Joint injection

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Joint injection

• Dr Amit Saha
• Consultant Rheumatologist Clinical Lead for
  Rheumatology- Maidstone and Tunbridge Wells NHS
  Trust
• Spire Tunbridge Wells- TALK

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• Introduction course-
• Focus on 90 of injections- knee, wrists shoulder
  
• When to inject and aspirate need diagnosis
  first
• Safety

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Shoulder

• Frozen shoulder (adhesive capsulitis)
• Subacromial impingement syndromes

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Frozen Shoulder

• Stiffened gleno-humeral joint that has lost
  significant range of motion (abduction and
  rotation).
• 40-60s
• Dis-use sling, recent operation, pre-existing
  shoulder complaint
• 50 reduction in all movements (especially
  external rotation)

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Frozen Shoulder

• In SAI though active movement reduced,
  passively you can push full movement.
• Patients with frozen shoulder have varying
  degrees of pain early in the disease course, but
  complain primarily of joint stiffness. Symptoms
  generally develop over the course of weeks to
  months.
• No X-rays generally needed (exception if you
  think there is gleno-humeral OA)

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Treatment

• Acute (first 8 weeks)- NSAIDs and avoid excessive
  activities
• Gentle exercises- Pendular exercises (evidence
  weak) plus stretching exercises.
• Revaluate in 8 weeks Continue or inject

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• Randomized trial of 109 patients.
• At seven weeks, 40 of 52 patients randomly
  assigned to glucocorticoid injection were
  considered to have a treatment success compared
  with 26 of 56 patients (46 percent) treated with
  physiotherapy.
• van der Windt DA et al. BMJ. 1998317(7168)1292.

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• Glucocorticoid injection may hasten recovery, and
  the addition of supervised physical therapy
  following glucocorticoid injection may result in
  more rapid improvement than injection alone.
  However, the long-term outcome of adhesive
  capsulitis may not be much affected by either
  intervention.

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• Four groups steroid plus supervised
  physiotherapy (PT), glucocorticoid injection
  alone, saline injection plus supervised PT, or
  saline injection alone.
• Those who received a glucocorticoid injection and
  supervised PT improved significantly more, and
  more rapidly, than any other group at six weeks
  those who received glucocorticoid injections were
  better than those who did not at three months.
• But by one year there was no discernible
  difference in improvement among the four groups.
• Carette et al. Arthritis Rheum. 200348(3)829.

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• Injection Approach - posterior approach

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Subacromial impingement syndromes

• Rotator cuff may be compressed during
  glenohumeral movement
• Painful daily activities may include putting on a
  shirt or brushing hair.
• Patients may localize the pain to the lateral
  deltoid and often describe pain at night,
  especially when lying on the affected shoulder.

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• Inspection Rotator cuff atrophy
• Palpation- focal subacromial tenderness at the
  lateral or posterior-lateral border of the
  acromion.
• Painful ROM that occurs between 60 and 120
  degrees of active abduction marks a positive arc
  test

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• Normal passive range of movement and power
• Beyond 150 degrees possible acromio-clavicular OA

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Treatment

• X-rays generally not needed
• Simple things first
• Injections- evidence weak. Systematic review poor
  trials.

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Knee

• OA knees
• Aspirate- gout/pseudogout/infection
• Works can be up to 6 months
• Certain patients better to use than others

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Carpal Tunnel syndrome

• Median nerve entrapment
• Classically 1-31/2 fingers
• Classic symptoms
• Tinels and phalens
• Splints first
• Surgery if severe damage
• Inject if splints fail

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Injections

• Discussed benefits already
• Risks Bleeding and infection less than 1 in
  10,000
• Aseptic
• INR less than 3 for large joints
• Post-injection flare- last few hours usually
  within 24-48 hours.
• Tendon damage Tendon rupture is most commonly
  encountered when undiluted glucocorticoid is
  given very near or into tendon
• Nerve damage
• Skin depigmentation
• Do not inject prosthetic joints
• Avoid general exertion for 24 hours.

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• Shoulder 40mg (1ml) Depo-medrone
  (methylprednisolone acetate) plus
  approximately1-2mls of 1 lidocaine
• Knee - 80mg (2ml) Depo-medrone (methylprednisolone
  ) plus approximately 2mls of 1 lidocaine
• Wrist 20mg (0.5ml) Depo-medrone plus 0.5ml 1
  lidocaine

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Frequency- evidence limited

• Inject very active large joints affected by
  rheumatoid arthritis as often as 3 injections per
  year for any given joint.
• For joints affected by osteoarthritis, can inject
  glucocorticoids as often as once every six months
  only if no other therapy is effective.

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• Green needle 21 gauge (knee and shoulder)
• Orange needle 25 gauge (wrist)
• 10ml syringe for knee and shoulder
• 1ml syringe for wrist
• Universal container
• Alcohol swabs (with 70 isopropyl alcohol)

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Knee injection

• Medial

• Superior
• Lateral

• Inferior

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