Joint injections

Kathy Rainsbury

February 2008

Why inject joints?

• Can be joint or soft tissue

• Inflammation– eg degenerative joint disease, bursitis,

tendinitis

• Corticosteroid injection (+ needle + LA) helps decrease inflammatory rxn – (includes limiting capillary dilatation + vascular

permeability)

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

Indications for injection• Osteoarthritis • Rheumatoid arthritis• Gouty arthritis• Synovitis• Bursitis• Tendonitis • Muscle trigger points • Carpal tunnel syndrome

Inject with caution

• Charcot joint (neuropathic sensory loss)

• Tumour

• Neurogenic disease

• Active infections (eg, tuberculosis)

• Immune-suppressed hosts

• Hypothyroidism

• Bleeding dyscrasias

Contraindication to injection• Adjacent osteomyelitis • Bacteraemia • Hemarthrosis • Impending (scheduled within days) joint replacement surgery • Infectious arthritis • Joint prosthesis • Osteochondral fracture • Periarticular cellulitis / severe dermatitis/ soft tissue infection• Poorly controlled diabetes mellitus • Uncontrolled bleeding disorder or coagulopathy

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

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 – ensure solution is DRY (esp iodine)

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

What to warn the patient

• 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

• Advise to seek help if systemic s/es develop

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.

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

Plantar fasciitis

• Procedure painful + no evidence for long-term benefit

• Pt indicate tender spot

• Approach from thinner skin + direct posterior-laterally

• Small blelbs as near to bony insertion as possible

• Do not inject fascia itself

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)

Glenohumeral joint injection1. Pt sits, arm by side,

externally rotated2. Find sulcus between head

of humerus and acromion 3. Posterolateral corner of

acromion (2-3 cm inferior) 4. Direct needle anteriorly

toward coracoid process 5. Insert needle to full length 6. Fluid should flow easily

AC joint injection

1. Palpate clavicle to distal aspect

2. Slight depression where clavicle meets acromion

3. Insert needle from anterior and superior approach

4. Direct needle inferiorly

Sub-acromial joint injection

1. Posterior and lateral aspect of shoulder

2. Inferior to lower edge of posterolateral acromion

3. Insert inferior to acromion at lateral shoulder

4. Direct needle toward opposite nipple

5. Insert needle to full length

6. Fluid should flow easily

Elbow epicondyle injection

• Very effective in short term – 92%

• Benefits do not normally persist beyond 6 weeks

• Lateral (tennis elbow) + medial (golfer’s elbow) epicondylitis

• Patient supine

Tennis elbow (lateral)

1. Arm adducted at side 2. Elbow flexed to 45

degrees 3. Wrist pronated 4. Insert needle

perpendicular to skin at point of maximal tenderness

5. Insert to bone, then withdraw 1-2 mm

6. Inject corticosteroid solution slowly

Golfer’s elbow (medial)1. Beware ulnar nerve!2. Rest arm in comfortable

abducted position 3. Elbow flexed to 45

degrees 4. Wrist supinated 5. Point of maximal

tenderness - insert to bone, then withdraw 1-2 mm

6. Inject corticosteroid solution slowly

                                                                                                                        

                                        

De Quervain’s tenosynovitis

• Inflammation of thumb extensor tendons

-Extensor pollicis brevis

-Abductor pollicis longus

• Occurs where tendons cross radial styloid

De Quervain’s tenosynovitis

1. Maximally abduct thumb (accentuates abductor tendon) Injection site

2. Snuffbox at base of thumb 3. Aim 30-45 degrees

proximally toward radial styloid

4. Insert needle between the 2 tendons (not in tendon)

5. Do not inject if paraesthesias (sensory branch radial nerve)