Download Joint Injection Workshop

Out Patient Procedures
Joint and Trigger point injections
Joint Aspiration or Arthrocentesis
Hands on workshop
Joint and Trigger point injections
Charles Haddad M.D. Associate Professor University of Florida
DISCLOSURES
I do not have any disclosures.
No financial interest in subject being discussed
OBJECTIVES
Upon completion of this activity, participants should be able to:
Understand advantages & disadvantages of joint injections.
Discuss the indications and contraindications of joint injections.
Evaluate different approaches and medications used in joint
injections.
Improve confidence level of giving joint injection and trigger
point injections.
Overview
 The Basics
 Who and what should be injected
 Who and what should not be injected
 Risks vs. Benefits
 What you need
 EPIC Documentation/ Charges
 HANDS ON WORKSHOP
The Basics
 ASPIRATION (Arthrocentesis)- inserting a needle into a
joint to remove synovial fluid, or blood.
 INJECTION is usually performed with corticosteroids and a
local anesthetic.
The Basics
 Aspiration and injection of a joint is performed to relieve
pressure, decrease inflammation and for diagnosis.
 Corticosteroids may be injected once it has been established
that the inflammation is not secondary to infection.
 Aspiration of the joint or bursa can obtain fluid for synovial
fluid analysis.
The Basics
 Joint fluid can be sent for:
WBCs
C&S
Gram Stain
Crystals
infection/inflammation
infection
infection
gout-negative birefringent
urate crystals
pseudogout- Calcium Phosphate
Dehydrate Crystals (CPPD)
Do steroid injections work?
 Very few studies support or refute the efficacy of common
joint intervention in medical practice
 Substantial practice based experience support the
effectiveness of joint/soft tissue injections
 Corticosteroid injections should always be viewed as adjuvant
therapy eg physical therapy
What can be Injected/Aspirated
 Clean injuries with effusions
 Degenerative Joint Disease with synovitis
 Trigger fingers
 Trigger points
 Hemarthrosis
 Areas of tendonitis
What can be Injected/Aspirated
 Knees: OA, Gout, Patellar bursitis, Meniscus injury
 Elbows : Lateral epicondyle tendonitis, Olecranon Bursa
 Shoulders : OA, Rotator cuff tendonitis, Frozen shoulder,
Subchromial Bursitis
 Wrists : Carpal tunnel, DeQuervain tenosynovitis
What can be injected/Aspirated
 Fingers/Thumb especially with trigger finger
 Hip: Trochanteric Bursitis
 Ganglion Cysts
 Trigger Point injections
Who and What should NOT be injected
 Any areas suspected to be infected
 Acute Fractures
 Prosthetic Joints
 Impending Joint replacement (within a few days)
Who and What should NOT be injected
 Patients with uncontrolled bleeding disorders or
uncontrolled diabetes
 Achilles Tendon
 Any ropey tendon
 Not as successful in the hip joint except at the trochanteric
bursa
More commonly seen Risks and ways
to avoid
 Fat necrosis : deeper injection avoid subcutaneous fat
 Patches of hypo pigmentation(especially with dark skin)
deeper injections help to avoid
 Elevations in blood sugar(transient from several to 21 days )
Monitor sugars more closely after injection, may need to
adjust meds
Risks and ways to avoid
 Pain: can be improved with ethyl chloride or distraction
techniques
 Infection (< 0.01%) : using sterile/clean techniques
 Bleeding : avoid vascular structure
 Tendon rupture: do not inject into the tendon itself
More Risks and ways to avoid
 Long term effects if done too frequently is the same as
chronic use of corticosteroids(weight gain, osteoporosis, high
sugars).
 Vasovagal reaction (frequent ~10%): perform injections in
supine position if possible
 If local anesthetic is injected into the vessel it can cause a
toxic reaction(heart arrhythmias):avoid intravenous
injection/aspirate
More Risks and ways to avoid
 Post injection flair(increased pain for several days after the
injection) : icing the area down after the injection
 White blood cell margination, transient increase in WBCs
Benefits
 Decreases pain: improve mobility for physical therapy
 Decreases pressure: especially with aspiration
 Decreases inflammation
 Improves range of motion
 Effects are seen quickly(usually within a few days)
Frequency(keep it simple)
 No more frequently than every 2-3 months
 No more than 2-3 time a year
 Some clinicians recommend a lifetime limit
What you need
 For preparation and skin anesthesia
1.
2.
3.
4.
5.
6.
Cleaning solution- usually povidone- iodine solution
A drape (sometimes)
Sterile gloves
Small syringe~ 1-3ML to anestitize the skin
18 gauge needle to draw the local anesthetic and 25-30
gauge needle to inject
1% Lidocaine without epinephrine
What you need
 For Aspiration
1. 18 gauge 1 ½ inch needle
2. 20 ml syringe for larger joints
3. 5-10 ml syringe for smaller joints
What you need
 For Corticosteroid injections
1. 22 gauge 1 ½ inch needle
2. 5-10 ml syringe
3. The Corticosteroid solution
4. 1% Lidocaine without epinephrine
5. Inject within a few minutes of mixing to avoid
crystallization
How much to give (Keep it simple)
 Large Joints 40 mg Triamcinalone
 Small Joints 10-20 mg Triamcinalone
 Large joints; knees, shoulders, etc. add 4cc of Lidocaine 1%
without epi
 Smaller joints e.g. wrist, elbows add 2ccs of Lidocaine
 Fingers, hand add 1cc of Lidocaine
Commonly Used Steroids
STEROID DOSING AND EQUIVALENTS
Common
Common
Approximate
concentration (mg equivalent dose* duration of action
Steroid
per mL)
(mg)
(days)
Methylprednisolo
40 or 80
40
8
ne acetate (DepoMedrol)
Triamcinolone
10 or 40
40
14
acetonide
(Kenalog)
Triamcinolone
20
40
21
hexacetonide
(Aristospan)
Dexamethasone
8
8
8
acetate (Decadron
LA†)
Dexamethasone
4
8
6
sodium
(Decadron†,
Solurex†)
NOTE: Steroid agents listed in order of prevalence of use.
Commonly Used Local Anesthetics
LOCAL ANESTHETICS OR JOINT INJECTION
Onset of action
(minutes)
30
Medication
0.25%
Bupivacaine
(Marcaine)
0.5% Bupivacaine 30
1% lidocaine
1 to 2
(Xylocaine)
2% lidocaine
1 to 2
Duration of action Max volume of
(hours)
injection*
8
60 mL
8
1
30 mL
20 mL
1
10 mL
*— Increased risk of cardiac toxicity or arrhythmia above these dosages.
Synvisc
Hylan G-F 20
• An elastoviscous high molecular weight fluid containing
hylan A and hylan B
• Produced from chicken combs
• Hyaluronan is a long chain polymer
Synvisc
Hylan G-F 20
• Indication: treatment of pain in osteoarthritis of the knee in patients
who have failed to respond to conservative therapy
• Contraindication: patients who are hypersensitive or allergic to
hyalurornan
patients who have joint or skin infections in the
injection site
• Precautions
• Patients allergic to egg products and avian proteins
Synvisc
Hylan G-F 20
• Technique: 2 mL Synvisc is injected intr-articularly
into the knee joint once a week for three weeks
• Strict aseptic technique must be followed
• 18-22 gauge needle is used
• Same needle can be used to drain joint and
inject Synvisc
• Effectiveness in other joints has not been
established
Synvisc
Hylan G-F 20
• Adverse effects: most commonly knee pain, swelling, and
joint effusion
QUESTIONS????
HANDS ON WORKSHOP