Ultrasound-Guided Hand, Wrist, and Elbow Injections

  • Marko Bodor
  • John M. Lesher
  • Sean Colio


Patients with pain, numbness, and weakness in the upper extremity are frequently referred to pain specialists. Carpal tunnel syndrome (CTS) combined with shoulder impingement can easily mimic cervical radiculopathy and disk herniation [1, 2]. Chronic pain at the thenar eminence following carpal tunnel surgery may stem from occult trigger thumb or carpometacarpal (CMC) joint arthritis. Median neuropathy at the wrist combined with impingement of the flexor pollicis longus (FPL) tendon on a fixation plate screw following fracture of the radius can mimic the pain, burning, and weakness of complex regional pain syndrome (CRPS). These and other conditions of the hand, wrist, and elbow can be effectively diagnosed and treated with diagnostic ultrasonography and ultrasound-guided injections.


  1. 1.
    Bodor M. Shoulder pathokinesiology and rehabilitation. In: Painful shoulder. AAEM Course Symposia, American Association of Neuromuscular and Electrodiagnostic Medicine; 2004.Google Scholar
  2. 2.
    Gorski JM, Schwartz LH. Shoulder impingement presenting as neck pain. J Bone Joint Surg Am. 2003;85-A(4):635–8.CrossRefPubMedGoogle Scholar
  3. 3.
    Bodor M, Fullerton B. Ultrasonography of the hand, wrist and elbow. Phys Med Clin N Am. 2010;21(3):509–31.Google Scholar
  4. 4.
    Lee D, van Holsbeeck MT, Janevski PK, Ganos DL, Ditmars DM, Darian VB. Diagnosis of carpal tunnel syndrome. Ultrasound versus electromyography. Radiol Clin N Am. 1999;37(4):859–72.CrossRefPubMedGoogle Scholar
  5. 5.
    Hobson-Webb LD, Massey JM, Juel VC, Sanders DB. The ultrasonographic wrist-to-forearm median nerve area ratio in carpal tunnel syndrome. Clin Neurophysiol. 2008;119(6):1353–7.CrossRefPubMedGoogle Scholar
  6. 6.
    Beekman R, Visser LH. Sonography in the diagnosis of carpal tunnel syndrome: a critical review of the literature. Muscle Nerve. 2003;27(1):26–33. Review.CrossRefPubMedGoogle Scholar
  7. 7.
    Grassi W, Farina A, Filippucci E, Cervini C. Intralesional therapy in carpal tunnel syndrome: a sonographic-guided approach. Clin Exp Rheumatol. 2002;20(1):73–6.PubMedGoogle Scholar
  8. 8.
    Smith J, Wisniewski SJ, Finnoff JT, Payne JM. Sonographically guided carpal tunnel injections: the ulnar approach. J Ultrasound Med. 2008;27(10):1485–90.CrossRefPubMedGoogle Scholar
  9. 9.
    Bland JD. Treatment of carpal tunnel syndrome. Muscle Nerve. 2007;36(2):167–71. Review.CrossRefPubMedGoogle Scholar
  10. 10.
    Armstrong T, Devor W, Borschel L, Contreras R. Intracarpal steroid injection is safe and effective for short-term management of carpal tunnel syndrome. Muscle Nerve. 2004;29(1):82–8.CrossRefPubMedGoogle Scholar
  11. 11.
    Bodor M, Flossman T. Ultrasound-guided first annular pulley injection for trigger finger. J Ultrasound Med. 2009;28(6):737–43.CrossRefPubMedGoogle Scholar
  12. 12.
    Wilhelmi BJ, Snyder NIV, Verbesey JE, Ganchi PA, Lee WP. Trigger finger release with hand surface landmark ratios: an anatomic and clinical study. Plast Reconstr Surg. 2001;108:908–15.CrossRefPubMedGoogle Scholar
  13. 13.
    Serafini G, Derchi LE, Quadri P, et al. High resolution sonography of the flexor tendons in trigger fingers. J Ultrasound Med. 1996;15:213–9.CrossRefPubMedGoogle Scholar
  14. 14.
    Guerini H, Pessis E, Theumann N, et al. Sonographic appearance of trigger fingers. J Ultrasound Med. 2008;27(10):1407–13.CrossRefPubMedGoogle Scholar
  15. 15.
    Quinnell RC. Conservative management of trigger finger. Practitioner. 1980;24:187–90.Google Scholar
  16. 16.
    Godey SK, Bhatti WA, Watson JS, Bayat A. A Technique for accurate and safe injection of steroid in trigger digits using ultrasound guidance. Acta Orthop Belg. 2006;72:633–4.PubMedGoogle Scholar
  17. 17.
    Fleisch SB, Spindler KP, Lee DH. Corticosteroid injections in the treatment of trigger finger: a level I and II systematic review. J Am Acad Orthop Surg. 2007;15:166–71.CrossRefPubMedGoogle Scholar
  18. 18.
    Peters-Veluthamaningal C, Winters JC, Groenier KH, Jong BM. Corticosteroid injections effective for trigger finger in adults in general practice: a double-blinded randomised placebo controlled trial. Ann Rheum Dis. 2008;67(9):1262–6.CrossRefPubMedGoogle Scholar
  19. 19.
    Lichtman DM, Schneider JR, Swafford AR, Mack GR. Ulnar midcarpal instability-clinical and laboratory analysis. J Hand Surg Am. 1981;6(5):515–23.CrossRefPubMedGoogle Scholar
  20. 20.
    Boutry N, Lapegue F, Masi L, Claret A, Demondion X, Cotten A. Ultrasonographic evaluation of normal extrinsic and intrinsic carpal ligaments: preliminary experience. Skelet Radiol. 2005;34(9):513–21.CrossRefGoogle Scholar
  21. 21.
    Taljanovic MS, Sheppard JE, Jones MD, Switlick DN, Hunter TB, Rogers LF. Sonography and sonoarthrography of the scapholunate and lunotriquetral ligaments and triangular fibrocartilage disk: initial experience and correlation with arthrography and magnetic resonance arthrography. J Ultrasound Med. 2008;27(2):179–91.CrossRefPubMedGoogle Scholar
  22. 22.
    Watson HK, Ryu J. Evolution of arthritis of the wrist. Clin Orthop Relat Res. 1986;202:57–67.Google Scholar
  23. 23.
    Koski JM, Hermunen H. Intra-articular glucocorticoid treatment of the rheumatoid wrist. An ultrasonographic study. Scand J Rheumatol. 2001;30(5):268–70.CrossRefPubMedGoogle Scholar
  24. 24.
    Boesen M, Jensen KE, Torp-Pedersen S, Cimmino MA, Danneskiold-Samsøe B, Bliddal H. Intra-articular distribution pattern after ultrasound-guided injections in wrist joints of patients with rheumatoid arthritis. Eur J Radiol. 2009;69(2):331–8.CrossRefPubMedGoogle Scholar
  25. 25.
    Lohman M, Vasenius J, Nieminen O. Ultrasound guidance for puncture and injection in the radiocarpal joint. Acta Radiol. 2007;48(7):744–7.CrossRefPubMedGoogle Scholar
  26. 26.
    Umphrey GL, Brault JS, Hurdle MF, Smith J. Ultrasound-guided intra-articular injection of the trapeziometacarpal joint: description of technique. Arch Phys Med Rehabil. 2008;89(1):153–6.CrossRefPubMedGoogle Scholar
  27. 27.
    Mandl LA, Hotchkiss RN, Adler RS, Ariola LA, Katz JN. Can the carpometacarpal joint be injected accurately in the office setting? Implications for therapy. J Rheumatol. 2006;33(6):1137–9.PubMedGoogle Scholar
  28. 28.
    Salini V, De Amicis D, Abate M, Natale MA, Di Iorio A. Ultrasound-guided hyaluronic acid injection in carpometacarpal osteoarthritis: short-term results. Int J Immunopathol Pharmacol. 2009;22(2):455–60.CrossRefPubMedGoogle Scholar
  29. 29.
    Fuchs S, Mönikes R, Wohlmeiner A, Heyse T. Intra-articular hyaluronic acid compared with corticoid injections for the treatment of rhizarthrosis. Osteoarthr Cartil. 2006;14(1):82–8.CrossRefPubMedGoogle Scholar
  30. 30.
    de Quervain F. Uber eine form von chronischer tendovaginitis, Corresp.-B1. f. Schweizer Arzte. 1895;25:389–94.Google Scholar
  31. 31.
    Roquelaure Y, Ha C, Leclerc A, et al. Epidemiologic surveillance of upper-extremity musculoskeletal disorders in the working population. Arthritis Rheum. 2006;55:765–78.CrossRefPubMedGoogle Scholar
  32. 32.
    Wolf JM, Sturdivant RX, Owens BD. Incidence of de Quervain’s tenosynovitis in a young, active population. J Hand Surg Am. 2009;34:112–5.CrossRefPubMedGoogle Scholar
  33. 33.
    Diop AN, Ba-Diop S, Sane JC, et al. Role of US in the management of de Quervain’s tenosynovitis: review of 22 cases. J Radiol. 2008;89(9 pt 1):1081–4. French.CrossRefPubMedGoogle Scholar
  34. 34.
    Zingas C, Failla JM, Van Holsbeeck M. Injection accuracy and relief of De Quervain’s tendinitis. J Hand Surg Am. 1998;23(1):89–96.CrossRefPubMedGoogle Scholar
  35. 35.
    Avci S, Yilmaz C, Sayli U. Comparison of nonsurgical treatment measures for de Quervain’s disease of pregnancy and lactation. J Hand Surg Am. 2002;27:322–4.CrossRefPubMedGoogle Scholar
  36. 36.
    Jeyapalan K, Choudhary S. Ultrasound-guided injection of triamcinolone and bupivacaine in the management of De Quervain’s disease. Skelet Radiol. 2009;38(11):1099–103.CrossRefGoogle Scholar
  37. 37.
    De Maeseneer M, Marcelis S, Jager T, Girard C, Gest T, Jamadar D. Spectrum of normal and pathologic findings in the region of the first extensor compartment of the wrist: sonographic findings and correlations with dissections. J Ultrasound Med. 2009;28(6):779–86.CrossRefPubMedGoogle Scholar
  38. 38.
    Plancher KD, Halbrecht J, Lourie GM. Medial and lateral epicondylitis in the athlete. Clin Sports Med. 1996;15:283–305.PubMedGoogle Scholar
  39. 39.
    Hamilton P. The prevalence of humeral epicondylitis: a survey in general practice. J R Coll Gen Pract. 1986;36:464–5.PubMedPubMedCentralGoogle Scholar
  40. 40.
    Rineer CA, Ruch DS. Elbow tendinopathy and tendon ruptures: epicondylitis, biceps and triceps ruptures. J Hand Surg Am. 2009;34(3):566–76. Review.CrossRefPubMedGoogle Scholar
  41. 41.
    Smidt N, Assendelft WJ, van der Windt DA, Hay EM, Buchbinder R, Bouter LM. Corticosteroid injections for lateral epicondylitis: a systematic review. Pain. 2002;96(1–2):23–40. Review.CrossRefPubMedGoogle Scholar
  42. 42.
    Barr S, Cerisola FL, Blanchard V. Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis: a systematic review. Physiotherapy. 2009;95(4):251–65.CrossRefPubMedGoogle Scholar
  43. 43.
    Mishra A, Pavelko T. Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. Am J Sports Med. 2006;34(11):1774–8.CrossRefPubMedGoogle Scholar
  44. 44.
    Rabago D, Best TM, Zgierska AE, Zeisig E, Ryan M, Crane D. A systematic review of four injection therapies for lateral epicondylosis: prolotherapy, polidocanol, whole blood and platelet-rich plasma. Br J Sports Med. 2009;43(7):471–81.CrossRefPubMedGoogle Scholar
  45. 45.
    Fullerton BD, Reeves KD. Ultrasonography in regenerative injection (prolotherapy) using dextrose, platelet-rich plasma and other injectants. Phys Med Clin N Am. 2010;21(3):585–605.Google Scholar
  46. 46.
    McShane JM, Shah VN, Nazarian LN. Sonographically guided percutaneous needle tenotomy for treatment of common extensor tendinosis in the elbow: is a corticosteroid necessary? J Ultrasound Med. 2008;27:1137.CrossRefPubMedGoogle Scholar
  47. 47.
    Arora R, Lutz M, Hennerbichler A, Krappinger D, Espen D, Gabl M. Complications following internal fixation of unstable distal radius fracture with a palmar locking-plate. J Orthop Trauma. 2007;21(5):316–22.CrossRefPubMedGoogle Scholar
  48. 48.
    Casaletto JA, Machin D, Leung R, Brown DJ. Flexor pollicis longus tendon ruptures after palmar plate fixation of fractures of the distal radius. J Hand Surg Eur Vol. 2009;34(4):471–4.CrossRefPubMedGoogle Scholar
  49. 49.
    Adham MN, Porembski M, Adham C. Flexor tendon problems after volar plate fixation of distal radius fractures. Hand (N Y). 2009;4(4):406–9.CrossRefGoogle Scholar
  50. 50.
    Skaf AY, Boutin RD, Dantas RW, et al. Bicipitoradial bursitis: MR imaging findings in eight patients and anatomic data from contrast material opacification of bursae followed by routine radiography and MR imaging in cadavers. Radiology. 1999;212:111–6.CrossRefPubMedGoogle Scholar
  51. 51.
    Sofka CM, Adler RS. Sonography of cubital bursitis. AJR Am J Roentgenol. 2004;183(1):51–5.CrossRefPubMedGoogle Scholar
  52. 52.
    Nakamichi K, Tachibana S. Ultrasonographic findings in isolated neuritis of the posterior interosseous nerve: comparison with normal findings. J Ultrasound Med. 2007;26(5):683–7.CrossRefPubMedGoogle Scholar
  53. 53.
    Finlay K, Ferri M, Friedman L. Ultrasound of the elbow. Skelet Radiol. 2004;33(2):63–79.CrossRefGoogle Scholar
  54. 54.
    Louis LJ. Musculoskeletal ultrasound intervention: principles and advances. Radiol Clin N Am. 2008;46(3):515–33. vi.CrossRefPubMedGoogle Scholar
  55. 55.
    Bruyn GA, Schmidt WA. How to perform ultrasound-guided injections. Best Pract Res Clin Rheumatol. 2009;23(2):269–79.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Marko Bodor
    • 1
  • John M. Lesher
    • 2
  • Sean Colio
    • 3
  1. 1.Department of Neurological SurgeryUniversity of California San Francisco, Department of Physical Medicine and Rehabilitation, University of California Davis, Bodor ClinicNapaUSA
  2. 2.Carolina Neurosurgery and Spine AssociatesHuntersvilleUSA
  3. 3.Department of Orthopedic SurgeryStanford UniversityLos GatosUSA

Personalised recommendations