9/25/2014. Ricki Loar, Ph.D., APN, FNP-BC, GNP-BC. Disclosure: No Disclosures. Strategic Nurse Practitioner Solutions, LLC

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1 Ricki Loar, Ph.D., APN, FNP-BC, GNP-BC 1 Dr. Ricki S. Loar, Ph.D., FNP-BC, GNP-BC Clinical Director, Be Well Partners in Health Nurse Practitioner, South Naperville Family Practice Faculty, Advanced Practice Education Specialists President, Strategic Nurse Practitioner Solutions, LLC Disclosure: No Disclosures 2 The information presented in this program is for educational purposes to help learn about joint/bursa aspiration and injection and is not intended to represent the only method appropriate Check specific details such as drug dosages and contraindications prior to clinical application In addition to this program, supervised clinical experience is highly encouraged 3 1

2 Identify the clinical indications and contraindications for knee joint, trochanteric bursa and trigger point injections Identify anatomical landmarks as appropriate for correct injection technique Select appropriate equipment and medications for injection Demonstrate injection and aspiration techniques for knee joint, trochanteric bursa and trigger point injections Discuss the clinical implications of synovial fluid analysis results 4 Femur Femoral condyle (subchondral cartilage) Meniscus Fat Pad Bursa Patella Patellar Tendon Tibial plateau Fibula cc syringe for aspiration 5 10 cc syringe for injection Needle Injection: 18, 20, 22 gauge, 1 ½ - 2 inch Aspiration: 18 gauge, 1 ½ - 2 inch Remainder of equipment as per previous injections 6 2

3 Anesthetic Xylocaine 1%: 2 3 cc Bupivacaine 0.25%: 2 3 cc Corticosteroid Methylprednisolone 40mg/mL: 1 2 cc Triamcinolone acetonide: 1 2 cc Betamethasone: 1 2 cc Hylauronic Acid: Orthovisc, Synvisc, Supartz, Hyalgan, Euflexxa 7 Osteoarthritis Rheumatoid arthritis flare Pseudogout Calcium pyrophosphate dihydrate crystal deposition Gouty arthritis 8 Hyaluronan is found in high concentrations in healthy joints and synovial fluid Decreases with osteoarthritis Injectable hyaluronan is made from avian products Indicated: Treatment of pain due to OA of the knees that has failed conservative treatment 9 3

4 Patella Patellar tendon Fibular head Tibial plateau Femoral condyle 10 Position seated with knee flexed Landmark the area Cleanse area Optional: local anesthesia Insert needle 1 2 cm above the tibial plateau, lateral or medial to the patellar tendon Needle should be 45 degrees to the knee, parallel to the floor

5 Knee flexed 20 degrees with a pillow or bolster Landmark Vertical lines at patellar edge Horizontal line at proximal patella osteoarthritis-pi150/ 14 Symptomatic relief with known diagnosis of arthritis that has fail to improve with conservative therapy Monoarticular effusion of unclear etiology Monitoring progress of treatment of known septic joint 15 5

6 Red top tube Crystals Gram stain C & S Lyme Purple top tube Cell counts Differential 17 WNL 16 Non- Inflammatory Inflammatory Septic Hemorrhagic Clarity Color Colorless Clear/ Straw Clear Cloudy Opaque Mixed Straw / Yellow Yellow Mixed Red WBCs/ < mm 3 50,000 >50,000 Like blood level PMNs < 25% < 25% 50 70% > 70% Like blood level Gram Stain Neg Neg Neg Positive Neg 18 6

7 19 Trochanteric Bursa 20 Symptomatic relief Point tenderness over greater trochanter Leg-length discrepancies, obesity, previous hip surgery, RA, OA Associated with trigger points of the IT band Week-end warriors or those beginning exercise 21 7

8 5 10 cc syringe 22 or 25 gauge, 1 ½ inch needle Skin prep Local anesthetic spray 22 Local anesthetic Xylocaine 1% Bupivacaine 0.25 or 0.5% Corticosteroid Depomedrol 40 mg Triamcinolone 40 mg Betamethasone 1 ml 23 Lateral recumbent position, affected side up Landmark the greater trochanter and point of maximal tenderness Cleanse skin Insert needle perpendicular to skin, advance until bone contact, withdraw ~2 mm Aspirate and 4 point fan injection within the bursa 24 8

9 Hyperirritable spots of skeletal muscles or fascia associated with palpable nodules in taunt bands of muscle fibers Twitch response Local and referred pain Active and latent 25 Acute trauma, repeated microtrauma Repetitive stress causing chronic muscle fiber stress Poor posture Tissues under tension Surgical scars 26 Muscular overload Prolonged release of calcium ions Resultant continued contraction Compression of capillaries Lactic acid accumulation Local muscle ischemia Local pain Decreased work ability 27 9

10 Primary cause of pain, result of other conditions or combination Treating the myofascial source if trigger points are painful 28 Treatment includes NSAIDS and other analgesics, muscle relaxants, stretching, physical therapy, injection, acupuncture, massage, dry needling Trigger point injections are more effective when combined with stretching exercises 29 Provide relief of local and referred pain Mechanical disruption of the muscle: action of the needle in the muscle Promote circulation Promote metabolism of excess calcium ions No evidence to suggest that one type of injectable is superior to any other injectable 30 10

11 Palpation with patient feedback Localized pain or radiation Twitch response 31 Splenis capitus, levator scapulea, upper trapezius Erector spinea Quardatus lumborum 32 Active skin infection Pain due to acute injury Pregnant Ill High risk for injection Allergy to anesthetic agents Fear of needles Caution around unstable joint 33 11

12 No evidence that analgesics/corticosteroid provides any additional long term benefits compared to dry needling alone Using local anesthetic provides pain relief during procedure Corticosteroids may cause lipoatrophy or hypopigmentation cc syringe gauge, 1 ½ inch needle Anesthetic of choice if used Corticosteroid of choice if used Others: Normal saline, ketorolac, Botox if used Local skin anesthetic spray (optional) Alcohol wipes, povidone iodine or other skin prep Adhesive bandages 35 Identify trigger point Cleanse the area Insert needle perpendicular to the skin Be aware of twitch response Some clinicians pinch the tissue up during injection Aspirate and inject 0.5-1cc of syringe mixture per trigger point, in a stellate pattern Can active needle 36 12

13 htm 37 Ice and/or NSAIDS can help to relieve post injection pain Post injection pain / tenderness can last up to hours Physical therapy and / or home stretching exercises Instruct in signs and symptoms of infection and pneumothorax if indicated 38 Think Green!!! Please complete your evaluation Have a great conference Don t forget the PAC Please volunteer for ISAPN Encourage your colleagues to join! 39 13