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

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

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

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

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

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

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

Medications Corticosteroid Local anesthetic Hyaluronic acid

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

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

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

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

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.

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

Adverse Reactions/Complications Loss of glucose control in DM Increased appetite Insomnia Irritability

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

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

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

Consent Written Vs. Verbal Your choice

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

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

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

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

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

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

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

Injection Technique Intraarticular knee Intraarticular Shoulder Subacromial bursa

Supplies

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

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

Palpate Patella

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

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

Needle Trajectory

Anterior Approach (bent knee)

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

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

Landmarks - Patella

Landmarks - Plateau

Landmarks

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

Trajectory

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

Landmarks

Palpate - Clavicle

Clavicle

Coracoid

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

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

Acromion

Subacromial Injection Direct needle under acromion

Questions?