2Why inject joints?Can be joint or soft tissue i.e. articular or periarticularLow risk e.g. septic arthritis occurs 1 in 40,000Provide good symptom relief
3Basic principles before you start History and examinationTry conservative treatment first e.g. physio, NSAIDs, orthotics and continue after joint injection.Careful patient selectionConsent & provide ARCUK PILeafletKnow your anatomy!Undertake as few injections as possible to settle the problem, max 3-4 monthly (no more than 3 for tennis elbow per lifetime)Increased injection s- incr risk of systemic absorption and joint damage
4Indications for injection OsteoarthritisRheumatoid arthritisGouty arthritisSynovitisBursitisTendonitisMuscle trigger pointsCarpal tunnel syndrome
5Inject with caution Reducing the risk of infection Never inject an infected joint.Avoiding injecting through infected skin or psoriatic plaques.Avoid injecting adjacent to infected skin/skin ulcers.Avoid injecting patient on concurrent oral steroids.Mediswabs or iodine should be used with a no touch or aseptic technique.Reducing the risk of bleedingIf injecting weight bearing joints advise rest for 24 hours post injection.Don’t inject patients on warfarinReducing the risk of tendon ruptureDon’t inject near the Achilles tendon.Don’t inject into tendons.
6Contraindication to injection Adjacent osteomyelitis or skin infectionBacteraemiaHemarthrosisImpending (scheduled within 3 months) joint replacement surgerySeptic arthritisJoint prosthesisOsteochondral fracturePeriarticular cellulitis / severe dermatitis/ soft tissue infectionPlaque psoriasis at the injection pointPoorly controlled diabetes mellitusUncontrolled bleeding disorder or coagulopathy
7TechniqueComplete the consent form and provide a Patient Information Leaflet prior to the procedureInject the corticosteroid with as little pain and as few complications as possible.Do not attempt any injections in the vicinity of known nerve or arterial landmarkse.g. lateral epicondyle of elbow ok, medial – beware ulnar nerveNever inject into the substance of a tendonSterile technique
8Technique 2 ANTICIPATION! Get your kit ready ie:Needles, syringes, sterile container, LA, steroid, gloves, drapes, chlorhexidine, cotton wool, plaster.1 or 2 needle technique (green to draw up and blue to give)Clean area – ensure solution has DRIED (esp iodine) prior to injectingCan mix this with corticosteroid but need bigger needle.
9Technique 3Always withdraw syringe back first to ensure not injecting into blood vesselDecide if you want to use lidocaine with the depomedroneUse a different needle to draw up (green) to the one you use to inject (blue or orange).Steroids in increasing order of potency
10What doses of depo-medrone should you use? Troc Bursitis 40-80mgKnee mgShoulder 40mgTennis elbow mg 9using a ‘peppering’ technique+/- Lidocaine when injecting the shoulder or knee
11What to warn the patient Pain returns after 2 hours, when the local anaesthetic wears off – may be worse than before.If pain is severe or increasing after 48hrs, seek adviceWarn of local side effectsAdvise to seek help if systemic s/es developEg chest tightness.
12Local side effectsInfection, subcutaneous atrophy, skin depigmentation, and tendon rupture (<1%).Post-injection ‘flare’ in 2-5%Often are the result of poor technique, too large a dose, too frequent a dose, or failure to mix and dissolve the medications properly.NB corticosteroid short duration of action – can be as short as 2-3 weeks relief.Post-injection, relieved with ice to the area for 15mins/ hour, decreased risk if c/t nsaidsResolves 24-48hrs
13Knee injections Patient on the couch, knee slightly bent Palpate superior-lateral aspect of patellaMark 1 fingerbreadth above + lateral to this siteCleanLA, corticosteroidClean + bandage
14Plantar fasciitisProcedure painful + no evidence for long-term benefitPt indicate tender spotApproach from thinner skin + direct posterior-laterallySmall blelbs as near to bony insertion as possibleDo not inject fascia itself
15Shoulder injection Glenohumeral joint AC joint Subacromial space Long Head of BicepsOlder patients: 2-3 x/ yearYounger – consider surgery if no improvement (risk rotator cuff rupture)
16Glenohumeral joint injection Pt sits, arm by side, externally rotatedFind sulcus between head of humerus and acromionPosterolateral corner of acromion (2-3 cm inferior)Direct needle anteriorly toward coracoid processInsert needle to full lengthFluid should flow easilyIndicationsShoulder OsteoarthritisAdhesive CapsulitisRheumatoid Arthritis affecting the shoulder
17AC joint injection Palpate clavicle to distal aspect Slight depression where clavicle meets acromionInsert needle from anterior and superior approachDirect needle inferiorlyIndications - OA
18Sub-acromial joint injection Posterior and lateral aspect of shoulderInferior to lower edge of posterolateral acromionInsert inferior to acromion at lateral shoulderDirect needle toward opposite nippleInsert needle to full lengthFluid should flow easilyIndicationsSubacromial bursitis (Subdeltoid Bursitis)Rotator Cuff Impingement or tendinosisAdhesive Capsulitis
19Elbow epicondyle injection Very effective in short term – 92%Benefits do not normally persist beyond 6 weeksLateral (tennis elbow) + medial (golfer’s elbow) epicondylitisPatient supine
20Tennis elbow (lateral) Arm adducted at sideElbow flexed to 45 degreesWrist pronatedInsert needle perpendicular to skin at point of maximal tendernessInsert to bone, then withdraw 1-2 mmInject corticosteroid solution slowly
21Golfer’s elbow (medial) Beware ulnar nerve!Rest arm in comfortable abducted positionElbow flexed to 45 degreesWrist supinatedPoint of maximal tenderness - insert to bone, then withdraw 1-2 mmInject corticosteroid solution slowly
22De Quervain’s tenosynovitis Inflammation of thumb extensor tendons-Extensor pollicis brevis-Abductor pollicis longusOccurs where tendons cross radial styloid
23De Quervain’s tenosynovitis Maximally abduct thumb (accentuates abductor tendon) Injection siteSnuffbox at base of thumbAim degrees proximally toward radial styloidInsert needle between the 2 tendons (not in tendon)Do not inject if paraesthesias (sensory branch radial nerve)