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Ultrasound-guided injection and aspiration of small joints: techniques, pearls, and pitfalls

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Abstract

Ultrasound (US)-guided musculoskeletal intervention of small joints or joints other than the shoulder, elbow, hip, knee, and ankle can be technically challenging. Small joints produce a narrower landing zone for the needle and a smaller target that may be made even more inaccessible by bulky osteophytes. Sonographic (US) guidance offers important advantages including near-field visualization of the joint and soft tissues, ease of access, portability, ability to compare with the contralateral side, and lack of ionization radiation. This review article focuses on the performance of US-guided injections and aspirations involving small joints (joint capacity < 2 mL and/or typically evaluated or injected with a compact linear transducer). For each joint (temporomandibular, acromioclavicular, sternoclavicular, distal radioulnar, symphysis pubis, and joints of the digits of the hands and feet), a brief overview of the relevant anatomy, indications, procedural description, pearls and pitfalls will be highlighted. This article demonstrates the various approaches to diagnostic or therapeutic injection and aspiration of small joints with the aid of US images, cines and graphic illustrations, emphasizing joint positioning, anatomic landmarks, and needle trajectory for a safe and efficacious procedure. A brief review of available literature for each joint will also be provided.

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Acknowledgements

Illustrations prepared by Dr. Dyan V. Flores, Ottawa, Canada, and Ilija Visnjic, Belgrade, Serbia.

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Authors and Affiliations

  1. Department of Radiology, Radiation Oncology and Medical Physics, Faculty of Medicine, University of Ottawa, ON, Ottawa, Canada

    Dyan V. Flores & Marcos Loreto Sampaio

  2. Department of Medical Imaging, The Ottawa Hospital, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada

    Dyan V. Flores & Marcos Loreto Sampaio

  3. Ottawa Hospital Research Institute, ON, Ottawa, Canada

    Dyan V. Flores & Marcos Loreto Sampaio

  4. Department of Radiodiagnosis, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

    Aakanksha Agarwal

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  1. Dyan V. Flores
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  2. Marcos Loreto Sampaio
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  3. Aakanksha Agarwal
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Correspondence to Dyan V. Flores.

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Supplementary information

62-year-old male with chronic pain on top of the shoulder, for steroid injection. Long-axis US image of the ACJ demonstrates the in-plane approach with the transducer parallel to the joint and depiction of the entire needle (arrows) as it is inserted in a lateral to medial direction. Technique details shown in Figure 6. (MP4 2.08 mb)

71-year-old male with longstanding SCJ OA and repeat injection for recurrent chest pain. Short-axis US image of the sternoclavicular joint shows the out-of-plane approach with the transducer perpendicular to the joint and the needle tip (arrow) within the joint space. Note the echogenic foci representing the injectate swirling around the needle tip. Technique details shown in Figure 2. (MP4 371 kb)

68-year-old female with longstanding left TMJ pain, suspected inflammatory arthritis, for steroid injection. Long-axis US image of the left TMJ shows localization of the condyle by dynamic maneuver from open to closed-mouth position, before using an in-plane approach to insert the needle (arrows) in a caudal-cranial direction. Echogenic foci representing the injectate at the target site (encircled) are also shown. (MP4 1.56 mb)

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Flores, D.V., Sampaio, M.L. & Agarwal, A. Ultrasound-guided injection and aspiration of small joints: techniques, pearls, and pitfalls. Skeletal Radiol 53, 195–208 (2024). https://doi.org/10.1007/s00256-023-04374-9

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  • DOI: https://doi.org/10.1007/s00256-023-04374-9

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