Presentation on theme: "Shoulder Girdle Joint Injection Workshop"— Presentation transcript:
1 Shoulder Girdle Joint Injection Workshop Virginia Osteopathic Medical Association2011 Fall CME ConferenceHotel Roanoke & Conference CenterRoanoke, VirginiaSeptember 23, 2011Bradley M. McCrady, DOFellow, Primary Care Sports MedicineEdward Via College of Osteopathic Medicine- Virginia CampusVirginia Polytechnic Institute and State University
2 ObjectivesIdentify 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.
4 Shoulder ComplexShoulder is a complicated anatomical and biomechanical joint“Fragile Equilibrium”Multiple jointsStatic and dynamic stabilizersStatic labrum, adhesion-cohesion, capsule, intra-articular pressureDynamic muscles, proprioceptive feedbackHoppenfeld, S. Physical Examination of the Spine and Extremities. Prentice Hall; 1976
5 What Providers Need to Know About Joint Injection and Aspiration Relatively simple procedureComplications are uncommonInjection/arthrocentesis can provide diagnosis, relieve pain, decrease joint damage“Liquid biopsy of joint”Useful information can be provided by relatively inexpensive testsCan help differentiate inflammatory from non-inflammatory arthritisJudicious use of anesthetics and steroids may be safer than systemic medicationsSummary There are often more reasons for doing than not in the right clinical scenarioACP Clinical Skills Series - Arthrocentesis & Joint Injection
6 Indications for Joint Injection/Aspiration DiagnosticAcute inflammatory arthritis (24-48 hours) in a patient who has never had these symptoms beforeAcute effusion in the setting of fever, chills, or presence of infection at another siteAcute effusion in the setting of traumaPrior to committing patients to long-term, expensive or toxic therapyTherapeuticProvide for a better musculoskeletal exam (i.e. pain control)To suppress inflammation in one or two isolated jointsAdjuvant therapy to a few joints resistant to systemic therapyTo facilitate a rehabilitative therapy programTo support a patient with active joint inflammation pending the effects of systemic therapyTo remove exudative fluid from a septic jointTo relieve pain in a swollen joint
7 Conditions Likely to be Improved by Joint or Periarticular Injections Rheumatoid arthritisSeronegative spondyloarthropathiesCrystal induced arthritisCarpal tunnelBursitisTenosynovitis/tendinitisAdhesive capsulitisOsteoarthritis
8 Contraindication to Joint Injection/Aspiration AbsoluteUncooperative patientAllergy to anesthesia or steroid (very rare)Lack of informed consentInjection through infected tissuesPrevious severe steroid flareInjection of steroid into critical weight-bearing tendonsRelativeInjection near critical structuresCoagulation disordersUncontrolled diabetesh/o AVNPrevious joint replacement at injection siteMore than 3 previous steroid injections in a major weight bearing joint in the preceding yearConcern to activate any latent diseaseExcessive anxiety
10 Safety First Position for comfort! Define anatomy Universal precautionsVaccinesGown and mask not necessaryClean vs sterile techniqueAspirate prior to injectionsDo not recap needlesProper disposal of equipmentObserve patient in office following injection for minAlcohol pads cost approximately 3 cents/pad; and povidone-iodine costs 13 cents/swabsterile 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) 1:88–91Hemani, 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 1:50,00070% isopropyl alcohol vs 10% povidone-iodineEthyl chloride fine spray may have antimicrobial activityAccording 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 releaseof free iodine when in a solution. Iodine acts in an antiseptic manner by destroying microbial proteins and DNA and safety on nearlyall 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 shortacting, has broad-spectrum antimicrobial activity, and is relatively inexpensive. Flammability can be avoided by allowing skinto 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) 1:88–91Hemani, M. Rev Urol. 2009;11(4):Darouiche, RO. N Engl J Med 2010;362:18-26Clinical Radiology, Volume 61, Issue 12, Pages
12 Steroids-HistoryHydrocortisone 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 athleticsTreat the secondary inflammationNeed to find the causeIn rheumatologic disease, inflammation is the problem, whereas in sports injury, performance recovery depends on restoration of both the injured tissue and its kinetic environmentIf 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 fireNepple, J. Sports Health: A Multidisciplinary Approach :Leadbetter WB. Clin Sports Med.1995;14(2):
13 Steroids-PhysiologyStabilizing lysosomal membranes of inflammatory cellsDecreasing local vascular permeabilityAltering neutrophil chemotaxis and functionAble to pass through cell membranes and bind to nuclear steroid receptorsWhere they influence RNA transcriptionNepple, J. Sports Health: A Multidisciplinary Approach :
15 Steroids-UseHill et al surveyed members of the American Academy of Orthopaedic Surgeons on use of corticosteroids90% of used corticosteroid injectionsPerformed an average of 150 intra-articular and 193 extra-articular injections per yearConditions warranting injectionEpicondylitis (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 AnestheticsDecrease nerve conduction through the blockade of Na channels, which disrupts axonal nerve conductionTypically steroid agent is combined with a local anesthetic agentDecrease the painDilute the steroidIncrease the distribution of the agent to the treated areaLidocaineRapid onset (minutes)Short duration (60-90 minutes)BupivicaineSlower onset (30 minutes)Longer duration (6-8 hours)BufferingSodium bicarbonatepH of 1% lidocaine is 6.5Bupivicaine is isotonicAdding sterile Na bicarbonate to lidocaine at 1:10 ratio neutralizesADD IN review of literatureNepple, J. Sports Health: A Multidisciplinary Approach :
17 What Patients (and Providers) Need to Know about Joint Injection Relief will typically last weeks or longerAvoid injecting ligamentous or tendon structure directlyActivity modification following injections of steroids is uncertainMaximal number of injections and the required period between injections have not been determinedNichols, A Clin J Sport Med 2005;15(5) : E370Pfenninger 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 rateThe 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 patientsPost injection flare (2-5%)Prolonged and repeated usage may increase the risk of complications and systemic side effectsIn 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 intervalsDietzel, D Current Sports Medicine Reports 2004, 3:310–315Nepple, 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 diagnosesDiscuss the proposed procedure and alternatives with the patientObtain written informed consent from the patientCollect and prepare the required materialsCorrectly position the patient for the procedureIdentify and mark the anatomic landmarks and injection site with inkDo not allow the patient to move the affected area from the time that the marks are placed until after the procedure is completedPress firmly on the skin with the retracted tip of a ballpoint pen to further identify the injection sitePrepare 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 effectProvide local anesthesia as indicated through use of tactile distraction, vapocoolant spray (ethyl chloride or PainEase), and/or injected local anesthesiaMcNabb, 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 areaAspirate fluid (optional) using a 18 or 20-g needle and send it for laboratory examination if indicatedIf 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 corticosteroidAlways aspirate before injection to avoid intravascular administrationInject corticosteroid solution into the treatment areaIf not aspirating then use 25-g needleDo not inject the medication against resistanceWithdraw the needleApply direct pressure over the injection site with a gauze padApply an adhesive dressingProvide the patient with specific post-injection instructionsMcNabb, 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 ConsentPatient’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 SubacromialPosteriorLateralGlenohumeralAnteriorAcromioclavicularSternoclavicularBiceps brachii long head
23 Subacromial Injection Lateral Approach Find lateral edge of acromion and markPalpate soft spot below the acromion and above the humeral headInsert needle perpendicular through the deltoid towards the bursa
24 Subacromial Injection Posterior Approach Find lateral edge of the acromion and markPalpate posterior edge of the acromion and markFind posterolateral edge of the acromion and mark a spot 2 cm below the cornerMcNabb, 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 acromionInsert the needle getting underneath the acromion and advance until the needle tip touches the undersurface of the acromionOnce at the acromion, back off 1-2mm
26 Glenohumeral Injection Posterior Approach Find lateral edge of acromionPalpate the posterior edge of the acromionMark spot 2 cm below posterior lateral cornerTarget 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 processInjection 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 acromionAdvance 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 elbowPalpate 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 proximallyAdvance needle until needle tip touches tendon, back needle off 1-2mmMedication 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 proceduresPinzon, 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 beamIsoechoic- structures are seen as bright as surrounding structures on conventional US imaging due to similar reflectivity to the US beamPinzon, 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 extentAnechoic- structures that lack internal reflectors fail to reflect the US beam to the transducer and are seen as homogenously black on imagingAnisotrophy- the effect of the beam not being reflected back to the transducer when the probe is not perpendicular to the structure being evaluatedPinzon, 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 viewSagittal (Longitudinal)- long axis plane viewCoronal- long axis plane view dividing anterior andposterior
40 Ultrasound Equipment High Resolution Machine Transducers Printer Linear 8-14 MHzCurvilinear 2-5 MHz“Hockey Stick”PrinterCD/DVD/USB unitAdd hockey stick transducerSchaefer, MP. Ultrasound Guided Interventions in PM&R. MRIO PM&R Grand Rounds. 9 November 2009.
41 Ultrasound Guidance Advantages Real-time guidanceAssess anatomySoft tissue visualizationVisualize neurovascular structuresNo radiationSchaefer, MP. Ultrasound Guided Interventions in PM&R. MRIO PM&R Grand Rounds. 9 November 2009.
42 Ultrasound Guidance Limitations Obesity (depth ~6cm)No contrast confirmationNo visualization deep to bony structures (very limited use in spine injections)Operator dependencySuperficial tendernessSchaefer, MP. Ultrasound Guided Interventions in PM&R. MRIO PM&R Grand Rounds. 9 November 2009.
43 Equipment for U/S Guided Injections Informed consentSterile vs non-sterile gloves?Marking penAlcohol padsPovidine-iodineGauze padsSyringesNeedles (typically longer than non-guided injections)Echoblock needle?Sterile transducer cover?Sterile gelAnestheticSteroidAdhesive bandagesThe 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.
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.
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.
53 Post Injection Instructions Recurring Pain- anesthetic effect ending before steroid effect beginsRest Injection Area- further injury may be caused by numbness of the siteInfection 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 bursaCode for injectable used (J code)$120 for injection$3-10 for steroidMcNabb, James. A Practical Guide to Joint & Soft Tissue Injection & Aspiration. 2nd Ed.LWW; 2010.
56 ReferencesBeggs, 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.