Transcript Joint Injections in Primary Care

Joint Injections in
Primary Care
Marc A. Aiken, MD
Watauga Orthopaedics
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
The Most Common
Joints Injected
• Knee
• Shoulder (glenohumeral jt.)
• Shoulder (subacromial bursa)
Indications Diagnostic
• Evaluate fluid aspirate for:
• Infection
• Inflammatory arthropathy
• Trauma
• Relief of pain immediately following
injection indicates an intraarticular
source
Indications Therapeutic
• Relief of pain/inflammation caused by:
• Effusion
• OA, RA, Gout
• Bursitis
• Selected tendonopathies
Absolute
Contraindications
• Local cellulitis
• Prosthetic joint
• Septicemia
• Acute fracture
• Patella and achilles tendonopathy
• Allergy to injection medications
Relative
Contraindications
• Anticoagulated/coagulopathic patient
• Diabetes
• Immunocompromised patient
• Minimal or no relief with 2 prior
injections
• Local osteoporosis
• Inaccessible joints
Medications
• Corticosteroid
• Local anesthetic
• Hyaluronic acid
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
Other Steroids
• Triamcinolone (Aristospan)
• Dexamethasone (Decadron)
• Methylprednisolone (Depo-Medrol)
Local
• 1% Lidocaine (Xylocaine) without epi
• useful for intraarticular injection and
subcutaneous injection when
aspirating
• onset within minutes
• can be diagnostic tool
Local
• Bupivicaine (Marcaine)
• Potential cause of chondrocyte death
• Avoid intraarticular use
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.
Reactions/Complicati
ons
• 2-5% - Post injection (steroid) flare
• 0.8% - Steroid arthropathy (AVN,
Chondrolysis, etc.)
• Iatrogenic infection
• Flushing
• Skin atrophy and depigmentation
Reactions/Complicati
ons
• Loss of glucose control in DM
• Increased appetite
• Insomnia
• Irritability
General
Considerations
• Evaluate the patient
• Patient education
• Consent
• Patient Comfort
• Sterile preparation and technique
• Documentation
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
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
Consent
• Written Vs. Verbal
• Your choice
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
•
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
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
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
Document
• Amount of fluid aspirated
• color, clarity and viscosity of fluid
• purulent?
• Blood? (trauma)
• Lipid?(trauma/occult fx)
Send Fluid for
Analysis
• Labs ordered from fluid:
• Cell Counts (stat if infection
suspected)
• Cultures
• Gram stain (stat)
• Polarized light microscopy
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
Injection Technique
• Intraarticular knee
• Intraarticular Shoulder
• Subacromial bursa
Supplies
Knee
Aspiration/Injection
• Superolateral approach most reliable
• 93% accuracy vs. 71-75% with bent
knee anteromedial/anterolateral
approach
Superolateral
Approach
•
•
Patient Supine with
knee extended
Palpate bony
landmarks
•
•
Patella
Lateral Femur
Palpate Patella
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
The Injection
•
•
•
Reassure patient
Relaxed quads = more
space at PF jt
Needle Trajectory
•
•
15-20 degrees
Toward trochlea of
femur
Needle Trajectory
Anterior Approach
(bent knee)
Anterior Approach
• Less reliable/accurate than
superolateral approach
• Can be easier in the obese knee
• Patient sitting with knee bent to 90
degrees
Anterior Approach
• Palpate landmarks
• Inferior pole of patella
• Patella tendon
• Tibial Plateau
Landmarks - Patella
Landmarks - Plateau
Landmarks
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
Trajectory
Shoulder (GH joint)
• Anterior approach
• Position patient sitting facing provider
• Palpate bony landmarks
• Clavicle
• Coracoid
Landmarks
Palpate - Clavicle
Clavicle
Coracoid
Needle Placement
•
•
•
Inject just lateral to
coracoid process
20 degree angle
Reposition if you
encounter resistance
Shoulder (SA Bursa)
• Given lateral or posterior
• Just beneath the angle of the acromion
Acromion
Subacromial Injection
•
Direct needle under
acromion
Questions?