Joint Injections in Primary Care

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Joint Injections in Primary Care

• Marc A. Aiken, MD
• Watauga Orthopaedics

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Objectives

• Understand when it is appropriate to inject
  /aspirate a joint
• Review common injection medications
• review pertinent anatomy for safe injection
  technique
• Review technique for injections in most common
  joints
• When to refer

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The Most Common Joints Injected

• Knee
• Shoulder (glenohumeral jt.)
• Shoulder (subacromial bursa)

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Indications - Diagnostic

• Evaluate fluid aspirate for
• Infection
• Inflammatory arthropathy
• Trauma
• Relief of pain immediately following injection
  indicates an intraarticular source

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Indications - Therapeutic

• Relief of pain/inflammation caused by
• Effusion
• OA, RA, Gout
• Bursitis
• Selected tendonopathies

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Absolute Contraindications

• Local cellulitis
• Prosthetic joint
• Septicemia
• Acute fracture
• Patella and achilles tendonopathy
• Allergy to injection medications

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Relative Contraindications

• Anticoagulated/coagulopathic patient
• Diabetes
• Immunocompromised patient
• Minimal or no relief with 2 prior injections
• Local osteoporosis
• Inaccessible joints

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Medications

• Corticosteroid
• Local anesthetic
• Hyaluronic acid

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Steroid

• Betamethasone (Celestone Soluspan)
• Agent of choice in my practice
• Long acting
• 6-12mg for large joint (knee, shoulder)
• 1.5-6mg for small/intermediate joints

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Other Steroids

• Triamcinolone (Aristospan)
• Dexamethasone (Decadron)
• Methylprednisolone (Depo-Medrol)

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Local

• 1 Lidocaine (Xylocaine) without epi
• useful for intraarticular injection and
  subcutaneous injection when aspirating
• onset within minutes
• can be diagnostic tool

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Local

• Bupivicaine (Marcaine)
• Potential cause of chondrocyte death
• Avoid intraarticular use

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Hyaluronic Acid

• Lube job for the knee
• Replaces HA deficient arthritic knee fluid with
  thick viscous HA.
• Expect 6 months of relief
• Given in 3 injections 1 week apart
• Relief may not be obtained for up to 8wks
  following last injection.

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Adverse Reactions/Complications

• 2-5 - Post injection (steroid) flare
• 0.8 - Steroid arthropathy (AVN, Chondrolysis,
  etc.)
• Iatrogenic infection
• Flushing
• Skin atrophy and depigmentation

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Adverse Reactions/Complications

• Loss of glucose control in DM
• Increased appetite
• Insomnia
• Irritability

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General Considerations

• Evaluate the patient
• Patient education
• Consent
• Patient Comfort
• Sterile preparation and technique
• Documentation

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Evaluate the Patient!!

• Avoid the Knee hurt....me inject mentality.
• Get a complete history
• Examine the patient including other joints
• Obtain x-rays
• MRI only if appropriate

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Patient Education

• What medications are being used
• What is the injection expected to do for them
• What it is not expected to do
• When they will notice effects of injection
• What if the expected results are not achieved

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Consent

• Written Vs. Verbal
• Your choice

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Patient Comfort

• Lying down for knees (superolateral approach)
• Sitting up for shoulders
• Take your time
• Use ethyl chloride (cold spray) immediately
  before injection
• Explain the steps of the procedure as you do them

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Patient Comfort

• In patients with severe anxiety regarding
  needles, provide alternatives or allow them to
  schedule the injection on a different date. This
  may allow them time to mentally prepare for the
  injection.
• Injections are usually far less painful than
  patient anticipate

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Sterile Prep/Technique

• Make sure injection site is fully exposed
• Should not be visibly soiled
• Use iodine or chlorhexidine prep over site to be
  injected
• Alway use aseptic technique
• Consider use of sterile gloves
• Sterile drapes generally unnecessary

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Documentation

• Document the history and physical exam findings
  that support the decision to perform
  aspiration/injection
• Site (which joint and which side)
• Anatomic placement (med, lat, ant etc)
• medications and doses injected
• Expiration dates and lot numbers

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Document

• Amount of fluid aspirated
• color, clarity and viscosity of fluid
• purulent?
• Blood? (trauma)
• Lipid?(trauma/occult fx)

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Send Fluid for Analysis

• Labs ordered from fluid
• Cell Counts (stat if infection suspected)
• Cultures
• Gram stain (stat)
• Polarized light microscopy

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Post Injection Care

• Remove visible prep solution
• Bandaid
• Pressure dressing on free bleeders
• Rest and Ice for 24 hours
• Warn about limitation of local anesthetic
• Warn about steroid flare

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Injection Technique

• Intraarticular knee
• Intraarticular Shoulder
• Subacromial bursa

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Supplies
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Knee Aspiration/Injection

• Superolateral approach most reliable
• 93 accuracy vs. 71-75 with bent knee
  anteromedial/anterolateral approach

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Superolateral Approach

• Patient Supine with knee extended
• Palpate bony landmarks
• Patella
• Lateral Femur

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Palpate Patella
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X Marks the Spot

• Palpate lateral border of patella and Lateral
  femur at the PF joint
• The space between these bony structures is your
  injection site

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The Injection

• Reassure patient
• Relaxed quads more space at PF jt
• Needle Trajectory
• 15-20 degrees
• Toward trochlea of femur

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Needle Trajectory
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Anterior Approach (bent knee)
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Anterior Approach

• Less reliable/accurate than superolateral
  approach
• Can be easier in the obese knee
• Patient sitting with knee bent to 90 degrees

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Anterior Approach

• Palpate landmarks
• Inferior pole of patella
• Patella tendon
• Tibial Plateau

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Landmarks - Patella
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Landmarks - Plateau
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Landmarks
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Injection Site

• May inject medial or lateral to patella tendon
• 1cm above tibial plateau or
• Half the distance from plateau to inferior pole
  of patella
• Trajectory of needle should be toward
  intercondylar notch

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Trajectory
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Shoulder (GH joint)

• Anterior approach
• Position patient sitting facing provider
• Palpate bony landmarks
• Clavicle
• Coracoid

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Landmarks
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Palpate - Clavicle
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Clavicle
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Coracoid
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Needle Placement

• Inject just lateral to coracoid process
• 20 degree angle
• Reposition if you encounter resistance

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Shoulder (SA Bursa)

• Given lateral or posterior
• Just beneath the angle of the acromion

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Acromion
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Subacromial Injection

• Direct needle under acromion

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Questions?