Sonographically guided sternoclavicular joint injection: description of technique and validation

The advantages of utilizing different ultrasound imaging techniques on joints of human cadavers in the teaching of anatomy - A scoping review

BACKGROUND

A common approach to define sonoanatomy is a reciprocal exchange of macroscopic and microscopic information in ultrasound imaging. High-resolution ultrasound has been long established and is crucial as an inexpensive and adaptable tool, not just in clinical settings but also while teaching anatomy. Early application of ultrasonography provides medical students with a couple of benefits: they acquire an improved understanding of anatomy and learn how to use it.

METHODS

A comprehensive literature review has been carried out, with relevant studies discovered in the following databases: MEDLINE, EMBASE, CENTRAL, BIOSIS Previews and Web of Science Core Collection. Gray literature was also considered in two different ways: (1) Regarding grey literature databases: National Gray Literature Collection. (2) For PhD theses and dissertations, the databases EThOS and Open Access Theses and Dissertations were screened for relevant studies by combining the keywords used in the search string. The reference lists of all relevant papers were scanned. Search process was performed on January 3rd, 2023. The search string was developed with the aid of and finally checked by a professional librarian. Only ultrasound studies on human cadavers were included, not animals or phantoms. If the studied subject was a joint, the article was included. Only B-Mode ultrasound was included, whereas Elastosonography, Doppler sonography and quantitative approaches including among others sound speed, backscatter attenuation were excluded. Intravascular, intraosseous, intraarticular, and three-dimensional or four-dimensional ultrasonography were also eliminated from the analysis. All appropriate information comprising articles, PhD theses, dissertations and chapters in textbooks were considered. There were solely English and German studies covered. There was no additional restriction on the publishing year. The included studies' general characteristics and ultrasound techniques were taken from them and examined. Using VOS viewer, a keyword analysis was also carried out.

RESULTS

142 of the 8899 results that were returned by the search satisfied the requirements. With a quarter of the included studies, the knee joint was the most extensively studied joint, followed by the elbow joint (10.6%) and the shoulder joint (9.2%). The methodological analysis includes 125 studies. Both the sample size and the ultrasonographer's qualifications were diverse. The probe position and the ultrasound method were precisely documented so that a reader could duplicate them in about three-quarters of the included studies (72.8%).

CONCLUSION

The current study, in our perspective, is the first scoping review to screen ultrasound studies on human cadaver joints. A heterogeneous field was shown by the methodological investigation. We suggest using a uniform method for conducting and presenting ultrasound examinations in future studies.

Ultrasound-guided interventions of the upper extremity joints

Ultrasound guidance is valuable for performing precise joint interventions. Joint interventions may be requested for therapeutic and diagnostic pain injections, joint aspiration in the setting of suspected infection, or contrast injection for arthrography. In practice, interventions of the shoulder girdle, elbow, and hand/wrist joints may be performed without any imaging guidance. However, imaging guidance results in more accurate interventions and better patient outcomes than those performed by palpation alone. When compared to other modalities used for imaging guidance, ultrasound has many potential advantages. Radiologists should be prepared to perform ultrasound-guided upper extremity joint interventions utilizing recommended techniques to optimize clinical practice and patient outcomes. KEY POINTS: 1. Ultrasound-guided injections of the glenohumeral, acromioclavicular, sternoclavicular, elbow, and hand/wrist joints have higher accuracy than injections performed without imaging guidance. 2. Ultrasound-guided aspirations of upper extremity joints have advantages to fluoroscopic-guided aspirations because of the potential to identify effusions, soft tissue abscess, or bursitis. 3. Ultrasound-guided contrast injection prior to MR arthrography is as accurate as fluoroscopic-guided injection for upper extremity joints.

Anatomical study of the sternoclavicular joint using high-frequency ultrasound

OBJECTIVES

The purpose of the present study was to determine whether ultrasound enables assessment of sternoclavicular structures.

METHODS

A preliminary study in 3 cadavers was followed by an ultrasound study, performed by 2 musculoskeletal radiologists working in consensus, in 59 patients without history of trauma, surgery or pain in the sternoclavicular joint. The visibility, echogenicity and thickness of the sternoclavicular structures were assessed.

RESULTS

The anterior sternoclavicular ligament and the interclavicular ligament could be seen in all patients (mean thickness: 1.4 mm and 1.3 mm, respectively). The articular disc was clearly seen in 66.1% of cases, and shoulder antepulsion enabled analysis in an additional 20.3%. Intra-articular joint gas was frequent (33.89% of cases), preventing analysis of the disc in 2 patients. Only the superficial anterior aspect of the clavicular and sternal articular cartilages could be assessed. Joint effusion was seen in 6.8% of cases. Clavicular osteophytes, sternal osteophytes and bone irregularities at the anterior sternoclavicular ligament insertion were detected in 33.9%, 16.9% and 16.9% of cases, respectively.

CONCLUSION

The anterior sternoclavicular ligament, interclavicular ligament and anterior intra-articular structures can be visualized by ultrasound. This means of assessment may have clinical applications, particularly in patients with trauma or microtrauma.

Ultrasound-guided sternoclavicular joint injection: technique and case series

Sternoclavicular joint pathology can be an uncommon cause of pain and discomfort around the neck and shoulder region. Typically, patients localize their pain deep to the joint and experience referred pain to the ipsilateral neck and shoulder; however, it often presents as a diffuse nonspecific pain. Given the paucity of this pathology and atypical presentation, the use of injections can be helpful to confirm the diagnosis of sternoclavicular arthropathy. Currently, most injections are done via computed tomography. Although this method is accurate, it exposes patients to radiation and burdens the patient with the requirement of multiple appointments. This case series outlines the use of ultrasound-guided sternoclavicular joint injections conducted in the clinic. The patients in this series underwent an ultrasound-guided injection in the affected sternoclavicular joint, which confirmed the diagnosis, and they were subsequently treated with resection arthroplasty. The use of ultrasound-guided injections of the sternoclavicular joint is a safe and accurate alternative diagnostic method, which saves the patient from harmful radiation and additional appointments. Limitations and efficacy may vary depending on skill and comfort level of the operator.

US-guided Musculoskeletal Interventions of the Body Wall and Core with MRI and US Correlation

Chest, abdominal, and groin pain are common patient complaints that can be due to a variety of causes. Once potentially life-threatening visceral causes of pain are excluded, the evaluation should include musculoskeletal sources of pain from the body wall and core muscles. Percutaneous musculoskeletal procedures play a key role in evaluating and managing pain, although most radiologists may be unfamiliar with applications for the body wall and core muscles. US is ideally suited to guide these less commonly performed procedures owing to its low cost, portability, lack of ionizing radiation, and real-time visualization of superficial soft-tissue anatomy. US provides the operator with added confidence that the needle will be placed at the intended location and will not penetrate visceral or vascular structures. The authors review both common and uncommon US-guided procedures targeting various portions of the chest wall, abdominal wall, and core muscles with the hope of familiarizing radiologists with these techniques. Procedures include anesthetic and corticosteroid injection as well as platelet-rich plasma injection to promote tendon healing. Specific anatomic structures discussed include the sternoclavicular joint, costochondral joint, interchondral joint, intercostal nerve, scapulothoracic bursa, anterior abdominal cutaneous nerve, ilioinguinal nerve, iliohypogastric nerve, genitofemoral nerve, pubic symphysis, common aponeurotic plate, and adductor tendon origin. Relevant US anatomy is depicted with MRI correlation, and steps to performing successful safe US-guided injections are discussed. Confidence in performing these procedures will allow radiologists to continue to play an important role in diagnosis and management of many musculoskeletal pathologic conditions. ^©RSNA, 2021.

Successful treatment in a child with enthesitis-related arthritis involving the sternoclavicular joint: a case report

Background

Although the sternoclavicular joint (SCJ) may be involved in ankylosing spondylitis, rheumatic arthritis, and Behçet’s disease and participates in the systemic inflammatory process of arthritis, it is often neglected during routine rheumatologic clinical examinations. To the best of our knowledge, this is the first study to report etanercept treatment in juvenile idiopathic arthritis (JIA) with SCJ involvement.

Case presentation

In this study, we describe an unusual case of a child with juvenile idiopathic arthritis with an initial presentation of sternoclavicular mass. The patient (age, 14 years 10 months) presented with an insidious onset atraumatic swelling of the left SCJ and complained of right hip and bilateral ankle tenderness without an apparent cause. Initial ultrasonography indicated a heterogeneous mass in the left SCJ, while computed tomography identified mild swelling of the left SCJ with a thickened synovial lining, mild bone erosion, and some turbid fluid. The patient ultimately underwent left SCJ arthrotomy, during which tapping of the SCJ revealed 2 cc of yellowish fluid, inflammation and necrosis of tissues within the SCJ. A clear yellow joint fluid was aspirated, and testing revealed a negative culture result. The patient was diagnosed with JIA. The joint tenderness improved and erythrocyte sedimentation rate decreased after administering anti-tumor necrosis factor etanercept. An additional ultrasonography demonstrated that the initial imaging findings have been resolved. At the end of a 2-year follow-up period, the patient was completely symptom-free.

Conclusions

JIA with SCJ involvement is an uncommon presentation in adolescents. Etanercept may be a beneficial treatment for SCJ involvement in patients with JIA. The upper limbs showed no signs of limited range of motion during the follow-up period. Further studies are warranted to elucidate the efficacy of etanercept in JIA with sternoclavicular joint involvement.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part I, shoulder

BACKGROUND

Image-guided interventional procedures around the shoulder are commonly performed in clinical practice, although evidence regarding their effectiveness is scarce. We report the results of a Delphi method review of evidence on literature published on image-guided interventional procedures around the shoulder with a list of clinical indications.

METHODS

Forty-five experts in image-guided musculoskeletal procedures from the ESSR participated in a consensus study using the Delphic method. Peer-reviewed papers regarding interventional procedures around the shoulder up to September 2018 were scored according to the Oxford Centre for Evidence-based Medicine levels of evidence. Statements on clinical indications were constructed. Consensus was considered as strong if more than 95% of experts agreed and as broad if more than 80% agreed.

RESULTS

A total of 20 statements were drafted, and 5 reached the highest level of evidence. There were 10 statements about tendon procedures, 6 about intra-articular procedures, and 4 about intrabursal injections. Strong consensus was obtained in 16 of them (80%), while 4 received broad consensus (20%).

CONCLUSIONS

Literature evidence on image-guided interventional procedures around the shoulder is limited. A strong consensus has been reached for 80% of statements. The ESSR recommends further research to potentially influence treatment options, patient outcomes, and social impact.

KEY POINTS

• Expert consensus produced a list of 20 evidence-based statements on clinical indications of image-guided interventional procedures around the shoulder. • The highest level of evidence was reached for five statements. • Strong consensus was obtained for 16 statements (80%), while 4 received broad consensus (20%).