![Left cadaveric elbow.
Similar to the right side, the skin, subcutaneous tissue and muscle layers have been removed
exposing the elbow joint. Cutting and lifting the anterolateral portion of the capsule (A), the needle
was clearly visualized traveling through the extensor carpi radialis longus/brachioradialis complex
(ECRL/BRc), CET (T) and the lateral capsule (C) to reach the articular space. Note that the needle’s
tip (white arrowhead) is exactly located within the radiohumeral space (white asterisk), allowing the
green latex dye to be widely distribute all over the articular surfaces of the elbow joint (B).
Yellow arrowhead: radial nerve, RH: radial head, HC: humeral condyle
[The inner surface of the CET (T) was partially reached by the green latex dye after the capsular dissection giving it a
greenish color]](https://www.researchgate.net/publication/368981263/figure/fig3/AS:11431281124327763@1677912188879/Left-cadaveric-elbow-Similar-to-the-right-side-the-skin-subcutaneous-tissue-and-muscle_Q320.jpg)
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Ultrasound‐Guided Injection of the Elbow: Cadaveric Description for the Proximal to Distal Approach
Abstract and Figures
Objectives:
To describe a proximal to distal approach for ultrasound (US) guided intra-articular elbow injection.
Design:
Cadaveric study.
Settings:
Academic institution.
Subjects:
Single cadaveric specimen.
Methods:
Both elbows of a single cadaver were injected with green-colored water-diluted latex dye using the US-guided proximal to distal approach. In the left elbow, the needle was kept in situ; in the right elbow, the needle was removed. Subsequently, a layer-by-layer anatomical dissection was performed in both elbows.
Main outcomes:
Presence and distribution of the latex dye and location of the needle tip within the elbow joint capsule.
Results:
Anatomical dissection of both elbows confirmed the correct intra-articular position of the needle tip in the left elbow as well as correct placement of the latex dye bilaterally. During layer-by-layer dissection of the left elbow, the position of the radial nerve was observed anterior to the needle.
Conclusions:
This cadaveric observation demonstrated that the US-guided proximal to distal approach is a convenient technique to access the elbow joint. Indeed, compared to the previously described techniques, the in-plane, proximal to distal approach may provide excellent needle visibility during the entire procedure, precisely targeting the articular space. Our preliminary data needs to be validated in additional clinical studies.
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... Previous clinical studies have reported good clinical outcomes of HR for MPS or similar pathologies [2], and some histological studies have revealed that the APF comprises two, three, or four layers [4]. Notably, a few studies have aimed to ascertain the solution distribution following US-guided inter-myofascial or intra-articular injection [5,6]. However, no cadaveric study has examined the precise distribution of the solution following injection between the layers of the two APFs through US. ...
Background: The relationship between human anatomy on ultrasonography (US) and dissection is unclear.Therefore, we investigated the precise location of a solution injected into eight legs from five fresh-frozen specimens between the fascial layers of two aponeurotic fascial (APF) regions using US.
Methods: The US-guided injection target points were the fascial lata-distal, crural fascia-proximal, and crural fascia-distal. The operator searched the optimal visualization area of two close fascial layers of the two APF regions; 2.5 mL of 0.9% saline was injected through US guidance. The layers with the solution were categorized as above the APF (between the superficial fascia and APF), intra-APF, between the APF and epimysium (EPI), or intra-muscle (under the EPI).
Results: A small amount of solution was identified within the intra-APF region, whereas a substantial amount was observed above the APF, between the APF and EPI, and intramuscularly. Regarding the fascia lata-distal and crural fascia-distal, a substantial volume of solution was observed between the APF and EPI in all cases. For the crural fascia-proximal, the solution was observed above the APF in 25% of cases and intramuscularly in 75% of cases.
Conclusions: Solution distribution may be associated with whether the muscle fibers are directly inserted into the APF and the absence of EPI in each area.
... However, no consensus about the best treatment for improving pain and function in people with TE has been reached (5). Among conservative treatments, injection therapy is widely used for the treatment of patients with TE (28)(29)(30), with hyaluronic acid (HA) peritendinous injections representing an emerging treatment option that, anyway, lacks strong evidence to support its use. ...
Tennis elbow is a tendinopathy of the lateral elbow that causes pain and functional limitation. This systematic review investigates the effects of hyaluronic acid injections for treating tennis elbow. A systematic search of scientific electronic databases (CENTRAL, EMBASE, MEDLINE, PEDro, Web of Science, Scopus, PubMed, and CINAHL) was performed up to October 2023 with no restrictions of time and language. This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria were articles that reported clinical outcomes about the use of hyaluronic acid for tennis elbow alone or in comparison with other injectable drugs. Outcome measures were the Visual Analogue Scale, handgrip strength, and the Quick-Disabilities of the Arm, Shoulder, and Hand score. Two independent authors performed the search and evaluated the articles. The inter-rater reliability in the quality assessment was evaluated using Cohen's kappa coefficient. The Modified Coleman Methodology Score was used to evaluate the methodological quality of the articles included in this systematic review. A total of seven articles were included with the overall quality of the included articles being evaluated as fair. Despite using different kinds of hyaluronic acid and injection protocols, and different scores applied, each included study showed clinically relevant improvements. Hyaluronic acid injections resulted in being superior to placebo but inferior in the short-term compared to other injections. Given the high heterogeneity of the included studies, we cannot conclude which kind of hyaluronic acid and injection protocol is the best for treating tennis elbow. Hyaluronic acid injections for treating tennis elbow seem safe and effective in reducing pain, improving function, and allowing a faster return to pain-free sports activities especially in the long term. High-quality and prospective long-term follow-up studies are needed to confirm the articles' outcomes in this systematic review.
... All of them were embalmed using the Fix for Life (F4L) method [14]. It is a specific type of corpse preservation that plausibly preserves anatomical/histological features of the body and it also guarantees high-quality US images for both the cadaveric tissues and the needle [9,12]. ...
Objective
Injection of the tibiotalar (TT) joint is commonly performed in clinical practice under ultrasound (US) guidance using an anteromedial approach. However, in some patients, this approach may be technically challenging due to post-traumatic and/or degenerative bony changes. Therefore, the aim of this cadaveric investigation was to demonstrate the feasibility of the ultrasound-guided (USG) injection of the ankle joint via the anterolateral sulcus (ALS) by confirming the dye placement/distribution inside the articular space. Likewise, the safety of the procedure has also been evaluated by measuring the distance between the needle and the intermediate dorsal cutaneous nerve of the foot.
Design
A descriptive laboratory study with eight embalmed cadaveric ankles using the Fix for Life (F4L) method was performed at the setting of an academic institution. The interventional technique and the related anatomical findings were illustrated. During the injection, the needle was advanced into the TT joint through the ALS under US guidance, i.e., in-plane anterior-to-posterior approach. With the objective to confirm its correct placement, the needle was kept in situ and—to demonstrate the location of the dye inside the articular space—all eight ankles were injected with 3 mL of green color dye. Thereafter, a layer-by-layer anatomical dissection was performed on all four cadavers.
Results
The position of the needle’s tip within the ALS was confirmed in all specimens. Accurate placement of the dye inside the articular space of the ankle was confirmed in seven of the eight cadaveric ankles, with 87.5% of accuracy. Herewith, unintentional spilling of the dye within the superficial soft tissues was reported in two of the eight ankles (25.0%). The mean distance between the needle and the intermediate dorsal cutaneous nerve of the foot, measured in all eight procedures, was 3 cm.
Conclusion
USG injection of the ALS using the in-plane, anterior-to-posterior approach can accurately place the injectate inside the articular space.
Clinical relevance
This cadaveric investigation described the accuracy and potential pitfalls of USG injection of the ankle via the anterolateral approach which represents an alternative technique in patients with reduced accessibility of the anteromedial recess due to degenerative and/or post-traumatic bony changes.
... As a side note, the F4L method is a specific type of corpse preservation that accurately preserves anatomical/histological features of the body and also guarantees high-quality US images for both the cadaveric tissues and the needle. [16,17]. ...
Background: Injections around the Achilles tendon (AT) are commonly performed in clinical practice to manage non-insertional Achilles tendinopathy, but the presence/distribution of the injectate with relation to its sheath has not been assessed specifically. Accordingly, the aim of this cadaveric
investigation was to demonstrate the feasibility of Achilles paratenon injection under ultrasound
guidance - by confirming the exact needle positioning as well as the dye distribution inside the paratenon lumen.
Methods: A descriptive laboratory study with three human cadaveric specimens (one fresh cadaver
and two cadavers embalmed using the Fix for Life (F4L) method) was performed in a tertiary-care academic institution. The interventional technique and the related anatomical findings were
illustrated. During the injection, the needle was advanced inside the Achilles paratenon under ultrasound guidance i.e. in-plane medial-to-lateral approach. With the objective to confirm its
correct placement, the needle was kept in situ on the right AT of the fresh cadaver. Likewise, to demonstrate the location of the dye inside the lumen of Achilles paratenon, the other five ATs - four on the embalmed cadavers and one on the fresh cadaver - were injected with 5 mL of green color dye. After removal of the needle, a layer-by-layer anatomical dissection was performed on all three cadavers.
Results: On the right AT of the fresh cadaver, the position of the needle’s tip within the Achilles paratenon was confirmed. Accurate placement of the dye inside the paratenon lumen was
confirmed in four (80%) ATs, one of the fresh and three of the embalmed cadavers. No spread inside the crural fascia compartment or between the AT and the Kager’s fat pad was observed. Herewith, unintentional spilling of the dye within the superficial soft tissues of the posterior leg was reported
in the left AT of one of the two embalmed cadavers (20%).
Conclusions: Ultrasound-guided injection using the in-plane, medial-to-lateral approach can accurately target the lumen of Achilles paratenon.
This study aimed to evaluate the efficacy and safety of a novel ultrasound-guided percutaneous tenotomy technique for treating chronic tendinosis of the common extensor tendon (CET) in the elbow (lateral epicondylitis).
The study was conducted on 25 elbows from 13 cadavers without prior local injuries. Each CET tenotomy was performed using a Mikro 64 scalpel under ultrasound guidance to ensure precision and safety. Key anatomical structures, including the lateral collateral ligament (LCL), radial nerve, and posterior antebrachial cutaneous nerve, were monitored to assess safety margins and detect potential complications.
In the 20 evaluated cases, the mean distance from the CET section to the radial epicondyle (DET) was 5.86 mm (range 5.96–12.8 mm), while the distance to the proximal LCL margin (DELCL) averaged 8.62 mm (range – 0.96–6.82 mm), yielding a confident tenotomy length of 2.76 mm. Partial LCL injury occurred in four cases without affecting joint stability, and no nerve injuries were observed. Incomplete CET sections were found in four cases, with residual fibers primarily along the medial and lateral margins.
The ultrasound-guided percutaneous tenotomy technique demonstrated safety and effectiveness in an anatomical setting. This minimally invasive approach may offer a viable surgical alternative for refractory lateral epicondylitis, minimizing the risk of complications and promoting a shorter recovery period.
Aim: To propose a standardized, high-resolution ultrasound (US) protocol to assess the patellar tendon–Hoffa fat pad interface (PTHFPI) in patients with (proximal) patellar tendinopathy (PPT).
Methods: Using a high-frequency transducer and a high-level machine, we matched the cadaveric and histological microarchitecture of the PTHFPI with multiple sonographic pat-terns of patients with PPT. Likewise, high-sensitive color/power Doppler assessments were also performed to evaluate the microcirculation of the soft tissues beneath the patellar ten-don.
Results: Modern US equipment allows for detailed assessment of the potential pain gener-ators located inside the PTHFPI in patients with PPT. They include anterosuperior portion of the Hoffa body and the loose connective tissue of the deep paratenon with its microvascu-lar plexus.
Conclusions: In patients with PPT, accurate sonographic assessment of the PTHFPI can be performed using adequate technological equipment. Accordingly, tailored ultrasound-guided interventions can also be planned if/when clinically indicated.
Ultrasound (US) imaging has consolidated its place
among the other routine evaluation/imaging methods
used by physiatrists in daily clinical practice.
There is an ever-increasing need for its prompt technical
application and interpretation. The aim of this letter is to clarify a particular issue as regards the orientation between probe positioning and the corresponding
images on the US screen.
We propose a practical approach for performing arthrography with fluoroscopic or ultrasound guidance. Different approaches to the principal joints of the upper limb (shoulder, elbow, wrist and fingers), lower limb (hip, knee, ankle and foot) as well as the facet joints of the spine are discussed and illustrated with numerous drawings. Whenever possible, we emphasise the concept of targeting articular recesses, which offers many advantages over traditional techniques aiming at the joint space.
Teaching Points
• Arthrography remains a foremost technique in musculoskeletal radiology
• Most joints can be successfully accessed by targeting the articular recess
• Targeting the recess offers several advantages over traditional approaches
• Ultrasound-guidance is now favoured over fluoroscopy and targeting the recess is equally applicable
In this protocol, the patient/probe positionings, anatomical drawings and ultrasound images of commonly scanned elbow structures are described. This practical guide is prepared (with an international consensus of several expert physiatrists) to serve as a uniform/standard approach especially for beginner sonographers.
Iatrogenic injury during the posterior approach to the humerus during operative fixation is not an uncommon occurrence. A comprehensive understanding of the normal anatomy and its variants is of paramount importance in order to avoid such injury. Typically, the inferior lateral cutaneous branch of the radial nerve originates towards the distal end of the humerus at the inferior portion of the spiral groove. Here, we report an important variant of this nerve, which originated significantly more proximal than expected, further emphasizing the importance of identification, dissection and protection of the radial nerve and its major branches.
Objective:
To define a standardized comprehensive sonographic approach for evaluating the different histo-anatomical compartments of the lateral elbow.
Design:
Using high-frequency US probes, we tried to match the anatomical features of the lateral elbow and its different sonographic patterns in patients with the diagnosis of lateral epicondylitis. Moreover, high-sensitive color/power Doppler assessments have also been performed to evaluate the microcirculation.
Results:
Modern US equipment appears to provide an extremely detailed sonographic assessment of the different anatomical layers located in the lateral compartment of the elbow. Moreover, high-sensitive color/power Doppler imaging allows for clear visualization of the perfusion patterns in pathological conditions.
Conclusion:
In clinical practice, high-frequency B-mode and high-sensitive color/power Doppler imaging can be integrated with the clinical findings to better define the pain generator(s) for optimizing the management of patients with lateral epicondylitis.
In this dynamic protocol, ultrasound examination of the elbow using different maneuvers is described for several/relevant elbow problems. Scanning videos are coupled with real-time patient examination videos for better understanding. The authors believe that this practical guide-prepared by an international consensus of several experts (EURO-MUSCULUS: European Musculoskeletal Ultrasound Study Group and USPRM: Ultrasound Study Group of ISPRM [International Society of Physical and Rehabilitation Medicine])-will help musculoskeletal physicians perform a better and uniform/standard approach.
Ultrasound has been reported to be a quick, cheap, and effective imaging modality to guide the interventional procedures in the musculoskeletal system. The use of ultrasound results in increased accuracy of needle placement associated with a reduction of complications. In the upper limb, ultrasound-guided procedures are applied to joints and soft tissues around the shoulder, elbow, wrist, and hand. This article reviews the clinical and technical aspects of the most common procedures performed in this anatomic area.
High-resolution ultrasonography can help clinicians visualize key anatomic structures of the elbow and guide periarticular and intra-articular injections. Historically, most procedures done around the elbow have been done using landmark guidance, and few studies have reported the accuracy of ultrasonography-guided injections in the elbow region. This article reviews common musculoskeletal disorders about the elbow that can be evaluated with ultrasonography, reviews the literature on ultrasonography-guided injections of the elbow region, and describes the senior author's preferred approach for the most commonly performed elbow region injections.
EURO-MUSCULUS/USPRM dynamic ultrasound protocols for elbow
- V Ricci
- O Güvener
- K V Chang
Ricci V, Güvener O, Chang KV, et al. EURO-MUSCULUS/USPRM
dynamic ultrasound protocols for elbow. Am J Phys Med Rehabil.
2022;101(6):e83-e92. doi:10.1097/PHM.0000000000001915
Anatomy and sonographic examination for lateral epicondylitis: EURO-MUSCULU-S/USPRM* approach
- V Ricci
- G Cocco
- K Mezian
Ricci V, Cocco G, Mezian K, et al. Anatomy and sonographic
examination for lateral epicondylitis: EURO-MUSCULU-S/USPRM* approach. Am J Phys Med Rehabil. 2022. doi:10.