Distal radioulnar joint arthrography

Sonographically Guided Distal Radioulnar Joint Injection

“…In appropriately selected patients, DRUJ injections may help confirm the diagnosis or facilitate pain relief and functional improvement as part of a comprehensive nonoperative treatment program 1 , 2 . Although palpation guided DRUJ injection techniques have been described, many authors recommend using fluoroscopic guidance to access the joint because of the challenging and variable anatomy in this region 1 , 10 , 11 , 13 , 27 , 28 . Prior research has demonstrated that sonographic guidance may provide a favorable alternative to fluoroscopy for a variety of joint and soft tissue injections when image guidance is clinically indicated 8 , 15 – 18 , 20 , 21 , 29 – 31 .…”

“…The dorsal capsule appeared as a thin (≈1 mm) hyperechoic fibrillar structure extending from the ulnar tip of the radius to at least the midportion of the dorsal ulnar head. Thus, the dorsal recess of the DRUJ space was located primarily over the dorsal aspect of the ulna 9 – 11 , 13 …”

“…A 25‐gauge, 38‐mm stainless steel needle was then advanced under direct sonographic guidance using an in‐plane, ulnar‐to‐radial approach, passing ulnar to the extensor digiti minimi tendon (Figure 2). Passing the needle on the ulnar side of the extensor digiti minimi tendon avoided sensitive neurovascular structures (transverse branches of the dorsal ulnar cutaneous nerve and dorsal branch of the anterior interosseous artery) while providing access to the more capacious portion of the DRUJ recess overlying the dorsal ulnar head 1 , 9 – 11 , 13 , 22 , 24 , 25 . Depending on regional anatomic variations, an oblique gel standoff (heaping gel under the ulnar side of the transducer) was used in some cases to keep the ulnar side of the transducer off the skin and facilitate joint access.…”

“…This bevel direction facilitated movement of the needle in a downward direction toward the joint and also provided the opportunity for the needle tip to grab the joint capsule and be drawn into the joint (). Once the joint capsule was penetrated, the bevel was rotated to face downward into the joint, and a total 1.0 to 1.5 mL of diluted yellow latex (50% latex and 50% water) was injected using direct sonographic guidance () 10 , 11 , 13 , 26 . During the injection, intra‐articular flow was continuously monitored, and any overflow into the ulnocarpal articulation (indicative of a TFCC tear) or other regions was recorded.…”

“…Despite the potential clinical utility of DRUJ injections, placing a needle into the joint can be challenging because of the joint's small size, atypical shape, and variable anatomy 7 , 13 . Consequently, fluoroscopic guidance is typically used to access the joint when accuracy is paramount 1 , 10 , 11 , 13 . Although the accuracy of fluoroscopically guided DRUJ injections with contrast control is implicit, fluoroscopy requires the use of large and at times cumbersome equipment and exposes the operator and patient to ionizing radiation 9 , 14 , 15 .…”