In this instructional video, we will present the use of needle impling technique for ultrasound-guided botulinum toxin injections of the upper limb. This video was created by Dr. Jeffrey Smith, who is a fellowship-trained spinal cord injury specialist along with Drs. Jessen Wepner and Sarah Reiser in the Department of Physical Medicine and Rehabilitation at the University of Virginia. The authors of this video have nothing to disclose. Objective number one, perform ultrasound-guided botulinum toxin injections with increased confidence by utilizing the needle impling technique for the following target muscles. Flexor carpi radialis, flexor carpi ulnaris, flexor digitorum profundus, flexor digitorum superficialis, flexor pollicis longus. Objective number two, describe the ergonomic challenges and methods for management of ultrasound-guided upper limb botulinum toxin injections. Objective number three, utilizing ultrasound guidance, identify the relevant anatomical landmarks, upper limb target muscles, and neurovascular structures to avoid when performing botulinum toxin injections. In this video, we will describe the rationale for use of needle impling technique for botulinum toxin injections of the upper limb, discuss ergonomic challenges inherent to these injections, we will demonstrate the use of electrical stimulation and isolated passive muscle movements to improve injection accuracy, we will demonstrate injections for the flexor carpi radialis, flexor carpi ulnaris, flexor digitorum profundus, flexor digitorum superficialis, and flexor pollicis longus. Finally, we will conclude with a review of key points from this instructional video. The idea for this video was born out of the article titled, Prevalence of Bleeding Complications Following Ultrasound-Guided Botulinum Toxin Injections in Patients on Anticoagulation or Antiplatelet Therapy. Dr. Jeffrey Smith was the principal investigator on this study. Dr. Smith evaluated the use of needle-implained ultrasound guidance for these injections. With the use of this technique, bleeding complications were found to occur less than 1% of the time. All bleeding complications identified on post-injection hematoma scan were subclinical. Thus, ultrasound guidance may provide added assurance for practitioners performing office-based procedures in patients at higher risk for bleeding complications. This rationale includes the following benefits. Visualizing the length of the needle-implained during injection. Visualizing injection of botulinum toxin in the target muscle. Reducing the risk of injury to vascular structures and bleeding complications. And performing a post-injection ultrasound to screen for hematomas in order to provide early identification of bleeding complications. Here we will demonstrate the in-plane needle technique. When the needle is inserted in long axis, the entire needle may be visualized. Note the positioning of the practitioner's hands in relation to the transducer and needle. Now we will demonstrate the out-of-plane needle technique. When the needle is inserted in the short axis, a cross-sectional view of the needle will be seen on ultrasound, appearing as a small dot on the display. Note that the needle only crosses the ultrasound beam once. Again, take note of the positioning of the practitioner's hands in relation to the transducer and needle. In contrast to the out-of-plane technique, the in-plane technique allows for constant visualization of the needle tip as it is being inserted. This allows the practitioner to guide the needle tip away from important anatomical structures such as blood vessels and nerves, as well as to confirm position of the needle tip in the target muscle.

needle impling technique

ultrasound-guided botulinum toxin injections

upper limb

ergonomic challenges

injection accuracy improvement methods