<p begin="00:00:09.598" end="00:00:13.480" style="s2">- The next structure to<br />examine is the iliotibial band.</p>
<p begin="00:00:13.480" end="00:00:15.787" style="s2">The iliotibial band attaches distally</p>
<p begin="00:00:15.787" end="00:00:18.519" style="s2">at the Gerdy's tubercle.</p>
<p begin="00:00:18.519" end="00:00:21.179" style="s2">This injury is commonly<br />involved in active individuals,</p>
<p begin="00:00:21.179" end="00:00:23.043" style="s2">including runners.</p>
<p begin="00:00:23.043" end="00:00:25.462" style="s2">Important landmarks in the<br />transducer will always face</p>
<p begin="00:00:25.462" end="00:00:27.444" style="s2">superior with the notch.</p>
<p begin="00:00:27.444" end="00:00:30.242" style="s2">Secondly, to palpate Gerdy's tubercle,</p>
<p begin="00:00:30.242" end="00:00:32.575" style="s2">I begin at the fibular head.</p>
<p begin="00:00:34.524" end="00:00:37.857" style="s2">I move medially until I<br />feel a bony protuberance,</p>
<p begin="00:00:37.857" end="00:00:39.602" style="s2">which is the Gerdy's tubercle.</p>
<p begin="00:00:39.602" end="00:00:43.769" style="s2">I'm going to place the probe<br />directly over Gerdy's tubercle.</p>
<p begin="00:00:45.751" end="00:00:49.916" style="s2">Here I see the fibers<br />of the iliotibial band,</p>
<p begin="00:00:49.916" end="00:00:52.335" style="s2">attaching on Gerdy's tubercle.</p>
<p begin="00:00:52.335" end="00:00:55.502" style="s2">An ultrasound bone is bright white due</p>
<p begin="00:00:57.098" end="00:00:59.181" style="s2">to its reflective nature.</p>
<p begin="00:01:00.201" end="00:01:04.368" style="s2">This is a clear image showing<br />a healthy iliotibial band.</p>

<p begin="00:00:09.732" end="00:00:12.901" style="s2">- Next we're going to examine<br />the acromioclavicular joint,</p>
<p begin="00:00:12.901" end="00:00:15.431" style="s2">also known as the AC joint.</p>
<p begin="00:00:15.431" end="00:00:18.348" style="s2">Now this structure is<br />very easy to identify</p>
<p begin="00:00:18.348" end="00:00:20.456" style="s2">and I begin by just looking at the patient</p>
<p begin="00:00:20.456" end="00:00:22.798" style="s2">and identifying their bony acromion,</p>
<p begin="00:00:22.798" end="00:00:25.331" style="s2">which you can feel by palpation.</p>
<p begin="00:00:25.331" end="00:00:27.907" style="s2">Next, I'm going to place<br />the probe on the patient,</p>
<p begin="00:00:27.907" end="00:00:31.077" style="s2">again with the notch facing<br />medially towards the patient.</p>
<p begin="00:00:31.077" end="00:00:33.163" style="s2">Now with this structure,<br />it's obviously close</p>
<p begin="00:00:33.163" end="00:00:35.891" style="s2">to the surface, so we can<br />use a very short depth,</p>
<p begin="00:00:35.891" end="00:00:40.051" style="s2">and here we are, which<br />should be adequate at 2.7.</p>
<p begin="00:00:40.051" end="00:00:43.241" style="s2">So here we can visualize<br />the acromioclavicular joint</p>
<p begin="00:00:43.241" end="00:00:46.715" style="s2">and if we suspect pathology<br />with this in a patient,</p>
<p begin="00:00:46.715" end="00:00:49.467" style="s2">we can do a dynamic study<br />and have the patient</p>
<p begin="00:00:49.467" end="00:00:52.118" style="s2">strain his acromioclavicular joint and see</p>
<p begin="00:00:52.118" end="00:00:55.765" style="s2">if there's any separation<br />or ligamentous laxity.</p>
<p begin="00:00:55.765" end="00:00:58.422" style="s2">So what I do is I recommend<br />that the patient slowly takes</p>
<p begin="00:00:58.422" end="00:01:02.102" style="s2">his right arm and reaches it<br />across to his left shoulder</p>
<p begin="00:01:02.102" end="00:01:05.102" style="s2">while maintaining contact<br />over the AC joint.</p>
<p begin="00:01:05.102" end="00:01:08.685" style="s2">You can go ahead and<br />slowly move your left.</p>
<p begin="00:01:10.102" end="00:01:11.917" style="s2">Great, and back.</p>
<p begin="00:01:11.917" end="00:01:14.718" style="s2">And what we look for is if<br />there's an abnormal separation</p>
<p begin="00:01:14.718" end="00:01:18.551" style="s2">between the two acromion<br />and clavicular bones.</p>
<p begin="00:01:19.655" end="00:01:23.333" style="s2">In some cases of degeneration<br />and osteoarthritis,</p>
<p begin="00:01:23.333" end="00:01:26.345" style="s2">we'll see irregular bone<br />formations or even something</p>
<p begin="00:01:26.345" end="00:01:30.013" style="s2">known as the Geyser phenomenon,<br />which is bursal fluid</p>
<p begin="00:01:30.013" end="00:01:34.180" style="s2">extending out of the<br />acromioclavicular joint upwards.</p>

<p begin="00:00:09.561" end="00:00:12.559" style="s2">- Next, I'm going to examine<br />the subscapularis tendon.</p>
<p begin="00:00:12.559" end="00:00:16.130" style="s2">I start with the patient<br />again with his palm up</p>
<p begin="00:00:16.130" end="00:00:19.226" style="s2">at the bicep tendon in<br />the cross-sectional view</p>
<p begin="00:00:19.226" end="00:00:22.797" style="s2">with my hand on the patient's shoulder,</p>
<p begin="00:00:22.797" end="00:00:25.299" style="s2">identify the bicep tendon.</p>
<p begin="00:00:25.299" end="00:00:27.624" style="s2">Next I'm going to have the<br />patient slowly externally</p>
<p begin="00:00:27.624" end="00:00:29.874" style="s2">rotate his arm to the side.</p>
<p begin="00:00:31.365" end="00:00:34.448" style="s2">What this does is opens up<br />the subscapularis tendon</p>
<p begin="00:00:34.448" end="00:00:36.531" style="s2">so we can clearly see it.</p>
<p begin="00:00:38.449" end="00:00:40.047" style="s2">Oftentimes, I'll have the patient resist</p>
<p begin="00:00:40.047" end="00:00:42.832" style="s2">against my hand in internal rotation</p>
<p begin="00:00:42.832" end="00:00:44.840" style="s2">to detect any pathology.</p>
<p begin="00:00:44.840" end="00:00:45.921" style="s2">Push against my hand.</p>
<p begin="00:00:45.921" end="00:00:47.616" style="s2">Good, relax.</p>
<p begin="00:00:47.616" end="00:00:48.449" style="s2">And again.</p>
<p begin="00:00:49.362" end="00:00:50.195" style="s2">Relax.</p>

<p begin="00:00:09.449" end="00:00:10.456" style="s2">- Lastly we're going to look at the</p>
<p begin="00:00:10.456" end="00:00:12.193" style="s2">supraspinatus tendon.</p>
<p begin="00:00:12.193" end="00:00:13.697" style="s2">I prefer to look at this last because</p>
<p begin="00:00:13.697" end="00:00:17.126" style="s2">this is the area that we<br />see most abnormalities.</p>
<p begin="00:00:17.126" end="00:00:20.777" style="s2">Now to make this examination<br />as time efficient</p>
<p begin="00:00:20.777" end="00:00:21.910" style="s2">as possible,</p>
<p begin="00:00:21.910" end="00:00:23.758" style="s2">what I will do, is have the patient</p>
<p begin="00:00:23.758" end="00:00:25.508" style="s2">take their right arm,</p>
<p begin="00:00:26.695" end="00:00:30.037" style="s2">and slowly put it back<br />behind their back pocket,</p>
<p begin="00:00:30.037" end="00:00:32.978" style="s2">while keeping their elbow inward.</p>
<p begin="00:00:32.978" end="00:00:36.406" style="s2">This is termed, "The<br />Modified Crass Technique."</p>
<p begin="00:00:36.406" end="00:00:38.837" style="s2">What this does is free<br />up the supraspinatus</p>
<p begin="00:00:38.837" end="00:00:40.478" style="s2">so it's not obscured,</p>
<p begin="00:00:40.478" end="00:00:43.509" style="s2">but I can clearly visualize<br />the tendon efficiently.</p>
<p begin="00:00:43.509" end="00:00:44.784" style="s2">There are two views we're<br />going to look at the</p>
<p begin="00:00:44.784" end="00:00:46.359" style="s2">supraspinatus tendon.</p>
<p begin="00:00:46.359" end="00:00:49.085" style="s2">First, where we see most pathology will be</p>
<p begin="00:00:49.085" end="00:00:50.925" style="s2">in cross-section.</p>
<p begin="00:00:50.925" end="00:00:52.297" style="s2">And with this technique,</p>
<p begin="00:00:52.297" end="00:00:55.261" style="s2">we keep the notch of<br />the probe faced upwards</p>
<p begin="00:00:55.261" end="00:00:57.837" style="s2">and we're going to angle the probe</p>
<p begin="00:00:57.837" end="00:00:59.727" style="s2">diagonally down towards the navel,</p>
<p begin="00:00:59.727" end="00:01:01.394" style="s2">or the belly button.</p>
<p begin="00:01:02.560" end="00:01:05.477" style="s2">Maintaining contact on the patient,</p>
<p begin="00:01:06.670" end="00:01:09.617" style="s2">I visualize the supraspinatus tendon</p>
<p begin="00:01:09.617" end="00:01:11.033" style="s2">and it's fibers.</p>
<p begin="00:01:11.033" end="00:01:14.306" style="s2">And I'm going to examine<br />the supraspinatus tendon</p>
<p begin="00:01:14.306" end="00:01:15.348" style="s2">in both directions,</p>
<p begin="00:01:15.348" end="00:01:17.625" style="s2">to clearly rule out any pathology.</p>
<p begin="00:01:17.625" end="00:01:21.679" style="s2">I'm gently maintaining<br />contact and rocking the probe,</p>
<p begin="00:01:21.679" end="00:01:24.941" style="s2">side to side, following<br />the length of the fibers.</p>
<p begin="00:01:24.941" end="00:01:26.663" style="s2">On top of the tendon here,</p>
<p begin="00:01:26.663" end="00:01:29.524" style="s2">we notice a little black, thin line,</p>
<p begin="00:01:29.524" end="00:01:32.597" style="s2">which is the subacromial subdeltoid bursa.</p>
<p begin="00:01:32.597" end="00:01:34.771" style="s2">In patients with shoulder abnormalities,</p>
<p begin="00:01:34.771" end="00:01:36.576" style="s2">this bursa fills with fluid</p>
<p begin="00:01:36.576" end="00:01:39.589" style="s2">and is often the target<br />of one of our injections.</p>
<p begin="00:01:39.589" end="00:01:42.578" style="s2">Next, I prefer to look at what's called</p>
<p begin="00:01:42.578" end="00:01:45.063" style="s2">the rotator cuff interval.</p>
<p begin="00:01:45.063" end="00:01:47.546" style="s2">And to do this, I<br />maintain the same position</p>
<p begin="00:01:47.546" end="00:01:50.206" style="s2">that I'm currently in.</p>
<p begin="00:01:50.206" end="00:01:52.888" style="s2">And I'm going to slowly move the probe</p>
<p begin="00:01:52.888" end="00:01:55.305" style="s2">medially towards the patient.</p>
<p begin="00:02:01.043" end="00:02:04.492" style="s2">This will allow me to<br />visualize the bicep tendon</p>
<p begin="00:02:04.492" end="00:02:07.279" style="s2">as well as the subscapularis tendon.</p>
<p begin="00:02:07.279" end="00:02:08.729" style="s2">On the left of the screen is the</p>
<p begin="00:02:08.729" end="00:02:10.205" style="s2">supraspinatus tendon.</p>
<p begin="00:02:10.205" end="00:02:12.074" style="s2">Next, there's the bicep tendon</p>
<p begin="00:02:12.074" end="00:02:15.229" style="s2">which is the white<br />circular structure seen.</p>
<p begin="00:02:15.229" end="00:02:17.181" style="s2">And just adjacent on the right to that,</p>
<p begin="00:02:17.181" end="00:02:19.509" style="s2">is the subscapularis tendon.</p>
<p begin="00:02:19.509" end="00:02:21.541" style="s2">In patients with tears,</p>
<p begin="00:02:21.541" end="00:02:23.874" style="s2">we measure the interval between</p>
<p begin="00:02:23.874" end="00:02:25.849" style="s2">the supraspinatus tendon as well as</p>
<p begin="00:02:25.849" end="00:02:27.932" style="s2">the subscapularis tendon.</p>
<p begin="00:02:29.421" end="00:02:31.366" style="s2">If there's increased<br />distance between the two,</p>
<p begin="00:02:31.366" end="00:02:34.282" style="s2">it's suggestive of a tear.</p>
<p begin="00:02:34.282" end="00:02:36.733" style="s2">Lastly, we're going to<br />look at the supraspinatus</p>
<p begin="00:02:36.733" end="00:02:39.845" style="s2">tendon in it's longitudinal view.</p>
<p begin="00:02:39.845" end="00:02:41.554" style="s2">I place the notch of the probe facing</p>
<p begin="00:02:41.554" end="00:02:43.397" style="s2">towards the patient's ear,</p>
<p begin="00:02:43.397" end="00:02:45.975" style="s2">which is an easy to remember landmark.</p>
<p begin="00:02:45.975" end="00:02:48.253" style="s2">Maintaining contact with my hand,</p>
<p begin="00:02:48.253" end="00:02:50.727" style="s2">on the patient's shoulder,<br />with the probe angled</p>
<p begin="00:02:50.727" end="00:02:53.110" style="s2">up towards the patient's ear,</p>
<p begin="00:02:53.110" end="00:02:54.983" style="s2">we can see the rotator cuff,</p>
<p begin="00:02:54.983" end="00:02:56.374" style="s2">in what's commonly referred to as</p>
<p begin="00:02:56.374" end="00:02:58.110" style="s2">a bird-beak type image,</p>
<p begin="00:02:58.110" end="00:02:59.506" style="s2">clearly seeing the fibers of the</p>
<p begin="00:02:59.506" end="00:03:01.197" style="s2">supraspinatus tendon, which are healthy</p>
<p begin="00:03:01.197" end="00:03:02.530" style="s2">in this patient.</p>
<p begin="00:03:04.725" end="00:03:07.238" style="s2">In abnormal cases, we<br />may see partial tearing,</p>
<p begin="00:03:07.238" end="00:03:08.757" style="s2">blackness within the tendon,</p>
<p begin="00:03:08.757" end="00:03:10.389" style="s2">as well as thickening,</p>
<p begin="00:03:10.389" end="00:03:14.502" style="s2">or tendonosis with chronic poor blood flow</p>
<p begin="00:03:14.502" end="00:03:15.585" style="s2">in a patient.</p>
<p begin="00:03:16.534" end="00:03:18.727" style="s2">What we're going to do is follow the</p>
<p begin="00:03:18.727" end="00:03:21.394" style="s2">length of the tendon, on one end</p>
<p begin="00:03:22.279" end="00:03:25.034" style="s2">where it attaches at the bird beak,</p>
<p begin="00:03:25.034" end="00:03:27.264" style="s2">as well as through the opposite end,</p>
<p begin="00:03:27.264" end="00:03:29.163" style="s2">looking at the fibers and continuity</p>
<p begin="00:03:29.163" end="00:03:31.568" style="s2">to see if there's any abnormalities.</p>
<p begin="00:03:31.568" end="00:03:33.322" style="s2">Additionally, one pearl to be aware of</p>
<p begin="00:03:33.322" end="00:03:35.905" style="s2">is a concept called anisotropy.</p>
<p begin="00:03:36.957" end="00:03:39.328" style="s2">And what may appear to be an abnormality,</p>
<p begin="00:03:39.328" end="00:03:41.127" style="s2">or a partial tear, where you can see a</p>
<p begin="00:03:41.127" end="00:03:44.039" style="s2">hypoechoic or black<br />signal within a tendon,</p>
<p begin="00:03:44.039" end="00:03:45.519" style="s2">that may suggest a tear,</p>
<p begin="00:03:45.519" end="00:03:47.398" style="s2">was really just a result of your probe</p>
<p begin="00:03:47.398" end="00:03:49.398" style="s2">not being perpendicular to the structure</p>
<p begin="00:03:49.398" end="00:03:50.695" style="s2">you're viewing.</p>
<p begin="00:03:50.695" end="00:03:53.753" style="s2">An example of that would<br />be a blackness here</p>
<p begin="00:03:53.753" end="00:03:56.203" style="s2">in the tendon, that you<br />can see on the bottom</p>
<p begin="00:03:56.203" end="00:03:58.998" style="s2">aspect of the tendon as<br />it inserts on the bone.</p>
<p begin="00:03:58.998" end="00:04:02.165" style="s2">But by rocking the probe side to side,</p>
<p begin="00:04:04.011" end="00:04:05.858" style="s2">I remove the blackness and realize</p>
<p begin="00:04:05.858" end="00:04:07.691" style="s2">that it was anisotric.</p>

<p begin="00:00:09.494" end="00:00:13.392" style="s2">- Next we're going to review<br />injection of the knee.</p>
<p begin="00:00:13.392" end="00:00:15.580" style="s2">Before we get started,<br />keep in mind that this is</p>
<p begin="00:00:15.580" end="00:00:19.340" style="s2">just a demonstration, and<br />normally these are performed</p>
<p begin="00:00:19.340" end="00:00:23.355" style="s2">under sterile environments,<br />with Betadine, and prepping</p>
<p begin="00:00:23.355" end="00:00:26.802" style="s2">the area properly, this<br />is just an idea to show</p>
<p begin="00:00:26.802" end="00:00:30.027" style="s2">the physician exactly the<br />approach that we use in doing</p>
<p begin="00:00:30.027" end="00:00:34.505" style="s2">injections with the proper<br />needle placement and approach.</p>
<p begin="00:00:34.505" end="00:00:37.462" style="s2">The most common target that<br />physicians typically inject</p>
<p begin="00:00:37.462" end="00:00:41.272" style="s2">the knee joint, is the<br />Suprapatellar Recess, or Bursa.</p>
<p begin="00:00:41.272" end="00:00:44.087" style="s2">We begin by placing the<br />transducer in a longitudinal</p>
<p begin="00:00:44.087" end="00:00:47.631" style="s2">plane, with the end of<br />the transducer just above</p>
<p begin="00:00:47.631" end="00:00:49.473" style="s2">the patient's Patella.</p>
<p begin="00:00:49.473" end="00:00:52.791" style="s2">Next, in setup for the<br />injection, I'm going to rotate</p>
<p begin="00:00:52.791" end="00:00:56.958" style="s2">my transducer to cross-section,<br />and here we can visualize</p>
<p begin="00:00:59.526" end="00:01:02.712" style="s2">the physiologic fluid of<br />the Suprapatellar Recess,</p>
<p begin="00:01:02.712" end="00:01:06.699" style="s2">which is the band of<br />darkness above the Cortex.</p>
<p begin="00:01:06.699" end="00:01:10.039" style="s2">This will be the target<br />site of our knee injection.</p>
<p begin="00:01:10.039" end="00:01:12.960" style="s2">The proper landmarks associated<br />with a knee injection</p>
<p begin="00:01:12.960" end="00:01:16.617" style="s2">are palpating the Iliotibial<br />Band, which is a structure</p>
<p begin="00:01:16.617" end="00:01:19.439" style="s2">that runs down the Lateral<br />Thigh, and in between</p>
<p begin="00:01:19.439" end="00:01:22.164" style="s2">the Iliotibial band and<br />the Vastus Lateralis</p>
<p begin="00:01:22.164" end="00:01:23.803" style="s2">is the soft spot.</p>
<p begin="00:01:23.803" end="00:01:25.470" style="s2">Palpated right here.</p>
<p begin="00:01:26.716" end="00:01:31.148" style="s2">A needle as it's inserted<br />in this soft spot,</p>
<p begin="00:01:31.148" end="00:01:35.372" style="s2">between the Iliotibial Band<br />and the Vastus Lateralis,</p>
<p begin="00:01:35.372" end="00:01:40.017" style="s2">in a direction directly beneath<br />the center of the transducer</p>
<p begin="00:01:40.017" end="00:01:42.934" style="s2">to ensure an accurate localization.</p>
<p begin="00:01:48.114" end="00:01:51.772" style="s2">The needle will be guided<br />into the Suprapatellar Bursa,</p>
<p begin="00:01:51.772" end="00:01:55.102" style="s2">and Lidocaine is typically<br />injected to ensure proper</p>
<p begin="00:01:55.102" end="00:01:58.519" style="s2">location, and we'll see the Bursa expand.</p>
<p begin="00:02:08.897" end="00:02:12.506" style="s2">In addition to injections<br />of Cortisone or Lidocaine,</p>
<p begin="00:02:12.506" end="00:02:16.127" style="s2">or other medications, we<br />often aspirate the knee</p>
<p begin="00:02:16.127" end="00:02:18.056" style="s2">if there is a significant effusion</p>
<p begin="00:02:18.056" end="00:02:20.753" style="s2">of the Suprapatellar Recess.</p>
<p begin="00:02:20.753" end="00:02:24.832" style="s2">By doing this, we use the<br />same approach as the described</p>
<p begin="00:02:24.832" end="00:02:28.296" style="s2">injection technique,<br />however, initially we'll use</p>
<p begin="00:02:28.296" end="00:02:30.431" style="s2">an 18-gauge needle.</p>
<p begin="00:02:30.431" end="00:02:34.598" style="s2">Insert the Suprapatellar<br />Recess, and drain the fluid out.</p>

<p begin="00:00:09.407" end="00:00:11.804" style="s2">- Next we're going to<br />demonstrate ultrasound-guided</p>
<p begin="00:00:11.804" end="00:00:13.971" style="s2">injection of the shoulder.</p>
<p begin="00:00:15.150" end="00:00:18.023" style="s2">Before we get started, keep<br />in mind that as with any</p>
<p begin="00:00:18.023" end="00:00:20.023" style="s2">procedure, it should be performed</p>
<p begin="00:00:20.023" end="00:00:21.549" style="s2">under sterile conditions.</p>
<p begin="00:00:21.549" end="00:00:25.100" style="s2">This is only a demonstration<br />of the appropriate setup.</p>
<p begin="00:00:25.100" end="00:00:28.433" style="s2">To begin the injection, we're<br />going to place the transducer</p>
<p begin="00:00:28.433" end="00:00:31.739" style="s2">on the patient's shoulder, with<br />the notch of the transducer</p>
<p begin="00:00:31.739" end="00:00:34.277" style="s2">aimed toward the patient's ear.</p>
<p begin="00:00:34.277" end="00:00:38.696" style="s2">And we can see the Supraspinatus<br />Tendon, in clear image.</p>
<p begin="00:00:38.696" end="00:00:41.154" style="s2">Just above the Supraspinatus Tendon,</p>
<p begin="00:00:41.154" end="00:00:44.750" style="s2">lies the Subachromial Subdeltoid Bursa.</p>
<p begin="00:00:44.750" end="00:00:48.800" style="s2">It's represented as a thin<br />black line above the tendon,</p>
<p begin="00:00:48.800" end="00:00:52.720" style="s2">and will be the target site<br />of our shoulder injection.</p>
<p begin="00:00:52.720" end="00:00:55.720" style="s2">Now that we've localized<br />the Subachromial Subdeltoid</p>
<p begin="00:00:55.720" end="00:00:58.796" style="s2">Bursa, we're ready for injection.</p>
<p begin="00:00:58.796" end="00:01:01.747" style="s2">Again remembering our<br />landmarks, that the notch</p>
<p begin="00:01:01.747" end="00:01:04.855" style="s2">of the upper-left-hand corner<br />of the ultrasound screen</p>
<p begin="00:01:04.855" end="00:01:08.763" style="s2">correlates with the<br />notch on the transducer.</p>
<p begin="00:01:08.763" end="00:01:12.473" style="s2">The goal is to introduce<br />the needle directly beneath</p>
<p begin="00:01:12.473" end="00:01:16.949" style="s2">the transducer; ideally,<br />the needle should be</p>
<p begin="00:01:16.949" end="00:01:20.532" style="s2">at the center point<br />beneath the transducer.</p>
<p begin="00:01:24.527" end="00:01:27.712" style="s2">And we can see it penetrate<br />the Deltoid, which is the area</p>
<p begin="00:01:27.712" end="00:01:30.184" style="s2">above the Supraspinatus Tendon.</p>
<p begin="00:01:30.184" end="00:01:31.724" style="s2">And then, it will penetrate</p>
<p begin="00:01:31.724" end="00:01:34.521" style="s2">the Subachromial Subdeltoid Bursa.</p>
<p begin="00:01:34.521" end="00:01:37.571" style="s2">It's important not to<br />continue needle penetration</p>
<p begin="00:01:37.571" end="00:01:40.328" style="s2">as this may penetrate<br />the Supraspinatus Tendon,</p>
<p begin="00:01:40.328" end="00:01:44.686" style="s2">and may cause pain as well<br />as eventual further injury</p>
<p begin="00:01:44.686" end="00:01:46.183" style="s2">to the patient.</p>
<p begin="00:01:46.183" end="00:01:49.427" style="s2">With injection of Kenalog<br />and Lidocaine into</p>
<p begin="00:01:49.427" end="00:01:53.289" style="s2">the Subachromial Subdeltoid<br />Bursa, we confirm proper</p>
<p begin="00:01:53.289" end="00:01:57.582" style="s2">location by seeing expansion of the Bursa.</p>
<p begin="00:01:57.582" end="00:02:01.688" style="s2">Here is an example of<br />fluid filling the Bursa.</p>
<p begin="00:02:01.688" end="00:02:05.855" style="s2">The injection is now complete<br />and the needle is withdrawn.</p>

<p begin="00:00:09.520" end="00:00:11.106" style="s2">- I'm examining the bicep tendon.</p>
<p begin="00:00:11.106" end="00:00:14.170" style="s2">Again it's important to<br />keep the notch of the probe</p>
<p begin="00:00:14.170" end="00:00:16.670" style="s2">immediately facing towards the patient.</p>
<p begin="00:00:16.670" end="00:00:18.838" style="s2">I'm gonna maintain contact at all times</p>
<p begin="00:00:18.838" end="00:00:20.574" style="s2">with my hand on the patient,</p>
<p begin="00:00:20.574" end="00:00:23.719" style="s2">using my second through fifth fingers</p>
<p begin="00:00:23.719" end="00:00:25.886" style="s2">to form a base on the patient's shoulder,</p>
<p begin="00:00:25.886" end="00:00:28.774" style="s2">and almost pinching the<br />probe between my two fingers.</p>
<p begin="00:00:28.774" end="00:00:32.136" style="s2">And it's fairly easy<br />to identify the bicep,</p>
<p begin="00:00:32.136" end="00:00:33.895" style="s2">which lies in the groove between</p>
<p begin="00:00:33.895" end="00:00:36.718" style="s2">the greater and lesser tuberosities.</p>
<p begin="00:00:36.718" end="00:00:41.294" style="s2">A helpful tip is to aim the<br />probe both upwards and downwards</p>
<p begin="00:00:41.294" end="00:00:42.566" style="s2">until you get a nice image</p>
<p begin="00:00:42.566" end="00:00:45.767" style="s2">of the bicep tendon in its groove.</p>
<p begin="00:00:45.767" end="00:00:49.172" style="s2">On top of the bicep tendon<br />lies the transverse ligament,</p>
<p begin="00:00:49.172" end="00:00:52.875" style="s2">which covers the bicep tendon<br />in its circular pattern.</p>
<p begin="00:00:52.875" end="00:00:55.955" style="s2">And here is a good image<br />of the bicep tendon,</p>
<p begin="00:00:55.955" end="00:00:58.195" style="s2">in its cross-section.</p>
<p begin="00:00:58.195" end="00:01:00.388" style="s2">And if there are abnormalities you may see</p>
<p begin="00:01:00.388" end="00:01:03.246" style="s2">some increased black fluid<br />surrounding the tendon,</p>
<p begin="00:01:03.246" end="00:01:05.692" style="s2">and there's some normal<br />physiologic fluid there,</p>
<p begin="00:01:05.692" end="00:01:08.044" style="s2">but this is a normal bicep tendon.</p>
<p begin="00:01:08.044" end="00:01:10.276" style="s2">I'm going to follow the<br />bicep tendon distally</p>
<p begin="00:01:10.276" end="00:01:12.445" style="s2">to examine if there's any pathology</p>
<p begin="00:01:12.445" end="00:01:15.612" style="s2">which is a commonplace of bicep tears.</p>
<p begin="00:01:16.692" end="00:01:19.380" style="s2">Next I'm gonna go back to<br />my initial starting point,</p>
<p begin="00:01:19.380" end="00:01:20.636" style="s2">and find the bicep tendon</p>
<p begin="00:01:20.636" end="00:01:23.668" style="s2">between the greater and<br />lesser tuberocities.</p>
<p begin="00:01:23.668" end="00:01:27.317" style="s2">I'm going to turn the probe<br />in a longitudinal manner,</p>
<p begin="00:01:27.317" end="00:01:30.652" style="s2">again maintaining the<br />notch of the probe upward.</p>
<p begin="00:01:30.652" end="00:01:32.996" style="s2">And what this is gonna<br />do, is change my view</p>
<p begin="00:01:32.996" end="00:01:34.060" style="s2">from cross-sectional</p>
<p begin="00:01:34.060" end="00:01:37.236" style="s2">to longitudinal of the<br />patient's bicep tendon.</p>
<p begin="00:01:37.236" end="00:01:40.359" style="s2">And a tendon tends to<br />have a fibular pattern.</p>
<p begin="00:01:40.359" end="00:01:42.804" style="s2">And we can follow this tendon</p>
<p begin="00:01:42.804" end="00:01:45.932" style="s2">as it runs along the humerus distally,</p>
<p begin="00:01:45.932" end="00:01:47.940" style="s2">looking for any abnormalities,</p>
<p begin="00:01:47.940" end="00:01:50.932" style="s2">until we begin to see<br />the pectoralis tendon</p>
<p begin="00:01:50.932" end="00:01:55.099" style="s2">coming in (slurred) here distally.</p>

<p begin="00:00:09.075" end="00:00:12.587" style="s2">- This is a demonstration<br />only for injecting</p>
<p begin="00:00:12.587" end="00:00:16.948" style="s2">the Median Nerve, placing<br />steroids into the carpal tunnel.</p>
<p begin="00:00:16.948" end="00:00:20.210" style="s2">So, I'm not using sterile technique,</p>
<p begin="00:00:20.210" end="00:00:22.878" style="s2">sterile gel or cleansing the area.</p>
<p begin="00:00:22.878" end="00:00:25.140" style="s2">This is for demonstration purposes only.</p>
<p begin="00:00:25.140" end="00:00:29.579" style="s2">And I am going to be doing an<br />injection in this direction.</p>
<p begin="00:00:29.579" end="00:00:32.101" style="s2">Again, I am going to be placing the needle</p>
<p begin="00:00:32.101" end="00:00:34.562" style="s2">parallel to the transducer.</p>
<p begin="00:00:34.562" end="00:00:36.562" style="s2">Apply some gel here.</p>
<p begin="00:00:36.562" end="00:00:39.019" style="s2">By placing the transducer transversely,</p>
<p begin="00:00:39.019" end="00:00:43.028" style="s2">I have in the middle of the<br />screen, the Median Nerve.</p>
<p begin="00:00:43.028" end="00:00:43.861" style="s2">I can find</p>
<p begin="00:00:45.529" end="00:00:48.480" style="s2">the Ulnar Artery on this side.</p>
<p begin="00:00:48.480" end="00:00:50.897" style="s2">And you can see it pulsating.</p>
<p begin="00:00:53.222" end="00:00:57.882" style="s2">I mark the Ulnar Artery<br />with an indelible pen.</p>
<p begin="00:00:57.882" end="00:01:02.412" style="s2">And then move just a little<br />bit to the radial side,</p>
<p begin="00:01:02.412" end="00:01:04.778" style="s2">so that the Ulnar Artery is down here.</p>
<p begin="00:01:04.778" end="00:01:07.028" style="s2">And place a 25 gauge needle</p>
<p begin="00:01:08.290" end="00:01:11.088" style="s2">in this direction, very superficially,</p>
<p begin="00:01:11.088" end="00:01:14.874" style="s2">because it's only two millimeters deep.</p>
<p begin="00:01:14.874" end="00:01:19.099" style="s2">And bring that needle in from<br />the left side of the screen.</p>
<p begin="00:01:19.099" end="00:01:23.589" style="s2">In this image, the Median<br />Nerve is sitting right here.</p>
<p begin="00:01:23.589" end="00:01:27.172" style="s2">The Retinaculum is<br />along this surface here.</p>
<p begin="00:01:28.237" end="00:01:29.545" style="s2">And the needle is coming in</p>
<p begin="00:01:29.545" end="00:01:31.749" style="s2">from the left side of the screen.</p>
<p begin="00:01:31.749" end="00:01:34.117" style="s2">This is bone down here.</p>
<p begin="00:01:34.117" end="00:01:37.867" style="s2">You'll see the needle<br />advanced superficial to</p>
<p begin="00:01:39.095" end="00:01:41.348" style="s2">the nerve and fluid,</p>
<p begin="00:01:41.348" end="00:01:45.265" style="s2">which includes steroids<br />and Lidocaine injected.</p>
<p begin="00:01:47.849" end="00:01:50.586" style="s2">In the next brief video,</p>
<p begin="00:01:50.586" end="00:01:54.223" style="s2">the needle is seen deep<br />to the Median Nerve,</p>
<p begin="00:01:54.223" end="00:01:55.940" style="s2">so the nerve is here.</p>
<p begin="00:01:55.940" end="00:01:59.976" style="s2">And the needle can be seen underneath it</p>
<p begin="00:01:59.976" end="00:02:00.809" style="s2">and again,</p>
<p begin="00:02:02.130" end="00:02:06.297" style="s2">injection with Lidocaine<br />and steroid is performed.</p>
<p begin="00:02:08.629" end="00:02:11.443" style="s2">The other approach that some people use</p>
<p begin="00:02:11.443" end="00:02:14.836" style="s2">is with the transducer longitudinal.</p>
<p begin="00:02:14.836" end="00:02:18.183" style="s2">Here's the Median Nerve on the screen.</p>
<p begin="00:02:18.183" end="00:02:22.586" style="s2">And you can approach the<br />Median Nerve this way,</p>
<p begin="00:02:22.586" end="00:02:24.419" style="s2">so distal to proximal.</p>

<p begin="00:00:09.622" end="00:00:11.637" style="s2">- We're going to examine the wrist today,</p>
<p begin="00:00:11.637" end="00:00:14.759" style="s2">and the best transducer<br />for this examination</p>
<p begin="00:00:14.759" end="00:00:17.869" style="s2">is the L25, the small footprint.</p>
<p begin="00:00:17.869" end="00:00:20.225" style="s2">We'll check that the exam type is correct.</p>
<p begin="00:00:20.225" end="00:00:22.892" style="s2">We're doing an MSK type of exam.</p>
<p begin="00:00:24.490" end="00:00:27.783" style="s2">For orientation, there<br />is a marker here which</p>
<p begin="00:00:27.783" end="00:00:31.791" style="s2">corresponds to the<br />turquoise dot on the screen.</p>
<p begin="00:00:31.791" end="00:00:35.958" style="s2">Keep this marker proximal when<br />I'm examining longitudinally</p>
<p begin="00:00:36.850" end="00:00:40.290" style="s2">and medial when I'm<br />examining transversally.</p>
<p begin="00:00:40.290" end="00:00:43.082" style="s2">We'll start the wrist<br />on the dorsal surface</p>
<p begin="00:00:43.082" end="00:00:45.568" style="s2">and examine transversally first.</p>
<p begin="00:00:45.568" end="00:00:47.860" style="s2">There are six compartments, beginning with</p>
<p begin="00:00:47.860" end="00:00:51.608" style="s2">the first compartment at<br />the base of the thumb,</p>
<p begin="00:00:51.608" end="00:00:54.768" style="s2">and the sixth compartment<br />near the ulnar styloid.</p>
<p begin="00:00:54.768" end="00:00:57.826" style="s2">When we look at the wrist structures,</p>
<p begin="00:00:57.826" end="00:01:01.440" style="s2">we're looking not only<br />at tendons and bones,</p>
<p begin="00:01:01.440" end="00:01:05.440" style="s2">but we're also looking<br />at a multitude of joints.</p>
<p begin="00:01:08.787" end="00:01:12.120" style="s2">If I come over here to a middle portion,</p>
<p begin="00:01:14.809" end="00:01:17.823" style="s2">we're looking at carpal bones here.</p>
<p begin="00:01:17.823" end="00:01:20.855" style="s2">With the presence of synovitis,</p>
<p begin="00:01:20.855" end="00:01:25.107" style="s2">we would have hyperechoic<br />or anechoic fluid</p>
<p begin="00:01:25.107" end="00:01:29.249" style="s2">and thickening of synovium<br />at these recesses,</p>
<p begin="00:01:29.249" end="00:01:31.196" style="s2">which are the joints.</p>
<p begin="00:01:31.196" end="00:01:32.860" style="s2">None of that is present here.</p>
<p begin="00:01:32.860" end="00:01:37.027" style="s2">We'll move over to the<br />extensor tendons of the thumb,</p>
<p begin="00:01:38.837" end="00:01:42.913" style="s2">where you can sometimes see<br />de Quervain's tenosynovitis,</p>
<p begin="00:01:42.913" end="00:01:45.303" style="s2">and here is a nice view of one of</p>
<p begin="00:01:45.303" end="00:01:48.436" style="s2">the long tendons of the thumb.</p>
<p begin="00:01:48.436" end="00:01:51.805" style="s2">These extensor digitorum tendons here</p>
<p begin="00:01:51.805" end="00:01:55.193" style="s2">are normal in appearance on cross-section.</p>
<p begin="00:01:55.193" end="00:01:58.373" style="s2">These are the two thumb<br />tendons that you see</p>
<p begin="00:01:58.373" end="00:02:01.700" style="s2">right over the distal end of the radius,</p>
<p begin="00:02:01.700" end="00:02:04.019" style="s2">which is right here.</p>
<p begin="00:02:04.019" end="00:02:08.186" style="s2">This then can be traced<br />distally out toward the thumb,</p>
<p begin="00:02:09.945" end="00:02:13.064" style="s2">and these tendons and<br />their peritendinous tissue</p>
<p begin="00:02:13.064" end="00:02:15.732" style="s2">can be examined carefully.</p>
<p begin="00:02:15.732" end="00:02:18.580" style="s2">On the other side of the<br />wrist toward the ulna,</p>
<p begin="00:02:18.580" end="00:02:20.201" style="s2">we have a very nice view of the</p>
<p begin="00:02:20.201" end="00:02:23.416" style="s2">extensor carpi ulnaris tendon, which is</p>
<p begin="00:02:23.416" end="00:02:26.310" style="s2">one of the largest extensor<br />tendons in the wrist</p>
<p begin="00:02:26.310" end="00:02:28.501" style="s2">and easiest to see.</p>
<p begin="00:02:28.501" end="00:02:32.173" style="s2">It also is frequently<br />surrounded, in a patient</p>
<p begin="00:02:32.173" end="00:02:35.310" style="s2">with an inflammatory process, with fluid</p>
<p begin="00:02:35.310" end="00:02:39.440" style="s2">or synovium, and that<br />can be seen as either</p>
<p begin="00:02:39.440" end="00:02:42.719" style="s2">anechoic or hyperechoic shadow around the</p>
<p begin="00:02:42.719" end="00:02:46.624" style="s2">distinct oval-shaped tendon, which is</p>
<p begin="00:02:46.624" end="00:02:51.117" style="s2">hyperechoic, and you can see<br />the fibrillar nature within it.</p>
<p begin="00:02:51.117" end="00:02:55.284" style="s2">If we look longitudinally,<br />keeping this dot proximal,</p>
<p begin="00:02:56.705" end="00:03:00.243" style="s2">and find that extensor<br />carpi ulnaris tendon,</p>
<p begin="00:03:00.243" end="00:03:03.057" style="s2">you can see these parallel lines,</p>
<p begin="00:03:03.057" end="00:03:05.369" style="s2">which are going from left to right.</p>
<p begin="00:03:05.369" end="00:03:07.544" style="s2">There are areas that are hyperechoic</p>
<p begin="00:03:07.544" end="00:03:09.971" style="s2">alternating with hypoechoic.</p>
<p begin="00:03:09.971" end="00:03:12.661" style="s2">This is a normal appearance of the tendon,</p>
<p begin="00:03:12.661" end="00:03:15.851" style="s2">and also visualize peritendonous tissue.</p>
<p begin="00:03:15.851" end="00:03:18.684" style="s2">The retinaculum, which is up here,</p>
<p begin="00:03:19.642" end="00:03:23.963" style="s2">in deep to this, this is<br />the distal part of the ulna.</p>
<p begin="00:03:23.963" end="00:03:26.101" style="s2">First part of carpal bones,</p>
<p begin="00:03:26.101" end="00:03:28.593" style="s2">and triangular ligament is in here.</p>
<p begin="00:03:28.593" end="00:03:32.760" style="s2">Next, we look at the volar, or<br />palmer surface of the wrist.</p>
<p begin="00:03:34.730" end="00:03:36.679" style="s2">Most of the time, we're going to be</p>
<p begin="00:03:36.679" end="00:03:39.490" style="s2">looking at the median nerve in this area.</p>
<p begin="00:03:39.490" end="00:03:43.855" style="s2">Again, the transducer<br />marker is placed medially.</p>
<p begin="00:03:43.855" end="00:03:47.630" style="s2">This structure here is the median nerve.</p>
<p begin="00:03:47.630" end="00:03:52.353" style="s2">We can go toward the radial<br />side and see the artery,</p>
<p begin="00:03:52.353" end="00:03:56.520" style="s2">the hyperechoic or anechoic<br />area that has a small pulsation.</p>
<p begin="00:03:58.271" end="00:04:01.991" style="s2">Sometimes checking color Doppler signal</p>
<p begin="00:04:01.991" end="00:04:06.790" style="s2">or Doppler signal is helpful,<br />and the median nerve, then,</p>
<p begin="00:04:06.790" end="00:04:09.779" style="s2">is seen right here in the middle.</p>
<p begin="00:04:09.779" end="00:04:13.832" style="s2">On the ulnar surface,<br />going in this direction,</p>
<p begin="00:04:13.832" end="00:04:17.278" style="s2">is the ulnar artery, and<br />we can freeze the image</p>
<p begin="00:04:17.278" end="00:04:20.282" style="s2">and take a measurement of the median nerve</p>
<p begin="00:04:20.282" end="00:04:24.396" style="s2">if it's desired to see<br />whether this is enlarged</p>
<p begin="00:04:24.396" end="00:04:28.227" style="s2">using direct correlation<br />between this measurement</p>
<p begin="00:04:28.227" end="00:04:30.579" style="s2">and the presence of<br />carpal tunnel syndrome.</p>
<p begin="00:04:30.579" end="00:04:34.045" style="s2">So I have placed my calipers on both sides</p>
<p begin="00:04:34.045" end="00:04:38.180" style="s2">of the median nerve, just<br />inside the perineurium,</p>
<p begin="00:04:38.180" end="00:04:40.914" style="s2">and then I'm going to<br />hit this ellipse button.</p>
<p begin="00:04:40.914" end="00:04:45.466" style="s2">Then I can actually take an<br />approximate surface area.</p>
<p begin="00:04:45.466" end="00:04:49.633" style="s2">She has a .08 centimeter<br />squared area, which is normal,</p>
<p begin="00:04:50.746" end="00:04:54.056" style="s2">and so by ultrasound<br />criteria does not have</p>
<p begin="00:04:54.056" end="00:04:55.973" style="s2">carpal tunnel syndrome.</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>