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Distal Intersection Syndrome Injection

From WikiSM

Other Names

  • Distal Intersection Syndrome Injection

Background

The extensor compartments of the wrist[1]
Anatomic diagram showing the intersection between the EPL, ECRB and ECRL. Note the angulation of the EPL as it changes course over Lister's tubercle (asterisk), and the extensor retinaculum constricting the space around the tendons[2]

Key Points

  • Needle: 25 gauge, 1.5 inch
  • Transducer: high frequency, linear
  • Target is the intersection of the 2nd and 3rd dorsal compartment

Anatomy

Palpation Guidance vs Ultrasound Guidance

  • It is recommended that this injection be performed with ultrasound guidance
  • There is no literature comparing palpation and ultrasound guidance

Indications

Contraindications

  • Absolute
    • Anaphylaxis to injectates
    • Overlying cellulitis, skin lesion or systemic infection
  • Relative
    • Can be treated with less invasive means
    • Hyperglycemia or poorly controlled diabetes
    • Lack of symptom improvement with previous injection

Procedure

Needle and probe position for short axis, out of plane approach[3]
Ultrasound view of short axis, out of plane approach with needle vector marked by white dots[3]
Needle and probe position for short axis, in plane approach[3]
Ultrasound view of short axis, in plane approach with needle vector marked by white arrow[3]

Equipment

  • Sterile including chloraprep, chlorhexidine, iodine
  • Gloves
  • Needle: typically 21-25 gauge, 1.5 inch
  • Syringe: 5-10 mL
  • Gauze
  • Ethyl Chloride
  • Bandage
  • Injectate
    • Local anesthetic
    • Corticosteroid
  • Sterile probe cover

Ultrasound Findings

  • Best visualized under short axis
    • Look just proximal or distal to Lister's tubercle
  • Common ultrasound findings include:
    • Can see pathology at any of the 3 tendons involved
    • Tendon or synovial sheath thickening
    • Peritendinous edema
    • Hyperemia on power doppler

Technique: Short Axis, Out-of-Plane

  • Patient position
    • Seated or supine
    • Forearm and hand prone on table
  • Transducer position
    • Short axis
  • Needle Approach/ Orientation
    • Out-of-plane
    • Distal to proximal/ proximal to distal
  • Target
    • Where the 2nd and 3rd dorsal compartment intersection
  • Pearls and Pitfalls
    • Use step wise approach to get the needle in the desired position
    • Can turn probe 90 degrees to confirm position if you have to

Technique: Short Axis, In-Plane

  • Patient position
    • Seated or supine
    • Forearm and hand prone on table
  • Transducer position
    • Short axis
  • Needle Approach/ Orientation
    • In-plane
    • Radial to ulnar/ ulnar to radial
  • Target
    • Where the 2nd and 3rd dorsal compartment intersection
  • Pearls and Pitfalls
    • Have to traverse more soft tissue with in-plane approach

Aftercare

  • No significant restrictions
  • Can augment with ice, NSAIDS
  • Consider placement in a Cock Up Wrist Splint

Complications

  • Skin: Subcutaneous fat atrophy, skin atrophy, skin depigmentation
  • Painful local reaction
  • Infection
  • Hyperglycemia
  • Tendon, nerve or blood vessel injury

See Also

References

  1. ↑ Image courtesy of teachmeanatomy.info, "The Extensor Tendon Compartments of the Wrist"
  2. ↑ Image courtesy of radsource.us, "tendon intersection syndromes"
  3. ↑ 3.0 3.1 3.2 3.3 Malanga, Gerard A., and Kenneth R. Mautner. "Atlas of ultrasound-guided musculoskeletal injections." (No Title) (2014).
Created by:
John Kiel on 6 May 2024 01:22:06
Authors:
Last edited:
6 May 2024 02:30:57
Category:
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