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  • 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,