Figure 5 - available via license: Creative Commons Attribution 4.0 International
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Ultrasound guided steroid injection of the wrist joint. a. The wrist joint (*) is seen placing the transducer in the longitudinal axis of the radius, in between the distal epiphysis of the radius (E) and the proximal carpal bones (C). It is important to differentiate the joint space (*) from the distal growth plate of the radius (G). b. Simulated wrist joint injection in a mannequin showing the advancement of the needle using an “out-of-plane” approach. c. The needle (arrow) is advanced into the joint space, keeping the distal radial epiphysis (E) as a reference.
Source publication
Background
The aim of this article is to describe the technique used to perform ultrasound guided steroid joint injections in children in a group of joints that can be injected using ultrasound as the only image guidance modality.
Findings
The technique is described and didactic figures are provided to illustrate key technical concepts.
Conclusio...
Context in source publication
Context 1
... preferred transducer is the 15 MHz linear array. The transducer is placed in the long axis of the radius and then advanced distally until the distal growth plate and radio-carpal joint are identified (Figure 5a). The needle is advanced into the radio-carpal joint space having the distal radius as a reference. ...
Citations
Background
Distal forearm fractures are a commonly encountered injury in the emergency department (ED), accounting for 500,000 to 1.5 million visits and 17% of ED fractures. The evaluation and management of these fractures frequently employs x-ray studies, conscious sedation, closed reduction, and splinting. Point-of-care ultrasound (POCUS) can offer significant benefit in the diagnosis and management of these common injuries.
Objective of the Review
To review the clinical utility of POCUS in the diagnosis of distal forearm fractures, as well as to demonstrate the performance of ultrasound-guided analgesia delivery and ultrasound-guided reduction technique.
Discussion
The initial evaluation of forearm injuries frequently includes x-ray studies. However, multiple studies have shown ultrasound to be sensitive and specific for distal radius fractures, with the added value of detecting soft tissue injuries missed by conventional radiography. POCUS may also facilitate analgesia through the use of ultrasound-guided hematoma blocks, which removes the need for conscious sedation prior to manipulation. Finally, POCUS can be used after manipulation to assess cortical realignment of the bone fragments and spare the patient multiple reduction attempts and repeat radiographs.
Conclusion
Distal forearm fractures are common, and the emergency physician should be adept with the evaluation and management of these injuries. POCUS can be a reliable modality in the detection of these fractures and can be used to facilitate analgesia and augment success of reduction attempts. These techniques may decrease length of stay, improve patient pain, and decrease reduction attempts.
Zusammenfassung
Der Artikel gibt einen Überblick zum aktuellen Stand der Ultraschallbefundung in der Kinderrheumatologie und geht insbesondere auf den praktischen Einsatz und die technischen Aspekte der Gelenksonografie ein. Dabei werden auch die wissenschaftlichen Entwicklungen der letzten Jahre zusammengefasst und berücksichtigt. Neben der Gelenksonografie wird die Ultraschalltechnik in der Kinderrheumatologie zunehmend auch auf weitere Körperregionen und -organe ausgeweitet, die für die kinderrheumatologische Diagnostik relevant sind.
The role of ultrasound imaging in the diagnosis and monitoring of paediatric rheumatic diseases with special emphasis on recent scientific work regarding the evidence base and standardization of this technique is being reviewed. An overview of the most important practical aspects for the use of musculoskeletal ultrasound in a clinical setting is also provided.
Huge scientific efforts and advances in recent years illustrate the increasing importance of musculoskeletal ultrasound in pediatric rheumatology. Several studies focused on setting an evidence-based standard for the ultrasound appearance of healthy and normal joints in children of all age groups. Physiologic vascularization and ossification were two main aspects of these studies. Other publications demonstrate that ultrasound imaging is also an important and useful tool to detect pathology as synovitis, tenosynovitis or enthesitis in children and to monitor pediatric patients with rheumatic conditions. Important practical aspects include training in the use of correct ultrasound techniques, as well as knowledge and experience of normal pediatric sonoanatomy and the appearance of pathological findings on ultrasound.
Ultrasound imaging guidance of needles introduced for the purpose of joint aspiration or joint injection is becoming increasingly popular. The use of ultrasound increases the safety and efficacy of joint injections in pediatric rheumatology. Needle guidance may be important for diagnostic purposes (fluid aspiration) as well as injections in juvenile idiopathic arthritis (JIA) for short-term relief via intraarticular corticosteroid (CS) injections or longer-term management of limited disease and treatment-resistant multi-joint disease. Ultrasound guidance can also be used to inject steroids into tendon sheaths or around entheses in inflammatory conditions. The following chapter gives an overview of typical indications for ultrasound-guided intraarticular injections in pediatric rheumatology and describes the procedures used for ultrasound guidance of CS injections in specific anatomic regions.
Objective
Intra-articular corticosteroid injections (IACI) are a fundamental part in the treatment of juvenile idiopathic arthritis. The current situation of IACI is reviewed in a population of children.
Methods
We conducted a narrative review of the literature related to IACI in children, with respect to the injection technique, use of local and general anaesthesia, ultrasound guidance of the procedure, indications, special joints and type of optimal corticosteroid.
Results
IACI are indicated in any subcategory of juvenile idiopathic arthritis, especially in oligoarticular juvenile idiopathic arthritis. The use of local anaesthetic is highly recommended, and in patients younger than 6 years or requiring multiple joint injections, conscious sedation can also be an option. Ultrasound guidance of injections is recommended in expert hands, but not in a generalised way. Triamcinolone hexacetonide is the corticosteroid of choice in large joints, whereas a more soluble corticosteroid is a better alternative in small or superficial joints (betamethasone or methylprednisolone) to avoid subcutaneous atrophy or hypopigmentation, the most frequent adverse effect of IACI.
Conclusions
IACI are performed heterogeneously and scientific evidence is limited in many cases.
