A positioning approach to upper extremity sonographic evaluation and intervention.

Total supported abduction, or TSA, is a position for ultrasound evaluations and guided interventions of the upper extremity. It provides optimal access to the medial arm through the volar wrist and palmar hand for diagnostic evaluations of the median and ulnar nerves as well as procedures including injections for carpal tunnel syndrome, ulnar neuropathy at the elbow, and stenosing tenosynovitis. It enables ease of both ipsilateral and bilateral evaluations/interventions without the need for significant positional changes by the patient or physician. Incorporation of TSA may enhance clinical efficiency by reducing the amount of time, materials, and space required to provide such services.

Comparison of Comfort and Patient Preference of Common and a Novel Position for Ultrasound-Guided Carpal Tunnel Injections.

OBJECTIVES: This study compared levels of discomfort among three positions for ultrasound-guided carpal tunnel injections (USCTI) to potentially facilitate and improve the procedure's tolerability in treating carpal tunnel syndrome (CTS). METHODS: Ambulatory Veterans referred for electromyography (EMG) evaluation of CTS were eligible for the study; a total of 30 participants were evaluated. Participants were asked to hold three different positions: 1) Hypersupination, 2) Airplane, and 3) total supported abduction (TSA). Participants rated their pain level, ease of performing/holding each position, exacerbation of underlying symptoms, and position preference. Results were analyzed with two-way repeated measures ANOVA. RESULTS: Hypersupination was determined to be the least preferred and most painful position to hold, demonstrating a statistically significant increase in the Numeric Rating Scale score for pain during the procedure compared with Airplane and TSA, which were not significantly different from one another. Pre-procedure neck, shoulder, elbow, and wrist pain were not significantly associated with intra-procedure pain. CONCLUSIONS: When performing USCTI, patient comfort can be optimized by avoiding Hypersupination. Utilizing the Airplane or TSA positions may provide similar access for ulnar approach injections while inducing lower levels of discomfort. Clinical space, resources, patient mobility, and laterality of procedures may further guide one's selection among the positions.

Femoral head collapse after hip intra-articular corticosteroid injection: An institutional response to improve practice and increase patient safety.

INTRODUCTION: Femoral head collapse (FHC) is a rarely reported complication of hip intra-articular corticosteroid injection (IACSI). Upon observing a high rate of FHC after hip IACSI, we sought to (1) describe how we addressed the problem through a systematic evaluation of clinical data and institutional care practices followed by process improvement efforts; and (2) report our results. METHODS: Patients receiving hip IACSI during a 27-month period underwent retrospective review to determine the rate of FHC and to identify associated patient factors or practice shortfalls. Findings led to institution-wide interventions: (1) to improve patient/provider awareness of this association; and (2) to develop/implement practice guidelines. Rates of FHC after hip IACSI and practice patterns among providers before and after intervention were compared. RESULTS: Initial FHC rate after hip IACSI was 20.4%. Patient-related factors included body mass index (p = 0.025), history of cancer therapy (p = 0.012), Vitamin D level (p = 0.030), and multiple injections (p = 0.004). Volume/dose of injectate and post-injection surveillance methods varied widely. Quality improvement (QI) intervention resulted in fewer treatment referrals (from 851 to 436), fewer repeat injections (mean = 1.61 to 1.37; p = 0.0006), and a 5% lower FHC rate (p = 0.1292). Variation in practice patterns persisted, so a systems-based Clinical Pathway was established. DISCUSSION: When a high rate of FHC after hip IACSI was found to be associated with certain patient and practice factors, introduction of education materials and treatment guidelines decreased number of referrals, number of injections per patient, and FHC rate. In the absence of the systems-based Pathway, the type, dose, and volume of injectate and post-procedure follow-up remained variable.