How To Guide: US Guided Shoulder Joint Injection

Author: Vinay Saggar MD, PGY-2

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THE CASE:

33 y/o M with a history of recurrent shoulder dislocations presents after he felt his right shoulder “pop out” while sleeping. Now feels similar to 2 prior shoulder dislocations.

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OBJECTIVES:

• Brief overview of the sensitivity and specificity of ultrasound for shoulder dislocations
• Advocate for usage of intra-articular analgesia in the ED
• Provide a stepwise procedural approach for securing those views/performing the localized block
• Discuss a case in which the discussed technique was applied with success

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BACKGROUND (argument for Intra-articular Analgesia):

• Shoulder dislocations account for 50% of all major joint dislocations.
• Anterior dislocation: most common (95-97%),
• Posterior dislocation: 2-4%, and
• Inferior dislocation: 0.5%
• Although plain radiography is normally the test of choice to rule out other pathology, growing evidence to suggest POCUS as a great tool for confirming dislocations and successful reductions.
• Multiple prospective observational studies suggest both a sensitivity and specificity of nearly 100%.
• When applied to the right patient population (normally young to middle aged, cooperative, and able to follow commands), intra-articular lidocaine can lead to significantly diminished pain intensity during reduction, similar success rates at first attempt reductions, and shorter time to discharge with less complications such as apnea, nausea, and hypoxia when compared to IV sedative and analgesia.

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Figure 1: Posterior US Probe Placement (Pay special attention to direction of US probe indicator)

ULTRASOUND OF NORMAL RIGHT Shoulder Labeled:

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Figure 2 (Secko, et al): PROBE PLACEMENT technique for appropriate views of LEFT Shoulder

Figure 3 (Secko, et al): LEFT Shoulder POCUS Examples: Normal vs Anterior vs Posterior dislocations

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ALIEM PROCEDURAL VIDEO (Without Set-Up/Instructions):

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CASE RESOLUTION:

Physical Exam revealed restricted ROM at R shoulder + pain with movement but otherwise neurovascularly intact (axillary, median, ulnar, and radial nerves all grossly intact on RUE, with equal palpable distal pulses).

POCUS showed the humeral head anteriorly dislocated in respect to the scapular spine and glenoid fossa:

Shoulder x-ray confirmed an anterior humeral head dislocation and a Hill-Sachs deformity. The patient was given intra-articular analgesia with 1% lidocaine to avoid moderate sedation and the shoulder was reduced via adduction and the external rotation method within minutes. He was discharged with orthopedic follow-up and is scheduled for surgical labral repair and possible remplissage.

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PROCEDURAL STEP-WISE APPROACH FOR INTRA-ARTICULAR LIDOCAINE:

General Considerations:

• Prior to starting the procedure, remember that any intra-articular block must be done under completely STERILE conditions to prevent severe complications such as septic joint.
• Our recommendation is to have two providers at bedside: (1) as the “sonologist” whose primary responsibility is to secure the dislocated view on ultrasound and (2) the other as the “performing provider” who will sterilely introduce the needle and medication (SEE PICTURE AT END).

Positioning:

• Have the patient seated on the stretcher
• The sonologist is behind the patient with the ultrasound facing him/her comfortably in reach, and
• The performing provider is on the side of the patient facing the affected joint.

Steps for Sonologist:

1. Enter patient’s information into ultrasound machine. Select the curvilinear probe for scanning (although a linear probe would work as well).
2. Place the curvilinear probe in a transverse (horizontal) plane on the posterior side of the patient. From there, ensure that probe marker is pointed towards patient’s left side (SEE FIGURE 1 ABOVE).
3. Using broad strokes, scan the UNAFFECTED side first to attain patient’s baseline shoulder anatomy. To do this, initially search for the hyperechoic scapular spine.
4. Once scapular spine is correctly identified, continue to follow it slowly onward (marching the probe laterally) to shoulder joint until glenoid fossa and humeral head is seen (SEE FIGURE 2 ABOVE). For confirmation of humeral head, you can ask patient to internally and externally rotate the arm.
5. Assist performing provider by sterilely opening up Chloraprep (or gauze with betadine), syringe and needle for procedure, holding the lidocaine for provider to draw up and putting on a sterile probe on the ultrasound.
6. After understanding patient’s baseline anatomy and helping performing provider completely prep for procedure, place the probe to the AFFECTED side and scan using the same process (SEE FIGURE 3 ABOVE for examples of dislocations on ultrasound). Again, look for scapular spine, followed by glenoid fossa and humeral head. Once the dislocation is found on ultrasound, make sure to capture a picture to prove diagnosis and then anchor your hand to keep the pathology in frame.
7. As the performing provider inserts needle laterally and catheter begins to come into frame, provide live feedback of its position with respect to the entry point of the desired dislocated space. If necessary, fan or scan through to track the needle as it advances.
8. Once it has entered the correct space (confirmed by visualization through ultrasound and withdrawal of blood in syringe by provider), record a clip of the medication injection.
9. Once the medication is administered and procedure is done, place the probe back onto machine, wipe down supplies/ultrasound, and press “end exam” to view images on QPath for quality assurance later!

Steps for Performing Provider:

1. First, ensure all the materials (syringe, needle, lidocaine, sterile gauze, Chloraprep/Betadine, ultrasound probe cover) are present within arm’s length for the procedure (SEE FIGURE 4 AT END).
2. Standing on the lateral aspect of the patient looking directly at the affected joint, palpate for the lateral edge of the acromion. This should feel similar to a semi-circular, bony edge and is located at the very top of the extremity right along the upper portion of the deltoid.
3. Once the lateral edge of the acromion is felt, palpate roughly 2 cm (or two finger lengths) INFERIOR and feel for the obvious divot that easily gives way when pressed and is somewhat tender. This deeper space will be the entry point for the procedure and attempt to make a small mark of the area.
4. Don sterile gloves of appropriate size.
5. Have your second provider open up 4×4 gauze so that you can grab them sterilely and then have your second provider pour betadine on the gauze. Make sure to begin the cleaning process at the marked entry point and slowly move outward (SEE FIGURE 5 AT END).
6. From there, with the aid of the sonologist in opening materials sterilely, grab the 10 ml syringe and with a large bore needle tip (18 guage) draw 9.5 ml of 1% Lidocaine. The extra 0.5 ml should be used as buffer space for when you will eventually need to retract back to aspirate blood to confirm you are in the correct space. Ensure that all air bubble pockets on the top are completely removed within the syringe.
7. Using a spinal needle (given the space is relatively deep), attach the 10 ml syringe at the end and introduce the catheter 2 cm inferior to lateral edge of acromion into glenohumeral joint (where you originally palpated- SEE FIGURE 6 AT END).
8. Follow the needle longitudinally with ultrasound as it is fed deeper, remembering to always apply constant negative pressure on the syringe. You should expect the needle to enter about 2-3 cm (SEE FIGURE 7 AT END) and continue to ask for feedback from sonologist on where tip is in respect to desired space (SEE FIGURE 8 AT END).
9. Once the needle is confirmed to be the right space, ensure that blood is aspirated back. After confirmation, inject the 9.5 ml 1% Lidocaine over 30 seconds (SEE FIGURE 9 AT END).
10. Safely remove the needle from the arm and apply direct pressure with another sterile gauze over the wound to control any lingering bleeding from the puncture site. Discard all sharps and supplies appropriately and wait for 15-20 minutes prior to attempting bedside reduction.

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KEY FIGURES:

Figure 4: Initial Materials Set Up

Figure 5: Prep a sterile area for injection

Figure 6: Sterile Insertion Technique (remember to wear sterile gloves when drawing up lidocaine and handling needle!)

2 Provider Technique (“Performing Provider” and “Sonologist”):

Figure 7: Identify lateral entry point on ultrasound

Figure 8: Follow needle tip into expanded joint space

Figure 9: Evaluate for successful injection of Lidocaine into joint space

REFERENCES:

1. Sherman, Scott C. “Shoulder Dislocation and Reduction.” Edited by Allan B Wolfson
   and Jonathan Grayzel, UpToDate, 17 Sept. 2020, www.uptodate.com/contents/shoulder-
   dislocation-and-reduction?search=ultrasound+of+anterior+shoulder+dislocation.
2. Abbasi S, Molaie H, Hafezimoghadam P, et al. Diagnostic accuracy of ultrasonographic
   examination in the management of shoulder dislocation in the emergency department.
   Ann Emerg Med 2013; 62:170.
3. Gottlieb M, Russell F. Diagnostic Accuracy of Ultrasound for Identifying Shoulder
   Dislocations and Reductions: A Systematic Review of the Literature. West J Emerg Med
   2017; 18:937.
4. Secko MA, Reardon L, Gottlieb M, et al. Musculoskeletal Ultrasonography to Diagnose
   Dislocated Shoulders: A Prospective Cohort. Ann Emerg Med 2020; 76:119.
5. Kashani P, Asayesh Zarchi F, Hatamabadi HR, Afshar A, Amiri M. Intra-articular
   lidocaine versus intravenous sedative and analgesic for reduction of anterior shoulder
   dislocation. Turk J Emerg Med. 2016 May 9;16(2):60-64. doi:
   10.1016/j.tjem.2016.04.001. PMID: 27896323; PMCID: PMC5121259.
6. Secko, Michael A., et al. “Musculoskeletal Ultrasonography to Diagnose Dislocated
   Shoulders: A Prospective Cohort.” Annals of Emergency Medicine, vol. 76, no. 2, 2020,
   pp. 119–128., doi:10.1016/j.annemergmed.2020.01.008.
7. Delia Kristol, PGY-3 for walking Vinay through the procedure the first time
8. Michael Halperin, PGY-7 for walking Maninder through the ultrasound the first time
9. Sandeep Dhillon, PGY-2 for her photography skills
10. Thomas O’Brien, RN for rights to use his shoulder for teaching purposes