Hip visualization of the hip is useful in suspected

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Hip Visualization of the hip is useful in suspected sepsis of the joint, as well as in the evaluation of synovitis. Figures 16.9 and 16.10 demonstrate normal hip Figure 16.9 Normal hip ( left ) and synovitis ( right ). Note the anechoic fluid (*) within synovium lateral to the femur (F). The growth plate (arrow) is visible as well in this pediatric case. Procedural ultrasound 305 Ultrasound for procedure guidance
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anatomy as well as effusions. The diagnosis of hip effusions is discussed in more detail in Chapter 13 . Knee The knee joint may be well visualized from a medial or lateral approach. In Figure 16.11 , a standard probe position and normal joint appearance is demonstrated. In Figure 16.12 , abnormal fluid is visualized in the joint. Figure 16.10 Hip effusion (*) is demonstrated lateral to femur (F) in another pediatric patient with hip pain and limp. (A) (B) Figure 16.11 ( A ) Lateral placement of probe for knee arthrocentesis. ( B ) Image seen on screen, demonstrating patella (P), tibia (T), and patellar tendon (arrows). 306 Procedural ultrasound Ultrasound for procedure guidance
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Ankle Figure 16.13 demonstrates placement of the probe longitudinally across the joint. Again, note the “seagull sign,” which directs the search for black fluid in the “V.” Fluid in this location, often accompanied by displacement of the bright echogenic joint capsule, represents an effusion. Shoulder Look for biceps tendon in bicipital groove ( Figure 16.14 ). Here fluid is observed in the subdeltoid bursa. It is extra-articular, because it does not displace the biceps tendon. Tips When only a small amount of fluid is seen on ultrasound, it is sometimes useful to place some pressure on the joint at a different location to bring more (A) (B) Figure 16.12 ( A ) Black fluid collection (*) within knee joint in child. Note the femur (F), tibia (T), and growth plate (arrow). ( B ) Pus aspirated from knee joint in the same patient. (A) (B) Figure 16.13 ( A ) Ankle probe position. ( B ) Ultrasound image obtained at this site. Procedural ultrasound 307 Ultrasound for procedure guidance
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fluid to the puncture site. For example, suprapatellar pressure can increase the size of the synovial space inferior, medial, and lateral to the patella, and make aspiration of the joint at these sites simpler. Pitfalls Even slight movements of the joints will have a major impact on the location and depth of fluid collections. Be sure the patient is in his or her final position for the procedure when beginning ultrasound. Alternatively, ultrasound can be used to assess the optimal joint position in real time, and the patient can hold that position for the procedure. Literature review Although well described in the orthopedic and rheumatology literature, few studies describe ultrasound-guided arthrocentesis by emergency physicians. Some authors have reported success when using the modality in ankle arthrocentesis [ 9 ] and hip arthrocentesis [ 10 ]. Recently a randomized con- trolled trial of ultrasound versus landmark-guided knee arthocentesis in the emergency department found similar success rates with both techniques [ 11 ].
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