Subacromial Bursa Injection

Transcription

1 Subacromial Bursa Injection 5 cc syringe, 21 gauge 1.5 inch needle 1% lidocaine - 4cc 40mg triamcinolone - 1 cc of 40mg/ml identify site-seat the patient with weight of arm hanging down, palpate the lateral or posterior lateral edge of the acromion, drop off into the soft spot below the acromion but above the humeral head, mark with the retracted end of a pen cleanse the area with bactericidal swab, while drying open gauze package and bandaid and place next to patient spray ethyl chloride until skin blanches with cold, insert needle with a sight superior angle aiming for the middle of the acromion, if any bone periosteum is met with the needle tip then redirect, typically need to advance nearly the full length of the 1.5 inches aspirate to make sure not in a blood vessel, then inject the full amount which should flow in easily, if not you may be in the tendon, slightly pull out the needle or redirect withdraw needle, apply firm pressure with gauze then place bandaid write down exact injection they received (just saying shoulder could be subacromial or glenohumeral or AC joint) advise to resume mild to moderate normal daily activities to help circulate the steroid within the bursa

2 Knee Intra articular Joint Injection 5 cc syringe, 21 gauge 1.5 inch needle 1% lidocaine - 4cc 40mg triamcinolone - 1 cc of 40mg/ml - superolateral patellar approach identify site-patient is relaxed and lying down with leg extended and knee slightly flexed, intersection of 1 finger breadth superior to the proximal pole of the patella and 1 finger breadth lateral to the lateral border of the patella in a soft depression between the lateral quadriceps tendon and ITB, mark with the retracted end of a pen (other possible sites include mid patellar either medial or lateral, or sitting up lateral or medial joint line to the side of the patellar tendon) cleanse the area with bactericidal swab, while drying open gauze package and band aid and place next to patient spray ethyl chloride until skin blanches with cold, insert needle parallel to the floor and slightly inferior towards the patella, if any bone periosteum is met with the needle tip then redirect, typically need to advance nearly the full length of the 1.5 inches (if aspirating a large effusion consider using 25 gauge 1.5 inch needle to infiltrate local anesthetic, withdraw needle and insert 18 gauge needle with cc syringe into joint, aspirate as much fluid as possible, if flow becomes difficult slightly change position of needle or press on plunger to free tip from a plug, hold needle hub with fingers or hemostat and change syringe to inject steroid preparation) aspirate to make sure not in a blood vessel and perhaps confirm joint fluid, then inject the full amount which should flow in easily, if not you may be in the quadriceps tendon, slightly pull out the needle or redirect withdraw needle, apply firm pressure with gauze then place band aid write down exact injection they received (intra-articular knee joint) advise to resume mild to moderate normal daily activities to help circulate the steroid within the knee joint

3 Tennis Elbow Injection 3 cc syringe, 25 gauge 1 inch needle 1% lidocaine - 1cc mg triamcinolone -.25 to.5 cc of 40mg/ml identify site-have the patient seated with arm resting on exam table or countertop or lying down on exam table with pillow under elbow with arm across abdomen, elbow flexed to 90 and forearm pronated, palpate the entire area of maximal tenderness which is typically along the superior to inferior edge of the lateral epicondyle, mark the center of this area with the retracted end of a pen cleanse the area with bactericidal swab, while drying open gauze package and band aid and place next to patient spray ethyl chloride until skin blanches with cold, insert needle at a 45 degree angle to the edge of the epicondyle directly down onto the periosteum, withdraw slightly and aspirate to make sure not in a blood vessel, then inject a portion of the steroid preparation just above the periosteal surface, partially withdraw and redirect the needle to a nearby area of tenderness fanning out from the initial central area in either direction along the tender edge of the lateral epicondyle write down exact injection they received (lateral epicondyle for tennis elbow) advise to resume mild to moderate normal daily activities to help spread the steroid within the tendon

4 Trochanteric Bursa Injection 3 cc syringe, 25 gauge 1.5 inch needle (sometimes longer needed depending on size of patient) 1% lidocaine - 1-2cc 10-20mg triamcinolone -.25 to.5 cc of 40 mg/ml variable length of time), obtain informed consent can be either verbal or signed identify site-patient is relaxed and lying on uninvolved side, palpate area of maximal tenderness typically over the middle of the greater trochanter (true bursitis) or may be more on posterior edge of greater trochanter (more of a gluteus medius insertion tendonitis), mark the center of this area with the retracted end of a pen cleanse the area with bactericidal swab, while drying open gauze package and band aid and place next to patient spray ethyl chloride until skin blanches with cold, insert needle directly down onto the periosteum in the middle of the greater trochanter, withdraw slightly and aspirate to make sure not in a blood vessel, then inject the steroid preparation just above the periosteal surface (if area of tenderness is more of the posterior edge of the greater trochanter then insert needle at a 45 degree angle to the edge of the greater trochanter directly down onto the periosteum, withdraw slightly and aspirate to make sure not in a blood vessel, then inject a portion of the steroid preparation just above the periosteal surface, partially withdraw and redirect the needle to a nearby area of tenderness fanning out from the initial central area in either direction along the tender posterior edge of the greater trochanter) write down exact injection they received (greater trochanteric injection) advise to resume mild to moderate normal daily activities to help circulate steroid within the bursa or tendon

5 de Quervain's Tenosynovitis Injection 3 cc syringe, 25 gauge 1 inch needle 1% lidocaine - 2cc 10mg triamcinolone -.25 cc of 40mg/ml variable length of time), obtain informed consent can be either verbal or signed identify site- have the patient seated with arm resting on exam table or countertop or lying down on exam table with arm out straight at side with radial or thumb side up, place in gentle Finkelstein's test position (ulnar wrist deviation with thumb adducted) to palpate first dorsal compartment abductor pollicis longus (APL) and extensor pollicis brevis (EPB), identify the point of maximal tenderness often just distal or proximal to distal radius at the snuff box, mark with retracted end of a pen cleanse the area with bactericidal swab, while drying open gauze package and band aid and place next to patient spray ethyl chloride until skin blanches with cold, insert needle at a shallow angle just distal to point of maximal tenderness advance cephalad alongside the APL/EPB tendons trying to enter the tendon sheath, aspirate to make sure not in a blood vessel, then inject the full amount which should flow in easily, if not you may be in the tendon, slightly pull out the needle or redirect write down exact injection they received (de Quervain's tenosynovitis) advise to resume mild to moderate normal daily activities to help circulate the steroid within the tendon sheath