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Joint Injections in Primary Care Marc A. Aiken, MD Watauga Orthopaedics.

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Presentation on theme: "Joint Injections in Primary Care Marc A. Aiken, MD Watauga Orthopaedics."— Presentation transcript:

1 Joint Injections in Primary Care Marc A. Aiken, MD Watauga Orthopaedics

2 Objectives Understand when it is appropriate to inject /aspirate a joint Review common injection medications review pertinent anatomy for safe injection technique Review technique for injections in most common joints When to refer

3 The Most Common Joints Injected Knee Shoulder (glenohumeral jt.) Shoulder (subacromial bursa)

4 Indications - Diagnostic Evaluate fluid aspirate for: Infection Inflammatory arthropathy Trauma Relief of pain immediately following injection indicates an intraarticular source

5 Indications - Therapeutic Relief of pain/inflammation caused by: Effusion OA, RA, Gout Bursitis Selected tendonopathies

6 Absolute Contraindications Local cellulitis Prosthetic joint Septicemia Acute fracture Patella and achilles tendonopathy Allergy to injection medications

7 Relative Contraindications Anticoagulated/coagulopathic patient Diabetes Immunocompromised patient Minimal or no relief with 2 prior injections Local osteoporosis Inaccessible joints

8 Medications Corticosteroid Local anesthetic Hyaluronic acid

9 Steroid Betamethasone (Celestone Soluspan) Agent of choice in my practice Long acting 6-12mg for large joint (knee, shoulder) 1.5-6mg for small/intermediate joints

10 Other Steroids Triamcinolone (Aristospan) Dexamethasone (Decadron) Methylprednisolone (Depo-Medrol)

11 Local 1% Lidocaine (Xylocaine) without epi useful for intraarticular injection and subcutaneous injection when aspirating onset within minutes can be diagnostic tool

12 Local Bupivicaine (Marcaine) Potential cause of chondrocyte death Avoid intraarticular use

13 Hyaluronic Acid “Lube job” for the knee Replaces HA deficient arthritic knee fluid with thick viscous HA. Expect 6 months of relief Given in 3 injections 1 week apart Relief may not be obtained for up to 8wks following last injection.

14 Adverse Reactions/Complicati ons 2-5% - Post injection (steroid) flare 0.8% - Steroid arthropathy (AVN, Chondrolysis, etc.) Iatrogenic infection Flushing Skin atrophy and depigmentation

15 Adverse Reactions/Complicati ons Loss of glucose control in DM Increased appetite Insomnia Irritability

16 General Considerations Evaluate the patient Patient education Consent Patient Comfort Sterile preparation and technique Documentation

17 Evaluate the Patient!! Avoid the “Knee hurt....me inject” mentality. Get a complete history Examine the patient including other joints Obtain x-rays MRI only if appropriate

18 Patient Education What medications are being used What is the injection expected to do for them What it is not expected to do When they will notice effects of injection What if the expected results are not achieved

19 Consent Written Vs. Verbal Your choice

20 Patient Comfort Lying down for knees (superolateral approach) Sitting up for shoulders Take your time Use ethyl chloride (cold spray) immediately before injection Explain the steps of the procedure as you do them

21 Patient Comfort In patients with severe anxiety regarding needles, provide alternatives or allow them to schedule the injection on a different date. This may allow them time to mentally prepare for the injection. Injections are usually far less painful than patient anticipate

22 Sterile Prep/Technique Make sure injection site is fully exposed Should not be visibly soiled Use iodine or chlorhexidine prep over site to be injected Alway use aseptic technique Consider use of sterile gloves Sterile drapes generally unnecessary

23 Documentation Document the history and physical exam findings that support the decision to perform aspiration/injection Site (which joint and which side) Anatomic placement (med, lat, ant etc) medications and doses injected Expiration dates and lot numbers

24 Document Amount of fluid aspirated color, clarity and viscosity of fluid purulent? Blood? (trauma) Lipid?(trauma/occult fx)

25 Send Fluid for Analysis Labs ordered from fluid: Cell Counts (stat if infection suspected) Cultures Gram stain (stat) Polarized light microscopy

26 Post Injection Care Remove visible prep solution Bandaid Pressure dressing on free bleeders Rest and Ice for 24 hours Warn about limitation of local anesthetic Warn about steroid flare

27 Injection Technique Intraarticular knee Intraarticular Shoulder Subacromial bursa

28 Supplies

29 Knee Aspiration/Injection Superolateral approach most reliable 93% accuracy vs. 71-75% with bent knee anteromedial/anterolateral approach

30

31 Superolateral Approach Patient Supine with knee extended Palpate bony landmarks Patella Lateral Femur

32 Palpate Patella

33

34 X Marks the Spot Palpate lateral border of patella and Lateral femur at the PF joint The space between these bony structures is your injection site

35 The Injection Reassure patient Relaxed quads = more space at PF jt Needle Trajectory 15-20 degrees Toward trochlea of femur

36 Needle Trajectory

37 Anterior Approach (bent knee)

38 Anterior Approach Less reliable/accurate than superolateral approach Can be easier in the obese knee Patient sitting with knee bent to 90 degrees

39 Anterior Approach Palpate landmarks Inferior pole of patella Patella tendon Tibial Plateau

40 Landmarks - Patella

41 Landmarks - Plateau

42 Landmarks

43 Injection Site May inject medial or lateral to patella tendon 1cm above tibial plateau or Half the distance from plateau to inferior pole of patella Trajectory of needle should be toward intercondylar notch

44 Trajectory

45 Shoulder (GH joint) Anterior approach Position patient sitting facing provider Palpate bony landmarks Clavicle Coracoid

46 Landmarks

47 Palpate - Clavicle

48 Clavicle

49 Coracoid

50

51 Needle Placement Inject just lateral to coracoid process 20 degree angle Reposition if you encounter resistance

52 Shoulder (SA Bursa) Given lateral or posterior Just beneath the angle of the acromion

53 Acromion

54 Subacromial Injection Direct needle under acromion

55 Questions?


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