Sonographically guided popliteus tendon sheath injection: techniques and accuracy.

OBJECTIVE: The purpose of this investigation was to describe two sonographically guided popliteus tendon sheath injection techniques and determine their accuracy in a cadaveric model. METHODS: A single experienced operator completed 24 sonographically guided popliteus tendon sheath injections, 12 using a longitudinal approach and 12 using a transverse approach relative to the tendon. The injection order was randomized, and all injections were completed with diluted colored latex. Coinvestigators blinded to the injection technique dissected each specimen and graded the colored latex location as accurate (in the sheath), accurate with overflow (within the sheath but also in other regions), or inaccurate (no latex in the sheath). RESULTS: All 12 sonographically guided popliteus sheath injections using the longitudinal approach placed latex into the sheath. Eight of these injections (67%) also resulted in overflow into the knee joint. Ten of 12 transverse approach injections placed latex into the sheath (83%), with 7 of these (70%) also producing overflow into the knee joint. Two of 12 transverse injections (17%) placed latex only into the knee joint and were therefore inaccurate. CONCLUSIONS: Sonographic guidance can be used to inject the popliteus tendon sheath with a high degree of accuracy. Although the longitudinal approach is potentially more accurate, both approaches may result in injectate overflow into the knee joint, likely through the popliteus hiatus.

The ability of multi-site, multi-depth sacral lateral branch blocks to anesthetize the sacroiliac joint complex.

OBJECTIVE: To determine the physiologic effectiveness of multi-site, multi-depth sacral lateral branch injections. DESIGN: Double-blind, randomized, placebo-controlled study. SETTING: Outpatient pain management center. PATIENTS: Twenty asymptomatic volunteers. BACKGROUND: The dorsal innervation to the sacroiliac joint (SIJ) is from the L5 dorsal ramus and the S1-3 lateral branches. Multi-site, multi-depth lateral branch blocks were developed to compensate for the complex regional anatomy that limited the effectiveness of single-site, single-depth lateral branch injections. INTERVENTIONS: Bilateral multi-site, multi-depth lateral branch green dye injections and subsequent dissection on two cadavers revealed a 91% accuracy with this technique. Session 1: 20 asymptomatic subjects had a 25-g spinal needle probe their interosseous (IO) and dorsal sacroiliac (DSI) ligaments. The inferior dorsal SIJ was entered and capsular distension with contrast medium was performed. Discomfort had to occur with each provocation maneuver and a contained arthrogram was necessary to continue in the study. Session 2: 1 week later; computer randomized, double-blind multi-site, multi-depth lateral branch blocks injections were performed. Ten subjects received active (bupivicaine 0.75%) and 10 subjects received sham (normal saline) multi-site, multi-depth lateral branch injections. Thirty minutes later, provocation testing was repeated with identical methodology used in session 1. OUTCOME MEASURES: Presence or absence of pain for ligamentous probing and SIJ capsular distension. RESULTS: Seventy percent of the active group had an insensate IO and DSI ligaments, and inferior dorsal SIJ vs 0-10% of the sham group. Twenty percent of the active vs 10% of the sham group did not feel repeat capsular distension. Six of seven subjects (86%) retained the ability to feel repeat capsular distension despite an insensate dorsal SIJ complex. CONCLUSION: Multi-site, multi-depth lateral branch blocks are physiologically effective at a rate of 70%. Multi-site, multi-depth lateral branch blocks do not effectively block the intra-articular portion of the SIJ. There is physiological evidence that the intra-articular portion of the SIJ is innervated from both ventral and dorsal sources. Comparative multi-site, multi-depth lateral branch blocks should be considered a potentially valuable tool to diagnose extra-articular SIJ pain and determine if lateral branch radiofrequency neurotomy may assist one with SIJ pain.

Shoulder and elbow injuries in the adolescent athlete.

The shoulder and elbow represent two of the most commonly injured joints in the adolescent population. Specific injuries vary by sport and can involve various structures, depending on the mechanism of injury. Unlike the adult shoulder, the immature skeletal structure of the adolescent athlete can lead to several unique injuries. By understanding the special demands placed on the immature shoulder, the sports physician can more effectively treat the resultant injury. This article reviews the diagnosis and management of unique injuries to the shoulder and elbow in the adolescent athlete.

Ultrasound-Guided Carpal Tunnel Release Using Dynamic Expansion of the Transverse Safe Zone in a Patient With Postpolio Syndrome: A Case Report.

The prevalence of carpal tunnel syndrome (CTS) in patients with postpolio syndrome occurs at a rate of 22%. Irrespective of those with CTS, 74% of postpolio patients weight bear through their arms for ambulation or transfers. As open carpal tunnel release is performed along the weight-bearing region of the wrist, their functional independence may be altered while recovering. This case demonstrates that ultrasound-guided carpal tunnel release was successfully performed in a patient with postpolio syndrome allowing him to immediately weight bear through his hands after the procedure so he could recover at home. LEVEL OF EVIDENCE: V.

Sonographically guided posterior subtalar joint injections: anatomic study and validation of 3 approaches.

OBJECTIVE: To describe and validate 3 different approaches to perform sonographically guided posterior subtalar joint (PSTJ) injections. DESIGN: Sonographically guided procedures performed on cadaveric specimens. SETTING: Procedural skills lab at a tertiary medical facility. METHODS: Three ultrasound-guided approaches to inject the PSTJ: anterolateral, posteromedial, and posterolateral were derived based on anatomic review, published fluoroscopic and computed tomography (CT) techniques, and clinical experience. Three separate unembalmed cadaveric ankle-foot specimens were injected by a single, experienced operator using a 25-gauge, 38-mm stainless steel needle. A different approach was used on each specimen. The needles were left in place and each specimen was subsequently dissected by co-investigators to confirm accurate needle placement and determine the proximity of each needle to local tendons and neurovascular structures. MAIN OUTCOME MEASUREMENTS: Direct assessment of needle placement within posterior subtalar joint. RESULTS: All 3 approaches provided accurate needle placement into the posterior subtalar joint while avoiding nearby tendinous and neurovascular structures. CONCLUSIONS: Sonographically guided PSTJ injections are technically feasible. All 3 approaches provide accurate needle placement while minimizing the risk of needle entry into adjacent soft tissue structures not visualized by other modalities such as fluoroscopy or CT.