Transcript Joint injections - East Scotland Postgraduate GP

East Deanery
Joint injections
Dave Shackles
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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
• And others?
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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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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?
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Indications for injection
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Osteoarthritis
Rheumatoid arthritis
Gouty arthritis
Synovitis
Bursitis
Tendonitis
Muscle trigger points
Carpal tunnel syndrome
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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
•Charcot joint (neuropathic
sensory loss)
•Tumour
•Neurogenic disease
•Active infections (eg,
tuberculosis)
•Immune-suppressed hosts
•Hypothyroidism
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What to warn the patient
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• 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
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The Drugs
Corticosteroids:
Suppress inflammation
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Short acting: Hydrocortisone
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Intermediate acting:
Methylprednisone/Triamcinolone
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Long acting: Dexamethasone
Local anaesthetics
Diagnostic ,Analgesic ,Dilution, Distension
• Commonly used
Lidocaine
Bupivacaine
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Technique
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• 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
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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
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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
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Local side effects
East Deanery
• Infection, subcutaneous atrophy, skin
depigmentation, and tendon rupture (<1%).
• 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.
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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
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Knee Joint
Lateral
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Medial
Knee slightly flexed
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Plantar fasciitis
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•Procedure painful + no
evidence for long-term
benefit
•Pt indicate tender spot
•Approach from thinner
skin + direct posteriorlaterally
•Small blelb as near to
bony insertion as possible
•Do not inject fascia itself
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Shoulder injection
East Deanery
•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)
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Glenohumeral joint injection
East Deanery
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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
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AC joint injection
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Palpate clavicle to
distal aspect
Slight depression
where clavicle meets
acromion
Insert needle from
anterior and superior
approach
Direct needle inferiorly
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Sub-acromial joint injection
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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
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The Elbow
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The Elbow
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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
Olecranon Bursitis
Diagnosis obvious
Approach: 20-ga needle
into dependent aspect of
sac
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Elbow epicondyle injection
• Very effective in short term – 92%
• Benefits do not normally persist beyond 6 weeks
• Lateral (tennis elbow) + medial (golfer’s elbow)
epicondylitis
• Patient supine
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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
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Golfer’s elbow (medial)
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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
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De Quervain’s tenosynovitis
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Inflammation of thumb extensor tendons
-Extensor pollicis brevis
-Abductor pollicis longus
Occurs where tendons cross radial styloid
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De Quervain’s tenosynovitis
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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)
East Deanery
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