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Shoulder Girdle Joint Injection Workshop

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1 Shoulder Girdle Joint Injection Workshop
Virginia Osteopathic Medical Association 2011 Fall CME Conference Hotel Roanoke & Conference Center Roanoke, Virginia September 23, 2011 Bradley M. McCrady, DO Fellow, Primary Care Sports Medicine Edward Via College of Osteopathic Medicine- Virginia Campus Virginia Polytechnic Institute and State University

2 Objectives Identify indications and contraindications for joint injections of the shoulder girdle. Review necessary equipment of shoulder injections. Discuss techniques to perform various shoulder girdle injections. Illustrate techniques of ultrasound-guided injections of the shoulder girdle. Demonstrate skills to perform various common shoulder girdle injections.

3 Resources

4 Shoulder Complex Shoulder is a complicated anatomical and biomechanical joint “Fragile Equilibrium” Multiple joints Static and dynamic stabilizers Static labrum, adhesion-cohesion, capsule, intra-articular pressure Dynamic muscles, proprioceptive feedback Hoppenfeld, S. Physical Examination of the Spine and Extremities. Prentice Hall; 1976

5 What Providers Need to Know About Joint Injection and Aspiration
Relatively simple procedure Complications are uncommon Injection/arthrocentesis can provide diagnosis, relieve pain, decrease joint damage “Liquid biopsy of joint” Useful information can be provided by relatively inexpensive tests Can help differentiate inflammatory from non-inflammatory arthritis Judicious use of anesthetics and steroids may be safer than systemic medications Summary There are often more reasons for doing than not in the right clinical scenario ACP Clinical Skills Series - Arthrocentesis & Joint Injection

6 Indications for Joint Injection/Aspiration
Diagnostic Acute inflammatory arthritis (24-48 hours) in a patient who has never had these symptoms before Acute effusion in the setting of fever, chills, or presence of infection at another site Acute effusion in the setting of trauma Prior to committing patients to long-term, expensive or toxic therapy Therapeutic Provide for a better musculoskeletal exam (i.e. pain control) To suppress inflammation in one or two isolated joints Adjuvant therapy to a few joints resistant to systemic therapy To facilitate a rehabilitative therapy program To support a patient with active joint inflammation pending the effects of systemic therapy To remove exudative fluid from a septic joint To relieve pain in a swollen joint

7 Conditions Likely to be Improved by Joint or Periarticular Injections
Rheumatoid arthritis Seronegative spondyloarthropathies Crystal induced arthritis Carpal tunnel Bursitis Tenosynovitis/tendinitis Adhesive capsulitis Osteoarthritis

8 Contraindication to Joint Injection/Aspiration
Absolute Uncooperative patient Allergy to anesthesia or steroid (very rare) Lack of informed consent Injection through infected tissues Previous severe steroid flare Injection of steroid into critical weight-bearing tendons Relative Injection near critical structures Coagulation disorders Uncontrolled diabetes h/o AVN Previous joint replacement at injection site More than 3 previous steroid injections in a major weight bearing joint in the preceding year Concern to activate any latent disease Excessive anxiety

9 Equipment Informed consent Non-sterile exam gloves Marking pen
Alcohol pads +/- povidine-iodine Gauze pads Syringe(s) Needle Anesthetic Steroid Adhesive bandages McNabb, James. A Practical Guide to Joint & Soft Tissue Injection & Aspiration. 2nd Ed.LWW; 2010.

10 Safety First Position for comfort! Define anatomy
Universal precautions Vaccines Gown and mask not necessary Clean vs sterile technique Aspirate prior to injections Do not recap needles Proper disposal of equipment Observe patient in office following injection for min Alcohol pads cost approximately 3 cents/pad; and povidone-iodine costs 13 cents/swab sterile gloves at $170.00/100 pair ($1.70 pair) and non-sterile gloves at under $3.00/100 pair ($0.03 pair) Baima, J.Curr Rev Musculoskelet Med (2008) 1:88–91 Hemani, M. Rev Urol. 2009;11(4): Darouiche, RO. N Engl J Med 2010;362:18-26

11 Topical Preparation Infection is not common
Actual reported incidence is unknown, but is thought to vary from 1: 3,000 to 1:50,000 70% isopropyl alcohol vs 10% povidone-iodine Ethyl chloride fine spray may have antimicrobial activity According to the surgical literature, povidone iodine has peak bactericidal action when allowed to air dry for 20 min after application. Aqueous-based iodophors, such as povidone-iodine, contain iodine complexed with a solubilizing agent, allowing for the release of free iodine when in a solution. Iodine acts in an antiseptic manner by destroying microbial proteins and DNA and safety on nearly all skin surfaces regardless of the patient’s age. • Ethyl and isopropyl alcohol are 2 of the most effective antiseptic agents available. When used alone, alcohol is fast and short acting, has broad-spectrum antimicrobial activity, and is relatively inexpensive. Flammability can be avoided by allowing skin to completely dry and by avoiding preparation of areas with excessive body hair that can delay alcohol vaporization. • Recent studies suggest that alcohol-based solutions may have greater efficacy, easier application, improved durability, and a superior cost profile when compared with traditional aqueous-based solutions. Plates were assessed for growth inhibition at 24 and 48 h, estimate of the percentage of bacteria remaining after spraying with ethyl chloride was 42.7%, Baima, J.Curr Rev Musculoskelet Med (2008) 1:88–91 Hemani, M. Rev Urol. 2009;11(4): Darouiche, RO. N Engl J Med 2010;362:18-26 Clinical Radiology, Volume 61, Issue 12, Pages

12 Steroids-History Hydrocortisone acetate was first introduced in the 1949 for Rheumatoid arthritis by Hollander “No other form of treatment has given such consistent local symptomatic relief in so many for so long with so few harmful effects.” Oriole baseball pitcher Jim Palmer “…cortisone is a miracle drug ... for a week!" Long history of use in athletics Treat the secondary inflammation Need to find the cause In rheumatologic disease, inflammation is the problem, whereas in sports injury, performance recovery depends on restoration of both the injured tissue and its kinetic environment If pain and signs of inflammation are persistent, repeated efforts to turn off the body's alarm is not a substitute for finding the cause of the fire Nepple, J. Sports Health: A Multidisciplinary Approach : Leadbetter WB. Clin Sports Med.1995;14(2):

13 Steroids-Physiology Stabilizing lysosomal membranes of inflammatory cells Decreasing local vascular permeability Altering neutrophil chemotaxis and function Able to pass through cell membranes and bind to nuclear steroid receptors Where they influence RNA transcription Nepple, J. Sports Health: A Multidisciplinary Approach :

14

15 Steroids-Use Hill et al surveyed members of the American Academy of Orthopaedic Surgeons on use of corticosteroids 90% of used corticosteroid injections Performed an average of 150 intra-articular and 193 extra-articular injections per year Conditions warranting injection Epicondylitis (93%) Shoulder bursitis (91%) Greater trochanteric bursitis (91%) DeQuervain’s tenosynovitis (87%) Bicipital tendonitis (81%) Hill JJ Jr,. Contemp Orthop. 1989;18:39-45. McNabb, James. A Practical Guide to Joint & Soft Tissue Injection & Aspiration. 2nd Ed.LWW; 2010.

16 Anesthetics Decrease nerve conduction through the blockade of Na channels, which disrupts axonal nerve conduction Typically steroid agent is combined with a local anesthetic agent Decrease the pain Dilute the steroid Increase the distribution of the agent to the treated area Lidocaine Rapid onset (minutes) Short duration (60-90 minutes) Bupivicaine Slower onset (30 minutes) Longer duration (6-8 hours) Buffering Sodium bicarbonate pH of 1% lidocaine is 6.5 Bupivicaine is isotonic Adding sterile Na bicarbonate to lidocaine at 1:10 ratio neutralizes ADD IN review of literature Nepple, J. Sports Health: A Multidisciplinary Approach :

17 What Patients (and Providers) Need to Know about Joint Injection
Relief will typically last weeks or longer Avoid injecting ligamentous or tendon structure directly Activity modification following injections of steroids is uncertain Maximal number of injections and the required period between injections have not been determined Nichols, A Clin J Sport Med 2005;15(5) : E370 Pfenninger JL. Procedures for primary care physicians. St. Louis: Mosby, 1994.

18 What Patients (and Providers) Need to Know about Joint Injection
In a meta-analysis summarizing 25+ studies, they noted a 5.5% complication rate The most common side effects included skin atrophy (2.4%), skin depigmentation (0.8%), localized erythema and warmth (0.7%), and facial flushing (0.6%) Post-injection pain was noted in up to 9% of patients Post injection flare (2-5%) Prolonged and repeated usage may increase the risk of complications and systemic side effects In diabetic patients, hyperglycemia has been shown to persist up to 5 days after a single soft tissue injection (very low risk) Fat atrophy has been reported to occur between 6 and 12 weeks after injection. A postinjection steroid flare, thought to be a crystal-induced synovitis caused by preservatives in the injectable suspension, may occur within the first 24 to 36 hours after injection. This is self-limited and responds to application of ice packs for no longer than 15-minute intervals Dietzel, D Current Sports Medicine Reports 2004, 3:310–315 Nepple, J. Sports Health: A Multidisciplinary Approach : Wang AA. J Hand Surg [Am]. 2006;31(6): Pfenninger, JL Procedures in Primary Care 2nd Ed. 2003:

19 Typical Injection/Aspiration Procedure
Determine the medical diagnosis and consider relevant differential diagnoses Discuss the proposed procedure and alternatives with the patient Obtain written informed consent from the patient Collect and prepare the required materials Correctly position the patient for the procedure Identify and mark the anatomic landmarks and injection site with ink Do not allow the patient to move the affected area from the time that the marks are placed until after the procedure is completed Press firmly on the skin with the retracted tip of a ballpoint pen to further identify the injection site Prepare the site for injection by cleansing with a topical antimicrobial agent (povidine-iodine and/or alcohol swab) If using the povidone, allow to dry for full antibacterial effect Provide local anesthesia as indicated through use of tactile distraction, vapocoolant spray (ethyl chloride or PainEase), and/or injected local anesthesia McNabb, James. A Practical Guide to Joint & Soft Tissue Injection & Aspiration. 2nd Ed.LWW; 2010. Pfenninger, JL Procedures in Primary Care 2nd Ed. 2003:

20 Typical Injection/Aspiration Procedure
Using the no-touch technique, introduce the needle at the injection site and advance into the treatment area Aspirate fluid (optional) using a 18 or 20-g needle and send it for laboratory examination if indicated If injecting corticosteroid immediately following aspiration, do not remove the needle from the joint or bursa; In this case, grasp the needle hub firmly (with a hemostat clamp if necessary), twist off the original syringe, and then immediately attach the second syringe that contains the corticosteroid Always aspirate before injection to avoid intravascular administration Inject corticosteroid solution into the treatment area If not aspirating then use 25-g needle Do not inject the medication against resistance Withdraw the needle Apply direct pressure over the injection site with a gauze pad Apply an adhesive dressing Provide the patient with specific post-injection instructions McNabb, James. A Practical Guide to Joint & Soft Tissue Injection & Aspiration. 2nd Ed.LWW; 2010. Pfenninger, JL Procedures in Primary Care 2nd Ed. 2003:

21 Informed Consent Patient’s consent to allow provider (and his/her pupils) to perform the procedure. All alternative treatments discussed with the patient in lieu of procedure. Benefits and risks to the procedure. Explanation of the procedure in lay language to the patient. Signature of the patient or authorized representative, witness, and provider.

22 Shoulder Girdle Injections
Subacromial Posterior Lateral Glenohumeral Anterior Acromioclavicular Sternoclavicular Biceps brachii long head

23 Subacromial Injection Lateral Approach
Find lateral edge of acromion and mark Palpate soft spot below the acromion and above the humeral head Insert needle perpendicular through the deltoid towards the bursa

24 Subacromial Injection Posterior Approach
Find lateral edge of the acromion and mark Palpate posterior edge of the acromion and mark Find posterolateral edge of the acromion and mark a spot 2 cm below the corner McNabb, James. A Practical Guide to Joint & Soft Tissue Injection & Aspiration. 2nd Ed.LWW; 2010. Seroyer, S. Sports Health 2009; 1 (2):

25 Subacromial Injection Posterior Approach
Position the needle at a 30 ° angle to the skin with the needle tip directed cephalad toward the acromion Insert the needle getting underneath the acromion and advance until the needle tip touches the undersurface of the acromion Once at the acromion, back off 1-2mm

26 Glenohumeral Injection Posterior Approach
Find lateral edge of acromion Palpate the posterior edge of the acromion Mark spot 2 cm below posterior lateral corner Target is coracoid process

27 Glenohumeral Injection Posterior Approach
Advance needle towards coracoid process until tip touches humeral head and retract needle 1-2mm

28 Glenohumeral Injection Anterior Approach
Identify coracoid process Injection point is 1 cm lateral to the coracoid

29 Glenohumeral Injection Anterior Approach
Insert needle perpendicular to the skin toward the target 2 cm caudad to the posterior lateral corner of the acromion Advance needle until it reaches the humeral head and retract 1-2mm

30 Long Head Biceps Injection
Palpate course of biceps long head tendon with the patient flexing the elbow Palpate location of maximal tenderness which is usually under the edge of the pectoralis major

31 Long Head Biceps Injection
Position needle at a 45° angle to the skin with needle directed proximally Advance needle until needle tip touches tendon, back needle off 1-2mm Medication should flow smoothly

32 Acromioclavicular Injection
Identify AC joint by palpating the clavicle in a medial to lateral direction until reaching a small depression that may be tender

33 Acromioclavicular Injection
Insert needle perpendicular to the skin with the needle tip directed caudad

34 Sternoclavicular Injection
Identify SC joint by palpating the clavicle in a lateral to medial direction until reaching a small depression that will likely be tender

35 Sternoclavicular Injection
Insert needle perpendicular to the skin and advance into SC space

36 Musculoskeletal Ultrasound
The use of high-frequency sound waves (3-17MHz) to image soft tissues and bony structures in the body for the purpose of diagnosing pathology or guiding real-time interventional procedures Pinzon, EG and Moore, RE. Musculoskeletal Ultrasound: a brief overview of diagnostic and therapeutic application in musculoskeletal medicine. Practical Pain Management. June 2009.

37 Ultrasound Terminology
Echogenecity- the ability of tissue to reflect ultrasound waves back toward the transducer and produce an echo. (The higher the echogenicity of tissues, the brighter they appear on ultrasound imaging) Hyperechoic- seen as brighter on ultrasound relative to surrounding tissues due to higher reflectivity of the US beam Isoechoic- structures are seen as bright as surrounding structures on conventional US imaging due to similar reflectivity to the US beam Pinzon, EG and Moore, RE. Musculoskeletal Ultrasound: a brief overview of diagnostic and therapeutic application in musculoskeletal medicine. Practical Pain Management. June 2009.

38 Ultrasound Terminology
Hypoechoic- structures are seen as darker relative to the surrounding structures on US imaging due to the US beam being reflected to a lesser extent Anechoic- structures that lack internal reflectors fail to reflect the US beam to the transducer and are seen as homogenously black on imaging Anisotrophy- the effect of the beam not being reflected back to the transducer when the probe is not perpendicular to the structure being evaluated Pinzon, EG and Moore, RE. Musculoskeletal Ultrasound: a brief overview of diagnostic and therapeutic application in musculoskeletal medicine. Practical Pain Management. June 2009.

39 Ultrasound Terminology
Transverse- cross sectional view Sagittal (Longitudinal)- long axis plane view Coronal- long axis plane view dividing anterior and posterior

40 Ultrasound Equipment High Resolution Machine Transducers Printer
Linear 8-14 MHz Curvilinear 2-5 MHz “Hockey Stick” Printer CD/DVD/USB unit Add hockey stick transducer Schaefer, MP. Ultrasound Guided Interventions in PM&R. MRIO PM&R Grand Rounds. 9 November 2009.

41 Ultrasound Guidance Advantages
Real-time guidance Assess anatomy Soft tissue visualization Visualize neurovascular structures No radiation Schaefer, MP. Ultrasound Guided Interventions in PM&R. MRIO PM&R Grand Rounds. 9 November 2009.

42 Ultrasound Guidance Limitations
Obesity (depth ~6cm) No contrast confirmation No visualization deep to bony structures (very limited use in spine injections) Operator dependency Superficial tenderness Schaefer, MP. Ultrasound Guided Interventions in PM&R. MRIO PM&R Grand Rounds. 9 November 2009.

43 Equipment for U/S Guided Injections
Informed consent Sterile vs non-sterile gloves? Marking pen Alcohol pads Povidine-iodine Gauze pads Syringes Needles (typically longer than non-guided injections) Echoblock needle? Sterile transducer cover? Sterile gel Anesthetic Steroid Adhesive bandages The EchoBlock MSK Echogenic Non-Insulated Needle for ultrasound guided joint and tendon injections features patented corner cube reflectors (CCR®) providing multiple angled surfaces near the tip for maximum reflection even at steep injection angles. Schaefer, MP. Ultrasound Guided Interventions in PM&R. MRIO PM&R Grand Rounds. 9 November 2009.

44 Subacromial Injection
Schaefer, MP. Ultrasound Guided Interventions in PM&R. MRIO PM&R Grand Rounds. 9 November 2009.

45 Subacromial Injection
Schaefer, MP. Ultrasound Guided Interventions in PM&R. MRIO PM&R Grand Rounds. 9 November 2009. Schaefer, MP. Ultrasound Guided Interventions in PM&R. MRIO PM&R Grand Rounds. 9 November 2009.

46 Acromioclavicular Injection

47 Acromioclavicular Injection
Schaefer, MP. Ultrasound Guided Interventions in PM&R. MRIO PM&R Grand Rounds. 9 November 2009. Schaefer, MP. Ultrasound Guided Interventions in PM&R. MRIO PM&R Grand Rounds. 9 November 2009.

48 Glenohumeral Injection

49 Glenohumeral Injection
Schaefer, MP. Ultrasound Guided Interventions in PM&R. MRIO PM&R Grand Rounds. 9 November 2009. Schaefer, MP. Ultrasound Guided Interventions in PM&R. MRIO PM&R Grand Rounds. 9 November 2009.

50 Long Head Biceps Brachii Injection

51 Long Head Biceps Brachii Injection

52 Sternoclavicular Injection

53 Post Injection Instructions
Recurring Pain- anesthetic effect ending before steroid effect begins Rest Injection Area- further injury may be caused by numbness of the site Infection Observation- fever, increased warmth/redness, ascending redness, increased swelling

54 Injection Coding CPT code Code for injectable used (J code)
20610 injection/aspiration of major joint or bursa Code for injectable used (J code) $120 for injection $3-10 for steroid McNabb, James. A Practical Guide to Joint & Soft Tissue Injection & Aspiration. 2nd Ed.LWW; 2010.

55 Questions and Demonstration

56 References Beggs, I., et al. Musculoskeletal Ultrasound Technical Guidelines: shoulder. European Society of Musculoskeletal Radiology. McNabb, James. A Practical Guide to Joint & Soft Tissue Injection & Aspiration. 2nd Ed. LWW; 2010. Pinzon, EG and Moore, RE. Musculoskeletal Ultrasound: a brief overview of diagnostic and therapeutic application in musculoskeletal medicine. Practical Pain Management. June 2009. Schaefer, MP. Ultrasound Guided Interventions in PM&R. MRIO PM&R Grand Rounds. November 2009.


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