If you're not good enough at Ultrasound, that's not an excuse to punish your patients with radiation.
Get out there, ultrasound some hearts, lungs, IVCS and let us know how you feel about it.
He got his wrist pain from over-aggressive high-fives.
Hello US podcast listeners, we've got another treat for you today.
We have the bone boss (Mike: can you please start that over again with some energy and excitement..giggle...giggle)
Matt: Hello US podcast listeners, we've got another incredible episode for you today.
Mike: We can't tell you how excited we are today to have Mark Goodman here with us today.
Mike: The Bone Boss, the Musculoskeletal Master.
He is back again for a 3rd podcast.
So I hear Mark, you're going to teach about hips today.
I think the main reason we asked you on, is because of the horrible mismanagement that Mike recently had of a pediatric case - of a hip complaint.
Mike, you want to tell us about that patient?
Mike: So, admittedly I don't a lot of hip US.
I don't have a lot of experience with it (I'm too busy playing around with the heart).
So, when an 8year old child with Down Syndrome comes into a small community hospital, that I'm working at.
And complaining of just not feeling right, it confuses me.
So, this was a little tyke who was 8years old, who wasn't feeling right.
He was acting weird according to the parents.
Which is always what you want to hear when you're dealing with pediatrics.
Mark: It just gives you so much to go off.
Mike: So, in interacting with him, we found out he wasn't moving one of his legs, the way he normally should.
And, I got that from his parents (because I surely didn't pick it up on physical exam).
And what ended up happening, over the course of 12hrs, I ended up diagnosing him with septic arthritis.
But it required 4 different sedations, a trip to X-ray, a trip to MRI, a trip back to IR (for an IR guided hip aspiration).
I mean, it was ridiculous!
It took me the entire day to get this kid dispo'd.
Not only that, but he was really sick and it took me that long to get him to definitive care.
So, what I'm hoping Mark, is that you can teach me how to do all those things myself,
so, I don't have to continuously sedate the kid,
send him over to radiology multiple times under sedation, it was a nightmare.
Mark: not that any of those things were wrong, but I might have gone about it a different way,
maybe aspirating the hip myself in the ED.
Mike: that would be great if I knew how to do it.
Matt: It wasn't that you were wrong, you just did a horrible job.
Mike: It's not that I'm a bad doctor, you're just a terrible doctor.
Mark: So, the diagnosis of hip effusion and use of US to guide the aspiration of a hip joint, and injection of a hip joint,
are typically outside the practice of regular EM,
but I don't think it needs to be.
And what I'm hoping to do today is talk you through the process,
so people like Mike, who are pretty average at most things, could even perform this.
This is something that is relatively straight forward if you know your landmarks and know what you're looking for.
And have a good sense of what you are doing with the US, this is something you could be doing yourself.
And hopefully saving the patient a lot of extra work, time - with all those consults and going back and forth to MRI and different thing.
Mike: sweet...I can't wait to hear about it.
Mark: A case like that, you definitely need synovial fluid to make a diagnosis.
And in order to do that, typically, a patient needs to go to IR and get a fluoroscopic injection,
or you need to get an orthopedic, who is either going to take that patient into the OR,
to get a synovial fluid sample and wash the joint out.
And all those things, especially in a smaller community hospital are going to take a lot of time and effort to do.
So, I'm going to show you how to go through a US guided hip aspiration.
the diagnosis of a hip effusion, and a US guided hip injection in the ED.
But before we get to that, I guess the question comes up is, who really needs US to do these?
And there is some literature out there looking at US guided injection,
that shows that the accuracy of all joint injections is actually improved quite a bit.
Matt: So, Mark it makes sense to me that US is going to make you much more accurate to get into these joints, but
which joints exactly and what kind of injections and aspirations are going to help.
Matt: Recently, I taught an orthopedic group some injections, and they kept saying over and over that they,
were never going to use US for subacromial bursa or for knee injections because that's really easy.
Are there any numbers on that?
Are they right about how easy they are?
Mark: So there's actually some data on that, and I kinda agree with them,
a knee injection or a subacromial injection is quite straight forward based on landmarks.
Unfortunately that's not really true in the studies that I found,
it shows that our accuracy is really not as good as we were hoping for.
So without US, the accuracy of a subacromial injection is actually 63%, and
knee or hip injection is about 79%.
And all just improved to between 95-100% using ultrasound.
And this is in experienced clinicians who have been doing a lot of these injections,
so I think, even if you have done a lot of these, you still have something to learn,
and can improve by using US in your practice.
Just to reiterate that point,
there's a study in the rheumatology literature,
where they took a trainee,
with a US machine and compared to an experienced
rheumatologist using clinical exam,
and the trainee actually had better accuracy
with doing joint aspiration and injections,
then the experienced rheumatologist did,
so if you have the clinical skills of Matt Dawson, then
and an US machine, you'll be pretty much unstoppable.
Matt: So, how exactly does US improve these aspiration and injections.
Mark: So, I think the biggest thing is you're able to see where your needle is exactly going.
And you can visualize the fluid either in the joint or in the bursa,
and you can put your needle directly into it.
And you can also minimize the risk to the patient,
by avoiding vascular structures and nerves that are nearby,
Mike: So I guess it's important that aspiration literature is pretty important too because sometimes
you don't really have a big effusion that you're going after
when you're trying to diagnose septic arthritis patients or for whatever reason you're trying to get fluid.
They often talk about injecting a bit of sterile saline and then pull it back out to see if there's anything in that
so, I guess that I was initially thinking I didn't really care as much about injecting since I'm
not really going to be doing a bunch of that in the ED
I'm really interested in pulling off that effusion, but sometimes,
there really isn't much of an effusion.
Mark: I think that's one of the biggest things, is you can look at a knee or a hip and
say that that's just swollen to go after - you're going to save the patient the risk and the pain
of putting a needle into the joint and trying to get fluid back.
So I think the first questions that come up when talking about EM physicians,
who typically have not been doing this is,
Can I do this?
Is this something that it within my scope of practice?
Is it safe for me to be doing this in the ED?
and the short answer is yes.
You have the US skills from your training.
From doing central lines, fast exams...you're facile enough with the US,
that you can be doing this in the ED.
There's a couple of case studies here, and a recent case report,
in Annals that describes doing this in the ED.
The radiology literature goes back to the 80s.
And Steve Smith from Hennepin actually did a study in 1999 describing this technique.
And out of all these case reports, this was well tolerated with no complications.
Mike: SO if I can measure diastolic dysfunction, I can aspirate a hip.
Mark: I'd say so. You're probably right on track.
Matt: What if I can't measure diastolic dysfunction?
Mark: then you can probably still aspirate a hip joint.
The 2nd question that comes up is,
Is it safe to do?
And there's some good data on this from the radiology literature,
showing about 800pts with US guided hip injection,
and none of those went on to have iatrogenic infections, complication from the femoral nerve, artery or vein.
Typically these are done in fluoro,
which I actually think has a disadvantage over US.
In fluoro, you're not really able to identify the femoral vessels and nerve,
whereas on US you really clearly see them and avoid them when you're doing an aspiration.
And then what about peds?
Like Mike's case, like he had...
There's some data on this as well, showing the aspiration of hip joints in kids
is something we can do.
You can even measure the synovial thickness,
and try to determine whether or not the hip has an effusion.
That's something that's a little bit beyond the level of this podcast,
but I think just looking, and like we're going to describe and seeing if there's a fluid collection,
and comparing with the contralateral side
is probably one of the best tools you have.
The second study from 2009 showing peds-em trained docs
trying to diagnose effusions, and they were actually really good with
minimal training, about 10minutes of training
to look for a hip effusion.
Which could really help with your diagnosis of a pediatric patient with a limp.
There sensitivity was pretty good at around 90%,
and when they got their skills up,
they actually had even higher sensitivity,
with a PPV of 100% and a NPV of 92%.
Matt: So, I was obviously joking,
with the Blaivas comment,
but to be serious, that kinda annoys me sometimes with some of these studies,
where it's the masters of US are the ones doing it.
I really really like this study where you talk about doing a study with minimal training,
or talk about the stuff that Zhang does with the 10minutes of training in US
This makes me feel a lot better, that anybody could do this.
That we could definitely learn this and do this.
Mark: So, how would you go about doing this?
Well, your landmarks are really going to be you femoral neck,
and if you think about that,
you're going to be about 30 degrees off of the axis of the shaft of the femur,
and pointing towards the pelvis,
so you're going to want to align your US probe over the femoral neck
so you're getting a view of looking over the femoral neck, over the ball of the femur.
Matt: And this is an important point.
I think a common mistake is that a lot of people want to align the probe with the femur,
but the hip joint isn't in line with the femur,
it's 30 degrees.
Mike: So are you going to see the vessels?
Are you going to see the femoral bundle?
Mark: So, you're actually not going to see it in this view,
we're going to talk about the process of actually getting a hip aspiration
And how you'd go about identifying those vessels and marking them.
So you can safely perform the test.
This is actually just getting the view so you can look for an effusion.
So, you're looking over the femoral neck,
and you're going to get a view that looks like this.
And what you're seeing there is the femoral head at the left side of the screen,
with the joint capsule wrapping around over the top of that
and coming into the femoral neck.
And that joint capsule comes in, and covers the femoral head and neck
and is a good place to look for fluid underneath there.
So if you do have a hip effusion,
what you're going to see is a dark hypoechoic area lifting up the joint capsule over the head and neck.
And you should be able to see this pretty easily,
and its always a good idea to compare to the other side.
To see if this is really a pathological finding.
Mike: So I might be jumping the gun here, but I'm just curious.
So, if there is an effusion - that you're still going to try to aspirate,
are you basically just going to push down to the bone, and then
just draw back to see what you're going to get?
Mark: So what I do first is, I'd probably put the knee in a little bit of flexion and some internal rotation,
and I'd see if I could visualize a small effusion there,
If I still don't see an effusion,
I think I'd be pretty hard pressed to put a needle in to try to get fluid out of that joint.
Mike: So you're going to use this mostly in a patient with a higher pretest probability,
somebody whose got an effusion,
you're not gonna say "well they got hip pain, I gotta make sure it's not infected".
Mark: Exactly, I think you have to really be thinking that this patient has an infection,
and you need fluid one way or another,
and if this patient has no effusion and you're still concerned,
that's somebody I'd send over to radiology,
and have someone else do this.
We're really talking about picking the low hanging fruit in the ED,
with the patients that are going to be an easy aspiration for us to do.
Mike: So, you lack confidence...
Matt: So, you're not going to rule out hip effusion with US? Is that what your telling me?
Because, you showed the study of about 90% sensitivity when physicians were confident in their ability to perform this.
Mark: So I think you can accurately look for hip effusion,
but if you decide you need fluid from a joint with no effusion in it to really make your diagnosis,
I think you're going to be in a tighter spot
trying to put a needle into a joint with no effusion and getting fluid back.
Mike: I can buy that,
I don't think I'd get excited about sticking a needle in a dry joint.
Mark: So, here's a second look at it,
a joint with a pretty large effusion,
you can see that large hypoechoic area surrounding the femoral head and neck,
and that makes it a pretty easy target for US guided aspiration.
Mike: this doesn't look nearly as scary as I thought it would.
Mark: we'll see the femoral vessels in a second here and that'll get ya......
Mark: there's some data out there, looking at acute v chronic effusions,
if you could diagnose those using US,
measuring the synovial capsule itself,
and I think that's way less relevant for us in the ED, and maybe more so for rheumatologist,
I think the bottom line, if the patient has fever, hip pain and an effusion
you probably need to get fluid out of that joint to be sure this isn't a septic process.
So there's some advantages to doing this under US instead of fluoroscopy,
the biggest being the lack of radiation, the ability to visualize
soft tissue and vascular structures,
and the biggest thing I think is being able to do it at the bedside,
in the emergency department, and not having to get the patient to the fluoroscopy suite to get it done.
Mike: or having to sedate them 4 times.
Matt: so it's also very cost-effective, Mark and I recently taught
an orthopedic group some injection and aspiration techniques,
and they were telling us about some patients that they had
sent out to have a fluoroscopically guided hip injection,
and the patient got a bill for $5000.
And they brought a couple of their patients in that day,
and we did on their patients in a few minutes.
And it definitely saved their patients a lot of money,
and it was successful injection.
Mike: $5000?
Matt: Yes, for a fluoroscopic guided.
I'm sure that the payers didn't pay that, I don't know what they paid for it,
but it was an incredible story. Crazy, for something that took a few minutes in the office.
Mark: Then, I think if you're doing this at 2am,
you could be hard pressed to convince a radiologist to come in and do this,
in your small community hospital.
Especially if it's something you could do by yourself at the bedside.
Mike: Man, I'd do it for $20 and 6 pack of beer.
Mark: So there is some data looking at how accurate US hip injections are, when compared to fluoroscopy.
I think we can generalize a little bit to aspiration,
And they looked at US v Fluoroscopy and found they were 97% accurate
in patients with a wide range of BMIs, up to about 39.
And on average this took about 2minutes to perform.
So, a pretty quick procedure to do.
And the one patient they missed in this study,
they dislodged the needle and when they attached the connection tubing.
So, they're probably closer to 100% compared to fluoro.
Matt: So, that's great, but what about the really really big patients,
that's always the question,
if you have a really really fat patient,
Is US still going to be useful?
Or do you need to do it fluoroscopically guided in?
Mark: So you're approach to doing this,
you're going to want to start with the linear probe in a
cross-section of the neurovascular structures of the hip,
so you're going to want to be looking in-line the inguinal ligament,
across the femoral nerve, artery and vein.
So you can really delineate those structure,
once you see those, you're going to want to switch to the curvilinear probe
and then doppler again before you do your injection
so you can identity the circumflex vessels
and then use that curvilinear probe for the needle guidance.
And we're going to go through those steps.
So, I think Matt Dawson actually coined the 25 Ps of joint injection
which include.
Prepping, Probe Placement, Poke, Push (of the medications) or Pull (of the joint fluid)
Pray
And the last P is the High Phives.
at the end, which is spelled with a P somewhere.
Matt: I actually think of this more of a mnemonic
because it spells out......pppppppppppp.p
because that the easiest way to remember the steps in my opinion.
Mike: So all I've got to do is..PPPPPPPPP...P
When I'm rehearsing those steps in from of the patient, it's going to be really awkward.
Mark: so, start with your linear probe,
identify your femoral vessels,
this is something you should be used to doing
for femoral lines, nerve blocks.
So, mark those and get a good idea
those are going to be quite a medial to where you're going to be doing your injection
So, you could either mark it with a pen, or keep a good idea where those are going to be.
Once you identify those, get that same view you were looking at
with a diagnosis of a hip effusion
with your curvilinear probe in line with the femoral neck
When you do that, put some color flow on a identify the circumflex vessels
coming around the neck of the femur.
Those are going to be good to avoid when you're doing your injection.
Mike: So when you're doing this particular aspiration,
do you wear gloves, or do you it like you did in this picture?
Mark: So, usually I lick my fingers first and hold the probe with one toe.
Yeah so - this is something I think everyone has their own ideas of how sterile this needs to be.
For me, this should have a full sterile prep, probe cover, gel, needles.
The risk of causing some type of infection is something I don't want to encounter.
Mike: It's kinda like you're sticking your needle in a petri dish, so, I'm pretty sure you don't want to be injecting any bacteria.
Matt: So, I gotta be honest and say something about the whole neuromuscular structure there.
When we do this, we're always quite a bit lateral to where those are.
It's great to look, but you're going to find you're not really that close.
Don't be scared by these pictures we show you here,
once take a look yourself you'll see that you're not really right there on the vessels.
Mark: You should be quite a ways away I think
when you're doing a couple of these initially,
it's a good idea to get a view of that anatomy in your head,
and realize that you need to be quite a bit lateral to that,
and you're not going to really see the view you need to do this aspiration unless you are lateral.
Matt: Absolutely, the pre-scan is 'p' in the ppppppp
so, you have to do the pre-scan, but you're going to be quite a ways away from it.
Mark: I think the next P is the prep, which Mike actually touched on.
I usually wear the sterile gloves, mask, full sterile drape, probe cover, and sterile gel.
And a patient that's a little thinner, you can use a 2.5 inch 22 gauge spinal needle,
which is going to be the most helpful with some IV connection tubing
attached to a syringe for you aspiration,
and in if a patient is bigger you can use a 3 or 3.5" needle.
Matt: The spinal needle really is key here, if you try to use a normal needle, you're not probably going to make it
unless you get really steep with your angle - in which case, you're not going to see your needle well.
Mark: The steeper you get with that needle, the more difficult
it's going to be to see where you are on the US.
Mike: Does it matter which bevel direction at all?
Mark: So, you can get kinda fancy with you bevel control,
which is going to determine which way your needle goes
when you're actually pushing the needle through the skin.
I think it's good to start with the bevel up,
just to get a good idea of where things are going to go,
when you do your aspiration, you're going to be in the right area.
Mark: So, once you're in an effusion, you should be able to withdraw synovial fluid from that point.
And after that, you're pretty much in the clear, pull the needle out.
And I think the pray and the high phive in the end were the last two Ps.
Mike: So all we need to remember is ppppppp...
Mark: So I think while we're talking about the aspiration,
we should touch on hip injections also,
because it's pretty much the same process and can also be useful for some of these patients in the ED.
Matt: I think that's a great idea, so, tell me how you use hip injections in the ER.
Mark: So I think there are a couple of roles,
I worked last night and had a patient who was an unfunded immigrant,
who had a terrible left hip osteoarthritis,
and had actually been in to see an orthopedic surgeon,
he had been scheduled for surgery, but was cancelled the day before when he realized
he didn't have insurance.
He had this terrible chronic hip pain for 6 months now to the point where he's barely able to walk.
So, in addition to getting him set up with case management to get him set up with an orthopedic surgeon
and talk about hip replacement -
I did a hip injection on him with some bupivicaine and some steroids to temporize things
until he was able to do that.
It was actually quite rewarding, he had full relief of his pain and walked out of the ED
after we did his injection.
Matt: And there are definitely going to be people that argue
whether or not hip injections in the ED, if it's really appropriate or fits the standard of care
But I think you gave that patient some great care
Another way I used it recently,
I had a patient who had a lot of hip pain,
it was really unclear if it was actually osteoarthritis or more sciatica.
We did an injection, we did not use any steroids just lidocaine,
and the patient's pain got completely better after the injection into the joint.
That was actually pretty diagnostic for osteoarthritis instead of sciatica.
And there are a couple of studies that show it is useful and not some technique that we just made up.
Mike: Ok, so I still want you guys to commit on this.
You're doing an injection to the hip,
you're going to stick a needle and go where?
You're going to put it just under the capsule? right next to the bone? Where does that injection go?
Mark: You're target is going to be pretty much the same,
you're going to want to be aiming right to the junction of the femoral head and femoral neck.
The normal joint capsule in a hip of joint without effusion is going to be a little bit difficult to see.
You're not really going to see that layer of fluid underneath there,
so you're going to go until you hit the bone, then pull back slightly.
Once you see that, your injection should flow really easily.
From that point you can look with the US and actually see the capsule filling up.
Which is going to look like an effusion.
Mike: So, by the capsule filling up, you mean that the fluid is going to run up and down the femoral head.
And injecting below the femoral head sort of where the head meets the neck,
I'm going to see an effusion start to create around the head itself.
Mark: And remember that that joint capsule actually extends down the femoral neck as well.
So you can get some fluid going both directions and that's normal.
Mike: I think that's key though, if I had just done this without talking to you guys first,
I'd probably just have aimed straight for the head, but it's not. It's to the neck.
Matt: right and an important point is that the capsule actually attaches at the base of the femoral neck.
So, you're going to be a little ways away from that head,
you're going to want to aim exactly where Mark was talking about,
but if you're a little lower,
you're probably going to be in the capsule.
And the flowing easily is an important thing.
Because, if it's flowing easily and you're not seeing it piling up somewhere, then it's filling into the capsule.
Mike: That's great Mark, I can't wait to try it.
I think it's a really interesting concept.
Obviously the aspiration of the hip is something i've been dying to do forever
because it drives me crazy sending people over to IR when we can do these things with US.
The injections are pretty interesting too.
Maybe I'm not going to be doing it on every patient I see in the ED with hip pain,
but as a diagnostic tool as Matt was mentioning,
or especially in the unfunded patients who are otherwise not going to get any care
and who are going to be sitting around being miserable all day long
maybe I can do a little good.
Matt: And if you guys thought this was a little too complicated for the ED,
you're going to love our next podcast
we have Mark on for two hours talking about bevel control.
So, look for that coming out very soon.