KAPA 2017 Musculoskeletal Aspiration and Injection Workshop. W. Scott Black, MD Physician Assistant Studies Program University of Kentucky

Transcription

1 KAPA 2017 Musculoskeletal Aspiration and Injection Workshop W. Scott Black, MD Physician Assistant Studies Program University of Kentucky

2 Aspiration Relatively quick and inexpensive Can be performed in the office Helps differentiate inflammatory from noninflammatory arthritis Helps establish diagnosis of crystal-deposition arthritis and septic arthritis

3 Reasons to Aspirate a Joint Patient with inflamed joint (or joints) who does not have an established diagnosis Any acute monoarthritis Anytime there is any suspicion of an infected joint Serial aspirations for pain relief Prior to injection of corticosteroids or hyaluronic acid preparation

4 Reasons Not to Aspirate a Joint Bacteremia (?) Joint Prosthesis (?) Overlying Skin and Soft Tissue Infection Uncontrolled Coagulopathy Severe Overlying Dermatitis Uncooperative Patient (?)

5 Would you aspirate that knee? 27 y/o male 3 day h/o flu-like illness Fever Chills Body aches Knee red, hot, and swollen X 24 hours Fever in your office

6 What about that knee? 64 y/o male Hypertension and NIDDM Acute onset knee swelling and pain Low-grade systemic symptoms Temp 99.9

7 Gout vs. Septic Joint vs. Other???

8 Is that elbow infected?

9 Evaluating Joint Fluid Physical Characteristics: Appearance, Color, Viscosity Chemical Analysis: Glucose, Protein Microscopic Evaluation: Cell Count and Differential, Crystal Analysis Microbiologic Evaluation: Gram Stain and Culture (may need to be very specific) Serologic and Cytological Evaluation

10 Synovial Fluid I usually ask for: Cell Count and Differential Crystal Analysis Gram Stain and Culture if suspicious for septic joint Check with your reference lab for appropriate collection, storage, and handling of synovial fluid

11 Synovial Fluid Analysis Palmer & Toombs. J Am Board Fam Pract 2004;17:S32-42.

12 Common Musculoskeletal Injections Cardone & Tallia. AFP 2002;66:283.

13 Common Musculoskeletal Injections Cardone & Tallia. AFP 2002;66:283.

14 Common Adverse Effect: Skin Hypopigmentation and SQ Tissue Atrophy

15 Common Musculoskeletal Injections Who to Inject Proper Diagnosis / Reason What to Inject Using the Right Medication / Combination How to Inject Correct Procedure Get Medication Where It is Supposed to Go

16 Foster, et al. AFP 2015;92(8):

17 What to Inject Less soluble corticosteroid preparations tend to have a longer duration of action but a greater incidence of cutaneous side effects Most commonly used corticosteroids at UK are triamcinolone and methylprednisolone Kenalog-10 or Kenalog-40 and Depo-Medrol 40 or Depo-Medrol 80 The corticosteroid is frequently mixed with a local anesthetic Manufacturers often recommend against mixing Some concern about cartilage toxicity Lidocaine (Xylocaine) 1% or 2% Bupivacaine (Marcaine) 0.25% or 0.5%

18 Subacromial Injection Indications Subacromial Impingement Chronic Rotator Cuff Tendinopathy Subacromial Bursitis Adhesive Capsulitis Evidence is fair Probably should think of this more as an adjuvant to Physical Therapy

19 Subacromial Injection 10ml syringe 23-25g 1 ½ Needle Kenalog or Depo-Medrol (40 80 mg) Around 6-8 ml 1% lidocaine, 0.25% bupivacaine or 50:50 mix Posterolateral approach About one finger breadth below posterior corner of acromion Direct toward AC joint

20 Ultrasound-Guided SA Injection

21 Chronic overuse injury of the ECRB and EDC Tendinosis vs. Tendinitis Tendinopathy Lateral Epicondylaglgia Less frequently an acute injury Injection may provide better short-term pain relief but no advantage long-term Again, probably best to consider as an adjuvant to therapy Tennis Elbow

22 5 ml Syringe 25g 1 Needle 40mg Kenalog or Depo- Medrol 2-4 ml 1% lidocaine or 0.25% bupivacaine Any benefit to fenestration? Autologous blood and PRP? Tennis Elbow

23 US-Guided Tennis Elbow Injection

24 Tennis Elbow Smidt, et al. Lancet 2002;359:657-62

25 Olecranon Bursa Aspiration / Injection Important to aspirate if considering septic bursitis Should not inject corticosteroids into a septic bursitis Sterile Technique Find boggy / tense area of bursa May need 21g needle (or larger) for aspiration Local anesthetic infiltration reduces discomfort

26 Elbow Joint Aspiration / Injection Aspirate effusion if septic joint suspected Aspirate hemarthrosis after radial head fracture Landmarks: Lateral Epicondyle Radial Head Olecranon Process

27 De Quervain s Tenosynovitis Tendinopathy of the APL and EPB in the FDC of the wrist Responds well to CSI Finkelstein Test

28 Injection for De Quervain Syndrome Tuberculin / Allergy Syringe (1 ml) 27g ½ needle 0.25 ml Kenalog-40 or Depo-Medrol 40 (10mg CS) 0.75 ml 1% lidocaine or 0.25% bupivacaine

29 Injection for De Quervain Syndrome

30 Trigger Finger Injection

31 Trigger Finger Pathophysiology

32 Trigger Finger Injection 3ml Syringe 25g needle (5/8 to 1 ) 10 20mg of Kenalog or DepoMedrol ml 1% lidocaine or 0.25% bupivacaine

33 Greater Trochanteric Bursitis Greater Trochanter Pain Syndrome 5-10 ml syringe 22-25g needle at least 1 ½ long May need spinal needle 40mg Depo-Medrol or Kenalog 5-7 ml 1% lidocaine or 0.25% bupivacaine Sometimes use guide needle and spinal needle Insert at point of maximum tenderness and go to bone Greater Trochanter

34 Greater Trochanter Pain

35 Knee Joint Aspiration / Injection Reasons to Aspirate Undiagnosed effusion Suspicion for septic joint Improve pain by decompressing large post-traumatic effusion Reasons to Inject Arthritis

36 Knee Joint Aspiration / Injection 10 ml syringe for injection May need much larger syringe for aspiration (30-60 ml) 23-25g 1 ½ needle for injection 21g needle (or larger) for aspiration Kenalog / Depo-Medrol mg Dextrose Prolotherapy? 1% lidocaine or 0.25% bupivacaine 5-8 ml or 50:50 mix

37 Knee Injection / Aspiration Lateral Approach

38 Knee Injection Anterior Approach

39 Ankle Joint Aspiration / Injection Aspiration is much more useful than injection OA of the ankle may have different pathophysiology than that at the knee and hip 10ml syringe (may need if aspirating large effusion) 20 25g 1 ½ needle 40mg Kenalog or Depo- Medrol diluted in 3-5 ml anesthetic

40 Ankle Aspiration / Injection Anterolateral Approach Between the lateral malleolus and the lateral border of the extensor digitorum longus Anteromedial Approach Between the medial malleolus and the medial border of the tibialis anterior

41 Plantar Fascia Injection Plantar fascia is relatively tough band of connective tissue described as originating at the medial calcaneal tuberosity and inserting into five bands surrounding the digital tendons Windlass Mechanism of Foot Supports Medial Longitudinal Arch

42 Plantar Fascia Injection Plantar fasciitis? Chronic Heel Pain Syndrome 3-5 ml syringe 25g 1 ½ needle 20mg Kenalog or Depo- Medrol diluted in 2 ½ to 3 ½ ml local anesthetic Medial Approach Avoid injecting through plantar foot

43 First MTP Joint Gout OA Turf Toe 1 3 ml Syringe 25 27g 1 Needle mg Kenalog or Depo-Medrol diluted in 1 2 ml local anesthetic

44 Approach from dorsomedial side of joint Angle needle about 60 degrees and enter from proximal to distal to follow contour of joint Distraction on the great toe can help open up joint making entry easier First MTP Joint

45 Joint Injection & Aspiration Thanks Questions???