POCUS Learning Modules

MODULE 10:  Musculoskeletal US & US-guided MSK Procedures

Curriculum Location: R2/R3 Orthopedics & Sports Medicine / Total Time: 2 hours

For this and all other modules, you are welcome and encouraged to take notes as helpful to you in your Ultrasound/POCUS for Family Medicine Evernote Notebook, found here. 

Learning Module Objectives:

  1. List the value of ultrasound-guidance in improving MSK procedure outcomes.

  2. Use ultrasound to guide common orthopedic procedures including: 1) joint effusion aspiration; 2) carpal tunnel syndrome perineural median nerve injection; 3) shoulder and knee joint injection

  3. Use ultrasound to evaluate for achilles tendon injuries.

  4. Use ultrasound to evaluate bone cortex for fracture such as rib or shaft bone fractures.

Musculoskeletal US:

  1. Background Case (Read this Case Summary and accompanying Case Questions for a brief example of how POCUS applies to family medicine regarding musculoskeletal ultrasound.)

    1. Case description: A 40 year old female presents with complaint of knee stiffness and pain following a knee twist injury playing indoor soccer. She denies the knee locking or giving way and reports no previous ligament or cartilage damage. On PE, you detect a moderate effusion and she is unable to flex the knee past 90 degrees. You diagnose a probable minor meniscal tear with effusion. You decide to aspirate the knee to improve patient comfort and function, and then provide supportive care, deferring additional imaging and referral if the patient does not show improvement in the next few weeks.

    2. Case Questions: Does the use of ultrasound-guidance improve large joint aspiration outcomes? Can you bill for U/S guided procedures differently than with non-U/S guidance? How do you perform a single-person dynamically U/S guided knee joint aspiration maintaining a sterile field?

  2. Assignments:

    1. First, watch this VIDEO (15m) (with Evernote reference notes available HERE) to learn some foundational principles of musculoskeletal ultrasound.

    2. Now, let’s move on to U/S guided musculoskeletal procedures. To complete this section, you will need to register to use the American Medical Society of Sports Medicine’s online didactics. Click HERE to find the AMSSM online didactics. Find the “INTRODUCTION TO ULTRASOUND GUIDED PROCEDURES” module and complete it, finishing with passing their test (30m video; 5m test). During the video, follow along with this Evernote summary.

    3. Next, let’s learn about a few key areas most pertinent for MSK U/S in Family Medicine (AMSSM modules (see the link above) are listed alphabetically in the AMSSM site; they are an excellent free resource—if you have more time and interest, check out additional modules!):

      1. KNEE (30m):

        1. Anterior Knee Ultrasound Examination (7m video; 5m test)

        2. US Guided Interventional Procedures of the Knee (12m video; 5m test)

        3. Sonosite Knee injection (2.5m):  https://www.youtube.com/watch?v=2s2bZGDcT7M

        4. USC Knee views (4m)  https://www.youtube.com/watch?v=KRRbpAyzfX4

        5. Mobile Medical Media, How to inject the knee with US guidance (4m):  https://www.youtube.com/watch?v=XVYTamp2K8g

      2. WRIST (12m):

        1. Volar Wrist in Ultrasound (6m video, watch 0:00-5:57 only—Median N/Carpal Tunnel; do not take test)

        2. US Guided Interventional Procedures of the Wrist and Hand (3m video, watch 0:34-3:18 only—Carpal Tunnel injection; do not take test)

        3. Click HERE to view a brief Sonosite video (2.5m) on U/S guidance for injections for Carpal Tunnel Syndrome. (TIP: This is a great procedure to learn to do with U/S guidance—be looking for the opportunity in the FMC. Remember these key tips: 1) place the transducer probe medially and inject from the ulnar approach; 2) stay shallow, the median n is only 2mm below the surface!; 3) avoid needle anisotropy by keeping the needle parallel with the transducer foot pad; 4) correctly identify the median n before the procedure by looking for “honeycombing” (if the superficial and deep flexor tendons around and below the median nerve all look dark, you’re not perpendicular with your probe—that’s anisotropy).)

      3. SHOULDER (14m):

        1. Sports US Shoulder Pathology (7m video, watch 7:10-14:35 only—Supraspinatus RC; do not take test)

        2. US Guided Interventional Procedures of the Shoulder (7m video, watch 0:35-6:43 only—SA Bursa and GH Joint; do not take test)

      4. ACHILLES (7m):

        1. Sports US Ankle/Foot Pathology (7m video, watch 9:35-16:33 only—Achilles tendon; do not take test)

    4. Finally, billing in MSK U/S: U/S guided joint injections and aspiration and CTS injections are a POCUS-tooled family doctor’s easiest opportunity to receive additional reimbursement for the procedure (because outcomes are improved!). How do you bill for an U/S guided injection/aspiration? Use 76942—and make sure you include saved images of the U/S guided procedure (use Haiku to capture a saved image). See your handy-dandy Evernote HERE for billing details.

Module FEEDBACK (Time: 2 minutes)

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