1. Joint Injections Workshop. RNZCGP Conference 2011 Dr Francesco Lentini FRNZCGP

2. CARPAL TUNNEL SYNDROME ANATOMY The carpal tunnel is formed by the carpal bones dorsally, and the transverse carpal ligament (Flexor Retinaculum), ventrally. The contents of the tunnel include the Median Nerve and flexor tendons of the hand. The median nerve sensory and motor distribution includes the palmar aspect of the thumb and the index and middle fingers, and it allows opposition of the tip of the thumb with the tips of the fingers.

3. Carpal Tunnel syndrome -Diagnosis-  Diagnosis of carpal tunnel syndrome is clinical. Electro-diagnostic studies (nerve conduction and electromyography) may assist in confirming the diagnosis. Weakness of thumb abduction is a specific and reliable sign.  Tinel’s test : Percuss lightly over the Flexor Retinaculum with a tendon hammer between the Palmaris Longus and the Flexor Carpi Radialis > tingling sensation in Median nerve distribution.  Phelan’s test : Hold wrist in flexion for up to 1 min > Pain and paraesthesia

4. Carpal Tunnel Syndrome Indications for injection  The major indication for carpal tunnel injection is the syndrome of median nerve compression, which may result from osteoarthritis, rheumatoid arthritis, diabetes mellitus, hypothyroidism, repetitive use injury or other traumatic injuries to the area.

5. Carpal Tunnel Syndrome Indications  The use of local corticosteroid injection for CTS has been shown to provide greater clinical improvement in symptoms one month after injection, compared with placebo. Injection of the CT is considered a later modality after appropriate nonsurgical therapeutic interventions have been undertaken. These include the use of NSAIDs, splinting, and avoidance of precipitating activities.

6. Carpal Tunnel Syndrome Injection Landmarks  Essential landmarks to palpate before performing this injection include the proximal wrist crease and the Palmaris Longus Tendon when present. The Palmaris Longus Tendon is best identified by having the patient pinch all the fingertips together while the wrist is in a neutral position.

7. Carpal Tunnel Syndrome Materials + Pharmaceuticals  Syringe: 5 Ml  Needle: 25 gauge, 1.5 inch  Anaesthetic: 2-3 Mls of 1% Lidocaine  Cortico-steroid: 1 Ml Methylprednisolone, 40 Mg in 1 Ml

8. Carpal Tunnel Syndrome Approach and needle entry  The injection is performed at a site just ulnar to the Palmaris Longus Tendon and at the proximal wrist crease. The needle is inserted at a 30-degree angle and directed toward the ring finger. If the needle meets obstruction or if the patient experiences paraesthesia, the needle should be withdrawn and re-directed in a more ulnar fashion.

9. Carpal Tunnel Syndrome Injection Site

10. 1 st Carpo-Metacarpal Joint Anatomy  The movements of the thumb are dictated by the saddle-shaped articular surface of the base of the first metacarpal, which articulates with the trapezium.

11. 1 st CMC Joint Indications and diagnosis  Pain associated with arthritis or overuse is the most common indication for injection of this joint. Diagnosis is determined by limitation of motion and palpation of crepitus and tenderness over the joint. Diagnosis may be confirmed by radiographs. Injection is usually performed after other more conservative therapies, including use of NSAIDs and a brief period of immobilization, have been tried. As with any arthritic joint, relief after injection may only be temporary, and surgical intervention may need to be considered.

12. 1 st CMC Joint Approach and needle entry  Palpate the joint space between the Trapezium and the First Metacarpal.  The needle enters just proximal to the first metacarpal on the extensor surface. Care must be taken to avoid the Radial Artery and the Extensor Pollicis tendons. To avoid the radial artery, the needle should enter toward the dorsal (ulnar) side of the Extensor Pollicis Brevis tendon. The needle should fall into the joint space. Traction can be applied to the thumb to further open the joint space.

13. 1 st CMC Joint Materials + Pharmaceuticals  Syringe: 3 Mls  Needle: 25 Gauge, 1 inch  Anesthetic: 0.5 Ml of 1% Lidocaine  Cortico-Steroid: 0.5 Ml of Methylprednisolone 40 Mg/1 Ml

14. 1 st CMC Joint

15. de Quervain’s Disease Anatomy  This disorder, a stenosing tenosynovitis, involves the Abductor Pollicis Longus and Extensor Pollicis Brevis tendons.

16. de Quervain’s Disease Indications and Diagnosis  Usually occurs with repetitive use of the thumb. Thickening is noted, and tenderness is elicited just distal to the radial styloid process over the site of the involved tendon sheath. The Finkelstein test is performed by having the patient make a fist with the thumb inside while simultaneously ulnar deviating the hand. Pain over the affected area is elicited in dQD

17. de Quervain’s Disease  Immobilization and the use of NSAIDs should be tried before injection therapy is performed.

18. De Quervain Disease Injection Approach  With the thumb abducted and extended, palpate the course of the tendons distal to the radial styloid process. The needle is placed into the first extensor compartment, directed proximally toward the radial styloid process and sliding in parallel to the abductor and extensor tendons. Do not inject directly into a tendon.

19. de Quervain’s Disease Materials + Pharmaceuticals  Syringe: 5 Ml  Needle: 25 gauge, 1.5 inch  Anaesthetic: 2 Mls of 1% Lidocaine  Cortico-steroid: 1 Ml Methylprednisolone, 40 Mg in 1 Ml

20. de Quervains Disease

21. Knee Joint Anatomy  Two functional joints, the femoral-tibial and the femoral-patellar, make up the knee. Primary stabilizers of the knee are the anterior and posterior cruciate ligaments, the medial and lateral collateral ligaments, and the capsular ligaments.

22. Knee Joint Indications for Aspiration  Unexplained effusion, possible septic arthritis and relief of discomfort caused by an effusion.

23. Knee Joint Indications for injection  The use of intra-articular corticosteroids is reserved for patients with more advanced disease (osteoarthritis and other non- infectious inflammatory arthritides such as gout) and after other modalities have been tried.

24. Knee Joint Position and Landmarks  Position of Patient: The patient is in the supine position with the knee slightly flexed with a pillow or rolled towel in the popliteal space.  Palpation of Landmarks: Identify the medial, lateral, and superior borders of the patella.

25. Knee Joint Techniques  There are many different techniques for aspirating or injecting the knee. These include medial, lateral, and anterior approaches. Each has its own merit, but choice of approach is dependent on physician preference

26. Knee Joint Materials + Pharmaceuticals  Syringe: 50 Mls for Aspiration; 10 Mls for Injection  Needles: 18, 20 or 22 gauge. 1.5 inch  Anaesthetics: 5 Mls 1% Lidocaine.  Cortico-steroid: 2-3 Mls of Methylprednisolone 40 Mg/1 Ml.

27. Knee Joint Approach and needle entry  The lateral approach is most commonly used. For this approach, lines are drawn along the lateral and proximal borders of the patella. The needle is inserted into the soft tissue between the patella and femur near the intersection point of the lines, and directed at a 45-degree angle toward the middle of the medial side of the joint.

28. Knee Joint Approach and needle entry

29.  For the medial approach, the needle enters the medial side of the knee under the middle of the patella (midpole) and is directed toward the opposite patellar midpole.

30. Knee Joint Approach and needle entry  In the anterior approach, the knee is flexed 60 to 90 degrees, and the needle is inserted just medial or lateral to the patellar tendon and parallel to the tibial plateau. This technique is preferred by some physicians for its ease of joint entry in advanced osteoarthritis. However, the anterior approach may incur greater risk for meniscal injury by the needle.

31. Joint injections Follow up care  Following injection, the joint or injected region may be put through passive range of motion. The patient should remain in the office for 30 minutes after the injection to monitor for any adverse reactions. Avoid strenuous activity involving the injected region for several days. Patients should be cautioned that they may experience worsening symptoms during the first 24 to 48 hours related to a possible steroid flare, which can be treated with ice and NSAIDs. Instruct against the application of heat. A F/u appointment should be scheduled within three weeks.

32. THANK YOU ANY QUESTIONS?