All right, so in summary, we want to plan our approach carefully with ultrasound guide injections. We need to understand the sonographic anatomy, including the at-risk structures. You should become proficient both in in-plane and out-of-plane techniques, and we should document what we're doing. Duluth really isn't that bad. Ten minutes. So we have a little time, questions. Hey, Doug, can I ask a question? Yeah. So on your knee injections, you know, if we do this from a non-ultrasound perspective, we typically go to safe turf, which is between the patella and the trochlea, as ways to stay out of the synovium and to be inter-articular. But I see in ultrasound, you're going into a small area of the suprapatellar pouch if there's no effusion. Why can't you do the same thing that we do under ultrasound and go between the patella and the trochlea? Can you see that under ultrasound? You can. You have more bony, I would say, inhibition or lack of visualization. So really, you're going into the recess, the patellofemoral recess at that point. And it's hard to see if you don't have a joint effusion. So you have an alar fold in there in the normal state. And so if I don't see fluid in that region, then I get a little confused on the landmarks. I mean, really, you can guide it and just go straight under the patella and do that, but I'm not seeing the needle tip. So I'm just trained always to see the needle tip. And in that, one of the first studies that came out on accuracy of injections, it was a technique where you're going right under the patella that was most accurate and going in anteriorly through the Hoffa's fat pad that was least accurate. Are you able to do SI joints under ultrasound? So the question is, can we do SI joint under ultrasounds? The answer is yes, we can. But the other part of that is I try not to. So my feeling is that fluoroscopic injections are more accurate. So we can actually see the dye go into the SI joint where we don't see that with ultrasound. Studies have shown that the accuracy is reasonable. And so the only SI joints that I do in my practice are with pregnant women. So we don't have the radiation exposure. Otherwise, I recommend sending them down to our under fluoroscopy. I might have missed it, but did you show a subacromial injection? Are you going direct lateral with your probe and then posterior to anterior? Yeah, so I didn't show, but we'll show this in the lab. So subacromial, the way I do it is I go, it's a long axis in-plane approach. And I'm essentially getting on the long axis of the supraspinatus. And you just have to understand your planes that you're going in. Because in the normal state, you don't see the bursa. And you can't confuse it with the subdeltoid fat. Right, so the question is, is why don't we go anteriorly of the coracoid, right? Because we don't see that well sonographically, so that's how I used to do those when I would go in just palpation guided before ultrasound. But we don't see that anatomy very well on ultrasound, and so that's why we go posteriorly. sterilize when you're doing just an inter-articular knee injection if the probe's far away from the needle? Yeah, so the question is, let's say I'm doing an inter-articular knee injection the way I showed short axis. And the probe is on top of the knee, and I'm going in on the side to the knee. Do we really need to sterilize the probe? Answer is, good question. Maybe not. Some people are wiping the probe down with a chlorhexidine solution and using that as sterilization. I'll tell you that a while ago, I went and did a fellowship in Europe, ultrasound fellowship in Europe, and had a chance to work with a couple of the world's experts. And the first guy, when he would do injections, he wouldn't use gel. He would use this chlorhexidine solution to do his diagnostic ultrasound. And then before he did the injection, he had to put on a mask no matter what. And he couldn't take that mask off until the Band-Aid was on, or he'd go crazy. And that's what he did. He didn't glove. And then I went to another guy in Paris. And the first time he did an injection, he just reached in his pants pocket and pulled out a condom and opened it up and just put it over the probe and barely wiped it off and did the injection. So the answer is, I don't know. The problem is, is if you get an infection, there always is a risk. But the risk of ultrasound-guided injections is really probably the same as regular injection. And it's one in 20, 40, 50,000. So it's pretty low. But if you were to get one and you're not using that technique. So for me, something like that, I think it's very reasonable to wipe down the probe if the probe is not in contact with the gel. I'm sorry, can you say that again? So my understanding with SI joint injections is it's a bundled, it's bundled with image guidance so you just say SI joint injection, it doesn't matter if it's ultrasound guided or fluoroscopy guided, you just get paid for the injection and the imaging is bundled in with that because I don't, I don't bill for an ultrasound guided SI joint injection, it's just the code is SI joint and it says under the code includes image guidance. Do you use ethyl chloride or any concern about it's less sterile than? Yeah you know prior to ultrasound I always used ethyl chloride and for whatever reason I don't use ethyl chloride now and part of the reason is is just the ultrasound gel is right there. Some people still do it, I'm not sure it makes a difference. I've gone to using a 30 gauge needle and using this for subcutaneous lidocaine and that works pretty well and so I still use it if I'm not doing ultrasound guidance but I don't, but you can, some people do. Thank you. Thanks.

ultrasound guide injections

sonographic anatomy

in-plane technique

out-of-plane technique

documenting procedures