Essex medical Society we peers stand together Limited spaces Book ASAP  Essex Medical Society are holding MSK CPD event on Steroid injections for all G. P’s Essential CPD for Primary care Upper and lower limb Steroid injections One to one hands on training course Thursday 22nd September 2016 at 7 PM Thursday 29th  September 2016 at 7 PM  Venue : Ye Olde Plough Orsett. RM14 3SR  Training. Consultants. Mr Ravindran Kuzhupilly Ranjith, Consultant Orthopaedic Surgeon, BTUH Mr Ravi Ray. Consultant Orthopaedic Surgeon, BTUH Upper limb Trigger finger, De-Quervain’s tenosynovitis, Tennis Elbow, Golfer’s Elbow, Carpal tunnel syndrome, Injections around the shoulder joint Lower limb Knee joint, Ankle joint, Morton’s neuroma, Plantar fasciitis, Trochanteric bursitis We are proud to be able to host such a useful training event to upskill our Colleagues.

Joint and Soft tissue injections- Indications Bursitis Tendonitis or tenosynovitis Trigger points Neuromas Entrapment Syndromes Fascitis Suspected Joint infection- aspiration Arthritis- Osteo, inflammatory Cardone et al. Joint and Soft Tissue Injection. American Family Physician.2002 July 15;66(2):283-289

Absolute Contraindications Local cellulitis Septic arthritis- can aspirate Acute fracture Joint prosthesis Achilles or patellar tendinopathies History of allergy to injectables Cardone et al. Joint and Soft Tissue Injection. American Family Physician.2002 July 15;66(2):283-289

Relative contraindications Minimal relief after previous injections Underlying coagulopathies- Warfarinised patients with INR<3 can be injected Anatomically difficult to access Uncontrolled diabetes Must have working diagnosis before injection Cardone et al. Joint and Soft Tissue Injection. American Family Physician.2002 July 15;66(2):283-289

Choice of injection Depomedrone- Intermediate potency and intermediate duration- 2- 10 mg for soft tissue and small joints, 80mg for larger joints Intraarticular Hyaluronic acid- Ostenil, Synvisc 1 etc Local anaesthetic- I prefer 0.5% plain levobupivacaine but any plain local anaesthetic of choice may be used. I titrate volume to size of joint- 0.25mL for tight tendon sheaths to upto 5-8 mL for larger joints Cardone et al. Joint and Soft Tissue Injection. American Family Physician.2002 July 15;66(2):283-289

Potential complications Infection Inflammatory flare Beware - Tendon rupture Hypopigmentation of skin Fat or soft tissue atrophy Hyperglycaemia in diabetics Direct needle injury to nerves and articular cartilage Allergic reactions- Observe for 20-30 minutes post injection Cardone et al. Joint and Soft Tissue Injection. American Family Physician.2002 July 15;66(2):283-289

Essential equipment Sterile tray Needle to withdraw drug Appropriate size needle to administer injections Syringes Chlorhexidine or Betadine prep Adhesive Dressing Sterile gloves Assistant Appropriate bottles for any specimens Equipment to deal with anaphylaxis if needed Cardone et al. Joint and Soft Tissue Injection. American Family Physician.2002 July 15;66(2):283-289

Morton‘s Neuroma First described by Durlacher, 1845 1876 Morton expanded the clinical description Perineural fibrosis of common digital nerve usually in 3rd interspace with underlying nerve degeneration Campbell’s Operative Orthopaedics, Ed. AHCrenshaw, 8th ed; pp2781-2786

Plantar Fascitis Originates from anteromedial plantar aspect of calcaneal tuberosity and extends to plantar plates of metatarsophalangeal joints- ‘windlass mechanism’

Tarsal Tunnel and medial structures

Structures of the lateral ankle joint

Anterior Ankle Joint