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Upper Extremity Injections

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Title: Upper Extremity Injections


1
Upper ExtremityInjections
Wren V. McCallister, MD
Surgery of the Hand Upper Extremity
2
Edmonds Orthopedic CenterEdmonds,
Washington425-673-3900
Jeffrey P. Remington, MD Brian D. Cameron,
MD James R. Alberts, MD Wren V. McCallister,
MD
3
Upper Extremity Injections
  • Trigger Finger
  • Carpal Tunnel
  • Thumb CMC joint
  • DeQuervians tenosynovitis
  • FCR tendonitis
  • Radial tunnel
  • Elbow Medial and lateral epicondylitis
  • Shoulder Subacromial and glenohumeral

4
Fundamentals of Injections
  • Risks
  • Nerve injury
  • Superficial branch of radial nerve when injecting
    1st dorsal compartment (DeQuervains
    tenosynotivitis)
  • Intraneural injection of median nerve (Carpal
    Tunnel syndrome)
  • Skin depigmentation
  • Fat atrophy
  • Tendon rupture
  • Repeated injections of flexor carpi radialis
    (FCR) tendon sheath

5
Fundamentals of Injections
  • What you inject
  • For intra-articular injections, can use
    longer-acting, less soluble steroids
  • For soft tissue injections, use shorter-acting,
    water soluble sodium dexamethasone
  • Sodium dexamethasone has also been shown to be
    the least toxic in the event of intraneural
    injection
  • In general, single injections are well tolerated.
    With multiple injections the risk of
    complications increases.

6
Trigger finger
  • Technique
  • Sterile skin preparation
  • 25g or smaller needle (use diabetic needle)
  • Can anesthetize skin with cold spray or
    subcutaneously with 1 lidocaine
  • Injection delivered near A1 pulley
  • evidence shows that you do not need to inject the
    pulley/tendon sheath itself

7
Trigger finger (continued)
  • Injection solution
  • 11 mixture 1 lidocaine without epinephrine and
    sodium dexamethasone (10mg/ml)
  • Anticipate numbness
  • in the digit after
  • injection

8
Carpal tunnel syndrome
  • Technique
  • Sterile skin preparation
  • 25g or smaller needle (use diabetic needle)
  • Can anesthetize skin with cold spray or
    subcutaneously with 1 lidocaine

9
Carpal tunnel (continued)
  • Injection delivered just ulnar to palmaris longus
    tendon
  • To identify the palmaris longus tendon, ask the
    patient to oppose thumb to small finger and flex
    wrist

Depiction of test to identify palmaris
longus (please disregard needle placement)
10
Carpal tunnel (continued)
  • Injection delivered just ulnar to palmaris longus
  • Asking patient to flex and extend fingers
  • will produce needle movement confirms
  • needle placement within carpal tunnel
  • (flexor tendon bounce test)
  • Ask patient to immediately inform you
  • of any electrical shocks or sensations
  • that would suggest intraneural needle
  • placement
  • Palpate distal edge of carpal tunnel with
  • opposite index finger to confirm filling

11
Carpal tunnel (continued)
  • Injection solution
  • 21 mixture 1 lidocaine without epinephrine and
  • sodium dexamethasone (10mg/ml)
  • Anticipate short duration of numbness in median
    nerve distribution

12
Thumb CMC joint arthritis
  • Technique
  • Sterile skin preparation
  • 25g or smaller needle (use diabetic needle)
  • Can anesthetize skin with cold spray or
    subcutaneously with 1 lidocaine
  • Injection delivered from dorsal approach into CMC
    joint
  • Can be challenging to locate joint, especially if
    there are large osteophytes

13
Thumb CMC joint (continued)
  • Injection solution
  • 11 mixture 1 lidocaine
  • without epinephrine and
  • sodium dexamethasone
  • (10mg/ml)
  • Injection is often painful as
  • joint is small and distends
  • rapidly

CMC joint
14
DeQuervains tenosynovitis
  • Technique
  • Sterile skin preparation
  • 25g or smaller needle (use diabetic needle)
  • Can anesthetize skin with cold spray or
    subcutaneously with 1 lidocaine
  • Injection delivered into 1st dorsal compartment
  • Palpate compartment filling with injection
  • Some advocate redirecting needle within
    compartment but cannot be sure that additional
    subcompartments are being entered. Balance
    against risk of injury to superficial branch of
    radial nerve

15
DeQuervains (continued)
  • Injection solution
  • 21 mixture 1 lidocaine without epinephrine and
    sodium dexamethasone (10mg/ml)
  • Risk of injury to superficial branch of the
    radial nerve (SRBN)
  • Patient may have a short duration of numbness in
    SBRN distribution if anesthetic is not contained
    in 1st dorsal compartment

16
Flexor carpi radialis (FCR) tendonitis
  • Technique
  • Sterile skin preparation
  • 25g or smaller needle (use diabetic needle)
  • Can anesthetize skin with cold spray or
    subcutaneously with 1 lidocaine
  • Injection delivered directly into FCR tendon
    sheath
  • Can palpate filling of the FCR tendon sheath (see
    Figure next slide)

17
FCR tendonitis (continued)
  • Injection solution
  • 11 mixture 0.5ml 1 lidocaine without
    epinephrine and 0.5ml sodium dexamethasone
    (10mg/ml)
  • Repeated
  • injections risk
  • tendon rupture

FCR?
18
Radial Tunnel
  • Coming soon

19
Medial epicondylitis
  • Coming soon

20
Lateral epicondylitis
  • Coming soon

21
Acromioclavicular (AC) joint
  • Coming soon

22
Glenohumeral joint
  • Coming soon

23
www.AskEdmondsHand.com
Stevens Orthopedic Group
Wren V. McCallister, MD
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