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Ultrasound · Hip

Anterior Intra-articular Injection (Femoral Head–Neck Junction)

hipintra-articulariliopsoaslfca

Treats

  • Hip osteoarthritis
  • Labral irritation
  • Diagnostic anesthetic

Contraindications

  • Active local skin infection at entry site (absolute)
  • Suspected septic joint (absolute — aspirate first)
  • Bacteremia (absolute)
  • Known allergy to local anesthetic, steroid, or antiseptic prep
  • Therapeutic anticoagulation — review case-by-case (deep injection)
  • Uncontrolled diabetes (relative)
  • Hip prosthesis at the target site (relative — coordinate with orthopedics)

Pre-procedure checklist

  • Confirm patient identity (two identifiers)
  • Confirm procedure, side, and site — mark with patient awake
  • Review allergies and anticoagulation
  • Confirm informed consent
  • Pre-scan: identify femoral NV bundle medial to target; NAVEL runs lateral-to-medial at the groin — Nerve (most lateral), Artery, Vein, Empty space, Lymphatics; needle entry is just lateral to the femoral nerve.
  • Confirm needle length adequate for depth — BMI > 35 may require 22G 5" / 127 mm
  • Time-out immediately before needle entry

Positioning

  • Supine; hip neutral (often ~20° abduction)
Positioning

Probe

  • Low-frequency curvilinear probe (2-5 MHz)
Probe

Landmarking — find the view

  • Visual Cue: The “Head-Neck Slope” — identify the round femoral head transitioning into the flatter neck.
  • Identify the iliopsoas muscle/tendon directly superficial to the capsule.
  • Oblique Transverse Scan: Align the probe with the long-axis of the femoral neck.
  • Doppler Survey: Identify the ascending branch of the lateral femoral circumflex artery (LFCA).

The correct ultrasound view

  • Round head narrowing into neck; thin capsule; iliopsoas superficial
The correct ultrasound view

Needle corridor

  • Inferolateral → superomedial under iliopsoas (above) to capsule at head-neck junction (below)
Needle corridor

Avoid

  • Femoral nerve, artery, vein (medial to needle entry) — NAVEL lateral-to-medial: Nerve · Artery · Vein · Empty space · Lymphatics
  • Ascending branch of lateral femoral circumflex artery
  • Lateral femoral cutaneous nerve — its branches cross the anterolateral entry region superficially; identify and avoid before needle entry (lateral thigh numbness if injured).

Steps

  1. 1In-plane to capsule; test inject to lift capsule.
  2. 2Stop the needle tip exactly at the capsule of the head-neck junction — do NOT advance past the capsule. Overpenetration directs the tip toward the femoral head articular cartilage or acetabulum, not toward the femoral vessels (which are medial at the femoral triangle).
  3. 3Complete injection as indicated; confirm intra-articular placement by seeing injectate distend the capsule and track along the femoral neck.
  4. 4STOP IMMEDIATELY if the patient reports electric, shooting, or paresthetic sensations in the leg.

Tips

  • Continuously track needle tip; small tilts help follow it through iliopsoas.
  • Limit corticosteroid to ≤ 3 per joint per year.
  • If color Doppler shows the LFCA ascending branch in the planned path, abandon and re-plan.

Resident pearls

  • Visualizing Depth: Use a spinal needle (22G 3.5" standard, 5"/127 mm if BMI > 35); the depth can be surprising. If the needle disappears, use a slight 'jiggle' to find it in the iliopsoas.
  • Scan the femoral head-neck junction using an oblique transverse plane.
  • Confirmation of intra-articular placement requires seeing injectate DISTEND THE CAPSULE and track along the femoral neck under the capsule — not simply pool under the iliopsoas (which would indicate iliopsoas bursa placement, ~15% communicate with the joint but this is bursa-only).
  • Identify the ascending branch of the lateral femoral circumflex artery with Doppler before entry.

Supplies

  • 10 mL Syringe
  • 22G 3.5" Spinal Needle (use 22G 5" / 127 mm in patients with BMI > 35)
  • 18G Drawing Needle
  • 1% Lidocaine (5-10 mL)
  • Triamcinolone 40 mg OR Dexamethasone 4-10 mg
  • Alcohol Swabs (vial tops)
  • Betadine/Chloraprep
  • Sterile Gloves
  • Sterile 4x4 Gauze Pads
  • Sterile Towels & Drapes
  • Adhesive Bandage (Band-Aid)
  • Washcloth/Towel (gel cleanup)
  • Needle Disposal Safety Cap
  • Sterile probe cover & gel

Post-procedure

  • Apply a clean dressing; remove after 24 hours.
  • Local anesthetic relief for 1-4 hours; steroid begins 24-72 hours.
  • Steroid 'flare' in 2–10% — manage with ice and acetaminophen.
  • Rest the hip 24-48 hours; resume normal activity as tolerated thereafter.
  • Return immediately for: spreading redness, swelling, fever, disproportionate pain, OR new leg weakness or numbness.
  • Diabetics: expect 50-100 mg/dL glucose rise for 3-5 days.
  • Maximum 3 injections per joint per year.