1. Educational Solutions for Workforce Development East Deanery Joint injections Dave Shackles

2. Educational Solutions for Workforce Development East Deanery Rationale Primary care providers should master the technique of joint aspiration and injection for many reasons: Diagnosing an inflamed joint Pain relief of a distended joint Injection of steroids for painful joint And others?

3. Educational Solutions for Workforce Development East Deanery Indications Diagnostic To evaluate synovial fluid Infections Rheumatic Traumatic Crystal-induced etiology Therapeutic Remove exudate from septic joint Relieve pain in grossly swollen joint Inject lidocaine, saline, corticosteroids

4. Educational Solutions for Workforce Development East Deanery Basic principles before you start History and examination Try conservative treatment first eg NSAIDs and continue after joint injection. Careful patient selection Consent Know your anatomy! Undertake as few injections as possible to settle the problem, max 3-4 in a single joint Consider differential diagnosis do you need x-ray first?

5. Educational Solutions for Workforce Development East Deanery Indications for injection Osteoarthritis Rheumatoid arthritis Gouty arthritis Synovitis Bursitis Tendonitis Muscle trigger points Carpal tunnel syndrome

6. Educational Solutions for Workforce Development East Deanery Contraindications Absolute Local sepsis Suspicion of infection Sepsis Hypersensitivity Early trauma Hemarthrosis Prosthetic joint Very unstable joint Reluctant patient Children

7. Educational Solutions for Workforce Development East Deanery Contraindications? Diabetic Anticoagulated Bleeding disorder Immunosuppressed Psychogenic pain Severe anxiety Gut feeling Charcot joint (neuropathic sensory loss) Tumour Neurogenic disease Active infections (eg, tuberculosis) Immune-suppressed hosts Hypothyroidism

8. Educational Solutions for Workforce Development East Deanery What to warn the patient Risks v benefits Pain returns after 2 hours, when the local anaesthetic wears off – may be worse than before. If pain is severe or increasing after 48hrs, seek advice Warn of local side effects. Depigmentation Tendon damage Bleeding Advise to seek help if systemic s/es develop suggesting infection

9. Educational Solutions for Workforce Development East Deanery The Drugs Corticosteroids: Suppress inflammation Short acting: Hydrocortisone Intermediate acting: Methylprednisone/Triamcinolone Long acting: Dexamethasone Local anaesthetics Diagnostic,Analgesic,Dilution, Distension Commonly used Lidocaine Bupivacaine

10. Educational Solutions for Workforce Development East Deanery Technique Object is to inject the corticosteroid with as little pain and as few complications as possible. Do not attempt any injections in the vicinity of known nerve or arterial landmarks eg lateral epicondyle of elbow ok, medial – beware ulnar nerve Never inject into substance of a tendon Sterile technique

11. Educational Solutions for Workforce Development East Deanery Technique 2 ANTICIPATION! Get your kit ready ie: Needles, syringes, sterile container, LA, steroid, gloves, drapes, chlorhexidine, cotton wool, plaster. 1 or 2 needle technique Clean area

12. Educational Solutions for Workforce Development East Deanery Technique 3 Always withdraw syringe back first to ensure not injecting into blood vessel Inject LA first eg lidocaine 1% or marcaine. Wait 3-5 mins then use larger bore needle to inject corticosteroid Eg hydrocortisone acetate, methylprednisolone acetate, triamcinolone hexacetonide

13. Educational Solutions for Workforce Development East Deanery Local side effects Infection, subcutaneous atrophy, skin depigmentation, and tendon rupture (<1%). Post-injection flare in 2-5% Often are the result of poor technique, too large a dose, too frequent a dose, or failure to mix and dissolve the medications properly. NB corticosteroid short duration of action – can be as short as 2-3 weeks relief.

14. Educational Solutions for Workforce Development East Deanery Knee injections Patient on the couch, knee slightly bent Palpate superior-lateral aspect of patella Mark 1 fingerbreadth above + lateral to this site Clean LA, corticosteroid Clean + bandage

15. Educational Solutions for Workforce Development East Deanery Knee Joint Lateral Medial Knee slightly flexed

16. Educational Solutions for Workforce Development East Deanery Plantar fasciitis Procedure painful + no evidence for long-term benefit Pt indicate tender spot Approach from thinner skin + direct posterior- laterally Small blelb as near to bony insertion as possible Do not inject fascia itself

17. Educational Solutions for Workforce Development East Deanery Shoulder injection Glenohumeral joint AC joint Subacromial space Long Head of Biceps Older patients: 2-3 x/ year Younger – consider surgery if no improvement (risk rotator cuff rupture)

18. Educational Solutions for Workforce Development East Deanery Glenohumeral joint injection Pt sits, arm by side, externally rotated Find sulcus between head of humerus and acromion Posterolateral corner of acromion (2-3 cm inferior) Direct needle anteriorly toward coracoid process Insert needle to full length Fluid should flow easily

19. Educational Solutions for Workforce Development East Deanery AC joint injection Palpate clavicle to distal aspect Slight depression where clavicle meets acromion Insert needle from anterior and superior approach Direct needle inferiorly

20. Educational Solutions for Workforce Development East Deanery Sub-acromial joint injection Posterior and lateral aspect of shoulder Inferior to lower edge of posterolateral acromion Insert inferior to acromion at lateral shoulder Direct needle toward opposite nipple Insert needle to full length Fluid should flow easily

21. Educational Solutions for Workforce Development East Deanery The Elbow

22. Educational Solutions for Workforce Development East Deanery The Elbow Landmarks Lateral epicondyle and radial head With elbow extended – the depression is palpated Insertion 22-ga needle from lateral aspect just distal to lateral epicondyle and direct medially

23. Educational Solutions for Workforce Development East Deanery The Elbow Olecranon Bursitis Diagnosis obvious Approach: 20-ga needle into dependent aspect of sac

24. Educational Solutions for Workforce Development East Deanery Elbow epicondyle injection Very effective in short term – 92% Benefits do not normally persist beyond 6 weeks Lateral (tennis elbow) + medial (golfers elbow) epicondylitis Patient supine

25. Educational Solutions for Workforce Development East Deanery Tennis elbow (lateral) Arm adducted at side Elbow flexed to 45 degrees Wrist pronated Insert needle perpendicular to skin at point of maximal tenderness Insert to bone, then withdraw 1-2 mm Inject corticosteroid solution slowly

26. Educational Solutions for Workforce Development East Deanery Golfers elbow (medial) Beware ulnar nerve! Rest arm in comfortable abducted position Elbow flexed to 45 degrees Wrist supinated Point of maximal tenderness - insert to bone, then withdraw 1-2 mm Inject corticosteroid solution slowly

27. Educational Solutions for Workforce Development East Deanery De Quervains tenosynovitis Inflammation of thumb extensor tendons -Extensor pollicis brevis -Abductor pollicis longus Occurs where tendons cross radial styloid

28. Educational Solutions for Workforce Development East Deanery De Quervains tenosynovitis Maximally abduct thumb (accentuates abductor tendon) Injection site Snuffbox at base of thumb Aim 30-45 degrees proximally toward radial styloid Insert needle between the 2 tendons (not in tendon) Do not inject if paraesthesias (sensory branch radial nerve)