Okay, so we're going to just do a demo for the elbow now. I know a lot of you are already on the elbow. So I'm going to do a couple demos. I'm going to do an interarticular radial capitellar joint and lots of questions about the common extensor tendon, what I do or what other people do. So right now I'm on the long axis of the common extensor tendon. And so to the left of the screen, we see the lateral epicondyle of the humerus. To the right of the screen, we see the bony acoustic contour of the radial head. And then we have the common extensor tendon in front of it. As I go a little bit anterior, that's all tendon. As I come a little bit posterior, I'm actually going to rotate the probe just slightly because it's an oblique orientation. It's actually radial collateral ligament, all right, as we go posterior. I don't like to do procedures on the radial collateral ligament. And so I like to stay anterior on the common extensor tendon. And there's a radial capitellar joint. And again, there's two options for the radial capitellar joint. I like to stay long axis and out of plane approach as one approach. So I'm just going to take my needle. I'm going to march it down. And then I'm in the joint. Convince yourself and then inject, okay? But now, again, we talked about that in-plane short axis approach, all right? So this is radial head. And we can see annular ligament on top of that. Now, we see the interarticular space. And now we're on humerus. And I actually can even go a little bit deeper. But it's in-plane. I can see my needle the whole way. And that's preferable for me. So there's the interarticular space right there. So that's the radial capitellar injection. So I'm going to go back to my long axis image, all right? So I'm on a common extensor tendon. I'm going to go anteriorly, get off the tendon, and make sure I'm where I want to be. So I'm anterior. Again, because if we're too posterior, we're getting into the lateral collateral ligament complex where we don't want to be, all right? Now one of the pitfalls in putting a needle in, so I go long axis distal to proximal for the common extensor tendon. And if you look to the right of my screen at the edge of the screen, that's where the needle is going to come in. And so yeah, I can see the whole tendon, but I have a long way to travel here to get the needle to the good stuff. So I'm actually going to translate my probe a little bit proximally before I stick the needle in. So that way, when I do stick the needle in there, I'm in a much better location. So people ask me what I do about PRP. So I'm going to go back anteriorly. Sometimes I bend my needle when I do this to stay superficial. All right, so I'm in the tendon. So what I often do with lateral epicondylosis is if I see that it's diffusely tendinopathic, and usually if it's diffusely tendinopathic, there's going to be some partial tearing. I do an ultrasound guided sonotomy with a 10X, and if there's a significant partial tear, I often bring them back a couple weeks later and do a PRP injection to address the partial tear. And I've had a series of cases that in a year, the tendon looks almost normal. If I don't see that the whole tendon is involved or it's more focal, then what I will do is just go in with the needle and I'll find the tendinopathic tissue, I'll fenestrate it, and then I'll put the PRP in. So I do a limited fenestration to break up that tendon, it's degenerative tissue. And then the other thing I do, and it's going to be hard without bending this needle, but I separate the aponeurosis of that extensor digitorum brevis and common extensor tendon from the subcutaneous tissue because the hypervascularity, which is painful from the tendon itself, comes from superficial to deep in this case. So by separating it, we actually break off that angiogenesis, which is part of the pathologic process. So that's how I do my tendon work as I go distal to proximal. We could just, we have to readjust them to do the injection, but I'm going to just show you posteriorly, that's the posterior olecranon fossa, and right here. So this is where I would, at the bottom of that fossa is where you would see an effusion. I'm just trying to optimize that a little bit, see if I can see articular cartilage. And there is your ulnar nerve, right at the medial epicondyle. So therefore, I want to go lateral to medial, or in the screen here, it would be left to right. And you can see, is what I'm going to do here is I'm just going to stick the needle in without a standoff. I'm just going to stick this needle in and try to angle. And you're going to see here that I would need a standoff. The needle's going to be way over. Yeah, we could there. So the needle's over here, and I'm not even close to the fossa here. And so, the point being is, you have to do a significant standoff. So I'm hitting bone right now. So I would have to come back, do a big standoff with the... There we go. So actually, I'm doing okay here. But typically, I would do a standoff and get right down to the cortex, and that's where I would put my needle, aspirate, and inject, at the bottom of that fossa right there. Okay, we'll do elbow.

elbow injection

interarticular radial capitellar joint approach

in-plane short axis approach

PRP injections

posterior olecranon fossa