JOINTS

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JOINTS

• Injections
• Aspirations

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Rationale

• Primary care providers should master the
  technique of joint aspiration and injection for
  many reasons
• Diagnosing an inflamed joint
• Pain relief of a distended joint
• Injection of steroids for painful joint

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Indications

• Diagnostic
• To evaluate synovial fluid
• Infections
• Rheumatic
• Traumatic
• Crystal-induced etiology
• Therapeutic
• Remove exudate from septic joint
• Relieve pain in grossly swollen joint
• Inject lidocaine, saline, corticosteroids

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Contraindications

• Cellulitis or broken skin over entry site
• Anticoagulant therapy not well tolerated
• Septic effusion of a bursa
• More than 3 previous injections to weight bearing
  joint in last 12 months
• Suspected bacteremia
• Unstable joint
• Inaccessible joint

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Contraindications

• Absolute
• Local sepsis
• Suspicion of infection
• Sepsis
• Hypersensitivity
• Early trauma

• Hemarthrosis
• Prosthetic joint
• Very unstable joint
• Reluctant patient
• Children

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Contraindications

• Diabetic
• Anticoagulated
• Bleeding disorder
• Immunosuppressed
• Psychogenic pain
• Severe anxiety
• Gut feeling

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Equipment

• Betadine
• Sterile gloves
• 22- to 27-gauge needle for injections
• 18-gauge needle for aspirations
• 10cc syringe
• 30cc syringe is aspirating large amount
• Lidocaine
• Culture tubes

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Pre-procedure Patient Education

• Risks
• Benefits
• Possible complications
• Pain
• Infection
• Bleeding
• Tendon damage

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Technique

• Before injection, consider differential.
• X-rays if tumor or fracture possible
• Identify entry site and mark
• Prep with betadine
• Inject wheel of lidocaine and advance for deeper
  anesthesia with 27-gauge needle
• Use 18-gauge needle inserted into desired
  location and aspirate or 22-gauge and inject
  medication

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Lab Analysis of Fluid

• White blood cell count
• lt50,000 inflammatory
• gt50,000 infectious
• Polymorphonucleocyte percentage
• Crystals
• If fluid cloudy, culture

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Septic Arthritis

• Infection occurs by
• Hematogenous spread
• Contiguous source
• Direct implantation
• Postoperative complication

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Septic Arthritis

• Early diagnosis essential
• Growth impairment
• Articular destruction
• Osteomyelitis
• Soft tissue expansion

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Septic Arthritis

• Neisseria gonorrheoae
• Adolescents and young adults
• Staphylococcus
• Patientsgt 40, medical illnesses
• Streptococcus

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N. gonorrhoeae

• Majority in women
• With or without anogenital symptoms
• Occurs during menstruation/pregnancy
• Positive culture 25-60
• Positive Gram stain 65
• WBC and glucose helpful

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Synovial Fluid Analysis

• String sign
• Cell count
• Glucose
• Gram stain
• Crystals

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Synovial Fluid Interpretation
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Joint Injection
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The Drugs

• Corticosteroids
• Rationale for Using Steroid Injection
• Suppressing inflammation
• Short acting Hydrocortisone
• Intermediate acting
• Methylprednisone/Triamcinolone
• Long acting Dexamethasone

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Side Effects

• Systemic
• Facial flushing
• Uterine bleeding
• Deterioration of Diabetic glycemic control
• Significant falls in the ESR and CRP levels
• Other rare side effects
• Anaphylaxis

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Side Effects

• Local
• Post-injection flare of pain
• Subcutaneous atrophy
• Bleeding or bruising
• Soft-tissue calcification
• Steroid arthropathy
• Tendon rupture
• Joint sepsis
• Soft tissue infection

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Local Anesthetics

• Rationale for using
• Diagnostic
• Analgesic
• Dilution
• Distension
• Commonly used
• Lidocaine
• Bupivacaine

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Safety Precautions

• Aseptic Technique
• Adverse Reactions
• Syncope
• Anaphylaxis

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Aspiration

• Frank blood
• Serous fluid
• Serous fluid streaked
• Xanthochromic fluid
• Turbid fluid
• Frank pus
• Other

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Injection Technique

• Equipment
• Syringes
• Needles
• Corticosteroids
• Local anesthetic
• Dosage and volume

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Injection Technique

• Technique
• Tissues
• Bursa and joint
• Tendons and ligaments
• Tendons with sheaths
• Blood vessels
• Aspirations

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Preparation Protocol

• Prepare patient
• Prepare equipment
• Prepare site
• Assemble equipment
• Sterile technique

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Most Common Aspirations and Injections
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The Knee
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The Knee
Landmarks Medial patella middle to superior
portion Insertion 1 cm medial to anteromedial
patella edge. Directed between posterior surface
of patella and intercondylar femoral notch
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Knee Joint
Lateral
Medial
Knee slightly flexed
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The Elbow
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The Elbow
Landmarks Lateral epicondyle and radial head With
elbow extended the depression is
palpated Insertion 22-ga needle from lateral
aspect just distal to lateral epicondyle and
direct medially
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The Elbow
Lateral Epicondylitis (Tennis Elbow) Symptoms
pain with elevation of third digit against
resistance, with wrist and elbow held in
extension Approach Point of Max Tenderness
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The Elbow
Olecranon Bursitis Diagnosis obvious Approach
20-ga needle into dependent aspect of sac
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The Wrist
De Quervains Synovitis Injection The needle is
placed into the first extensor compartment and
directed proximally toward the radial styloid.
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Questions?