INDICATIONS FOR INJECTIONS
⦁ Wound Anesthesia ⦁ Osteoarthritis ⦁ Rheumatoid arthritis ⦁ Gouty arthritis ⦁ Synovitis ⦁ Bursitis ⦁ Tendonitis ⦁ Muscle trigger points ⦁ Carpal tunnel syndrome
- injecting into subcutaneous tissue of open wounds
local infiltration
LOCAL INFILTRATION
- injecting into subcutaneous tissue of open wounds
- clean & sterilize wound
- avoid toxic doses of lidocaine
⦁ 4 mg/kg for plain lidocaine
⦁ 7 mg/kg for lido + epi - epi = decreases blood loss / controls bleeding
max doses of lidocaine
⦁ 4 mg/kg for plain lidocaine (jen says 4.5)
⦁ 7 mg/kg for lido + epi
FIELD BLOCKS
- good for superficial lesions, such as skin abscesses
⦁ local anesthesia is not effective and is painful. May spread the infection
- prep skin with betadine or chlorohexidine
- inject slowly while advancing the needle, only go thru the skin twice
DIGITAL BLOCKS
- use 25-27 gauge needle
- each digit is supplied by 4 nerves: 2 dorsal, 2 palmar / plantar
- start dorsally, inject straight down each side of proximal phalanx
⦁ inject as you go - change angle
⦁ Big toe - may need to make a 3rd pass on the dorsal aspect
- Do not use if there is vascular compromise
⦁ be cautious using EPI HERE**
STEROID INJECTIONS
- for inflamed tendon / bursa by a bony prominence (ex: subacromial bursitis - tendonitis)
- inject combo: Lidocaine + Steroid
- indicated for when conservative treatment fails and for diagnosis
Prep skin with betadine swab (3x) or chloroprep (1x) - let dry
- slowly inject into point of maximum tenderness
- advance the needle to bone, then withdraw 2mm
common areas for injections
- Tennis elbow = lateral epicondylitis (pain with resisted wrist dorsiflexion = extension)
- Greater trochanteric bursitis - pain with stretching of lateral side of hip
⦁ Ober’s test
⦁ may need spinal need if bigger pt - Ischial tuberosity bursitis = Weaver’s bottom - pain with resisted knee flexion
⦁ be careful of sciatic nerve
Ober’s test
to identify tightness of the iliotibial band (iliotibial band syndrome)
AFTERCARE FOR TENDONITIS / BURSITIS INJECTIONS
- Rest, Ice, Anti-inflammatories
- Resume conservative treatment, including stretching
TRIGGER POINT INJECTIONS
⦁ Smaller volume ⦁ Inject into areas of tenderness ⦁ Mostly located into upper neck and mid back areas ⦁ Usually just use Lidocaine ⦁ Small needle, and gauge depth. ⦁ Remember skin atrophy and blanching
trigger points are most commonly located
in upper neck and mid back areas
sensitive areas in the muscle or connective tissue (fascia) that becomes painful when compressed
JOINT INJECTIONS
- intra-articular injections with steroids are useful, safe, and cost-effective treatments
- most joint injections are for symptoms of arthritis
⦁ shoulder - also for rotator cuff tendonitis & subacromial bursitis
- for knee, shoulder, AC joint - must know your anatomy
- can also put needles into joints to aspirate (remove synovial fluid - analysis for arthritis or infection)
most joint injections are for symptoms of
arthritis
WHY INJECT JOINTS
- can be joint or soft tissue issue
- inflammation
⦁ could be from degenerative joint disease, bursitis, and tendonitis - corticosteroid injections help decrease inflammatory reaction - limits capillary dilatation & vascular permeability
BASIC PRINCIPLES TO JOINT INJECTIONS
- HX & PE
- try conservative treatment first - NSAIDS, RICE, etc. - continue these treatments after joint injection
- careful patient selection
- informed consent - get signature
- know your anatomy!
- undertake as few injections as possible to settle the problem: q3-4 months
RISKS OF JOINT INJECTIONS
⦁ infections
⦁ soft tissue infection
⦁ acceleration of a septic joint (missed septic joint)
⦁ SubQ atrophy & skin depigmentation - where steroid was injected subcutaneously
⦁ steroid flare: facial flushing in first 24-48 hrs
- clears in 1-2 days - not an allergic reaction!!!
⦁ Exacerbation of diabetes*** - warn patients to monitor their blood sugars (spikes)
⦁ Cartilage damage - happens with repeated serial injections
⦁ Tendon rupture - only if injecting around the tendon
⦁ Allergic reaction
⦁ Anaphylactic reaction - within 5-10 minutes of the injection
CONTRAINDICATIONS TO JOINT INJECTIONS
⦁ Adjacent osteomyelitis
⦁ Evidence of bacteremia or febrile illness
⦁ Hemarthrosis
⦁ Impending joint replacement surgery (scheduled within days)
⦁ Infectious arthritis
⦁ Joint prosthesis
⦁ Osteochondral fracture
⦁ Periarticular cellulitis / severe dermatitis/ soft tissue infection
⦁ Poorly controlled diabetes mellitus
⦁ Uncontrolled bleeding disorder or coagulopathy
⦁ Clotting disorder and anticoagulation(correct before injecting)
- Probably okay if INR < 1.8
⦁ Broken skin or cellulitis over injection site
⦁ Joint infection
⦁ Allergy to local anesthetic or steroid preservative
⦁ Immunosuppressed (by drugs or disease)
INJECT WITH CAUTION IN THE FOLLOWING PATIENTS
o Charcot joint (neuropathic sensory loss)
o Tumor
o Neurogenic disease
o Active infections (ex: TB)
o Hypothyroidism
o Blood dyscrasias
o Diabetics (likely to raise BG levels for several days)
EQUIPMENT NEEDED FOR INJECTONS
Sterile gloves and drapes Retractable ball point pen Alcohol wipes 5 Gauze pads (4x4) Skin prep solution Lidocaine 1% Steroid of choice Syringes….3ml,5ml, 20 ml, 30 ml, 60 ml Needles….18 or 20 G and 25 or 27 G - Morbidly obese patients may require a 21 G spinal needle for arthrocentesis
Hemostat
Specimen tubes
Bandage
INFORMED CONSENT - PATIENT EDUCATION
- Risks ⦁ infection ⦁ bleeding ⦁ allergic reaction ⦁ pain
- Benefits
⦁ simple office procedure
⦁ may provide relief for patients that are too frail for definitive treatment - Realistic Expectations
⦁ may not help or may only help for limited amount of time
⦁ may have increased pain for 1-2 days after injection
⦁ may take several days to take effect
ANESTHESIA PRIOR TO JOINT INJECTION
- often warranted - good idea!
- after skin prep / draping / identification of needle insertion site, use 25-27 gauge needle to inject 2-5 mL of local anesthetic into subcutaneous tissue
⦁ OK if you enter joint space; will have minimal effect to alter synovial fluid analysis results
⦁ Biggest concern = introducing bacteria while injecting anesthetic
biggest concern of anesthetic injection prior to steroid + lido injection
introducing bacteria while injecting anesthetic
STEROIDS FOR INJECTIONS
- some take effect faster, others take and therefore last longer
- short acting preparations (soluble)
⦁ Hydrocortisone
⦁ Prednisolone - long acting preparations (depot steroids)
⦁ Kenalog (triamcinolone acetonide): 40mg / large, 30mg / medium, 10mg / small
⦁ Depo-Medrol (methylprednisolone)
⦁ Decadron (dexamethasone) - Combination preparations (soluble + depot)
⦁ Celestone Soluspan - Half life of intra-articular injections - can give months of relief
⦁ Depo Medrol = 6 days
⦁ Kenalog = 22 days
soluble (short-acting) steroids
⦁ Hydrocortisone
⦁ Prednisolone
depot steroids (long-acting preparations)
⦁ Kenalog (triamcinolone acetonide): 40mg / large, 30mg / medium, 10mg / small
⦁ Depo-Medrol (methylprednisolone)
⦁ Decadron (dexamethasone)
combination steroid
soluble + depot preparation
⦁ Celestone Soluspan
INJECTION TECHNIQUE
- swab top of vials with alcohol before drawing into syringe - let dry first!!!!!!
- change needles after drawing up solution in the syringe
- visualize anatomy
- mark area for the injection with marker or pen
- need sterile gloves only if you need to feel the site after prep
- prep area with betadine swabs or chlorohexadine or alcohol
- choose needle & syringe based on joint involved
- advance needle slowly until you feel a pop —through capsule
- once needle is felt to be in the joint, aspirate before injecting
- grasp needle with hemostat while you twist off the syringe and swap syringes while leaving needle in
- put aspirated fluid in collection tube
- if you meet resistance while injecting = probably not in the joint! - back up a bit
⦁ the amount of resistance felt depends on the diameter of the needle
ASPIRATION TECHNIQUE
- for suspected septic joint or for painful hemarthrosis
⦁ Use same route as for injection
⦁ Larger needle so fluid can be withdrawn (effusion and hemarthrosis)
⦁ Large syringe to withdraw fluid
⦁ Anesthetize track down to the joint
⦁ Same skin prep as for injections
so use same needle to aspirate into syringe, then swab out with hemostat to anesthetize. then switch to different needle/syringe to inject steroid + lido
KNEE INJECTIONS FOR OSTEOARTHRITIC PAIN
⦁ Best approach to a knee injection is the path of least obstruction and maximal access to the synovial cavity….which could be superolateral, superomedial or anteromedial/anterolateral
⦁ Plain radiographs recommended for assessment of the bony anatomy of the individual knee joint
⦁ The knee injection site can be selected according to the patient’s bony anatomy and marked with the tip of a retracted ball point pen before sterile prep
⦁ 3-5 ml 1% Lidocaine and 20-80 mg
methylprednisolone/or 40mg of Kenalog.
best approach to knee injection - to have maximal access to synovial cavity
SUPEROLATERAL
superomedial
or anteromedial/anterolateral
KNEE INJECTIONS
- common & relatively easy - as it is a large joint and there are good landmarks
- knee joint = one of the most common joints for PCP to aspirate & inject
- Superolateral Approach = lateral side at level of superior pole of patella
⦁ Anterior medial approach = can end up injecting into the fat pad rather than the joint
best injection site for knee injection
superolateral
which knee injection site can you end up injecting into the fat pad rather than the joint
anteromedial
KNEE INJECTION PROCEDURE - superolateral approach
- Position slightly flexed knee with a towel in the popliteal space on exam table
- Superolateral approach
⦁ Clinician’s thumb is used to gently rock then stabilize the patella
⦁ Palpate the superior lateral aspect of the patella and insert the needle 1 cm superior and lateral to the this point
⦁ Apply gentle pressure on the contralateral side of the knee to encourage the fluid to pool in the area of aspiration.
⦁ Direct the needle under the patella at a 45 degree angle to the midpoint area
⦁ Aspirate all fluid prior to injection
⦁ There should be no resistance!
KNEE INJECTION PROCEDURE - anterolateral / medial approach
- Anterolateral / mediolateral approach
⦁ Facing patient with knee hanging over the end of the table
⦁ Palpate the inferior pole of the patella, and move medial or lateral depending on which side you want.
⦁ You will feel for the edge of the patellar tendon and will fall into a “soft spot”. This is your area of injection.
⦁ Make a mark with thumbnail or pen. Clean area with betadine or scrub of choice.
⦁ Insert needle at marked point angling towards center of knee on a horizontal.
⦁ Feel needle enter joint and inject slowly. Should inject easily.
⦁ Remove and place band aid.
SHOULDER INJECTIONS
INDICATIONS
o intra-articular
⦁ arthritis
⦁ rotator cuff tear
⦁ frozen shoulder
o Subacromial
⦁ rotator cuff tendonitis
⦁ bursitis
o AC joint
⦁ inflammation / arthritis
most common shoulder injection location
posterior shoulder
POSTERIOR SHOULDER INJECTIONS
= most common route
- patient sitting
- inject 2 cm blow the base of the acromion, and 2 cm medial to the edge of the humerus
- can feel the joint move in the slender angle towards the tip of the coracoid process
ANTERIOR SHOULDER INJECTION
- not used as much
- patient supine
- fingertip below the clavicle and lateral to the tip of coracoid process
⦁ inject into the upper half of the joint; avoid brachial plexus - can usually feel the joint move!
how should the patient sit for AC joint injection
sitting with hands behind back - makes joint more prominent and easier to palpate
AC JOINT INJECTION
- patient sitting with hands behind back = makes the joints more prominent and easier to palpate
- palpate the joint - inject from above and angle medially
JOINT INJECTION AFTER-CARE
⦁ Passive ROM after injection
⦁ Explain that immediate effect is due to local anesthetic, steroid may take several days to show benefit and they may have a flare up of pain before seeing benefit from steroid
⦁ OK to use ice/OTC anti-inflammatories – do not use hot pad
⦁ Call if signs of infection/allergic reactions