1. Ultrasound-Guided
Injections: Upper Extremity
Alan M. Hirahara, M.D., FRCS(C)
Board Certified in Orthopaedic Surgery & Orthopaedic Sports Medicine
Specializing in arthroscopic shoulder surgery
Medical Director Team Physician Consultant
Sacramento State Athletics Sacramento River Cats Oakland A’s
MiLB - AAA

2. Improved Accuracy
• Despite overwhelming evidence that accuracy in injections is quite low
and ultrasound significantly improves this accuracy, many DO NOT
BELIEVE
• Many physicians will feel that they are “excellent” at injections and
“never” miss

3. Ultrasound – Accurate / Versatile
• 30% of injections miss subacromial bursa – Experts
– Eustace (1997)
– Yamakado (2002)
– Henkus (2006)
– Sethi (2006)
• Naredo et al. (2004)
– Randomized cohort (41 patients) to blind vs. U/S guided subacromial
cortisone injection
– VAS (p=0.001) & SFA (p=0.012) sig better in
U/S guided group

4. My Experience
• “My patients have significantly less pain when
done under ultrasound guidance”
• My Explanation:
– “I was missing some!”

5. Ultrasound
• Already used in OB/GYN, emergency medicine
• Becoming accepted in Orthopaedic Sports Medicine
• Sidelines of sports events for immediate diagnosis
• Courses in ultrasound filling up everywhere

6. Injections

7. HOW DO I DO INJECTIONS?

8. What Do You Need?
• Sterile gloves / gown
– with mask/hat
• Sterile drapes
• Sterile transducer sheath or cover
• Sterile gel
• Sterile operating room

9. Sterile Technique

10. SHOULDER INJECTIONS

11. Subacromial Injection

12. Subacromial Injection – Arm Neutral

13. Bursitis – Subacromial Injection

14. Massive RCT – Injection

15. Shoulder Joint Injection

16. Calcific Tendonitis

17. Partial-thickness RC Tears

18. Partial Subscapularis Tear

19. Subscapularis Calcific Tendonitis

20. Biceps Sheath Injection

21. AC Separation – Injection

22. ELBOW INJECTIONS

23. Lateral Epicondyle Injection

24. Lateral Ext. Pain

25. Medial Epicondylitis

26. Elbow Joint Injection

27. Proximal pUCL Tear – PRP
Injection

28. WRIST & HAND INJECTIONS

29. Median Nerve – MSK vs. NRV

30. Median Nerve - Injection

31. Wrist Joint Injection

32. Trigger Finger

33. Thank You!