1. 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.

2. 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):

3. 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):

4. 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):

5. Choice of injection
Depomedrone- Intermediate potency and intermediate duration 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):

6. 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 minutes post injection
Cardone et al. Joint and Soft Tissue Injection. American Family Physician.2002 July 15;66(2):

7. 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):

8. Morton‘s Neuroma First described by Durlacher, 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; pp

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

10. Tarsal Tunnel and medial structures

11. Structures of the lateral ankle joint

12. Anterior Ankle Joint