Long Head of Biceps Brachii Tendon Sheath Injection

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. 
==Anatomy==
==Indications==
*pain
*diagnostic injection
*alternative access to the glenohumeral joint (shoulder)
The tendon sheath is continuous with the glenohumeral joint. And so fluid in the sheath may indicate glenohumeral joint pathology, and a shoulder joint injection may be more appropriate.
==Contraindications==
*Absolute: anaphylaxis to contrast/ injectates, active local/ systemic infection
*Relative: bleeding diathesis, recent injection with steroid in same/ other body parts, long head of biceps and/ or rotator cuff tendon tears, unable to remain still for the procedure, young age
==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 focussed 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 anaesthetic i.e. 30 or 25-gauge needle
* needle to cannulate the tendon sheath i.e. 25 or 27-gauge needle
* injectants i.e. local anaesthetics, iodinated contrast, corticosteroid preparation
* sterile gauze
* adhesive dressing/ band aid
==Technique==
The general principles of guided injections are to:
cannulate the structure under image guidance
administer injectate under visualisation, usually a corticosteroid and a small amount of longer-acting local anaesthetic, and avoiding intra-tendinous injection
===Ultrasound Guided===
* optimise 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, optimise imaging and mark a lateral skin entry point
* clean skin and draw up appropriate medications
* consider local anaesthesia 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 anaesthetic, which should flow freely
* administer steroid containing injectate under direct visualisation, avoiding intra-tendinous injection
* removed needle and apply dressing/ band-aid as required
* pain diary given if a diagnostic injection
===Fluoroscopy Guided===
===Landmark Guided===
==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
==Aftercare==
==Videos==
==See Also==
Shoulder
==External Links==
==References==
#Gofeld M, Hurdle MF, Agur A. Biceps Tendon Sheath Injection: An Anatomical Conundrum. (2019) Pain medicine (Malden, Mass.). 20 (1): 138-142. doi:10.1093/pm/pny051 - Pubmed
#Park SK, Choi YS, Kim HJ. Hypopigmentation and subcutaneous fat, muscle atrophy after local corticosteroid injection. (2013) Korean journal of anesthesiology. 65 (6 Suppl): S59-61. doi:10.4097/kjae.2013.65.6S.S59 - Pubmed
Category:Infoboxes
Category:Partially complete articles
Category:Shoulder Procedures