Benefits of Aspiration and Injection JOINT INJECTIONS Mark Niedfeldt, M.D. Medical College of Wisconsin Decrease or resolution of pain Decrease or resolution of inflammation Decrease or resolution of effusion Mechanism of Action Injection Indications Anti-inflammatory (Steroids) Inhibits both cyclooxygenase and lipoxygenase pathways More water soluble solutions for acute conditions More water-insoluble for chronic conditions Additional mechanisms Rupture of adhesions Drainage of effusion Therapeutic Bursitis, tenosynovitis, arthritis, trigger points Alternatives include ice, NSAIDs, oral steroids, PT modalities Diagnostic Crystals, r/o infection, arthritis, fracture 1
Injection Contraindications Infection Overlying cellulits Septic joint Bacteremia Joint problems Joint prosthesis or unstable joint Past history of injections 3 or more injections in past year or failure to respond to previous injections Coagulation problems Risks Post injection flare 2-5% Unknown etiology Starts 6-12 hrs after injection Treat with ice and NSAIDs Infections.072% with aseptic technique.0001% with sterile technique Most are staph aureus Don t inject if aspirate is not clear! Risks Fat atrophy Skin atrophy and depigmentation (<5mm) Tendon rupture Soft tissue injury (nerve or articular cartilage) Allergic reaction Hypopituitary-adrenal axis suppression 2-7 d with multiple joint injections Steroid induced arthropathy Types of Steroids Duration inversely proportional to water solubility More soluble = shorter acting 2
Relative Potency of Steroids Hydrocortisone acetate(hydrocortone) Agent Potency Duration Low Short Methylprednisolone acetate (Depo-Medrol) or triamcinolone acetonide(aristocort) Intermediate Intermediate Dexamethasone sodium phosphate(decadron), Triamcinolone acetate (Kenalog) High Long Betamethasone sodium phosphate and acetate (Celestone Soluspan) High Long General Rules Never inject directly into a tendon Relative rest after injection Avoid lidocaine with parabens preservatives which may precipitate out Aspirate first if any doubt regarding infection Injection Technique Locate injection site Sterile prep Anesthetize skin (optional) Relocate injection site Insert needle, aspirate fluid and change syringes or inject after withdrawing Mobilize joint or massage area to distribute medication Observe for allergic reaction, routine wound care Wrist Interconnecting synovium Often single injection will affect entire joint Dorsal approach Wrist flexed 20-30 Lateral of extensor pollicis longus 1-2 cm deep 3
Wrist Carpal Tunnel Ganglion Cyst Medial or lateral to palmaris longus at level of distal crease 45 angle toward tip of middle finger If any discomfort in palm or fingers - withdraw & reposition needle Advance 1 to 2 cm into space Aspirate contents prior to injection Elbow Radiohumeral joint Elbow flexed to 90 Locate radiohumeral articulation Inject perpendicular to skin surface Avoid ulnar nerve which passes medial to olecranon Lateral & Medial Epicondylitis Elbow flexed to 90 Locate points of maximal tenderness Infiltrate areas of severe tenderness Avoid hitting bone with needle to minimize damage 4
Olecranon Bursa Shoulder Subacromial bursa Locate lateral edge of acromion Palpate distally until space between acromion and humerus is reached Needle perpendicular to skin Aspirate fluid; change needles and inject Shoulder Joint Posterior approach Have patient rotate shoulder forward (to open up posterior joint space) Insert needle on posterior aspect of shoulder at level of coracoid process Biceps Tendon Long head of the biceps Locate bicipital groove Insert needle into most tender area parallel to the groove Inject the groove; avoid injecting into tendon Short head of the biceps Locate coracoid process Locate point of maximal tenderness Insert needle into tendon (grating sensation may be felt) Withdraw needle 1-2 mm inject peritendinous area 5
Acromioclavicular Joint Anterior-inferior or superior approaches Hip Trochanteric Bursa Find lateral prominence of the greater trochanter Insert needle carefully to bone Aspirate fluid prior to injection Withdraw 5 mm; Inject 2 to 3 cc Withdraw another 5 mm; Inject another 2 to 3 cc Knee Joint Patient supine with knee extended Superior-lateral patella palpated Needle inserted 1 cm superior & lateral to this point Direct needle under patella Similar for medial approach May also use flexed knee approach Prepatellar Bursa Patient supine with leg extended Mild pressure placed over patella Insert needle into bursa Aspirate fluid prior to injection 6
Pes Anserine Bursa Patient supine with leg flexed to 90 Palpate inferno-medial to patella to locate point of maximum tenderness Insert carefully down to bone Withdraw needle 2 to 3 mm & inject 7