Transcript Musculoskeletal Injections - Canadian Rural Orthopedics CJP

Clinical Musculoskeletal
Injections
Chris Parfitt MD FRCS©
Disclosures
► none
► (I
like giving injections)
Musculoskeletal Injections
►A
bit like moose
hunting
► Chasse
l’orignal
Moose Hunting
► Hunting
licence
► Right animal (moose)
► Right caliber rifle
► Right type of bullet
► YOU HAVE TO HIT
THE TARGET
Musculoskeletal Injections
► Medical
licence
► Right diagnosis
► Right needle
► Right dose of medicine
► YOU HAVE TO HIT
THE TARGET
MSK Injections General
► Informed
consent
► Procedure
► Benefits
► Risks
► In writing or verbal
► ALWAYS ASK ABOUT
ALLERGY!!
MSK Injections General
► The
equipment
► Antiseptics
► bandages
MSK Injections General
► Equipment
► Assorted
long and
short acting local
anesthetics
► With and without
epinephrine
Types of Cortisone
► Triamcinolone
40 mg
cc (potency 5)
► Methylprednisone 40
mg/cc (potency 5)
► Betamethasone 6 mg
/cc ( Potency 25)
► Kenalog
► Depomedrol
► Celestone
SAFETY of WHAT we INJECT
► Currently
no strongly
stated rules about
what we inject into a
joint
► BUT!!!
Steroid shots and blood sugar
► Methylprednisolone
► No
effect
40 mg
► Triamcinolone 40 mg
► Increases
blood sugar
► betamethasone
► Increases
blood sugar
PAIN PUMPS
► Used
post operatively
starting about 2002
► Marcaine with epi
Bupivacaine and Chondrolysis
► Bupivocaine
epinephrine infusion
pumps caused high
rates of chondrolysis
► 2005 to 2008
Bupivacaine Chondrolysis
► Now
a whole crop of
pain pump lawsuits
Injections and Chondrotoxicity
► Apoptosis
of
chondrocytes is a
validated
measurement of
chrondrocyte toxicity
Injections and Chondrotoxicity
prednisolone cause
chondrocyte death in
ex vivo chondrocytes,
betamethasone did not
► Farkas et al CORR
2010
►
► All
local anesthetics
caused chondrocyte
death
► Dose and time related
► Farkas et al CORR
2010
Injections and chondrotoxicity
► All
local anesthetic
toxicity to
chondrocytes
potentiated with
epiniphrine
Injections and Chondrotoxicity
► The
combination of
cortisone and local
anesthetic is possibly
synergistic in causing
chondrotoxicity
Chondrotoxicity: current
recommendations
► Although
common
practice is to inject
steroid and local
anesthetic together
► There are no specific
recommendations in
the literature
Injections and Chondrotoxicity
► Intuitively?
► Use
.5% lidocaine,
.25% bupivocaine
► Use bupivocaine, also
prednisolone
► Inject steroid with
saline
Injections and Chondrotoxicity
► If
joint already bone
on bone, there are no
chondrocytes to be
toxic to, therefore
longer acting local
anesthetic can be
used!
Injections: Tenocyte toxicity
► Some
studies show
tenocyte toxicity with
steroids and local
anesthetic
► More dilute local
anesthetic less toxic
MSK Injections General
► Assorted
syringes
► Preneedled
syringes
are time saving
► Draw
up solution with
larger needle
► demo
MSK Injections Needle size
► 1.5
inch 25 gauge for
fine injections
► 1.5
inch 21 gauge is
optimal for larger
joints (shoulder and
knee)
MSK Injections General
► Triamcinolone
► 40
mg mil
► Methyl
prednisone
40 mg miL
► Betamethasone
6 mg mil
MSK Viscosupplementation
► Hyaluronic
acid now
just over 200$
► Approved for arthitis
(mostly knee studies)
PLATELET RICH PLASMA
► Becoming
more
common
► Cost from 400 to 800$
PRP Soft tissue
► Cochrane
review 2014
► Insufficient
evidence to
support use for MSK
soft tissue injuries and
tendopathies
PRP Knee arthritis
► General
concensus is
that PRP injections as
good
► Or slightly better than
Hyaluronic acid and
saline injection
► More side effects
► AAOS March 2015
MSK Injections Technique
► One
needle (mixed)
► Two
needles
(prefreezing)
► Less
experienced
should prefreeze
MSK Injections Technique
► Betadine
best as you
can see where it is
demo
► Wait
until it dries (until
the screaming stops)
► Prep,
then prepare the
injection
Tricks of the trade
► Assess
resistance for injections into space
► DO NO HARM
► Need
► demo
large bore needle to draw up solutions
MSK Injections: New kid on the
block
► Ultrasonically
guided injections
► Rapidly becoming more common
► Need US machine and training
► Price of US machine decreasing
► Not discussed today
TRIGGER FINGER INJECTIONS
► Evidence
based
► ANN RHEM DIS 2008
sept;7(9) 1262-1266
Trigger Finger
► .5cc
steroid
► 1 – 2 cc local
anesthetic
► Don’t inject into the
tendon
► Inject into or around
synovial sheath
Trigger Finger
► HOT
OFF THE PRESS
► Peri
pulley injection
had higher success
rate than intra sheath
injection
Basal Joint arthritis
► CMC
joint arthritis
Basal Joint Arthritis
► Slight
traction
► Prefreezing
very
helpful
► .5 cc steroid (20mg)
1cc of local anesthetic
marcaine E
De Quervains Disease
► Evidence
based
► BMC MSK disorders
2009 Oct 27;10;131
► .5 to 1 cc steroid (20 –
40 mg) 2cc to 3 cc
local anesthetic
De Quervain’s Disease
► Inject
into or around
the sheath
Tennis Elbow
► Evidence
that
cortisone is beneficial
for at least short term
relief
Tennis Elbow
► Use
3 to 5cc, marcaine
with epi 40 mg
cortisone
► Inject the extensor
origin
► Use single needle
► Patient leaves office
pain free
Shoulder Injections
► Cochrane
summary
says no better
injection success with
clinical vs ultrasound
guided injection
► (for now)
Shoulder Injections
► Rotator
Cuff Tendinitis
or tear in elderly
► Evidence based
► Duration of benefit
variable in different
studies
Shoulder Injections
► Subacromial
injection
► Use 2 cc of steroid
(80) mg with 8 cc of
long acting local
anesthetic
► Posterior, slide needle
under acromion
Shoulder Injections
► Arthritis
or frozen
shoulder
► 8cc marcaine with epi,
1-2 cc steroid (40 to
80mg)
Shoulder Injections
► Glenohumeral
injection
► Posterior, in soft spot
► Arm internally rotated
Trochanteric Bursa injections
► Evidence
► Journal
based
rheum. 1996
► Dec;23;(12) 2104-6
Trochanteric bursitis
► Large
joint
► 2cc 80 mg steroid
► 8cc marcaine with epi
► Lateral position, hip
extended
► Long needle
► Marcaine with epi
► Single needle
Knee injections
► Evidence
based
► Cochrane
database
► Both
steroids and
viscosupplemtation
Knee injections
► Large
joint
► Use 2 cc steroid
► (80 mg)
► 8cc anesthetic/saline
.5% lidocaine, .25%
marcaine
► Lateral subpatellar
approach
Knee Injection
► Leg
extended
► Relaxed
► Pull kneecap laterally
► Needle goes under the
superior patella
► Great for aspiration
Knee injection: Preaspiration?
► One
study on RA
patients demonstrates
better response with
preaspiration for
steroid injections
► Weitoff, Journal
rheumatic dis. 2000
Hallux Rigidus Injection
► Arthritis
great toe
► No good studies on
this
► Lots of personal
positive experience
Hallux rigidus injection
► Better
done with 2
needle (prefreeze)
► 25 gauge needle
► Small joint
► 1cc marcaine E and
less than one half cc
steroid
MSK Injections
► Questions