their hair, clasp-
meral head, acetabulization of the shoulder, and
ing a bra behind their back, reaching behind
collapse of the humeral head. Poor vascularity,
their back, or sleeping on the affected shoulder.
the inferior mechanical properties of an aging
Weakness can appear during lifting or in rotating
rotator cuff, type III acromions, and subacromial
the arm. Pain while performing overhead activities
impingement are the most outstanding factors
and at night is common; it is usually located over
leading to this condition.
the outside of the shoulder and upper arm. Crepi-
tus or a crackling sensation may also be noted
when the shoulder is moved in certain positions.
Epidemiology
Most commonly, an elderly patient will present Ultrasound Diagnosis

with massive rotator cuff tears altering the bio-
mechanics of the shoulder and leading to pro- A massive rotator cuff tear is diagnosed when a
gressive superior migration of the humeral head. complete rupture of at least two tendons of the
The end-stage of cuff tear arthropathy is the ac- rotator cuff is identified.
etabulization of the shoulder, with collapse of the
humeral head.
Treatment Options
Several different surgical treatment options for

cuff tear arthropathy have been proposed. How-
ever, in elderly patients, surgery may be more fre-
quently associated with complications or may be
precluded due to concurrent medical conditions.
Ospedale S. Corona Viscosupplementation can help in the conserva-
Pietra Ligure (SV), Italy tive management of this condition.

42 G. Serafini
Interventional Procedure space so as to facilitate gliding of the acromial

and humeral cortical bones in the acromial-hu-
Indications meral articulation.
Cuff tear arthropathy. Percutaneous treatment is

not indicated in case of a recent history of shoul- Equipment
der trauma.
- Two syringes (5 ml and 10 ml)
- Lidocaine (2–5 ml)
Objective - High-molecular-weight hyaluronic acid (6 ml)
- 18G needle
To inject a viscosupplement into the subacromial - Plaster.
Our Procedure
Fig. 6.1a
Fig. 6.1b
STEP 1
The subacromial space is visualized on a coronal US scan that includes the acromial supero-
lateral cortical bone and the superior aspect of the humeral head (Fig. 6.1a, b); A acromion, H
humeral head. Local anesthetic is injected along the path of the 18G needle under US guidance
with an in-plane approach and an oblique direction (lateral to medial and superior to inferior) to
reach the subacromial space.
6 Hyaluronic Supplementation of the Subacromial Space 43
Fig. 6.1c
STEP 2
As shown in Fig. 6.1c, once the subacromial space is reached by the needle (arrowheads), a
syringe pre-filled with 6 ml of high-molecular-weight hyaluronic acid is attached to the needle,
and the operator slowly and gently injects the drug into the subacromial space (asterisk). There
should be no resistance against the injection; if this is not the case, a slight retraction of the nee-
dle may be necessary. A plaster is then applied to the skin at the puncture site.
The injection should be repeated after one week. Treatment can be repeated in case of pain
recurrence.
Intra-articular Injections
7
Francesca Lacelli
Essentials
This condition is classified as primary idiopathic
Intra-articular injections of the shoulder can be
when there is no detectable underlying causes for
performed in the treatment of a variety of patho-
the symptoms, or as secondary to shoulder af-
logical conditions. The drugs administered in
fections, either traumatic or non-traumatic, that
these cases may be anti-inflammatory agents,
determine secondary pain and stiffness. A recog-
such as the use of steroids for the various forms
nized different form of secondary frozen shoul-
of capsulitis, or viscosupplements such as hya-
der is seen in diabetic patients and tends to be
luronic acid, which are injected to decelerate the
more severe and protracted. The diagnosis is es-
physiological process of osteoarthritis.
sentially clinical. Patients report increasing pain,
especially at night, and a progressively reduced
range of motion. In most cases, adhesive capsuli-
Adhesive Capsulitis tis is considered as a self-limiting disorder but it
lasts for years in up to 40% of patients.
Etiology
Adhesive capsulitis of the shoulder (frozen Treatment Options

shoulder) is a common disease with unclear
pathogenesis, resulting in chronic inflammation Conservative treatment includes physical thera-
of the capsular tissues and abnormal tissue repair py, anti-inflammatory and analgesic medications,
with fibrosis. and oral administration or intra-articular injec-
tions of steroids.
Epidemiology
Interventional Procedure
Approximately 2% of the general population is
affected, with a peak incidence between 40 and Indications
60 years and a slight female predominance.
Intra-articular injection of steroids. Primary idi-
opathic or secondary adhesive capsulitis, degen-
erative osteoarthritis associated with articular
Ospedale S. Corona effusion. Contraindicated in diabetes-related
Pietra Ligure (SV), Italy secondary adhesive capsulitis.

46 F. Lacelli
Intra-articular injection of hyaluronic acid. De- Equipment

generative osteoarthritis without articular effusion. - 1 syringe (2–5 ml)
- 20G spinal needle
- Long-acting steroid (1 ml, 40 mg/ml) or low-
Objective molecular-weight hyaluronic acid (2 ml)
- Plaster.
To deliver anti-inflammatory or viscosupplement
drugs within the joint space.
Our Procedure
Intra-articular joint injections of the shoulder can be performed with either an anterior or a pos-
terior approach. The anterior approach suffers from the deep location of the joint with respect
to the skin surface, as well as the presence of the coracoid process, which makes it extremely
difficult to accurately visualize the needle tip. Thus, the posterior approach is generally more
convenient.
This procedure can also be used for the injection of contrast agents within the joint for pur-
poses of arthrography.
Anterior Approach
Fig. 7.1a
STEP 1
The patient is placed in the supine position, with the forearm flexed 90° and the hand lying on
the abdomen. An anterior axial US scan is performed at the level of the coracoid process. The
correct scanning plane should reveal the coracoid at the middle third of its height, the subscapu-
laris tendon on its long axis, and the humeral lesser tuberosity (Fig. 7.1a).
7 Intra-articular Injections 47
Fig. 7.1b
STEP 2
The space between the coracoid and the humeral head is centered at the middle of the scanning
plane and a 20G needle (arrow) is inserted perpendicular to the skin, at the middle of the probe
(Fig. 7.1b) between the humeral head (H) and the glenoid (G) and the coracoid (C). Passage
of the needle tip into the glenohumeral joint is generally associated with a distinct feeling of
capsular resistance followed by the sensation of a resistance-free space.
Fig. 7.1c
STEP 3
Once correct intra-articular positioning of the needle tip has been confirmed (asterisk), the drug
can be injected (Fig. 7.1c). There should be no resistance to the injection; if this is not the case,
a short retraction (1–2 mm) of the needle should be considered because the needle tip could
be pointed against the humeral cartilage or into the anterior glenoid labrum. At the end of the
injection, the needle can be removed and a plaster applied at the cutaneous site of approach.
C coracoid, SSC subscapularis tendon, G glenoid.
48 F. Lacelli
Posterior Approach
Fig. 7.2a
Fig. 7.2b Fig. 7.2c
Lateral Approach
STEP 1
The patient is in a prone position with the upper arm not completely abducted and the forearm
flexed, in order to avoid tension on the posterior joint capsule (Fig. 7.2a).
A longitudinal US scan of the posterior articular recess is performed. The transducer is aligned
with the long axis of the musculotendinous junction of the infraspinatus muscle, just inferior to
the scapular spine, with the posterior glenoid rim and posterior glenohumeral joint line centered
in the field of view (Fig. 7.2b,c). Transducer angulation is adjusted to clearly show the contours
of the posterior glenoid rim, the posterior glenoid labrum, and the humeral head. The articular
cortex of the humeral head appears as a spherically curved echogenic line, and the cortical sur-
face of the posterior glenoid rim as a triangular echogenic structure just medial to this line. The
fibrocartilaginous posterior glenoid labrum is seen as a well-defined, triangular, and uniformly
echogenic structure.
Fig. 7.3a
Fig. 7.3b
Co-axial Approach
STEP 1
A co-axial out-of-plane approach is also possible (Fig. 7.3a-b), although the needle will be less
visible. The passage of the needle tip (arrow) into the glenohumeral joint is generally associ-
ated with a distinct feeling of capsular resistance followed by the sensation of a resistance-free
space. The asterisk indicates the distended posterior glenohumeral joint recess. G glenoid, H
humerus, D deltoid.
STEP 2
Once correct intra-articular positioning of the needle tip has been confirmed, the drug can be
injected. There should be no resistance to injection; if this is not the case, a short retraction
(1–2 mm) of the needle should be considered because the needle tip could be pointed against
the humeral cartilage or into the posterior glenoid labrum. Distension of the articular capsule is
usually not visible because of the small amount of fluid injected. At the end of the injection, the
needle can be removed and a plaster applied at the cutaneous site of the approach.
The patient should be kept under observation for at least 30 min after the procedure. Pain may
occur after treatment and is managed with oral NSAIDs.
Long Head of the Biceps Brachii
Tendon Injection 8
Luca Maria Sconfienza
Essentials
An anechoic fluid collection around the fibrillar
Etiology
tendinous structure of the LHBB can be demon-
strated on axial and longitudinal scans. If thick-
Pathologies of the LHBB include synovial effu-
ening of the synovial component of the sheath
sion, synovial hypertrophy and, rarely, calcifica-
and power-Doppler signs of hypervascularity are
tions. Tenosynovitis can be found alone or, more
present, a rheumatic condition should be sus-
often, associated with glenohumeral effusion
pected.
since the joint space is usually in communication
with the sheath of this tendon.
Treatment Options
Epidemiology
Physiotherapy is the treatment of choice. In the
acute phase, the percutaneous injection of ster-
A small amount of fluid within the sheath of the
oids can have a prompt effect on pain, while as-
LHBB is a common and asymptomatic finding
piration is usually required when a large amount
and is typically associated with glenohumeral
of fluid is present.
joint effusion. Conspicuous effusions are usually
symptomatic.
Pain is usually described as originating from the

anterior aspect of the shoulder and irradiating an-
teriorly down the humerus. The onset is typically
subacute or chronic.
Luca Maria Sconfienza ( )

Radiology Unit
IRCCS Policlinico San Donato

52 L.M. Sconfienza
Interventional Procedure Equipment
Indications - 1 syringe (2 ml)

- 22G needle
Symptomatic effusion in the sheath of the LHBB - Lidocaine (2 ml)
tendon. - Long-acting steroid (1 ml, 40 mg/ml)
- Plaster.
Objective
To inject a small amount of steroid in the distend-

ed sheath of the LHBB.
Our Procedure
Fig. 8.1a
STEP 1
The patient is placed in the supine position with his or her hand in a neutral position (Fig. 8.1a).
The LHBB tendon is seen on an axial scan, starting from the bicipital groove and moving the
probe caudally to identify the level of larger effusion.
8 Long Head of the Biceps Brachii Tendon Injection 53
Fig. 8.1b
Fig. 8.1c
Fig. 8.1d
STEP 2
The needle is inserted with an in-plane approach lateral to the probe (Fig. 8.1b,c) and advanced
towards the tendon (arrows) while a small amount of local anesthetic is injected along the path.
Once the needle (arrowheads) has reached the distended synovial sheath (Fig. 8.1c, asterisk),
the fluid content is drained (Fig. 8.1d, asterisk). H humerus.
54 L.M. Sconfienza
Fig. 8.1e
STEP 3
The syringe with the steroid is then connected to the needle and the drug is injected (Fig. 8.1e,
asterisks), avoiding penetration of the tendon (arrows) by the needle tip (arrowheads). The nee-
dle is removed and a plaster applied on the skin.
The patient is kept under observation for at least 10 min. Pain may occur after treatment and is
managed with oral NSAIDs. After treatment, patients should avoid heavy activities and refrain
from overhead movements for 5–10 days.
Acromioclavicular Joint Injection
9
Enzo Silvestri
Essentials
Patients usually have insidious onset of pain. On
Etiology
physical examination, there is tenderness to pal-
pation of the AC joint. A lump over the joint space
The most common AC joint pathologies that can
indicates the presence of a cyst arising from the
be treated using a percutaneous approach include
articular capsule and is usually associated with
osteoarthritis and osteolysis of the distal clavi-
a degenerative shoulder arthropathy. Pain occurs
cle. Osteoarthritis usually develops secondary
with active or passive adduction of the shoulder
to previous trauma, while osteolysis of the distal
and may be exacerbated by asking the patient to
clavicle may be associated with repetitive weight
hold the opposite shoulder while pushing the el-
training involving the shoulder. The history and
bow cranially against resistance.
physical examination are extremely important in
diagnosing these conditions.
Epidemiology
Degenerative changes of the AC joint include an
irregular profile of the cortical bone surfaces of
Degeneration of the AC joint typically affects
the distal clavicle and acromion, associated with
middle-aged patients and is often associated with
an articular joint effusion and a thickened cap-
rotator cuff disorders. However, it is also found
sule.
in young athletes (20s to 30s) with repetitive falls
on the shoulder.
Treatment Options
Physiotherapy is the preferred treatment. Ster-

oids or hyaluronic acid can help in reducing pain
and thus in facilitating rehabilitation.
Enzo Silvestri ( )
Radiology Unit
Genoa, Italy

56 E. Silvestri et al.
Indications - 1 syringe (2 ml)

- 23G needle
Osteoarthritis and osteolysis of the distal clavicle. - Long-acting steroid (1 ml, 40 mg/ml) and/or
Contraindicated in the acute or subacute phase of low-molecular-weight hyaluronic acid (1 ml)
traumatic injury. - Plaster.
Objective
To deliver steroid or hyaluronic acid in the AC

joint space. Local anesthetic can be used as a di-
agnostic tool to assess the origin of shoulder pain.
Our Procedure
Fig. 9.1
STEP 1
The patient is seated opposite the examiner in a neutral position, with the hand lying on the thigh
(Fig. 9.1). An out-of-plane co-axial approach is suggested, but an in-plane lateral approach is
also possible.
9 Acromioclavicular Joint Injection 57
Fig. 9.2a
Fig. 9.2b
Fig. 9.2c
STEP 2
With an out-of-plane co-axial approach (Fig. 9.2a–c), the AC joint is visualized at the middle of
a coronal scan (A and C) and the needle is inserted perpendicularly to the skin at the exact half
of the probe. A clear sensation of resistance should be appreciated as the joint capsule is passed
(arrowheads). The probe is gradually tilted towards the needle such that the needle tip (arrow)
can be seen as a hyperechoic dot in the distended articular space (asterisk). There should be no
resistance during the injection.
With an in-plane approach, the AC joint space is visualized on a sagittal US scan. The needle is
inserted lateral to the probe and advanced with a 30–45° inclination.
58 E. Silvestri et al.
The patient is kept under observation for at least 10 min. An ice pack over the treated shoulder
should be maintained for at least 1 h. Pain may occur after treatment and is managed using
oral NSAIDs. Patients should avoid overhead movements and carrying heavy weights for up
to 3 days.
Part II
The Elbow
The Elbow: Focused US Anatomy
Enzo Silvestri and Emanuele Fabbro
The elbow is divided into four compartments: an- Scanning Technique

terior, lateral, medial, and posterior. The patient’s forearm is positioned as supinated
as possible on the table to improve tendon vis-
ibility. The probe must be placed longitudinally
Anterior Compartment to evaluate the tendon along its long axis up to
the insertion on the radial tuberosity. Due to the
Distal Tendon of the Biceps Brachii tendon’s oblique course, which becomes deeper
as it courses distally, it is important to press the
Anatomy distal edge of the probe on the patient’s skin to
The tendon originates from the distal portion of avoid anisotropy artifacts.
the biceps brachii muscle. It courses obliquely
from anterior to posterior, inserting on the bicipi-
tal tuberosity of the radius and surrounded by the
bicipitoradial bursa.
Enzo Silvestri ( )
Radiology Unit
Genoa, Italy

62 E. Silvestri and E. Fabbro
Fig. 10.1 Evaluation of the biceps brachii distal

tendon. a The probe and patient are positioned
for an evaluation of the biceps brachii distal
tendon on a long-axis scan. b Anatomical
scheme of the biceps brachii distal tendon
(arrowheads). RT radial tuberosity, RH radial
head. c US long-axis scan of the biceps brachii
distal tendon (arrowheads)
10 The Elbow: Focused US Anatomy and Examination Technique 63
Lateral Compartment Scanning Technique

With the patient’s forearm slightly flexed, the
Common Extensor Tendon probe is placed on the lateral epicondyle to evalu-
ate the tendon complex on a longitudinal scan.
Anatomy Occasionally, it is possible to differentiate the lat-
The extensor tendon complex is composed of eral collateral ligament from the tendon, based on
several tendons: extensor carpi radialis brevis, their echotexture.
extensor carpi ulnaris, extensor digitorum com-
munis, and extensor digiti quinti. Normally, all of
them have a fibrillar echogenic structure.
c
Fig. 10.2 Evaluation of the common extensor
for an evaluation of the common extensor tendon
on a long-axis scan. b Anatomical scheme of
the common extensor tendon (arrowheads).
LE lateral epicondyle, RH radial head. c US
long-axis scan of the common extensor tendon
(arrowheads)
Radial-Humeral Joint Scanning Technique

The probe is placed in the same position used to
Anatomy evaluate the common extensor tendon. A longitu-
The radial-humeral joint comprises the capitulum dinal scan allows visualization of the underlying
humeri and the radial proximal epiphysis, each radial-humeral synovial meniscus filling in the
covered by hyaline cartilage. The annular liga- gap of the lateral surface of the radial-humeral
ment accrues from the anterior edge of the radial joint. The radial head and the annular ligament
notch of the ulna and inserts on the posterior edge can be correctly assessed by having the patient
of the radial notch. It is involved in passive stabi- pronate and supinate the forearm.
lization of the elbow joint.
c Fig. 10.3 Evaluation of the radial-humeral joint.

a The probe and the patient are positioned for
an evaluation of the radial-humeral joint on a
long-axis scan. b Anatomical scheme of the
radial-humeral joint. c US long-axis scan of the
radial-humeral joint. The articular space (arrow)
can be seen between the capitulum humeri (CH)
and the radial head (RH). The synovial meniscus
(asterisk) is also visible
10 The Elbow: Focused US Anatomy and Examination Technique 65
Medial Compartment Scanning Technique

With the patient’s forearm slightly flexed and ex-
Common Flexor Tendon ternally rotated, the proximal edge of the probe is
placed over the medial epicondyle (epitrochlea)
Anatomy to scan the common flexor tendon along its long
The common flexor tendon is composed of the axis.
pronator teres, flexor carpi radialis, flexor digi-
torum superficialis, palmaris longus, and flexor
carpi ulnaris. The tendon is shorter and flatter
than the common extensor tendon.
Fig. 10.4 Evaluation of the common flexor

for an evaluation pf the common flexor tendon
on a long-axis scan. b Anatomical scheme of
the common flexor tendon (arrowheads). ME
medial epicondyle, U ulna. c US long-axis scan
of the common flexor tendon (arrowheads)
Posterior Compartment Olecranon Fossa and

Posterior Olecranon Recess
Triceps Brachii Muscle and Tendon The posterior olecranon recess and the olecranic
fossa can be assessed on longitudinal scans. The
Anatomy olecranon fossa appears as a wide concavity
The distal triceps tendon consists of the myoten- filled with a fat pad, localized deep to the triceps
dinous junction of the three bellies forming the muscle and cranially to the distal humeral epi-
triceps muscle (long, medial, and lateral heads); condyle. The olecranon process is visualized as
the tendon inserts approximately 1 cm distal to a hyperechoic curvilinear bony structure covered
the apex of the olecranon. by the synovial olecranon bursa. It is not visible
under normal conditions. With the patients elbow
Scanning Technique flexed 90°, dynamic flexion and extension scans
The triceps brachii muscle and tendon must be are used to assess the presence of intra-articular
evaluated on long- and short-axis scans, position- effusion.
ing the elbow flexed 90°, the arm intrarotated,
and the palm placed on the table. The US beam
should be maintained as perpendicular as possible
to the tendon fibers to avoid anisotropy artifacts.
Fig. 10.5 Evaluation of the posterior compartment of

c the elbow. a The probe and patient are positioned for an
evaluation of the posterior compartment of the elbow on
a long-axis scan. b Anatomical scheme of the posterior
compartment of the elbow. c US long-axis scan of the
posterior compartment of the elbow. The triceps tendon
(arrowheads) inserts on the olecranon process (O).
The posterior joint recess (arrow) and the olecranic fossa
(OF) are also seen
Treatment of Lateral Epicondylitis
11
Giovanni Serafini
Essentials
The main symptom is pain, which is localized
Etiology
in the lateral elbow region, corresponding to
the lateral epicondyle of the humerus. It is typi-
Epicondylitis is one of the most commonly di-
cally related to activity and exacerbated by wrist
agnosed musculoskeletal disorders of the upper-
and hand movements. Pain may radiate into the
extremity. Lateral epicondylitis, also known
forearm and impair handgrip. Clinical tests, con-
as “tennis elbow,” is a painful condition of the
sisting of active and resisted movements of the
tendinous origin of the wrist extensor muscles.
extensor muscles of the forearm, provoke epicon-
Anatomically, the three major components of
dylar pain (Cozen’s sign: pain with resisted wrist
the common extensor tendon are the extensor
extension). During clinical examination, a typical
carpi radialis brevis, the extensor digitorum, and
tenderness at the lateral side of the elbow will of-
the extensor carpi ulnaris tendon. Injury is due
ten become apparent. Symptom duration usually
to repetitive stress on the common extensor ten-
ranges from a few weeks to a few months.
don around its attachment to the lateral humeral
epicondyle in response to manual tasks, forceful
activities, or sports that require high force com-
bined with high repetition or awkward posture
Diagnosis
(tennis, water polo, baseball, fencing).
In most cases, imaging is not necessary since the
diagnosis of lateral epicondylitis is usually clini-
Epidemiology cal, based on symptoms and findings during the
physical examination. Imaging can be used to
Lateral epicondylitis is more common than medi- evaluate the extent of tissue damage, to exclude
al epicondylitis and generally affects individuals other causes of elbow pain, when the clinical
40–60 years old, with equal prevalence among presentation is atypical, or to confirm the diagno-
males and females. sis in patients not responding to treatment.
Ospedale S. Corona

68 G. Serafini
In epicondylitis, the tendon can be thicker Interventional Procedure

or thinner than normal, of poor definition, of
decreased echogenicity, and accompanied by Indications
peritendinous effusion. In addition, the extensor
tendon complex may show alterations in intra- Insertional overload tendinopathy of the com-
tendinous vascularity. In severe cases, partial- or mon extensor tendon. Contraindicated in case
full-thickness tendon tears are seen as focal an- of traumatic lesions of the common extensor
echogenic areas with loss of the normal fibrillar tendon.
pattern.
Objective
Treatment Options
To cause local hyperemia and bleeding into the
First-line therapy usually consists of ice applica- tendon, thus promoting post-procedural platelets-
tion, immobility of the upper limb, and NSAIDs. induced recovery phenomena.
Shockwave therapy can reduce symptoms in the
middle term. Surgical debridement is reserved
for refractory cases. US-guided scarification (dry Equipment
needling) can be considered as a minimally inva-
sive option. - 1 syringe (5–10 ml)
- 20G needle
- Plaster.
11 Treatment of Lateral Epicondylitis 69
Our Procedure
Fig. 11.1a
Fig. 11.1b
Fig. 11.1c
STEP 1
The patient is seated opposite the operator. The elbow is flexed 90° and the thumb points upward
(Fig. 11.1a). The common extensor tendon is visualized by means of a longitudinal scan. The
proximal portion of the probe is placed on the hyperechoic bony line of the lateral epicondyle
(LE), while the distal part of the probe is aligned according to the common extensor tendon.
The 20G needle (arrowheads) is inserted with an in-plane approach (Fig. 11.1b), in either a
distal-proximal or a proximal-distal direction. Anesthetic (asterisks) is injected along the path
of the needle, in the peritendinous soft tissues (Fig. 11.1c), and in the degenerated portions of
the common extensor tendon (CET). RH radial head.
70 G. Serafini
Fig. 11.2a
Fig. 11.2b
STEP 2
Figure 11.2a,b shows the needle (arrowheads) during a series of 15–20 repeated punctures
(dry-needling) on the insertional portion of the tendon (CET), hitting also the periostum that
covers the lateral epicondyle (LE). The radial head (RH) is also visible.
11 Treatment of Lateral Epicondylitis 71
Fig. 11.3a
Fig. 11.3b
STEP 3
The end of the procedure is shown in Fig. 11.3a,b. One ml of steroid (asterisks) is injected into
the peritendinous soft tissues, superficially to the tendon enthesis (CET). The needle (arrow-
heads) is then removed and a plaster applied. LE lateral epicondyle, RH radial head.
managed with oral NSAIDs.
Patients are advised to use an orthotic support and to reduce their manual activity, although no
systematic rest period is suggested.
Treatment of Medial Epicondylitis
12
Enzo Silvestri
Essentials
The main symptom is pain, which is localized
Etiology
in the medial elbow region, corresponding to
the medial epicondyle of the humerus. Pain is
Epitrochleitis, or medial epicondylitis, is the
typically related to activity and is exacerbated
most commonly diagnosed musculoskeletal dis-
by wrist and hand movements. Moreover, it may
order of the medial elbow. Medial epicondylitis,
radiate into the forearm and impair handgrip.
also known as “golfers elbow,” is a painful con-
Clinical tests, consisting of active and resisted
dition of the tendinous origin of the wrist flexor
movements of the flexor muscles of the forearm,
muscles. Anatomically, the major components of
provoke epitrochlear pain with resisted wrist
the common flexor tendon include the pronator
flexion. During clinical examination, a typical
teres, flexor carpi radialis, palmaris longus, flexor
tenderness at the medial side of the elbow will
carpi ulnaris, and flexor digitorum superficialis.
become apparent. The duration of epitrochleitis
This condition is caused by repetitive stress
symptoms usually ranges from a few weeks to a
on the common flexor tendon around its attach-
few months.
ment to the medial humeral epicondyle due to
manual tasks, forceful activities, and sports that
require high force combined with repetitive val-
Diagnosis
gus stress on the elbow joint (golf, baseball, goal-
keeper).
In most cases, imaging is not needed since the
diagnose of medial epicondylitis is usually clini-
cal, based on symptoms and findings during the
Epidemiology
physical examination. Diagnostic imaging can
be used to evaluate the extent of tissue damage,
Medial epicondylitis is less common than later-
to exclude other causes of elbow pain, when the
al epicondylitis, with males slightly more often
clinical presentation is atypical, or to confirm the
affected than females. The typical age range is
diagnosis in patients not responding to treatment.
from 30 to 50 years.
Ultrasound can demonstrate thinning or
thickening of the tendon, sometimes associated
Enzo Silvestri ( )
Radiology Unit
with a peritendinous effusion. Also, tendon vas-
Ospedale Evangelico Internazionale cularity, evaluated using power Doppler, may be
Genoa, Italy increased. More rarely, partial tears are seen.

74 E. Silvestri
Treatment Options Objective
First-line therapy usually consists of ice applica- To cause local hyperemia and bleeding into the
tion, immobility of the upper limb, the use of or- tendon, thus promoting relevant post-procedural
thotic devices, and NSAIDs. Shockwave therapy platelets-induced recovery phenomena.
can reduce symptoms in the middle term. Surgi-
cal debridement is reserved for refractory cases.
US-guided scarification (dry needling) can be Equipment
considered as a minimally invasive option.
Interventional Procedure - 20G needle
Indications - Long-acting steroid (1 ml, 40 mg/ml)
- Plaster.
Insertional overload tendinopathy of the com-
mon flexor tendon. Contraindicated in case of
traumatic lesions of the common flexor tendon.
Our Procedure
Fig. 12.1a
STEP 1
The patient is seated opposite the operator. The elbow is flexed 90° and the thumb points later-
ally (see Fig. 10.4a). The common flexor tendon (CFT) is visualized by means of a longitudinal
scan. The proximal portion of the probe is placed on the hyperechoic bony line of the medial
epicondyle (ME), while the distal part of the probe is aligned according to the common flexor
tendon (see Fig. 10.4b,c).
12 Treatment of Medial Epicondylitis 75
Fig. 12.1b
Fig. 12.1c
STEP 2
A 20G needle (arrowheads) is inserted with an in-plane approach, in either a distal-proximal
or a proximal-distal direction (Fig. 12.1a–c), while a small amount of anesthetic (asterisks) is
injected along the path of the needle, in the peritendinous soft tissues, and in the degenerated
portions of the common flexor tendon (CFT). ME medial epicondyle.
76 E. Silvestri
Fig. 12.2a
Fig. 12.2b
STEP 3
A series of 15–20 repeated punctures (dry needling, arrowheads) are performed in the inser-
tional degenerated portions of the tendon (CFT), hitting also the periostium covering the medial
epicondyle (Fig. 12.2a,b). ME medial epicondyle, arrow needle tip.
12 Treatment of Medial Epicondylitis 77
Fig. 12.3a
Fig. 12.3b
STEP 4
At the end of the procedure, 1 ml of steroid (asterisks) is injected in the peritendinous soft tis-
sues superficially to the tendinous insertion (CFT) (Fig. 12.3a,b). The needle (arrowheads) is
then removed and a plaster applied. ME medial epicondyle, U ulna.
Patients are advised to use an orthotic support and to reduce their manual activity, although no
systematic rest period is suggested.
Olecranon Bursa Drainage
13
Francesca Lacelli
Essentials
Patients usually complain of swelling in the olec-
Epidemiology
ranon region. Pain can vary from a subtle dis-
comfort to an intense symptomatology. Pressure
Olecranon bursitis is a relatively common condi-
or active and passive movements may result in a
tion that typically affects men between the ages
worsening of symptoms. If fever is present, the
of 30 and 60 years. It is characterized by an in-
diagnosis of septic bursitis must be considered.
flammatory process with fluid distension or hy-
pertrophy of the synovial membrane.
Etiology
Olecranon bursitis is seen as a localized fluid col-
lection and synovial wall hypertrophy. Color- and
The most common cause of olecranon bursitis is
power-Doppler imaging demonstrate soft-tissue
local contusion: 66% of cases are aseptic and usu-
hyperemia. Both edema of the surrounding soft
ally occur when trauma or repeated small injuries
tissues and cellulitis are frequently associated
lead to bleeding into the bursa or the release of in-
with hemorrhagic and septic bursitis. In patients
flammatory mediators (student’s elbow, miner’s
with chronic renal failure, it is common to iden-
elbow). Bursitis can also develop secondary to
tify a calcified bursitis. The presence of synovial
calcific enthesopathy of the distal triceps tendon,
proliferation and fibrosis suggests a differential
systemic disorders such as rheumatoid arthritis,
diagnosis that includes solid tumor and chronic
gout, hydroxyapatite and calcium pyrophosphate
bursitis. In patients with rheumatoid arthritis,
deposition diseases, septic conditions, or chronic
subcutaneous nodules can be seen in the olec-
hemodialysis.
ranon region and along the proximal ulna. Fluid
collection can lead to bursal rupture dissecting
the superficial soft tissues.
Treatment Options
Ospedale S. Corona Most patients respond to conservative manage-
Pietra Ligure (SV), Italy ment, including ice, activity modification, and

80 F. Lacelli
NSAIDs. In cases of septic bursitis, oral antibiot- Objective

ics may be administered. Drainage in the acute
phases usually relieves swelling and discomfort, To drain distended olecranic bursa. To deliver
while steroid injection is performed in chronic or anti-inflammatory drugs into the bursal space.
recurrent bursitis.
Equipment
Interventional Procedure
- 1 syringe (1 ml)
Indications - 1 syringe to drain the bursal effusion (up to
20 ml)
Chronic or recurrent bursitis non-responsive to - 14G–20G simple needle or shielded cannula
conservative treatment. Septic bursitis can be - Long-acting steroid (1 ml, 40 mg/ml)
drained but steroid should not be injected. - Plaster.
Our Procedure
Fig. 13.1a
Fig. 13.1b
STEP 1
The patient is positioned prone, with the forearm flexed and the hand lying on the examination
table (Fig. 13.1a). This position can help to squeeze the bursa in case of a drainage procedure
to address a consistent effusion. A longitudinal US scan is performed on the olecranic region
(O) to assess the anatomical extension of the bursa and to identify the enlarged bursa (asterisks)
(Fig. 13.1b).
13 Olecranon Bursa Drainage 81
Fig. 13.2a
Fig. 13.2b
Fig. 13.2c
STEP 2
A needle connected to a syringe is inserted with an in-plane approach until the tip enters the
bursa (Fig. 13.2a). In some patients the bursal content is very dense, such that drainage is ex-
tremely challenging. In these cases, a larger shielded cannula (Fig. 13.2b,c, arrowheads) and the
application of manual compression over the bursa (asterisks) may be helpful. A biopsy handle
may also be used to obtain a more effective vacuum. T triceps tendon, O olecranon.
82 F. Lacelli
Fig. 13.3
STEP 3
When the bursa (asterisks) has been completely drained, a small amount of steroid (circles) is
injected (Fig. 13.3). In case of infection, lavage using warm saline solution may help. In these
cases, however, steroid injections are to be avoided. The needle is then removed and a plaster
applied at the cutaneous puncture site. T triceps tendon, O olecranon.
The patient is advised to avoid stressing the olecranon region on hard surfaces for a few days.
Intra-articular Injections
14
Essentials Interventional Procedure
Treatment Options Indications
Intra-articular injections of the elbow can be per- Intra-articular injection of steroids: rheumatoid
formed in the treatment of a variety of pathologi- arthritis, crystal arthropathies, degenerative os-
cal conditions. teoarthritis with articular effusion.
The drugs administered in these cases may be Intra-articular injection of hyaluronic acid:
an anti-inflammatory agent, such as the use of degenerative osteoarthritis without articular ef-
steroids for rheumatoid arthritis or crystal-in- fusion.
duced arthropathies, or a viscosupplement, such Intra-articular injection of local anesthetic:
as hyaluronic acid, which is injected in joints in- assessment of intra-articular relevance of pain,
volved by osteoarthritis. Local anesthetic can be traumatic fractures of the radial head.
injected to assess the intra-articular relevance of
referred pain or as short-term analgesia. In trau-
matic fractures of the radial head, aspiration and Objective
analgesic injection are an option.
This procedure can also be used to inject con- To deliver anti-inflammatory or viscosupplement
trast agent within the joint for arthrography. agents into the intra-articular joint space.
Equipment

- 21G needle
- Long-acting steroid (1 ml, 40 mg/ml) or low-
molecular-weight hyaluronic acid (2 ml)
- Plaster.

Radiology Unit

84 L. M. Sconfienza
Our Procedure
Fig. 14.1a
STEP 1
The patient is seated facing the operator with the elbow flexed 90° and the hand in a neutral posi-
tion. The transducer is aligned longitudinally to visualize the humeral-radial joint (Fig. 14.1a). A
longitudinal US scan of the lateral articular recess is performed, examining the cortical bone of
the capitulum humeri, the synovial meniscus, and the proximal radial epiphisis covered with hy-
aline cartilage. The humeral-radial joint line is then centered in the field of view (see Fig. 10.3).
Fig. 14.1b
Fig. 14.1c
STEP 2
A 20G needle is inserted perpendicularly to the skin at the center of the probe, with an out-of-
plane (coaxial) approach (Fig. 14.1b). Passage of the needle tip into the joint is generally associ-
ated with a distinct feeling of capsular resistance followed by the sensation of a resistance-free
space. When the needle tip (arrow) reaches the US scanning plane (Fig. 14.1c), it is visualized
as a hyperechoic dot appearing in the anechoic articular space between the capitulum humeri
(CH) and the radial head (RH), underlying the common extensor tendon (CET). The injection
should be made slowly but with consistent pressure. At the end of the injection, the needle can
be removed and a plaster applied on the skin.
The patient should be kept under observation for at least 30 min after the procedure. Pain may
occur after treatment and is managed with oral NSAIDs.
A short resting period of 1 or 2 days should be recommended.
Part III
The Wrist
The Wrist: Focused US Anatomy and
Examination Technique 15
Enzo Silvestri and Giulio Ferrero
Scanning Technique
Extensor Tendons To evaluate the first compartment, the wrist must
be kept in an intermediate position between pro-
Anatomy nation and supination and the probe must be
On the dorsal side of the wrist, the extensor ten- placed on the lateral side of the radial styloid.
dons run within six compartments, numbered The second to fifth compartments are evaluated
from 1 to 6, from the radial to the ulnar side. The with the palm facing down in a neutral position.
first compartment consists of the abductor pol- The sixth compartment is assessed with the hand
licis longus and extensor pollicis brevis tendons. slightly bent on the radial side. Long- and short-
The second comprises the extensor carpi radialis axis scans of each tendon up to its distal insertion
longus and brevis tendons. The third, separated must be obtained, also during finger flexion and
from the second by the Lister tubercle, contains extension.
the extensor pollicis longus tendon. The fourth
compartment is the widest, as it must accommo-
date the extensor indici and the four extensor dig-
itorum tendons. The fifth consists of the extensor
digiti quinti tendon, and the sixth the extensor
carpi ulnaris tendon.
Enzo Silvestri ( )
Radiology Unit
Genoa, Italy

90 E. Silvestri and G. Ferrero
b c
d e
Fig. 15.1 a Overview of the extensor compartments of

f
the wrist. b Abductor pollicis longus (APL) and extensor
pollicis brevis (EPB) tendons. R radius. c Extensor carpi
radialis longus (ECRL) and brevis (ECRB) tendons.
d The extensor pollicis longus tendon (EPL) is separated
from the second compartment by the Lister tubercle (L).
The extensor digiti secundi (EDS) and the extensor
digitorum communis (EDC) tendons are contained in the
fourth compartment. e Extensor digitorum communis
(EDC) and extensor digiti quinti (EDQ) within the fourth
compartment. f Extensor carpi (ECU) tendon overlying
the ulna (U). All tendons are stabilized by the extensor
retinacula (arrowheads)
15 The Wrist: Focused US Anatomy and Examination Technique 91
Carpal Joints carpal joint. The trapezium also articulates with

the first metacarpal bone.
Anatomy
The radiocarpal joint is formed by the radius, the Scanning Technique
radioulnar capsule recess, and three bones of the The radiocarpal joint can be assessed by plac-
proximal carpal row: scaphoid, lunate, and tri- ing the probe on the dorsal side of the wrist on
quetrum. Between the scaphoid and the lunate a longitudinal scan. A small amount of effusion
and between the lunate and the triquetrum there will stretch the proximal side of the capsule.
are two important ligaments that act as passive The trapezium-metacarpal joint is scanned with
wrist stabilizers, the scapho-lunate and lunate- the wrist kept in the same position used for the
triquetrum. The integrity or interruption of these first dorsal compartment, with the probe aligned
structures defines the distribution of drugs inside along a longitudinal axis.
the compartments and their spread into the mid-
Fig. 15.2a,b Sagittal scan over the radio-mid-

carpal joints. The distal radius (R), lunate (L),
and capitate (C) are seen. The radiocarpal
(arrow) and the mid-carpal (arrowhead) joints
are visible
92 E. Silvestri and G. Ferrero
Fig. 15.3a,b Trapeziometacarpal joint. The

articular space (arrow) can be seen between the
trapezium (T) and the metacarpal base (M). The
joint capsule (arrowheads) is visible as well
Treament of De Quervain’s Disease
and Other Forms of Tenosynovitis 16
Giovanni Serafini
Essentials
Typical symptoms include pain or tenderness
Epidemiology
over the radial styloid, sometimes radiating to
the thumb, forearm, or shoulder. On physical ex-
De Quervain’s disease occurs in 0.5% of males
amination, swelling over the radial styloid with
and 1.3% of females; in the latter, it is often as-
tenderness and crepitations on palpation may be
sociated with pregnancy and nursing. The preva-
noted. There may also be associated functional
lence and incidence of De Quervain’s tenosyno-
limitations. Finkelstein’s test (deviating the wrist
vitis in primary care are not known. This disease
to the ulnar side while grasping the thumb, result-
has a considerable impact on daily activities.
ing in pain) is typically positive.
Etiology
De Quervain’s disease is a chronic tenosynovi-
Retinaculum thickening in the extensor compart-
tis of the first dorsal compartment of the wrist,
ment can be seen on US. Power Doppler can be
caused by a thickening of the retinaculum. This
used to detect hypervascularity. A dynamic US
impairs the normal sliding of the extensor pol-
evaluation may demonstrate the impaired mo-
licis brevis and abductor pollicis longus tendons.
bility of the tendons within the compartment. In
Retinaculum thickening reflects degenerative
some cases, an accessory tendon or a fibrous hy-
changes, such as myxoid degeneration, fibrocar-
perechoic septum separating the two tendons is
tilaginous metaplasia, and mucopolysaccharide
seen. The detection of these findings is important
deposition. This condition should be not con-
as they imply an improvement or worsening of
fused with acute tenosynovitis, in which inflam-
the disease.
mation and synovial effusion within the tendon
sheath are seen.
Treatment Options
Therapy initially consists of resting the thumb

and wrist with or without splinting and ice appli-
Ospedale S. Corona cation. An intracompartmental injection can pro-
Pietra Ligure (SV), Italy vide the complete relief of symptoms. In some

94 G. Serafini
cases, however, surgery is needed to release the anti-inflammatory effects possibly resulting in
retinaculum or to remove the accessory tendon or relief from both pain and swelling. Advanced dis-
the fibrous septum. ease stages, characterized by a severe stenosis of
the compartment due to retinaculum thickening,
may benefit from a first injection of steroid, fol-
Interventional Procedure lowed by 1–2 weeks of delayed hyaluronic acid
injection. This second step has the advantage of
Indications both improving tendon sliding and stretching the
If the condition is symptomatic and limits dai- thickened retinaculum.
ly life activities, then US-guided percutaneous
treatment is indicated. There are no specific con-
traindications to this procedure. Equipment
- 25G or smaller needle

Objective - 1 syringe (1–2 ml)
Early or subacute De Quervain’s disease re- - Low-molecular-weight hyaluronic acid (2 ml,
sponds well to corticosteroid injection, with the optional)
- Plaster.
16 Treament of De Quervain’s Disease and Other Forms of Tenosynovitis 95
Our Procedure
Fig. 16.1a
Fig. 16.1b
Fig. 16.1c
Lateral Approach
The wrist must be placed in an intermediate position between pronation and supination (Fig.
16.1a). The probe is then positioned on the lateral side of the radial styloid to assess the first
compartment along its short axis (Fig. 16.1b). APL abductor pollicis longus, EPB extensor pol-
licis brevis.
We prefer to use a lateral approach to treat De Quervain’s disease (Fig. 16.1c). The needle
(arrowheads) is inserted within the thickened retinaculum (arrows) and the drug (asterisks) is
injected. The abductor pollicis longus (APL), extensor pollicis brevis (EPB), and extensor carpi
radialis longus (ECRL, second compartment) can be seen.
96 G. Serafini
Fig. 16.2a
Fig. 16.2b
Longitudinal Approach
Note that a long-axis approach is also possible (Fig. 16.2a). In Fig. 16.2b, the needle (ar-
rowheads) is inserted within the thickened retinaculum (arrows). The abductor pollicis longus
(APL) is seen overlying the radius (R).
Patients are advised to reduce their manual activity, although no systematic rest period is sug-
gested.
Other Forms of Tenosynovitis of the ment differs from the other five in that sheath ef-
Dorsal Compartments fusion frequently occurs in conjunction with joint
effusion, due to the physiological communication
Not just the first compartment but also other ex- between the two structures. In this case, sheath
tensor compartments can be affected by acute or effusion should not be treated.
chronic tenosynovitis, which can similarly cause Also in these cases, steroid injection is a valid
pain and functional limitations. Acute tenosyno- option, as it is able to reduce pain and effusion.
vitis is characterized by a fluid effusion within Sometimes, hyaluronic acid is injected to im-
the compartment or the tendon sheath, while in prove tendon sliding and to stretch a retinaculum
chronic tenosynovitis there is synovial thicken- stenosis. The injection technique is similar to that
ing or proliferation. The sixth extensor compart- described for De Quervain’s disease.
Articular Ganglia Drainage
17
Leonardo Callegari
signs of inflammation. On palpation, they are a

Essentials firm swelling well tethered in place by an attach-
ment to the underlying joint capsule or tendon
Epidemiology sheath.
While ganglia are frequently asymptomatic,
Ganglion cysts are the most common benign
symptoms may include general wrist pain, espe-
soft-tissue lesions of the wrist. They occur three
cially during activities, functional limitation, or a
times more often in women than in men, are pre-
decrease in grip strength. In some cases, ganglia
dominantly seen in young adults, and are rare in
may cause pain by compressing small branches
children. In 60–70% of affected individuals, the
of the peripheral nerves.
ganglion cyst is localized in the dorsal aspect of
the wrist and communicates with the synovial
joint via a pedicle that usually originates at the Ultrasound Diagnosis
scapholunate ligament but also may arise from a
number of other sites over the dorsal aspect of the Wrist ganglia have a typical cystic pattern on US,
wrist capsule. In 13–20% of the cases, ganglia i.e., roundish or oval hypo/anechoic findings and
are found on the volar side of the wrist. well delimited by a thin and regular wall. When
the cyst content is not exactly hypo/anechoic,
the presence of a well-defined pedicle may help
Etiology to differentiate a ganglia from other pathological
conditions.
Ganglia are articular cysts that originate from the
articular cavity. The exact mechanism of gangli-
on formation remains unknown. Treatment Options
Ganglion cyst can be treated conservatively, by

Clinical Presentation percutaneous drainage, or surgically. Bandaging
is the most common conservative treatment and
On examination, wrist ganglia are usually 1- to
is aimed at limiting wrist mobility. Percutaneous
2-cm lumps, but they are rarely accompanied by
drainage is the second treatment option but about
50% of these treated ganglion cysts will relapse.
Leonardo Callegari ( )
Radiology Unit B However, as this procedure is relatively non-in-
Ospedale di Circolo, Fondazione Macchi vasive, it can be repeated several times. In case
Varese, Italy of recurrent cysts, surgery, performed using an

98 L. Callegari
arthroscopic or open-air approach, is the last op- Objective

tion. It is associated with a 35% recurrence rate,
especially in patients with a longer history and a Ganglia drainage is aimed at reducing lesion vol-
larger ganglion cyst. ume. Steroid injection after drainage may help to
keep the ganglia wall collapsed.
Indications - 18G needle

- 1 syringe (10 ml)
Articular ganglia can be treated to reduce pain or - Lidocaine (2–4 ml)
other symptoms. Asymptomatic ganglia can be - Long-acting steroid (1 ml, 40 mg/ml).
drained also for aesthetic reasons.
Our Procedure
Fig. 17.1a
Fig. 17.1b
STEP 1
The wrist should be positioned according to the ganglion’s location (Fig. 17.1a). Ganglia more
commonly occur on the dorsal side of the wrist. The probe is usually positioned along the ma-
jor axis of the ganglion. As seen in Fig. 17.1b, the ganglion (G) should be assessed also with
respect to the other structures of the wrist. Particular attention should be paid to avoid injury of
the radial artery (A) that frequently surrounds the ganglion.
17 Articular Ganglia Drainage 99
Fig. 17.2a
Fig. 17.2b
STEP 2
Using an in-plane lateral approach (see Fig. 17.1a), a small amount of anesthesia is injected
into the subcutaneous tissues around the ganglion (G). Then, a large-bore needle (arrowheads)
is advanced within the ganglion (Fig. 17.2a,b), with care taken to avoid surrounding structures,
such as the radial artery (A). R radius, S scaphoid.
Fig. 17.3
STEP 3
The ganglion’s content is completely drained using a syringe (Fig. 17.3). Continuous US moni-
toring of the needle (arrowheads) is mandatory. This procedure is usually quite slow, as the
material contained in the ganglion is often very dense. In these cases, a larger shielded cannula
and the application of manual compression over the ganglion may be helpful. A biopsy handle
may also be used to obtain a more effective vacuum.
100 L. Callegari
Fig. 17.4
STEP 4
At the end of the procedure, a small amount of steroid (asterisks) is injected into the ganglion
cavity (Fig. 17.4).
A compressive bandage is applied to the involved site for 5-10 days in order to keep the ganglion
wall collapsed and to minimize the probability of recurrence.
Trapeziometacarpal
Joint Injection 18
Francesca Lacelli
Essentials
The typical symptom is pain that occurs either
Epidemiology
after prolonged activities or as a result of simple
anteposition and opposition movements of the
Trapeziometacarpal osteoarthritis occurs most
thumb. Pain is mostly reported over the volar side
often in women over the age of 40. In approxi-
of the thumb base.
mately 80% of cases, it is associated with os-
teoarthritis between the trapezium and the base
of the second metacarpal, and in 40% of cases
with osteoarthritis between the trapezium and the
scaphoid.
The trapeziometacarpal joint is easily evaluated
by placing the probe on the volar side of the car-
pus and detecting the joint along its long axis. US
Etiology
signs of rhizarthrosis are joint effusion, a reduc-
tion of the articular space, erosive phenomena,
The trapeziometacarpal joint may be involved by
and osteophytes.
different kinds of arthritis. The most common is
osteoarthritis, also known as rhizarthrosis, and it
is a result of natural joint aging. As the degenera-
Treatment Options
tive process continues, the cartilage becomes in-
creasingly thinner, and eventually disappears. At
Conservative treatment of trapeziometacarpal ar-
later stages, the articular space may be lost and
thritis includes physiotherapy, orthopedic splint-
osteophytes are frequently seen. There may also
ing, and drug injection. The aim is to control
be progressive subluxation of the base of the first
symptoms and to delay or avoid surgery.
metacarpal bone.
In case of severe arthritis or persisting symptoms
despite conservative therapy, surgery is an option.
Ospedale S. Corona

102 F. Lacelli
Interventional Procedure repeated weekly, three times. This cycle can be

repeated in case of pain recurrence.
Indications Early stages of the disease respond well to
this form of treatment. In patients with later-stage
US-guided percutaneous treatment is indicated disease, the outcome is worse and there is earlier
if the patient complains of pain and functional symptom recurrence.
limitation. This form of therapy has been shown
to delay surgery and in some cases to allow the
patient to completely avoid it. Equipment
- 25G or smaller needle

Objective - 1 syringe (1–2 ml)
- Local anesthetic (0.5 ml)
Steroid injection is useful in reducing both the in- - Long-lasting steroid (0.5 ml, 40 mg/ml)
flammatory component of osteoarthritis and pain. - Low-molecular-weight hyaluronic acid (0.5–
Hyaluronic acid is injected 10–15 days later and 1 ml)
improves joint mobility. The injection should be - Plaster.
Our Procedure
Fig. 18.1a
Co-axial Approach
STEP 1
The wrist must be positioned in an intermediate position between pronation and supination. The
probe is placed on the lateral side of the wrist along its long axis, visualizing the trapeziometa-
carpal joint along its long axis. The needle is inserted with a co-axial out-of-plane approach
(Fig. 18.1a).
18 Trapeziometacarpal Joint Injection 103
Fig. 18.1b
Fig. 18.1c
STEP 2
The articular space (arrow) can be seen between the trapezium (T) and the metacarpal base (M).
As shown in Fig. 18.1b,c, the needle is inserted in the joint space, where it is seen as a small
hyperechoic dot (arrow). Steroid (asterisk) is then injected into the joint, distending the capsule
(arrowheads). After 10–15 days, hyaluronic acid is injected according to the same technique.
104 F. Lacelli
Fig. 18.2a
Fig. 18.2b
Fig. 18.2c
The procedure can also be performed using a lateral approach (Fig. 18.2a). The needle (ar-
rowheads) is inserted in the joint space (Fig. 18.2b,c) and drug (asterisk) is then injected in the
joint, distending the capsule (arrows). Delayed hyaluronic acid injection is performed as above.
M metacarpal base, T trapezium.
After treatment, patients should avoid heavy activities for 5–10 days. Pain may occur after treat-
ment and is managed with oral NSAIDs.
Radiocarpal Joint Injections
19
Equipment
Similar to the other joints discussed thus far,
intra-articular injections of the wrist can be per-
- 21G–23G needle
formed to address a variety of pathological con-
ditions. The drug of choice will depend on the
- Local anesthetic (5 ml) and/or
condition and the treatment goals. The technique
- Long-lasting steroid (1 ml, 40 mg/ml) and/or
can also be used in the injection of intra-articular
- Medium-molecular-weight hyaluronic acid
contrast agent for arthrography.
(2 ml)
- Plaster.
Indications
Intra-articular injection of steroids: rheumatoid

arthritis, crystal arthropathies, degenerative os-
teoarthritis with articular effusion.
Intra-articular injection of hyaluronic acid:
degenerative osteoarthritis without articular ef-
fusion.
Intra-articular injection of local anesthetic:
assessment of intra-articular relevance of pain,
traumatic fractures of the radial head, short-term
analgesia.

Radiology Unit

106 L.M. Sconfienza
Our Procedure
Fig. 19.1a
STEP 1
The hand is positioned on the table with the palm facing down (Fig. 19.1a). The probe is placed
over the relevant joint to be injected. To inject the radiocarpal joint, the probe is positioned on
the dorsal side of the wrist along its long axis (see Fig. 15.2a); this also allows visualization of
the distal radial epiphysis and the first carpal row (see Fig. 15.2b).
19 Radiocarpal Joint Injections 107
Fig. 19.1b
Fig. 19.1c
STEP 2
The needle is inserted into the joint using an out-of-plane co-axial approach (Fig. 19.1b).
Fig. 19.1c shows the injection of steroid in a patient with rheumatoid arthritis accompanied by
synovial proliferation. The needle (arrows) can be seen as a small hyperechoic dot within the
synovial proliferation (asterisks). The latter arises between the carpal bones (CB). The extensor
tendons (ET), radius (R), and metacarpal bone (M) are also seen.
Patients should avoid heavy activities for 5–10 days. Pain may occur after treatment and is man-
aged with oral NSAIDs.
Part IV
The Hand
The Hand: Focused US Anatomy
Francesca Lacelli and Chiara Martini
Scanning Technique
Flexor Digitorum Tendons With the patient’s hand placed on the table with
the palmar side facing up, the probe is placed at
Anatomy the carpal tunnel level and then is moved distally
There are nine flexor tendons for each hand, a to follow the tendons until their insertions. Axial
flexor digitorum superficialis and a flexor digi- scans allow the changing relationship between
torum profundus for each finger, from the second superficial and deep flexor tendons to be as-
to the fifth. The thumb is provided with a single sessed; longitudinal scans are useful for passive
flexor tendon only. The flexor digitorum profun- dynamic evaluation, e.g., in patients with tendon
dus tendon originates from the anterior and medi- impingement under the pulleys.
al aspects of the ulna, while the flexor digitorum
superficialis tendon has two heads: humero-ulnar
and radial. Both muscles originate from long Metacarpophalangeal and
tendons that proximally enter the carpal tunnel Interphalangeal Joints
and then insert on the fingers. Deep tendons run
straight up to the bases of the distal phalanges, Scanning Technique
where they insert. Superficial tendons run up With the patient’s palm facing up, the probe is
to the middle of the proximal phalanges, where placed along the longitudinal axis over the per-
they split into two branches that surround the tinent joint. Each joint is renforced by a capsule
deep tendons and insert on the head of the mid- and a palmar plate, which together form a cap-
dle phalanges. The superficial and deep tendons suloligamentous complex that is located on the
have common tendon sheaths. Flexor tendons are ventral side. A small amount of intra-articular
kept in place by several fibrous bands referred to fluid can be seen under normal conditions.
as pulleys. These structures are very thin and are
occasionally seen US as thin hypoechoic bundles
that overhang the tendons.
Ospedale S. Corona

112 F. Lacelli and C. Martini
Fig. 20.1 a The probe position and b a long-axis

scan of the flexor tendons. The flexor digitorum
superficialis (FDS) and flexor digitorum
profundus (FDP) can be seen. The A1 reflection
pulley is indicated (arrowheads). MH metacarpal
head, PP proximal phalanx
Fig. 20.2 Long-axis lateral scan of the second

metacarpophalangeal joint. The joint space
(arrow) is located between the metacarpal
head (MH) and the proximal phalanx (PP) and
surrounded by the joint capsule (arrowheads)
Treatment of Trigger Finger
21
Leonardo Callegari
Essentials
Symptoms include triggering or catching of the
Etiology
finger during movement, pain on passive exten-
sion, and locking. Clinically, finger clicking
Trigger finger is a stenosing tenosynovitis that
can be clearly perceived. Sometimes, a palpable
originates from a thickening of the first annular
nodule may be appreciated over the metacar-
(A1) pulley of the flexor tendons. In order of fre-
pophalangeal joint.
quency, the thumb, annular, middle, little, and
index fingers are affected.
Most cases of trigger finger are idiopathic. In
some patients, high pressures on the A1 pulley
during maximum flexion may cause changes in
Hypoechoic thickening of the A1 pulley and
the pulley itself, with hypertrophy and fibrocar-
nodular thickening of the flexor tendon can be
tilaginous metaplasia. It is thought that chronic,
demonstrated using US. Dynamic US scans can
repetitive friction causes a nodule in the tendon
confirm the diagnosis of trigger finger when
as the fibers lose their normal arrangement.
thickening of the pulley or the tendon cannot oth-
erwise be detected.
Epidemiology
Alternative Treatments
Trigger finger is one of the most common pathol-
Alternative treatments of trigger finger include:
ogies of the upper limb (28 cases per 100,000 per
splintage, if the symptoms are mild: simply rest-
year). It is more frequent in women, with a peak
ing the finger may be enough to relieve the prob-
of incidence between the age of 50 and 60. There
lem; pharmacological therapy with NSAIDs; and
may be an associated clinical condition (diabetes
surgical release of the A1 pulley by open or per-
mellitus, rheumatoid arthritis, hypothyroidism,
cutaneous techniques.
obesity). In other patients it is due to repetitive
activities (work, sport).
Leonardo Callegari ( )
Radiology Unit B
Ospedale di Circolo, Fondazione Macchi
Varese, Italy

114 L. Callegari
Interventional Procedure of hyaluronic acid into the sheath is performed

to improve tendon sliding under the pulley by
Indications stretching the A1 pulley fibrosis.
The US-guided percutaneous treatment of trigger

finger is indicated when the patient complains Equipment
of pain or functional limitation (presence of dis-
comfort or blockage during movements of the - 25G needle
finger, or an inability to actively achieve flexion). - Two syringes (2 ml)
- Lidocaine (0.5 ml)
Objective - Low-molecular-weight hyaluronic acid (1 ml)
The aim of steroid injection is to reduce pain and - Plaster.
inflammation. A 10- to 15-day delayed injection
21 Treatment of Trigger Finger 115
Our Procedure
Fig. 21.1a
Fig. 21.1b
Fig. 21.1c
STEP 1
The patient is seated opposite the examiner with his or her hand placed on the table and the palm
facing up (Fig. 21.1a). The probe is placed at the level of the metacarpophalangeal joint, along
the major axis of the flexor tendons (Fig. 21.1b,c). Note the thickened pulley (arrows) and the
chronic tenosynovitis (arrowheads). FDS flexor digitorum superficialis, FDP flexor digitorum
profundus, MH metacarpophalangeal head, PP proximal phalanx.
116 L. Callegari
Fig. 21.2a
Fig. 21.2b
Fig. 21.2c
Fig. 21.3
STEP 2
As seen in Fig. 21.2a–c, the needle (arrowheads) is inserted along a longitudinal axis with a dis-
tal-proximal approach and the anesthetic is injected within the tendon sheath (arrows indicate
the A1 pulley), avoiding the tendons. FDS flexor digitorum superficialis, FDP flexor digitorum
profundus. Then, with the needle (arrowhead) kept in place, steroid (asterisks) is injected within
the sheath (Fig. 21.3), avoiding the tendons.
21 Treatment of Trigger Finger 117
Fig. 21.4a
Fig. 21.4b
Fig. 21.4c
Lateral Approach
STEP 2
A short-axis approach is also possible, as shown in Fig. 21.4a-c. In this case, the probe is ori-
ented on the short axis of the tendons (FT) and the needle (arrowheads) is inserted laterally.
Steroid (asterisk) is then injected.
118 L. Callegari
Fig. 21.5
STEP 3
After 10–15 days, hyaluronic acid (asterisks) is injected using the same longitudinal or lateral
injection technique (Fig. 21.5), avoiding the tendons. FDS flexor digitorum superficialis, FDP
flexor digitorum profundus. Arrowheads indicate the needle.
After hyaluronic acid has been injected into the sheath, passive flexion- extension movements
of the treated finger should be performed in order to favor the homogeneous spreading of hyal-
uronic acid within the sheath.
Intra-articular Injections:
Metacarpophalangeal 22
and Interphalangeal Joints
Objective
Essentials The aim of injecting intra-articular steroids and
anesthetic is to reduce inflammation and pain,
Intra-articular injections of drugs are an option
improving joint functionality. The intra-articular
also for the metacarpophalangeal and inter-
injection of hyaluronic acid improves joint lubri-
phalangeal joints. They are administered as de-
cation.
scribed for the others joints of the upper limb.
Equipment
Interventional Procedures - 23–35G or smaller needle
Indications
- Local anesthetic (1 ml)
- Steroid (0.5–1 ml, 40 mg/ml)
Intra-articular injection of steroids: rheumatoid
- Low-molecular-weight hyaluronic acid (1 ml)
arthritis, degenerative osteoarthritis with articu-
- Plaster.
lar effusion.
Intra-articular injection of hyaluronic acid:
degenerative osteoarthritis without articular ef-
fusion.
Intra-articular injection of local anesthetic:
assessment of the intra-articular relevancy of
pain, short-term analgesia.

Radiology Unit

120 L.M. Sconfienza
Our Procedure
Fig. 22.1a
STEP 1
The patient is seated in front of the table, opposite the examiner, with his or her hand placed on
the table, palm facing down (Fig. 22.1a). The probe is positioned on the dorsal side of the joint
for treatment along the longitudinal axis.
Fig. 22.1b
Fig. 22.1c
STEP 2
The needle is inserted out-of-plane in the ulnar or radial (Fig. 22.1b,c) side of the joint. Inser-
tion of the needle is easier on the less degenerated side of the joint. A small amount of anesthet-
ic is injected. In the next step, with the needle kept in place, steroid and then hyaluronic acid
are injected within the joint capsule. MH metacarpophalangeal head, PP proximal phalanx. Ar-
rowheads indicate the joint capsule, the arrow the needle tip, and asterisks the drugs. A similar
approach can be used for the interphalangeal joints. although caution is needed to avoid injury
to the interdigital neurovascular bundle. A palmar approach is also possible.
After treatment, patients should avoid heavy activities for 5–10 days. Pain may occur after
treatment and is managed with oral NSAIDs.
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Ultrasound-Guided Musculoskeletal Procedures - The Upper Limb

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Ultrasound-Guided Musculoskeletal Procedures - The Upper Limb

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Ultrasound-guided Musculoskeletal

ISBN 978-88-470-2741-1 ISBN 978-88-470-2742-8 (eBook)

Library of Congress Control Number: 2012939782

© Springer-Verlag Italia 2012

7654321 2012 2013 2014

Springer-Verlag Italia S.r.l. – Via Decembrio 28 – I-20137 Milan

Ultrasound is an emergent imaging modality that is widely used to assess

May 2012 Luca Maria Sconﬁenza

1 General Aspects of US-guided Musculoskeletal Procedures 1

Part I The Shoulder

2 The Shoulder: Focused US Anatomy and Examination

3 Subacromial-Subdeltoid Bursa Injections . . . . . . . . . . . . . . . . 25

4 Treament of Calciﬁc Tendinitis of the Rotator Cuff . . . . . . . . 29

5 Calciﬁc Enthesopathy Dry-Needling . . . . . . . . . . . . . . . . . . . . 37

6 Hyaluronic Supplementation of the Subacromial Space . . . . 41

8 Long Head of the Biceps Brachii Tendon Injection . . . . . . . . 51

9 Acromioclavicular Joint Injection . . . . . . . . . . . . . . . . . . . . . . 55

Part II The Elbow

10 The Elbow: Focused US Anatomy and Examination

11 Treatment of Lateral Epicondylitis . . . . . . . . . . . . . . . . . . . . . 67

12 Treatment of Medial Epicondylitis . . . . . . . . . . . . . . . . . . . . . 73

13 Olecranon Bursa Drainage . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

Part III The Wrist

15 The Wrist: Focused US Anatomy and Examination

16 Treament of De Quervain’s Disease and Other Forms

17 Articular Ganglia Drainage . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

18 Trapeziometacarpal Joint Injection . . . . . . . . . . . . . . . . . . . . 101

19 Radiocarpal Joint Injections . . . . . . . . . . . . . . . . . . . . . . . . . . 105

Part IV The Hand

20 The Hand: Focused US Anatomy and Examination

21 Treatment of Trigger Finger . . . . . . . . . . . . . . . . . . . . . . . . . . 113

22 Intra-articular Injections: Metacarpophalangeal

Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121

Alice Arcidiacono Post-graduate School in Radiodiagnostics, University

Leonardo Callegari Radiology Unit B, Ospedale di Circolo, Fondazione

Armando Conchiglia Radiology Department, Ospedale San Salvatore,

Angelo Corazza Post-graduate School in Radiodiagnostics, University of

Emanuele Fabbro Post-graduate School in Radiodiagnostics, University

Giulio Ferrero Post-graduate School in Radiodiagnostics, University of

Lorenzo Maria Gregori Radiology Department, Ospedale San Salvatore,

Francesca Lacelli Diagnostic Imaging Department, Ospedale S. Corona,

Chiara Martini Post-graduate School in Radiodiagnostics, University of

Carlo Masciocchi Radiology Department, Ospedale San Salvatore,

Francesca Nosenzo Post-graduate School in Radiodiagnostics, University

Davide Orlandi Post-graduate School in Radiodiagnostics, University of

Luca Maria Sconﬁenza Radiology Unit, IRCCS Policlinico San Donato,

Giovanni Seraﬁni Diagnostic Imaging Department, Ospedale S. Corona,

Enzo Silvestri Radiology Unit, Ospedale Evangelico Internazionale,

Luigi Zugaro Radiology Department, Ospedale San Salvatore, University

L.M. Sconﬁenza, G. Seraﬁni, E. Silvestri (eds.), Ultrasound-guided Musculoskeletal Procedures, 1

Fig. 1.1 a In US-guided lateral approach the

Drugs Adverse Effects

Corticosteroids Dexamethasone-type preparations, however,

The most feared complication after ster- Hyaluronic Acid

Fig. 1.2 A well-organized tray containing all the

General Workﬂow for US-Guided Interventional Procedures

The shoulder can be subdivided into three com- Scanning Technique

L.M. Sconﬁenza, G. Seraﬁni, E. Silvestri (eds.), Ultrasound-guided Musculoskeletal Procedures, 13

Fig. 2.1 Evaluation of the long head of the biceps brachii

Fig. 2.2 Evaluation of the long head of the biceps brachii

Subscapularis Tendon Scanning Technique

Fig. 2.3 Evaluation of the subscapularis tendon.

Fig. 2.4 Evaluation of the subscapularis tendon.