Long head of biceps brachii tendon sheath injection (technique)

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Long head of biceps brachii (LHB) tendon sheath injections under ultrasound-guidance ensures accurate delivery of injectate, which is important as these injections are often performed for diagnostic purposes.

Indications

Contra-indications

Absolute
  • anaphylaxis to contrast/ injectates
  • active local/ systemic infection 
Relative

Procedure

The general principles of guided injections are to:

  • cannulate the structure under image guidance
  • administer injectate under visualization, usually a corticosteroid and a small amount of longer-acting local anesthetic, and avoiding intra-tendinous 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.

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. 30 or 25-gauge needle
  • needle to cannulate the tendon sheath i.e. 25 or 27-gauge needle
  • injectants i.e. local anesthetics, iodinated contrast, corticosteroid preparation
  • sterile gauze
  • adhesive dressing/ band aid
Syringe selection

A suggested syringe and injectate selection for an ultrasound-guided LHB tendon sheath 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 cannulate a structure. Ensure the needle length is long enough to reach the target point in the sheath.

  • LHB tendon sheath: 25 or 27-gauge 40mm needles 
  • LHB tendon sheath: 25 gauge Quincke needle (larger patients)

Technique

Ultrasound
  • check for allergies and if on blood thinners
  • consent
  • optimize patient positioning by lying them flat and supine or with minimal upright bed angulation with the target arm straight, by their side with the hand supinated, targeting a lateral access
  • identify the LHB tendon in the transverse plane; perpendicular to the long axis, optimize imaging and mark a lateral skin entry point
  • clean skin and draw up appropriate medications
  • consider local anesthesia along the proposed needle path
  • under ultrasound guidance using lateral approach, insert the needle in-plane with the probe into the lateral and inferior aspect of the LHB tendon sheath
  • the needle tip position can be checked with a small amount of injected local anesthetic, which should flow freely
  • administer steroid containing injectate under direct visualization, avoiding intra-tendinous injection
  • removed needle and apply dressing/ band-aid as required
  • pain diary given if a diagnostic injection

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.  Fat necrosis causing skin dimpling and skin discolouration can occur due to steroid leaking into the surrounding soft tissues .