Okay. All right. Can everybody hear me? So, I think the format for this afternoon is going to be, that I'm going to go over a certain region or a certain joint, and we'll go over the shoulder joint injections, and then we'll practice, and then we'll go down to the elbow. I'll do a couple of demos, and then we'll practice, and so on and so forth. Again, a lot of good instructors out there. So, if there's a particular injection on the joints we're covering that you want us to go over, we're glad to do that. Couple of other comments is, that air is bad with ultrasound. So, you need to have all the air bubbles out of your syringes, and not inject air into the image, because once you inject air, it doesn't leave. So, you're done with the image for the rest of the course. So, you got to be very careful about that. Then finally, we have a 25 gauge needle here, it's three and a half inches. It's going to be a little challenging, don't get frustrated. I'm a little challenged. So, just be patient, and we'll help you with these things. Obviously, the larger joints are going to be a little more challenging, the deeper joints than the lower ones. So, we're going to start with the posterior glenohumeral joint injection. As I mentioned in my talk, the lateral decubitus position is a position that I like. So, if we can, do we see the ultrasound machine? Can we put it on the ultrasound? Or you get to see that my image here, it's the same image we had in the talk. Again, it's a posterior glenohumeral joint, and it's a long axis. So, to the left. So, one other detail that I didn't talk about is, every ultrasound probe has a little notch on it, and the notch is always the left of the screen. So, I typically put the notch where I enter the needle. So, for this injection, I'm going to put the notch lateral. So, on the screen, you see medial is to the left of the screen, and laterals to the right. So, I'm going to find the humeral head. I'm going to find the glenoid. So, there we see the glenoid. If we scan a little bit medially, this is spinal glenoid notch. You can actually see the vessel on the bottom of that. We're back to the glenoid. We can see the labrum, and we see the articular cartilage of the humeral head. That's the infraspinatus muscle under it. And so, you can see the steep angle that I enter when I do this injection. So, it's a fairly steep angle down. I'm going to go through the posterior deltoid. I'm going to go through the infraspinatus, and then you can see my needle tip right there. And what I like to do, again, the thinness of the needle, but you can see my needle tip right there. I like to just kind of go right over that articular cartilage of the humerus. Now, you can see my needle tip right there. And then I kind of very gently stay on that articular cartilage, and I know I'm going to be intraarticular. And again, don't inject unless you know you don't have air. And then I'm injecting right now, and you don't see it because it's going into the glenoid humeral joint. Okay, so we may want to start with that injection. I'm going to go over the other shoulder ones right now, but let's start with that, and then we'll rotate the cadaveric specimen on its back. So, let's go ahead and rotate it on its back now. Here, can I help you? Are you going to slide it this way? Oh, perfect. That can fit. Perfect. Is there a normal-sized chair? The table doesn't come up, does it? All right. Okay, so we're going to go to the front of the shoulder after you practice the glenohumeral joint, and we're going to go to subacromial injection. And it's an anatomic oblique plane. So again, it's very similar to the MR, and so it's not a coronal plane, it's not a sagittal plane, but if you go 45 degrees to that, you're going to be pretty close to the long axis of the supraspinatus. How do I know I'm on the long axis? Well, I'm going to go a little bit anteriorly, and I see the long head of the biceps tendon right there. I'm going to optimize that long head of the biceps tendon. Now I'm on the long axis of the tendon, so now you know that the supraspinatus, which is parallel to the long axis of the long biceps tendon, is on its true long axis. I'm going to scan back, and there we see the supraspinatus tendon. And so I'm just going to point on the supraspinatus, we see the cortex of the humerus, we see the tendon, the articular cartilage, the tendon, and then we see the deltoid muscle above that, and below the deltoid muscle there is a hyperechoic stripe. That is a subdeltoid fat, that is not the bursa. The bursa is just beneath that hyperechoic subdeltoid stripe, and in this individual it is hypoechoic. And so I'm going to go a lateral to medial, long axis, in-plane approach. Now I'm not being very ergonomically correct here, which is okay. So I'm going to enter in, and I'm going to look for my needle as I enter. And there's my needle. Alright, so I want to talk about just what you do when you enter your needle and you're not where you want to be. And so what you want to do is not change everything. And so in this case I'm pretty much where I want to be, but let's just say we're not. Okay, let's say it's way off. So what you want to do then is just move, slide your probe back and forth to find out where you want to be. Don't move your needle. And so let's say I wanted to be here and the probe is more. Then I back out my needle and then change its angle. But don't change everything. And so I'm going to come in long axis. I see the needle tip, so I never advance in a long axis plane until I see the needle tip. And I'm going to just go right in. And then what I'm going to do is put a little injectate as I go in and then try to separate that bursa. Right there, there I am on the bursas. And I like to see the injectate go laterally because as you know the bursa goes over the lateral greater tuberosity. So that's my bursal injection right there. Now this needle is pretty flimsy, but I usually use a 22 gauge, one and a half inch needle. And then what I do with that needle is I kind of actually go up a little more distally, I mean approximately into that bursa. There we go. And so that's our bursal injection. Okay so let's go to our acromiocavicular joint. And first thing we're going to do is just find the long axis of the joint. To the left of the screen is going to be lateral and to the right of the screen is going to be the clavicle or medial. And so in this particular case, if we could just, there's many of these ultrasound probes that will have a mark in the middle. All right so that's the center of the probe which would be the center of the image. And so it helps me in planning my entry site. If you were to zoom this, all bets are off. So those markings are only good if you're not zooming in. So let's just start with a anterior to lateral short axis approach. So my needle is in right now and you can see I have no idea where I am. All right so I could be anywhere. So I'm going to take my probe, move it towards the needle and find it. And there it is right there. Then I can slide that forward, make the adjustments I need to make, and I, and essentially I'm just carrying it right in to the joint. And there we are. All right so let's just take this and now go short axis. That's a good way to get used to this. Go short axis. So there is clavicle. There is a chromium. So there in the middle is the joint. All right and then you can see, I'm going to just wiggle the needle a little bit, and there I'm in the joint. And so I could actually back out and put a little deeper if I wanted to, but I'm in the joint. The challenge becomes with a younger patient, let's say if they have osteosymptomatic osteolysis and you want to inject that. Younger patients have a meniscus that fills the joint. And so it's important to be accurate and you're not going to put as much injectate in where someone who's older with osteoarthritic changes, you're going to be able to fill that joint up. All right so then the last one is going to be the biceps. I'm going to just briefly to show you, I'm going to go back to my supraspinatus. Okay so this is my supraspinatus tendon. Would you hold this for me for a second, and I'm going to take my probe and rotate it 90 degrees. Go a little bit anterior and I'm on the rotator interval. So that's my rotator interval. We see the long head of the biceps tendon in the middle. Just to the right a little bit. There we go, it's that white dot. There we go. Long head of the biceps tendon. To the left is a supraspinatus. So underneath that tendon is the superior glenohumeral ligament. Above it is a coracohumeral ligament. And so if I were to actually go in that little hypoechoic space right there, I'm injecting the tendon sheath of the long head of biceps tendon. I just wanted to show you that we can practice. I don't want to take too much time. But this is a more traditional approach to the long head of the biceps tendon. I'm in the inner tubercular sulcus right here. And the one caveat to keep in mind with this is, can you freeze that Chris for me, is right here is the ascending branch of the anterior surf complex artery. You don't want to inject that. So typically you want to go over that tendon and inject on the medial aspect of the inner tubercular sulcus. And it's a pretty standard injection. We're going to go lateral to medial in plane. So I'm not going to go through every step. I mean it's pretty simple the injection. I know we want to maximize our time. You guys doing it. So I'll stop there and go at it. Thank you Chris.

joint injections

shoulder joint injection

subacromial injection

acromioclavicular joint injection

biceps tendon injection