<p begin="00:00:09.437" end="00:00:12.693" style="s2">- Today I'm gonna demonstrate<br />the sacroiliac joint injection</p>
<p begin="00:00:12.693" end="00:00:15.489" style="s2">as facilitated by ultrasonography.</p>
<p begin="00:00:15.489" end="00:00:19.498" style="s2">The anatomic considerations<br />are the posterior superior</p>
<p begin="00:00:19.498" end="00:00:24.366" style="s2">iliac spine, the sacrum,<br />and the insertion formed</p>
<p begin="00:00:24.366" end="00:00:26.366" style="s2">of the sacroiliac joint.</p>
<p begin="00:00:28.084" end="00:00:33.060" style="s2">The C60 probe is placed in<br />the transverse orientation.</p>
<p begin="00:00:33.060" end="00:00:36.908" style="s2">After anesthetizing the<br />skin the needle enters</p>
<p begin="00:00:36.908" end="00:00:41.075" style="s2">out of plane into the joint,<br />thusly performing the block.</p>
<p begin="00:00:42.658" end="00:00:45.801" style="s2">The sacroiliac joint injection<br />is useful specifically</p>
<p begin="00:00:45.801" end="00:00:49.537" style="s2">to diagnose issues within the<br />sacroiliac joint that might</p>
<p begin="00:00:49.537" end="00:00:51.699" style="s2">be causing hip pain to the patient.</p>
<p begin="00:00:51.699" end="00:00:55.458" style="s2">Typically on physical examination,<br />there might be a positive</p>
<p begin="00:00:55.458" end="00:01:00.148" style="s2">FABER or flexion abduction<br />external rotation test,</p>
<p begin="00:01:00.148" end="00:01:02.029" style="s2">also known as Patrick's sign,</p>
<p begin="00:01:02.029" end="00:01:04.435" style="s2">or a positive Gaenslen's maneuver.</p>
<p begin="00:01:04.435" end="00:01:07.582" style="s2">This can also occur when the<br />patient has a pelvic tilt</p>
<p begin="00:01:07.582" end="00:01:10.152" style="s2">or a leg-length discrepancy.</p>
<p begin="00:01:10.152" end="00:01:12.726" style="s2">The injection is useful<br />both diagnostically</p>
<p begin="00:01:12.726" end="00:01:14.316" style="s2">and therapeutically.</p>
<p begin="00:01:14.316" end="00:01:17.711" style="s2">Traditionally, fluoroscopy is<br />utilized to place the needle</p>
<p begin="00:01:17.711" end="00:01:21.275" style="s2">within the sacroiliac joint space.</p>
<p begin="00:01:21.275" end="00:01:24.556" style="s2">The sacroiliac joint is a<br />very complicated joint in that</p>
<p begin="00:01:24.556" end="00:01:28.637" style="s2">it is a fibrous insertion<br />superiorly and a traditional</p>
<p begin="00:01:28.637" end="00:01:32.753" style="s2">articulating joint in<br />the lower portion of it.</p>
<p begin="00:01:32.753" end="00:01:36.020" style="s2">On fluoroscopy, issues<br />arise such as parallax</p>
<p begin="00:01:36.020" end="00:01:39.654" style="s2">and it is well-documented<br />that sometimes the injection</p>
<p begin="00:01:39.654" end="00:01:43.000" style="s2">is not placed within the joint<br />but rather periarticularly</p>
<p begin="00:01:43.000" end="00:01:45.850" style="s2">and, therefore, not providing the coverage</p>
<p begin="00:01:45.850" end="00:01:48.077" style="s2">or the response that is expected.</p>
<p begin="00:01:48.077" end="00:01:50.000" style="s2">To perform this particular block,</p>
<p begin="00:01:50.000" end="00:01:52.899" style="s2">the following equipment is necessary.</p>
<p begin="00:01:52.899" end="00:01:56.047" style="s2">Chlorhexidine for sterile technique.</p>
<p begin="00:01:56.047" end="00:02:00.214" style="s2">Local anesthetic syringe<br />containing 1% buffered lidocaine.</p>
<p begin="00:02:01.556" end="00:02:06.097" style="s2">And then a syringe containing<br />5cc of bupivacaine,</p>
<p begin="00:02:06.097" end="00:02:10.264" style="s2">one-half percent mixed with<br />5cc of one percent lidocaine.</p>
<p begin="00:02:11.154" end="00:02:15.112" style="s2">And then 40-80 milligrams<br />of triamcinolone kenalog</p>
<p begin="00:02:15.112" end="00:02:18.008" style="s2">which is a particulate steroid.</p>
<p begin="00:02:18.008" end="00:02:21.199" style="s2">A 3 1/2 inch, 25 gauge spinal<br />needle will also be utilized</p>
<p begin="00:02:21.199" end="00:02:22.699" style="s2">for the procedure.</p>
<p begin="00:02:23.571" end="00:02:26.876" style="s2">There will be sterile 4 x 4s<br />necessary to clean the area</p>
<p begin="00:02:26.876" end="00:02:28.261" style="s2">at the conclusion.</p>
<p begin="00:02:28.261" end="00:02:31.947" style="s2">And a simple band-aid will<br />suffice to cover the wound.</p>
<p begin="00:02:31.947" end="00:02:34.556" style="s2">The patient is placed in the<br />traditional prone position.</p>
<p begin="00:02:34.556" end="00:02:38.514" style="s2">There is a bolster within<br />and under the abdomen</p>
<p begin="00:02:38.514" end="00:02:41.559" style="s2">to facilitate opening of<br />the sacroiliac joints.</p>
<p begin="00:02:41.559" end="00:02:46.344" style="s2">And then I utilize the C60<br />probe with its curvy linear</p>
<p begin="00:02:46.344" end="00:02:50.507" style="s2">structure to better visualize<br />the interface between</p>
<p begin="00:02:50.507" end="00:02:53.121" style="s2">the sacrum and the iliac crest.</p>
<p begin="00:02:53.121" end="00:02:56.992" style="s2">The depth is usually set<br />to 7 - 9 centimeters,</p>
<p begin="00:02:56.992" end="00:02:59.643" style="s2">depending on the patient's habitus.</p>
<p begin="00:02:59.643" end="00:03:02.984" style="s2">Additionally, I utilize the<br />muscoloskeletal, or the MSK,</p>
<p begin="00:03:02.984" end="00:03:06.695" style="s2">setting because it provides<br />enhancement of the bony</p>
<p begin="00:03:06.695" end="00:03:11.105" style="s2">structures and the enhancement<br />of the joint space.</p>
<p begin="00:03:11.105" end="00:03:15.767" style="s2">The probe is placed on the<br />patient in the transverse</p>
<p begin="00:03:15.767" end="00:03:19.934" style="s2">orientation approximately<br />a centimeter or two above</p>
<p begin="00:03:20.840" end="00:03:22.966" style="s2">the beginnings of the gluteal folds.</p>
<p begin="00:03:22.966" end="00:03:27.003" style="s2">And I've found the anatomic<br />midline by identifying</p>
<p begin="00:03:27.003" end="00:03:30.032" style="s2">the spinous process of the sacral plate.</p>
<p begin="00:03:30.032" end="00:03:34.199" style="s2">As I roll the probe laterally,<br />the posterior superior</p>
<p begin="00:03:35.698" end="00:03:39.403" style="s2">iliac spine comes into view<br />very clearly at the top</p>
<p begin="00:03:39.403" end="00:03:41.320" style="s2">of the screen, up here.</p>
<p begin="00:03:42.394" end="00:03:46.561" style="s2">The space between the<br />posterior superior iliac spine</p>
<p begin="00:03:47.414" end="00:03:52.184" style="s2">and the shadow cast by the<br />iliac crest and the sacrum</p>
<p begin="00:03:52.184" end="00:03:55.932" style="s2">as it dives down represents<br />the sacroiliac joint.</p>
<p begin="00:03:55.932" end="00:03:58.774" style="s2">And you can see that in<br />the center of the screen.</p>
<p begin="00:03:58.774" end="00:04:02.941" style="s2">It's important to remember<br />that the iliac crest and ilium</p>
<p begin="00:04:03.953" end="00:04:07.912" style="s2">folds and cantilevers towards the sacrum.</p>
<p begin="00:04:07.912" end="00:04:12.392" style="s2">Therefore, the needle angle<br />needs to track from medial</p>
<p begin="00:04:12.392" end="00:04:15.012" style="s2">to lateral into the space identified</p>
<p begin="00:04:15.012" end="00:04:16.829" style="s2">in the center of the screen.</p>
<p begin="00:04:16.829" end="00:04:19.416" style="s2">Local anesthetic is placed.</p>
<p begin="00:04:19.416" end="00:04:23.583" style="s2">And as a finder needle, this<br />injectate using hydrodissection</p>
<p begin="00:04:24.908" end="00:04:27.486" style="s2">demonstrates the needle tip at all times.</p>
<p begin="00:04:27.486" end="00:04:30.667" style="s2">The needle is going in<br />the short axis, therefore,</p>
<p begin="00:04:30.667" end="00:04:33.780" style="s2">it won't be completely<br />visualized on the screen.</p>
<p begin="00:04:33.780" end="00:04:37.090" style="s2">However, hydrodissection<br />can help notice where</p>
<p begin="00:04:37.090" end="00:04:39.090" style="s2">the tip is at all times.</p>
<p begin="00:04:40.113" end="00:04:43.975" style="s2">Then I'll utilize the 3 1/2<br />inch spinal needle, 25 gauge,</p>
<p begin="00:04:43.975" end="00:04:46.913" style="s2">and enter that track that I have placed</p>
<p begin="00:04:46.913" end="00:04:48.614" style="s2">local anesthetic with it.</p>
<p begin="00:04:48.614" end="00:04:51.094" style="s2">The needle tip will then<br />be placed within that joint</p>
<p begin="00:04:51.094" end="00:04:53.663" style="s2">identified in the center<br />of the screen, right here.</p>
<p begin="00:04:53.663" end="00:04:57.903" style="s2">At this point, I attach my<br />syringe containing the local</p>
<p begin="00:04:57.903" end="00:05:00.736" style="s2">anesthetic steroid and saline mix.</p>
<p begin="00:05:02.236" end="00:05:06.403" style="s2">And then I could utilize<br />color flow Doppler to actually</p>
<p begin="00:05:07.546" end="00:05:10.403" style="s2">visualize perturbations of the liquid</p>
<p begin="00:05:10.403" end="00:05:12.320" style="s2">as it enters the joint.</p>
<p begin="00:05:15.174" end="00:05:17.454" style="s2">- [Voiceover] The view is in<br />the short axis, therefore,</p>
<p begin="00:05:17.454" end="00:05:19.662" style="s2">the needle is not visible.</p>
<p begin="00:05:19.662" end="00:05:22.684" style="s2">The iliac crest is visible<br />as the large hyperechoic</p>
<p begin="00:05:22.684" end="00:05:25.337" style="s2">structure on the right of the screen.</p>
<p begin="00:05:25.337" end="00:05:28.926" style="s2">The lateral crest of the<br />sacrum is visible below.</p>
<p begin="00:05:28.926" end="00:05:31.290" style="s2">The target is the void<br />between the lateral crest</p>
<p begin="00:05:31.290" end="00:05:34.187" style="s2">of the sacrum and the iliac crest.</p>
<p begin="00:05:34.187" end="00:05:36.791" style="s2">This helps solidify understanding<br />of the three-dimensional</p>
<p begin="00:05:36.791" end="00:05:39.624" style="s2">structure of the sacroiliac joint.</p>
<p begin="00:05:40.952" end="00:05:44.864" style="s2">- At this point the probe is removed.</p>
<p begin="00:05:44.864" end="00:05:48.364" style="s2">I utilize the 4 x 4s to clean the area.</p>
<p begin="00:05:52.208" end="00:05:55.223" style="s2">And a band-aid is placed over the wound.</p>
<p begin="00:05:55.223" end="00:05:58.404" style="s2">This successfully completes<br />the ultrasonographic</p>
<p begin="00:05:58.404" end="00:06:02.237" style="s2">facilitation of a<br />sacroiliac joint injection.</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="00:00:09.404" end="00:00:13.825" style="s2">- So I'm going to show a technique<br />for injection of fingers,</p>
<p begin="00:00:13.825" end="00:00:17.911" style="s2">and we'll do on the Dorsal<br />surface or Extensor surface,</p>
<p begin="00:00:17.911" end="00:00:22.078" style="s2">a simulation of injection<br />of either a PIP or MCP joint</p>
<p begin="00:00:23.072" end="00:00:27.011" style="s2">and then turn the hand<br />around on the Palmar surface,</p>
<p begin="00:00:27.011" end="00:00:31.241" style="s2">and show you an injection<br />approach for Flexor tendons.</p>
<p begin="00:00:31.241" end="00:00:33.991" style="s2">I'm gonna use the L25 transducer.</p>
<p begin="00:00:35.700" end="00:00:39.568" style="s2">Normally we would be dealing<br />with a sterile field,</p>
<p begin="00:00:39.568" end="00:00:43.735" style="s2">and a sterile gel, and most<br />likely a transducer cover,</p>
<p begin="00:00:45.699" end="00:00:48.375" style="s2">which is also sterile, but<br />for the purposes of this,</p>
<p begin="00:00:48.375" end="00:00:51.999" style="s2">we're just showing you an approach.</p>
<p begin="00:00:51.999" end="00:00:55.926" style="s2">If the joint is swollen and has Synovitis,</p>
<p begin="00:00:55.926" end="00:00:59.355" style="s2">or a joint diffusion, it's<br />quite easy to see the space</p>
<p begin="00:00:59.355" end="00:01:01.639" style="s2">that you're aiming for.</p>
<p begin="00:01:01.639" end="00:01:05.637" style="s2">This particular exam, we<br />don't have that finding.</p>
<p begin="00:01:05.637" end="00:01:09.804" style="s2">Normally for an injection<br />into a small joint like this,</p>
<p begin="00:01:10.659" end="00:01:14.826" style="s2">I like to approach the joint<br />with the transducer placed</p>
<p begin="00:01:15.785" end="00:01:19.952" style="s2">transversely, in this type<br />of a plane, and then have</p>
<p begin="00:01:22.371" end="00:01:26.538" style="s2">the needle in the same<br />direction parallel, or in plane</p>
<p begin="00:01:27.542" end="00:01:32.292" style="s2">with the transducer, so my<br />needle and my transducer are</p>
<p begin="00:01:32.292" end="00:01:37.022" style="s2">parallel, and I'm going as<br />superficial as possible,</p>
<p begin="00:01:37.022" end="00:01:40.567" style="s2">with a very small needle<br />so it doesn't hurt,</p>
<p begin="00:01:40.567" end="00:01:44.123" style="s2">and trying to place the<br />needle into the skin,</p>
<p begin="00:01:44.123" end="00:01:47.623" style="s2">and in the one millimeter ultrasound beam,</p>
<p begin="00:01:49.237" end="00:01:51.320" style="s2">into the target this way.</p>
<p begin="00:01:52.641" end="00:01:57.143" style="s2">On the other side, we'll be<br />looking at a Flexor tendon,</p>
<p begin="00:01:57.143" end="00:01:59.785" style="s2">which travels in this direction.</p>
<p begin="00:01:59.785" end="00:02:03.368" style="s2">I will place the<br />transducer longitudinally,</p>
<p begin="00:02:04.521" end="00:02:08.438" style="s2">and approach with the<br />needle in this direction.</p>
<p begin="00:02:09.588" end="00:02:13.205" style="s2">If you keep the needle<br />parallel to the surface</p>
<p begin="00:02:13.205" end="00:02:15.777" style="s2">of the transducer, it shows up the best.</p>
<p begin="00:02:15.777" end="00:02:19.371" style="s2">The insertion point can be quite close</p>
<p begin="00:02:19.371" end="00:02:23.440" style="s2">to the transducer's edge,<br />especially if you're going</p>
<p begin="00:02:23.440" end="00:02:27.492" style="s2">very superficially; in a<br />small area like a finger,</p>
<p begin="00:02:27.492" end="00:02:31.270" style="s2">or a tendon around here, you<br />don't have a lot of space</p>
<p begin="00:02:31.270" end="00:02:34.388" style="s2">and so you have to go<br />very close, and can insert</p>
<p begin="00:02:34.388" end="00:02:37.638" style="s2">the needle very flat and superficially.</p>
<p begin="00:02:38.656" end="00:02:42.953" style="s2">Because there's very little<br />space between the skin surface</p>
<p begin="00:02:42.953" end="00:02:45.997" style="s2">and the tendon, and here it's probably</p>
<p begin="00:02:45.997" end="00:02:48.683" style="s2">about two or three millimeters.</p>
<p begin="00:02:48.683" end="00:02:51.251" style="s2">And watch exactly where<br />the tip of the needle</p>
<p begin="00:02:51.251" end="00:02:52.834" style="s2">and the bevel goes.</p>

<p begin="00:00:09.853" end="00:00:13.771" style="s2">- I'm going to examine the<br />MCM and PIP joints now.</p>
<p begin="00:00:13.771" end="00:00:17.492" style="s2">We'll be looking at the<br />dorsal, or extensor, surfaces,</p>
<p begin="00:00:17.492" end="00:00:20.795" style="s2">as well as the palmar surface of the MCPs</p>
<p begin="00:00:20.795" end="00:00:23.853" style="s2">and just take a brief look at the PIP.</p>
<p begin="00:00:23.853" end="00:00:27.872" style="s2">The best transducer for<br />this exam is the L25,</p>
<p begin="00:00:27.872" end="00:00:31.268" style="s2">which has a small<br />footprint and it allows you</p>
<p begin="00:00:31.268" end="00:00:34.768" style="s2">to retain contact with the skin's surface.</p>
<p begin="00:00:36.283" end="00:00:40.684" style="s2">There is a marker on the<br />transducer, which represents</p>
<p begin="00:00:40.684" end="00:00:44.851" style="s2">this turquoise dot, so in keeping<br />your orientation straight,</p>
<p begin="00:00:47.649" end="00:00:51.443" style="s2">you always want to keep this<br />proximal, so this is held</p>
<p begin="00:00:51.443" end="00:00:55.193" style="s2">that way for longitudinal<br />images, and medial,</p>
<p begin="00:00:56.310" end="00:00:59.226" style="s2">so this marker should be on the outside.</p>
<p begin="00:00:59.226" end="00:01:02.083" style="s2">As a rheumatologist, we're<br />going to be looking for</p>
<p begin="00:01:02.083" end="00:01:06.346" style="s2">boney detail tendon<br />anatomy, and the presence</p>
<p begin="00:01:06.346" end="00:01:09.919" style="s2">or absence of synovitis and erosions.</p>
<p begin="00:01:09.919" end="00:01:12.868" style="s2">I'll look, today at the<br />second and third MCPs,</p>
<p begin="00:01:12.868" end="00:01:16.104" style="s2">both in the transverse<br />and longitudinal planes,</p>
<p begin="00:01:16.104" end="00:01:17.780" style="s2">and we'll take a brief look at the PIP</p>
<p begin="00:01:17.780" end="00:01:21.613" style="s2">and then the palmar<br />surface of the second MCP.</p>
<p begin="00:01:22.658" end="00:01:26.896" style="s2">We'll look longitudinally<br />over the second MCP first</p>
<p begin="00:01:26.896" end="00:01:29.896" style="s2">and see the skin surface on the top.</p>
<p begin="00:01:31.343" end="00:01:34.247" style="s2">The bones, this is proximal, so this is</p>
<p begin="00:01:34.247" end="00:01:36.747" style="s2">the end of the 2nd Metacarpal.</p>
<p begin="00:01:37.733" end="00:01:41.108" style="s2">Here's the Articular<br />Surface, and then here is</p>
<p begin="00:01:41.108" end="00:01:44.781" style="s2">the proximal portion of the 1st Phalanx.</p>
<p begin="00:01:44.781" end="00:01:48.698" style="s2">The black anechoic surface,<br />here, is Cartilage,</p>
<p begin="00:01:49.605" end="00:01:51.245" style="s2">and there's some cartilage here,</p>
<p begin="00:01:51.245" end="00:01:56.183" style="s2">and this is a normal joint<br />structure at the second MCP.</p>
<p begin="00:01:56.183" end="00:02:00.481" style="s2">There is frequently a small<br />articular cortical defect</p>
<p begin="00:02:00.481" end="00:02:04.425" style="s2">on the dorsal surface of this metacarpal.</p>
<p begin="00:02:04.425" end="00:02:06.271" style="s2">That is not an erosion.</p>
<p begin="00:02:06.271" end="00:02:08.868" style="s2">An erosion would appear elsewhere</p>
<p begin="00:02:08.868" end="00:02:11.205" style="s2">with this type of an appearance.</p>
<p begin="00:02:11.205" end="00:02:14.115" style="s2">We can also see the Extensor<br />Tendon superficially</p>
<p begin="00:02:14.115" end="00:02:16.484" style="s2">right under the surface of the skin.</p>
<p begin="00:02:16.484" end="00:02:19.252" style="s2">Could you move your finger<br />just up a little bit,</p>
<p begin="00:02:19.252" end="00:02:22.970" style="s2">and you can see that tendon<br />moving and the joint moving.</p>
<p begin="00:02:22.970" end="00:02:27.228" style="s2">We'll then take a transverse image and see</p>
<p begin="00:02:27.228" end="00:02:31.392" style="s2">a transverse oval image<br />of that Extensor Tendon.</p>
<p begin="00:02:31.392" end="00:02:33.577" style="s2">We're going to look for hyperechoic</p>
<p begin="00:02:33.577" end="00:02:37.097" style="s2">or anechoic fluid or synovium around it.</p>
<p begin="00:02:37.097" end="00:02:40.181" style="s2">In this case, none of that is present.</p>
<p begin="00:02:40.181" end="00:02:43.378" style="s2">We can also now look at the third MCP.</p>
<p begin="00:02:43.378" end="00:02:47.948" style="s2">Here, again, we see the<br />extensor tendon, the joint</p>
<p begin="00:02:47.948" end="00:02:50.023" style="s2">is V-shaped structure.</p>
<p begin="00:02:50.023" end="00:02:53.925" style="s2">This is anechoic where the<br />cartilage is and hypoechoic</p>
<p begin="00:02:53.925" end="00:02:58.874" style="s2">where the actual joint<br />material is within the capsule.</p>
<p begin="00:02:58.874" end="00:03:01.190" style="s2">The joint extends from approximately here</p>
<p begin="00:03:01.190" end="00:03:02.686" style="s2">all the way over to here.</p>
<p begin="00:03:02.686" end="00:03:04.353" style="s2">That's quite normal.</p>
<p begin="00:03:05.221" end="00:03:06.846" style="s2">We'll look at the PIP.</p>
<p begin="00:03:06.846" end="00:03:10.690" style="s2">This is the distal end of the 1st Phalanx.</p>
<p begin="00:03:10.690" end="00:03:15.075" style="s2">The Joint is this space,<br />here, and she happens</p>
<p begin="00:03:15.075" end="00:03:18.520" style="s2">to have a small amount<br />of osteoarthritis, here,</p>
<p begin="00:03:18.520" end="00:03:22.208" style="s2">with some Irregularity<br />of this Cortical surface.</p>
<p begin="00:03:22.208" end="00:03:25.713" style="s2">I can slip my finger in<br />here and show you where</p>
<p begin="00:03:25.713" end="00:03:28.016" style="s2">this is actually moving and you can see</p>
<p begin="00:03:28.016" end="00:03:30.766" style="s2">that joint flexing and extending.</p>
<p begin="00:03:31.916" end="00:03:36.083" style="s2">We'll look at the flexor<br />surface of the second MCP.</p>
<p begin="00:03:39.716" end="00:03:41.870" style="s2">These tendons are quite a bit bigger.</p>
<p begin="00:03:41.870" end="00:03:45.010" style="s2">We see the Flexor Tendon<br />moving very nicely</p>
<p begin="00:03:45.010" end="00:03:48.106" style="s2">as she flexes and extends<br />her finger, and you can see</p>
<p begin="00:03:48.106" end="00:03:50.675" style="s2">the superficial border<br />between the tendon and the</p>
<p begin="00:03:50.675" end="00:03:53.754" style="s2">Subcutaneous Tissues, and you can see</p>
<p begin="00:03:53.754" end="00:03:55.959" style="s2">the Joint very nicely, here.</p>
<p begin="00:03:55.959" end="00:03:59.087" style="s2">This Hypoechoic area is the A1 pulley,</p>
<p begin="00:03:59.087" end="00:04:02.170" style="s2">which is just proximal to this joint.</p>