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Joint injections

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Joint injections Dave Shackles Rationale Primary care providers should master the technique of joint aspiration and injection for many reasons: Diagnosing an inflamed ... – PowerPoint PPT presentation

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Title: Joint injections


1
Joint injections
  • Dave Shackles

2
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
  • And others?

3
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

4
Basic principles before you start
  • History and examination
  • Try conservative treatment first eg NSAIDs and
    continue after joint injection.
  • Careful patient selection
  • Consent
  • Know your anatomy!
  • Undertake as few injections as possible to settle
    the problem, max 3-4 in a single joint
  • Consider differential diagnosis do you need x-ray
    first?

5
Indications for injection
  • Osteoarthritis
  • Rheumatoid arthritis
  • Gouty arthritis
  • Synovitis
  • Bursitis
  • Tendonitis
  • Muscle trigger points
  • Carpal tunnel syndrome

6
Contraindications
  • Absolute
  • Local sepsis
  • Suspicion of infection
  • Sepsis
  • Hypersensitivity
  • Early trauma
  • Hemarthrosis
  • Prosthetic joint
  • Very unstable joint
  • Reluctant patient
  • Children

7
Contraindications?
  • Charcot joint (neuropathic sensory loss)
  • Tumour
  • Neurogenic disease
  • Active infections (eg, tuberculosis)
  • Immune-suppressed hosts
  • Hypothyroidism
  • Diabetic
  • Anticoagulated
  • Bleeding disorder
  • Immunosuppressed
  • Psychogenic pain
  • Severe anxiety
  • Gut feeling

8
What to warn the patient
  • Risks v benefits
  • Pain returns after 2 hours, when the local
    anaesthetic wears off may be worse than before.
  • If pain is severe or increasing after 48hrs, seek
    advice
  • Warn of local side effects. Depigmentation
  • Tendon damage
  • Bleeding
  • Advise to seek help if systemic s/es develop
    suggesting infection

9
The Drugs
  • Corticosteroids
  • Suppress inflammation
  • Short acting Hydrocortisone
  • Intermediate acting
  • Methylprednisone/Triamcinolone
  • Long acting Dexamethasone
  • Local anaesthetics
  • Diagnostic ,Analgesic ,Dilution, Distension
  • Commonly used
  • Lidocaine
  • Bupivacaine

10
Technique
  • Object is to inject the corticosteroid with as
    little pain and as few complications as possible.
  • Do not attempt any injections in the vicinity of
    known nerve or arterial landmarks eg lateral
    epicondyle of elbow ok, medial beware ulnar
    nerve
  • Never inject into substance of a tendon
  • Sterile technique

11
Technique 2
  • ANTICIPATION!
  • Get your kit ready ie
  • Needles, syringes, sterile container, LA,
    steroid, gloves, drapes, chlorhexidine, cotton
    wool, plaster.
  • 1 or 2 needle technique
  • Clean area

12
Technique 3
  • Always withdraw syringe back first to ensure not
    injecting into blood vessel
  • Inject LA first
  • eg lidocaine 1 or marcaine.
  • Wait 3-5 mins then use larger bore needle to
    inject corticosteroid
  • Eg hydrocortisone acetate, methylprednisolone
    acetate, triamcinolone hexacetonide

13
Local side effects
  • Infection, subcutaneous atrophy, skin
    depigmentation, and tendon rupture (lt1).
  • Post-injection flare in 2-5
  • Often are the result of poor technique, too large
    a dose, too frequent a dose, or failure to mix
    and dissolve the medications properly.
  • NB corticosteroid short duration of action can
    be as short as 2-3 weeks relief.

14
Knee injections
  • Patient on the couch, knee slightly bent
  • Palpate superior-lateral aspect of patella
  • Mark 1 fingerbreadth above lateral to this site
  • Clean
  • LA, corticosteroid
  • Clean bandage

15
Knee Joint
Lateral
Medial
Knee slightly flexed
16
Plantar fasciitis
  • Procedure painful no evidence for long-term
    benefit
  • Pt indicate tender spot
  • Approach from thinner skin direct
    posterior-laterally
  • Small blelb as near to bony insertion as possible
  • Do not inject fascia itself

17
Shoulder injection
  • Glenohumeral joint
  • AC joint
  • Subacromial space
  • Long Head of Biceps
  • Older patients 2-3 x/ year
  • Younger consider surgery if no improvement
    (risk rotator cuff rupture)

18
Glenohumeral joint injection
  • Pt sits, arm by side, externally rotated
  • Find sulcus between head of humerus and acromion
  • Posterolateral corner of acromion (2-3 cm
    inferior)
  • Direct needle anteriorly toward coracoid process
  • Insert needle to full length
  • Fluid should flow easily

19
AC joint injection
  • Palpate clavicle to distal aspect
  • Slight depression where clavicle meets acromion
  • Insert needle from anterior and superior approach
  • Direct needle inferiorly

20
Sub-acromial joint injection
  • Posterior and lateral aspect of shoulder
  • Inferior to lower edge of posterolateral acromion
  • Insert inferior to acromion at lateral shoulder
  • Direct needle toward opposite nipple
  • Insert needle to full length
  • Fluid should flow easily

21
The Elbow
22
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
23
The Elbow
Olecranon Bursitis Diagnosis obvious Approach
20-ga needle into dependent aspect of sac
24
Elbow epicondyle injection
  • Very effective in short term 92
  • Benefits do not normally persist beyond 6 weeks
  • Lateral (tennis elbow) medial (golfers elbow)
    epicondylitis
  • Patient supine

25
Tennis elbow (lateral)
  • Arm adducted at side
  • Elbow flexed to 45 degrees
  • Wrist pronated
  • Insert needle perpendicular to skin at point of
    maximal tenderness
  • Insert to bone, then withdraw 1-2 mm
  • Inject corticosteroid solution slowly

26
Golfers elbow (medial)
  • Beware ulnar nerve!
  • Rest arm in comfortable abducted position
  • Elbow flexed to 45 degrees
  • Wrist supinated
  • Point of maximal tenderness - insert to bone,
    then withdraw 1-2 mm
  • Inject corticosteroid solution slowly

27
De Quervains tenosynovitis
  • Inflammation of thumb extensor tendons
  • -Extensor pollicis brevis
  • -Abductor pollicis longus
  • Occurs where tendons cross radial styloid

28
De Quervains tenosynovitis
  • Maximally abduct thumb (accentuates abductor
    tendon) Injection site
  • Snuffbox at base of thumb
  • Aim 30-45 degrees proximally toward radial
    styloid
  • Insert needle between the 2 tendons (not in
    tendon)
  • Do not inject if paraesthesias (sensory branch
    radial nerve)
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