Greater trochanteric bursa injection (technique)

Radiopaedia • CC-by-nc-sa 3.0 • de

Greater femoral trochanteric bursa injections under ultrasound-guidance ensures the injectate is accurately given into the bursa. The greater trochanteric bursa is the largest of the bursae surrounding the proximal femur, with the others including the subgluteus minimus and subgluteus medius bursae, which can also be targeted.

Indications

Contra-indications

Absolute
  • anaphylaxis to contrast/ injectates
  • active local/ systemic infection 
Relative
  • bleeding diathesis
  • recent injection with steroid in same/ other body parts
  • gluteus minimus and/or gluteus medius tendon tear
  • ipsilateral hip arthroplasty
  • unable to remain still for the procedure
  • young age

Procedure

The general principles of guided injections are to:

  • cannulate the bursae under image guidance
  • administer injectate, usually a corticosteroid and a small amount of longer-acting local anesthetic, and avoid intratendinous injection
Pre-procedural evaluation

Relevant imaging should be reviewed, and details of the patient confirmed.  The patient should have an opportunity to discuss the risks and benefits and consent obtained. A focused pre-procedure ultrasound is usually performed to assess bursae, and the gluteus minimus and medius tendons which are also referred to the ‘rotator cuff of the hip’.

Risks include -

  • infection
  • bleeding
  • allergy 
  • focal fat necrosis/ skin discolouration at injection site
  • complete tendon tear
Equipment
  • ultrasound machine, sterile probe cover and a skin marker
  • skin cleaning product
  • sterile drape
  • sterile field and tray for sharps
  • syringe selection i.e. 5mL and 3mL
  • larger bore drawing up needle
  • needle to administer local anesthetic i.e. 25-gauge needle
  • needle to cannulate the bursae i.e. 25 or 22-gauge 90mm Quincke needle
  • injectants i.e. local anesthetics, iodinated contrast, corticosteroid preparation
  • sterile gauze
  • adhesive dressing
Syringe selection

A suggested syringe and injectate selection for an ultrasound-guided greater trochanteric bursa injection -

  • 5 mL syringe: 5 mL of local anesthetic i.e. 1% lidocaine
  • 3 mL syringe: 40mg triamcinolone acetonide (40 mg/1 mL) and 2 mL 0.5% ropivacaine
Needle selection

Smaller gauge needles can be less painful but are less stiff and can bend when trying to pass through the iliotibial band to reach the bursa. Pre procedure planning should calculate length required to reach the bursa, as larger patients will require longer needles .

  • Greater trochanteric bursa: 25 or 22-gauge 90mm Quincke needle
Technique
Ultrasound
  • check for allergies and if on blood thinners
  • consent
  • optimize patient positioning by lying them on the side and facing away, with the ipsilateral hip facing upwards and exposing the lateral targeted proximal femur, aiming for posterior access
  • identify the greater trochanteric bursa in a transverse plane; perpendicular to the long axis, with dynamic maneuvers helping to identify a non-distended bursa
  • optimize imaging and mark a posterior skin entry point
  • clean skin and draw up appropriate medications
  • give local anesthesia along the proposed needle path
  • under ultrasound guidance using posterior to anterior approach, insert the needle in-plane with the transverse probe into the posterior aspect of the bursa
  • the needle tip position can be checked with a small amount of local anesthetic which should freely flow and distend the bursa
  • administer steroid containing injectate under direct visualization
  • removed needle and apply dressing/ band-aid as required
  • pain diary given if required

Complications

The most serious complication is infection. Steroid containing injections should be postponed if there are signs and/or symptoms of local and/ or systemic infection.  Possible fat necrosis causing skin dimpling and skin discolouration can occur due to steroid leaking into the surrounding soft tissues.