US-guided procedures in the management of muscular trauma

Transcription

1 US-guided procedures in the management of muscular trauma Poster No.: P-0132 Congress: ESSR 2015 Type: Educational Poster Authors: B. Ruiz, J. L. del Cura, F. Diez Renovales, I. Corta, J. Cardenal Urdampilleta, R. Zabala Landa, D. Grande Icaran, N. Nates Uribe; Bilbao/ES Keywords: Musculoskeletal soft tissue, Extremities, Ultrasound, Drainage, Treatment effects, Trauma, Acute DOI: /essr2015/P-0132 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 17

2 Learning objectives Know the different types of acute muscle injuries. Show the US- guided treatment techniques that can be used to accelerate healing. Analize their indications. Show the treatment technique itself. Discuss their effectiveness. Background There are two main types of muscular lesion depending on the mechanism agent. - External trauma: Contusion Laceration Hematoma - Intrinsic injuries : Muscle tears Myotendinous breaks Bruising In some cases fluid collections and hematomas are associated to delaying recovery. US-guided procedures can play a role in the management of these lesions. Imaging findings OR Procedure Details Page 2 of 17

3 HEMATOMA Radiological management: In traumatic hematomas or muscular strains the physiological process of healing muscular lesions requires the formation of a scar between the broken fibers. The presence of fluid collections or hematomas between them prevents or delays the formation of the scar. The evacuation of hematomas speeds up the healing process, thanks to the muscle fibers approximation, and reduces the downtime. Avoids compartmental syndrome associated to the increased volume. Indication: Symptomatic hematomas: Pain. Fever or malaise produced by the hematoma. Structures compression. Functional impotence Infection. Speed healing. Conditions: Absence of active bleeding. Hemostasis enough. A coagulation test must be done including prothrombin time, INR and a platelet count. (The requirements for the drainage are INR < 1.4 and a platelet count > /mm³. In case of bleeding due to anticoagulation therapy, correct coagulability levels and move from oral warfarin to low molecular weight heparin. Antibiotic coverage with a broad spectrum antibiotic until the catheter is retrieved. Treatment: Fluid collections: We usually use 8-10 French catheters. Fig. 1 on page G needle Clotted collections: Drainage through thick catheter (10-12 F). Using intracavitary urokinase: IU pushed by20-40 cc of saline. Repeat procedure every 8-12 hours. Page 3 of 17

4 We connect the catheter to a bag or a collector to allow the fluid to be drained Fig. 2 on page 7, until resolution or until collection decrease is appreciated (usually 1 to 3 days) Technique: The technique of drainage can vary depending on the size and the contents of the hematomas. Drainage catheters will be necessary for larger hematomas and those with clots. Drainage catheters have side holes in their distal end which enable the discharge of fluid. They can be placed using the Seldinger technique or the Trocar system. We normally use the trocar system (Skater; Inter V, Stenlose, Dinamarca). The trocar catheter is a catheter mounted on a hollow rigid metallic guide, inside which a sharp metallic needle is introduced Fig. 1 on page 6. Once mounted, the whole device looks like a sharp needle covered by the catheter. It is introduced directly in the collection by a direct puncture through the skin. This technique enables drainage to be performed in one single step. Moreover, it is easier to perform by less skilled radiologists. We use a free-hand technique to introduce the catheter in the collection, in which the probe is controlled with one hand and the catheter is introduced with the other hand along the plane of imaging. In this way the location and pogress of the catheter tip are monitored continuously (figure 4 on page 11). Free-hand technique requires only moderate skill and is easier to approach the lesion. Diagnostic and subsequent interventional examinations are performed using either linear (7-12 MHz) or curved phase array (3,5 MHz) transducers, based on deep and local geometry. Local anesthesia (1% lidocaine) is used. To maintain the procedure aseptic is enough to keep sterile the puncture site and the needle or catheter used. Usually it is not necessary to use sterile covers for the transducers. After drainage all patients are monitored regularly every 2-3 days, to aspirate the rests of the collection and to perform lavages with saline solution. We maintain the drain until the hematoma is no longer visible on US or no reduction of the collection is detected in 3 consecutive days. Here we have different examples: Fig. 3 on page 8, Fig. 4 on page 9, Fig. 5 on page 10 Page 4 of 17

5 Complications: Bleeding. Watch the Color of the fluid drainage:the more red the more likely is the possibility of active bleeding. Any rate change size of the collection. Close the catheter. Infection. Antibiotic coverage. Drain. Incomplete resolution. Our Results: There is clinical improvement and total or subtotal resolution in 100% of bruises. Drain duration: 1-13 days. In 40% of the cases the drain is removed within 72 h. SMALL HEMATOMA Aspiration by needle may be enough for small-sized fluid collections with low viscosity and without clots. In case of clotted hematoma injecting urokinase directly 24-48h before the aspiration is advisable. Fig. 6 on page 11 MYOTENDINOUS STRAIN INJURY. Tennis Leg Fig. 7 on page 12 Classical treatment: Surgery Conservative treatment: Compressive bandage +Rehabilitation Discharge whithin 7-77months (Ahmad FAI 2013; 34:1074) Nowadays approach: Page 5 of 17

6 Similar to the above described us-guided drainage techniques can be used. Fig. 8 on page 13, Fig. 9 (video). Precautions: Antibiotic coverage and heparinization. Our Results: 42 patients (mean age 48) Urokinase in 5 cases 1 failure Drainage period between 1 and 15 days (mean 4.5) Gradual return to physical activity between 7 and 66 days (mean 22) MUSCLE TEARS In this case as well, us-guided drainage techniques can be used. Fig. 9 on page 14 Images for this section: Page 6 of 17

7 Fig. 1 Page 7 of 17

8 Fig. 2 Page 8 of 17

9 Fig. 3 Page 9 of 17

10 Fig. 4 Page 10 of 17

11 Fig. 5 Page 11 of 17

12 Fig. 6: Small clotted hematoma among the muscles of the anterior compartment of the leg in a professional football player. On Tuesday IU of urokinase were introduced in the collection. 24 hours later, the hematoma was directly drained. On Sunday, he could play the match. Page 12 of 17

13 Fig. 7 Page 13 of 17

14 Fig. 8 Page 14 of 17

15 Fig. 9 Page 15 of 17

16 Fig. 10: The procedure must be performed maintaining an aseptic environment. 1% lidocaine for local anaesthesia is used. Using a free-hand technique the catheter is introduced in the collection, by a direct puncture through the skin. The fluid is drained by manual aspiration until the hematoma is no longer visible on US or no more content comes through the catheter. Pressing the collection with the transducer may help the drainage. Afterwards catheter lavage must be performed introducing saline to ensure permeability. Finally, the catheter must be fixed to avoid its movement. Page 16 of 17

17 Conclusion Acute muscle injuries can be treated by ultrasound-guided techniques. Evacuation should be first treatment option in hematoma. The use of urokinase allows solving the problem of evacuating the clotted hematomas. Small fluid collection can be treated with needle disposal. Larger ones require a catheter. Drainage can accelerate recovery. References Personal Information Page 17 of 17