<p begin="00:00:07.442" end="00:00:09.161" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.161" end="00:00:11.351" style="s2">with a musculoskeletal exam type</p>
<p begin="00:00:11.351" end="00:00:14.278" style="s2">is used to perform an<br />ultrasound guided injection</p>
<p begin="00:00:14.278" end="00:00:16.258" style="s2">of the pubic symphysis.</p>
<p begin="00:00:16.258" end="00:00:18.665" style="s2">The patient is in a supine position.</p>
<p begin="00:00:18.665" end="00:00:21.467" style="s2">The transducer is placed longitudinally</p>
<p begin="00:00:21.467" end="00:00:23.198" style="s2">over the pubic prominence</p>
<p begin="00:00:23.198" end="00:00:26.593" style="s2">with the orientation marker<br />directed to the patient's right.</p>
<p begin="00:00:26.593" end="00:00:28.603" style="s2">The right and left pubic bodies</p>
<p begin="00:00:28.603" end="00:00:32.134" style="s2">are seen as bright,<br />hyperechoic curved structures.</p>
<p begin="00:00:32.134" end="00:00:34.986" style="s2">The pubic symphysis is seen as a darker,</p>
<p begin="00:00:34.986" end="00:00:38.201" style="s2">hypoechoic line between the two bodies.</p>
<p begin="00:00:38.201" end="00:00:41.189" style="s2">The needle is inserted using<br />an out-of-plane technique</p>
<p begin="00:00:41.189" end="00:00:43.676" style="s2">superior to the transducer.</p>
<p begin="00:00:43.676" end="00:00:47.083" style="s2">The needle is advanced until<br />it enters the pubic symphysis</p>
<p begin="00:00:47.083" end="00:00:49.429" style="s2">where the injection can be performed.</p>
<p begin="00:00:49.429" end="00:00:51.588" style="s2">The pubic symphysis should be scanned</p>
<p begin="00:00:51.588" end="00:00:52.929" style="s2">following needle removal</p>
<p begin="00:00:52.929" end="00:00:57.096" style="s2">to ensure there is no bleeding<br />following the procedure.</p>

<p begin="00:00:07.749" end="00:00:09.332" style="s2">- [Voiceover] A curved array transducer</p>
<p begin="00:00:09.332" end="00:00:11.596" style="s2">with a musculoskeletal exam type</p>
<p begin="00:00:11.596" end="00:00:14.226" style="s2">is used to perform an<br />ultrasound guided injection</p>
<p begin="00:00:14.226" end="00:00:16.908" style="s2">of the proximal hamstring muscle.</p>
<p begin="00:00:16.908" end="00:00:19.168" style="s2">The patient is in a prone position</p>
<p begin="00:00:19.168" end="00:00:21.615" style="s2">with the leg slightly abducted.</p>
<p begin="00:00:21.615" end="00:00:23.978" style="s2">The transducer is place transversely</p>
<p begin="00:00:23.978" end="00:00:26.981" style="s2">over the ischial tuberosity<br />with the orientation marker</p>
<p begin="00:00:26.981" end="00:00:31.148" style="s2">directed to the patient's right<br />at a nine o'clock position.</p>
<p begin="00:00:32.248" end="00:00:34.232" style="s2">The ischial tuberosity is seen</p>
<p begin="00:00:34.232" end="00:00:38.015" style="s2">as a bright, hyperechoic,<br />curved structure.</p>
<p begin="00:00:38.015" end="00:00:40.650" style="s2">The hamstring muscle and<br />it's conjoined tendon</p>
<p begin="00:00:40.650" end="00:00:42.860" style="s2">is seen on cross-section<br />in the mid portion</p>
<p begin="00:00:42.860" end="00:00:44.724" style="s2">of the scan field.</p>
<p begin="00:00:44.724" end="00:00:47.306" style="s2">The transducer is translated superiorly</p>
<p begin="00:00:47.306" end="00:00:50.884" style="s2">to see the origin of the<br />muscle in a short access plane.</p>
<p begin="00:00:50.884" end="00:00:54.152" style="s2">The transducer is then<br />rotated 90 degrees clockwise</p>
<p begin="00:00:54.152" end="00:00:57.279" style="s2">with the orientation marker<br />directed at the patient's head</p>
<p begin="00:00:57.279" end="00:01:00.516" style="s2">to obtain a long access view<br />of the hamstring muscle.</p>
<p begin="00:01:00.516" end="00:01:03.236" style="s2">The needle is inserted<br />in a long access approach</p>
<p begin="00:01:03.236" end="00:01:05.895" style="s2">lateral to the transducer.</p>
<p begin="00:01:05.895" end="00:01:08.374" style="s2">The needle is slowly<br />advanced to lie in plane</p>
<p begin="00:01:08.374" end="00:01:09.936" style="s2">to the transducer beam</p>
<p begin="00:01:09.936" end="00:01:13.804" style="s2">and is seen as a bright,<br />hyperechoic, linear structure.</p>
<p begin="00:01:13.804" end="00:01:14.637" style="s2">The needle is slowly advanced</p>
<p begin="00:01:14.637" end="00:01:17.363" style="s2">under direct ultrasound visualization</p>
<p begin="00:01:17.363" end="00:01:18.670" style="s2">until the tip is seen</p>
<p begin="00:01:18.670" end="00:01:21.824" style="s2">to puncture the anterior<br />surface of the muscle.</p>
<p begin="00:01:21.824" end="00:01:23.070" style="s2">The needle should be advanced</p>
<p begin="00:01:23.070" end="00:01:26.030" style="s2">until the needle tip lies<br />just above the bony surface</p>
<p begin="00:01:26.030" end="00:01:28.270" style="s2">within the conjoined tendon.</p>
<p begin="00:01:28.270" end="00:01:29.983" style="s2">Care should be taken to avoid</p>
<p begin="00:01:29.983" end="00:01:32.236" style="s2">the posterior cutaneous thigh nerve</p>
<p begin="00:01:32.236" end="00:01:35.297" style="s2">which often overlies the conjoined tendon.</p>
<p begin="00:01:35.297" end="00:01:38.047" style="s2">The needle should be aspirated<br />prior to the injection</p>
<p begin="00:01:38.047" end="00:01:39.720" style="s2">of the anesthetic agent.</p>
<p begin="00:01:39.720" end="00:01:41.937" style="s2">At the conclusion of the procedure,</p>
<p begin="00:01:41.937" end="00:01:43.992" style="s2">the hamstring muscle should be scanned</p>
<p begin="00:01:43.992" end="00:01:46.513" style="s2">using a short and long access approach</p>
<p begin="00:01:46.513" end="00:01:50.680" style="s2">to ensure that there is no<br />bleeding following the procedure.</p>

<p begin="00:00:09.894" end="00:00:13.434" style="s2">- I'm gonna do a simulated<br />hip injection now,</p>
<p begin="00:00:13.434" end="00:00:16.769" style="s2">and show you how this is approached.</p>
<p begin="00:00:16.769" end="00:00:18.377" style="s2">I'm not using a sterile technique,</p>
<p begin="00:00:18.377" end="00:00:21.007" style="s2">and I'm not actually going<br />to insert the needle,</p>
<p begin="00:00:21.007" end="00:00:23.802" style="s2">but I will show you how it's approached.</p>
<p begin="00:00:23.802" end="00:00:26.871" style="s2">The needle that I've selected is</p>
<p begin="00:00:26.871" end="00:00:29.712" style="s2">an echo block needle, is what it's called.</p>
<p begin="00:00:29.712" end="00:00:31.564" style="s2">This is a hundred millimeter,</p>
<p begin="00:00:31.564" end="00:00:33.387" style="s2">approximately four inch needle.</p>
<p begin="00:00:33.387" end="00:00:35.178" style="s2">You can also use a spinal needle,</p>
<p begin="00:00:35.178" end="00:00:38.283" style="s2">but in an individual who is large,</p>
<p begin="00:00:38.283" end="00:00:42.641" style="s2">sometimes you need a<br />special needle like this,</p>
<p begin="00:00:42.641" end="00:00:46.808" style="s2">which has marks on it that<br />reflect the ultrasound beam</p>
<p begin="00:00:48.606" end="00:00:50.730" style="s2">and make it much more visible.</p>
<p begin="00:00:50.730" end="00:00:52.079" style="s2">The orientation will be the same</p>
<p begin="00:00:52.079" end="00:00:54.384" style="s2">as demonstrated previously.</p>
<p begin="00:00:54.384" end="00:00:58.096" style="s2">The image on the screen the<br />same as we've seen before,</p>
<p begin="00:00:58.096" end="00:01:02.447" style="s2">with the femoral neck<br />being the target area.</p>
<p begin="00:01:02.447" end="00:01:06.530" style="s2">And what I would do is<br />mark with an indelible pen</p>
<p begin="00:01:07.788" end="00:01:09.828" style="s2">close to the transducer,</p>
<p begin="00:01:09.828" end="00:01:12.624" style="s2">cleanse this area, anesthetize it,</p>
<p begin="00:01:12.624" end="00:01:16.791" style="s2">and insert the needle at<br />approximately this angle.</p>
<p begin="00:01:18.042" end="00:01:20.165" style="s2">Parallel to the transducer,</p>
<p begin="00:01:20.165" end="00:01:24.248" style="s2">so that the needle is<br />as visible as possible.</p>
<p begin="00:01:24.248" end="00:01:27.582" style="s2">You can check the angle of<br />the needle quite quickly</p>
<p begin="00:01:27.582" end="00:01:31.257" style="s2">once you see the needle<br />coming in on the right top</p>
<p begin="00:01:31.257" end="00:01:35.424" style="s2">of the screen, and adjust<br />the angle depth accordingly.</p>
<p begin="00:01:37.147" end="00:01:41.296" style="s2">The goal is to bring the tip of the needle</p>
<p begin="00:01:41.296" end="00:01:43.213" style="s2">into the V of the neck,</p>
<p begin="00:01:45.657" end="00:01:47.907" style="s2">and that will be the joint.</p>
<p begin="00:01:51.810" end="00:01:54.705" style="s2">This injection could be performed</p>
<p begin="00:01:54.705" end="00:01:58.161" style="s2">with a transducer in the<br />longitudinal position,</p>
<p begin="00:01:58.161" end="00:02:02.426" style="s2">coming in this way, or<br />could be done transversely,</p>
<p begin="00:02:02.426" end="00:02:04.548" style="s2">with the transducer in this position,</p>
<p begin="00:02:04.548" end="00:02:07.785" style="s2">but I'm using an in-plane approach.</p>
<p begin="00:02:07.785" end="00:02:11.558" style="s2">The needle and the syringe<br />are parallel to the direction</p>
<p begin="00:02:11.558" end="00:02:13.058" style="s2">of the transducer.</p>
<p begin="00:02:14.127" end="00:02:18.478" style="s2">I would then insert the needle<br />approximately a centimeter</p>
<p begin="00:02:18.478" end="00:02:20.979" style="s2">away from the transducer.</p>
<p begin="00:02:20.979" end="00:02:25.267" style="s2">The closer you get, the more<br />steep the angle has to be</p>
<p begin="00:02:25.267" end="00:02:27.479" style="s2">to get down to this depth,</p>
<p begin="00:02:27.479" end="00:02:31.140" style="s2">and so sometimes it's better<br />to be a little distance away</p>
<p begin="00:02:31.140" end="00:02:33.452" style="s2">from the edge of the transducer.</p>
<p begin="00:02:33.452" end="00:02:36.749" style="s2">By looking at the screen<br />you can see that the depth</p>
<p begin="00:02:36.749" end="00:02:40.946" style="s2">of the marker is nearly four centimeters,</p>
<p begin="00:02:40.946" end="00:02:43.818" style="s2">and the surface where the tendons are</p>
<p begin="00:02:43.818" end="00:02:45.312" style="s2">and the bursa,</p>
<p begin="00:02:45.312" end="00:02:49.479" style="s2">is down about two and a<br />half to three centimeters.</p>
<p begin="00:02:50.321" end="00:02:53.913" style="s2">So I'm gonna have to get<br />an angle that gets this</p>
<p begin="00:02:53.913" end="00:02:56.233" style="s2">down to the depths,</p>
<p begin="00:02:56.233" end="00:02:58.976" style="s2">and it's probably gonna<br />be something like this.</p>
<p begin="00:02:58.976" end="00:03:03.477" style="s2">The angle will be changed<br />by me as I enter the skin</p>
<p begin="00:03:03.477" end="00:03:05.667" style="s2">to direct the tip into the structure</p>
<p begin="00:03:05.667" end="00:03:07.334" style="s2">that I'm aiming for.</p>
<p begin="00:03:08.380" end="00:03:10.337" style="s2">This can also be injected</p>
<p begin="00:03:10.337" end="00:03:13.004" style="s2">in a transverse plane, this way,</p>
<p begin="00:03:14.200" end="00:03:17.468" style="s2">sometimes it's easier to<br />have the alignment going</p>
<p begin="00:03:17.468" end="00:03:20.028" style="s2">in the same direction as you're looking,</p>
<p begin="00:03:20.028" end="00:03:23.786" style="s2">so I'm looking across the<br />patient at the ultrasound screen,</p>
<p begin="00:03:23.786" end="00:03:27.953" style="s2">and I now have my transducer<br />pointing in that direction.</p>

<p begin="00:00:09.801" end="00:00:11.472" style="s2">- We're gonna examine the hip today,</p>
<p begin="00:00:11.472" end="00:00:13.825" style="s2">this is her right hip<br />and we'll look anteriorly</p>
<p begin="00:00:13.825" end="00:00:16.134" style="s2">at the femoral acetabular joint,</p>
<p begin="00:00:16.134" end="00:00:17.822" style="s2">and then we'll also look laterally</p>
<p begin="00:00:17.822" end="00:00:20.205" style="s2">at the greater trochanter.</p>
<p begin="00:00:20.205" end="00:00:21.644" style="s2">Positioning is important,</p>
<p begin="00:00:21.644" end="00:00:25.934" style="s2">she is lying on her back<br />with her leg extended</p>
<p begin="00:00:25.934" end="00:00:28.384" style="s2">and slightly externally rotated.</p>
<p begin="00:00:28.384" end="00:00:31.484" style="s2">This is the best position<br />to see this joint.</p>
<p begin="00:00:31.484" end="00:00:33.901" style="s2">I've chosen a C60 transducer.</p>
<p begin="00:00:34.805" end="00:00:38.646" style="s2">There is a line here which corresponds</p>
<p begin="00:00:38.646" end="00:00:42.242" style="s2">to the turquoise dot on the screen,</p>
<p begin="00:00:42.242" end="00:00:45.568" style="s2">and this we usually, by tradition,</p>
<p begin="00:00:45.568" end="00:00:47.901" style="s2">keep proximally or medially,</p>
<p begin="00:00:49.065" end="00:00:51.433" style="s2">and that's the way I'll orient this image.</p>
<p begin="00:00:51.433" end="00:00:53.384" style="s2">I'm trying to align the transducer</p>
<p begin="00:00:53.384" end="00:00:57.277" style="s2">approximately parallel<br />with the femoral neck,</p>
<p begin="00:00:57.277" end="00:00:59.944" style="s2">and the left side of the screen,</p>
<p begin="00:01:01.262" end="00:01:04.982" style="s2">the hyperechoic line is the acetabulum.</p>
<p begin="00:01:04.982" end="00:01:08.725" style="s2">The curved structure,<br />or circular structure,</p>
<p begin="00:01:08.725" end="00:01:10.503" style="s2">is the femoral head.</p>
<p begin="00:01:10.503" end="00:01:12.990" style="s2">It then drops down to the femoral neck,</p>
<p begin="00:01:12.990" end="00:01:15.629" style="s2">and we can see the femur itself extending</p>
<p begin="00:01:15.629" end="00:01:18.720" style="s2">parallel to the top part of the image,</p>
<p begin="00:01:18.720" end="00:01:20.678" style="s2">out toward the right.</p>
<p begin="00:01:20.678" end="00:01:23.478" style="s2">You can even see the joint capsule</p>
<p begin="00:01:23.478" end="00:01:25.990" style="s2">and the cartilage on the femoral head,</p>
<p begin="00:01:25.990" end="00:01:29.598" style="s2">and in the corner where<br />the neck joins the ball</p>
<p begin="00:01:29.598" end="00:01:34.014" style="s2">of the femur you can see<br />the femoral joint space.</p>
<p begin="00:01:34.014" end="00:01:37.174" style="s2">And that area right there at the base</p>
<p begin="00:01:37.174" end="00:01:41.510" style="s2">is where you aim when you<br />want to do an injection.</p>
<p begin="00:01:41.510" end="00:01:42.733" style="s2">Before you do anything,</p>
<p begin="00:01:42.733" end="00:01:45.008" style="s2">you want to identify the great vessels,</p>
<p begin="00:01:45.008" end="00:01:49.009" style="s2">and I will turn the<br />transducer transversely,</p>
<p begin="00:01:49.009" end="00:01:50.509" style="s2">and look medially,</p>
<p begin="00:01:52.341" end="00:01:56.508" style="s2">and we can see the anechoic<br />structures that are pulsating.</p>
<p begin="00:01:57.690" end="00:01:59.607" style="s2">I'll turn on the color.</p>
<p begin="00:02:03.283" end="00:02:06.746" style="s2">Should be able to confirm<br />that those are the vessels.</p>
<p begin="00:02:06.746" end="00:02:09.663" style="s2">We want to, obviously, avoid those.</p>
<p begin="00:02:10.683" end="00:02:13.218" style="s2">When I turn back longitudinally,</p>
<p begin="00:02:13.218" end="00:02:16.532" style="s2">I see that those vessels are medial</p>
<p begin="00:02:16.532" end="00:02:19.410" style="s2">to where I was looking before,</p>
<p begin="00:02:19.410" end="00:02:23.290" style="s2">and now that area that I have examined</p>
<p begin="00:02:23.290" end="00:02:25.842" style="s2">does not have blood vessels.</p>
<p begin="00:02:25.842" end="00:02:28.829" style="s2">Sometimes it's a good idea to look</p>
<p begin="00:02:28.829" end="00:02:29.912" style="s2">in this area,</p>
<p begin="00:02:30.942" end="00:02:32.831" style="s2">because that's the direction the needle</p>
<p begin="00:02:32.831" end="00:02:33.750" style="s2">is gonna be coming,</p>
<p begin="00:02:33.750" end="00:02:35.768" style="s2">to make sure there are no branches</p>
<p begin="00:02:35.768" end="00:02:40.487" style="s2">of the femoral artery or<br />vein going in that direction.</p>
<p begin="00:02:40.487" end="00:02:42.278" style="s2">If an effusion is present,</p>
<p begin="00:02:42.278" end="00:02:45.258" style="s2">you'll usually see it right<br />at that junction point</p>
<p begin="00:02:45.258" end="00:02:48.603" style="s2">between the femoral head and the neck.</p>
<p begin="00:02:48.603" end="00:02:51.815" style="s2">You'll see a bulge in the joint capsule,</p>
<p begin="00:02:51.815" end="00:02:54.439" style="s2">it will be coming up and to the right,</p>
<p begin="00:02:54.439" end="00:02:57.822" style="s2">and we'll usually move<br />the iliopsoas muscle</p>
<p begin="00:02:57.822" end="00:03:01.705" style="s2">and tendon dorsally, or superficially.</p>
<p begin="00:03:01.705" end="00:03:04.846" style="s2">I'm gonna examine the<br />lateral aspect of her hip,</p>
<p begin="00:03:04.846" end="00:03:07.774" style="s2">the greater trochanter especially.</p>
<p begin="00:03:07.774" end="00:03:09.938" style="s2">This would be an area that you can examine</p>
<p begin="00:03:09.938" end="00:03:12.831" style="s2">with ultrasound in a symptomatic patient.</p>
<p begin="00:03:12.831" end="00:03:14.999" style="s2">She's lying on her left side</p>
<p begin="00:03:14.999" end="00:03:16.832" style="s2">with her hip extended.</p>
<p begin="00:03:18.911" end="00:03:21.127" style="s2">Just slight flexion position.</p>
<p begin="00:03:21.127" end="00:03:23.367" style="s2">I'm using a linear transducer now.</p>
<p begin="00:03:23.367" end="00:03:26.085" style="s2">Sometimes in a person who has a</p>
<p begin="00:03:26.085" end="00:03:29.237" style="s2">much deeper area to traverse,</p>
<p begin="00:03:29.237" end="00:03:30.737" style="s2">I might use a C60.</p>
<p begin="00:03:32.764" end="00:03:35.765" style="s2">This transducer has a linear mark here,</p>
<p begin="00:03:35.765" end="00:03:39.077" style="s2">which corresponds to the<br />turquoise dot on the screen,</p>
<p begin="00:03:39.077" end="00:03:41.709" style="s2">and we keep that proximal,</p>
<p begin="00:03:41.709" end="00:03:43.626" style="s2">or we keep that medial.</p>
<p begin="00:03:45.220" end="00:03:47.479" style="s2">The hyperechoic curved line</p>
<p begin="00:03:47.479" end="00:03:51.446" style="s2">is the superior edge of<br />the greater trochanter.</p>
<p begin="00:03:51.446" end="00:03:54.446" style="s2">There are muscles and tendons, then,</p>
<p begin="00:03:55.308" end="00:03:57.141" style="s2">just beneath the skin.</p>
<p begin="00:03:58.308" end="00:04:01.700" style="s2">Going distally, we see the<br />rest of the greater trochanter</p>
<p begin="00:04:01.700" end="00:04:03.845" style="s2">with tendinous insertions</p>
<p begin="00:04:03.845" end="00:04:05.762" style="s2">of the gluteus muscles.</p>
<p begin="00:04:07.861" end="00:04:10.573" style="s2">If we turn this transversely,</p>
<p begin="00:04:10.573" end="00:04:13.948" style="s2">we can again see the bony outline</p>
<p begin="00:04:13.948" end="00:04:16.615" style="s2">deep as a hyperechoic structure,</p>
<p begin="00:04:17.895" end="00:04:19.100" style="s2">and above it,</p>
<p begin="00:04:19.100" end="00:04:21.668" style="s2">a series of tendinous structures,</p>
<p begin="00:04:21.668" end="00:04:24.516" style="s2">the gluteus muscles come in and attach</p>
<p begin="00:04:24.516" end="00:04:26.909" style="s2">to the greater trochanter.</p>
<p begin="00:04:26.909" end="00:04:27.742" style="s2">Anteriorly</p>
<p begin="00:04:28.951" end="00:04:30.201" style="s2">and posteriorly</p>
<p begin="00:04:31.616" end="00:04:35.783" style="s2">we can see these images<br />around the greater trochanter,</p>
<p begin="00:04:37.012" end="00:04:40.031" style="s2">and there are a series<br />of bursae present there,</p>
<p begin="00:04:40.031" end="00:04:42.416" style="s2">with fluid-filled sacs</p>
<p begin="00:04:42.416" end="00:04:46.083" style="s2">visible in a person who<br />would have bursitis.</p>