Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Joint injection Dr Amit Saha Consultant Rheumatologist & Clinical Lead for Rheumatology- Maidstone and Tunbridge Wells NHS Trust Spire Tunbridge Wells- TALK Introduction course Focus on 90% of injections- knee, wrists shoulder When to inject and aspirate – need diagnosis first Safety Shoulder Frozen shoulder (adhesive capsulitis) Subacromial impingement syndromes Frozen Shoulder Stiffened gleno-humeral joint that has lost significant range of motion (abduction and rotation). 40-60s Dis-use – sling, recent operation, preexisting shoulder complaint 50% reduction in all movements (especially external rotation) Frozen Shoulder In SAI – though active movement reduced, passively you can push full movement. Patients with frozen shoulder have varying degrees of pain early in the disease course, but complain primarily of joint stiffness. Symptoms generally develop over the course of weeks to months. No X-rays generally needed (exception if you think there is gleno-humeral OA) Treatment Acute (first 8 weeks)- NSAIDs and avoid excessive activities Gentle exercises- Pendular exercises (evidence weak) plus stretching exercises. Revaluate in 8 weeks – Continue or inject Randomized trial of 109 patients. At seven weeks, 40 of 52 patients randomly assigned to glucocorticoid injection were considered to have a treatment success compared with 26 of 56 patients (46 percent) treated with physiotherapy. van der Windt DA et al. BMJ. 1998;317(7168):1292. Glucocorticoid injection may hasten recovery, and the addition of supervised physical therapy following glucocorticoid injection may result in more rapid improvement than injection alone. However, the long-term outcome of adhesive capsulitis may not be much affected by either intervention. Four groups: steroid plus supervised physiotherapy (PT), glucocorticoid injection alone, saline injection plus supervised PT, or saline injection alone. Those who received a glucocorticoid injection and supervised PT improved significantly more, and more rapidly, than any other group at six weeks; those who received glucocorticoid injections were better than those who did not at three months. But by one year there was no discernible difference in improvement among the four groups. Carette et al. Arthritis Rheum. 2003;48(3):829. Injection Approach - posterior approach Subacromial impingement syndromes Rotator cuff may be compressed during glenohumeral movement Painful daily activities may include putting on a shirt or brushing hair. Patients may localize the pain to the lateral deltoid and often describe pain at night, especially when lying on the affected shoulder. Inspection – Rotator cuff atrophy Palpation- focal subacromial tenderness at the lateral or posterior-lateral border of the acromion. Painful ROM that occurs between 60 and 120 degrees of active abduction marks a positive arc test Normal passive range of movement and power Beyond 150 degrees possible acromioclavicular OA Treatment X-rays generally not needed Simple things first Injections- evidence weak. Systematic review poor trials. Knee OA knees Aspirate- gout/pseudogout/infection Works – can be up to 6 months Certain patients better to use than others Carpal Tunnel syndrome Median nerve entrapment Classically 1-31/2 fingers Classic symptoms Tinel’s and phalens Splints first Surgery if severe damage Inject if splints fail Injections Discussed benefits already Risks – Bleeding and infection – less than 1 in 10,000 Aseptic INR less than 3 for large joints Post-injection flare- last few hours usually within 24-48 hours. Tendon damage – Tendon rupture is most commonly encountered when undiluted glucocorticoid is given very near or into tendon Nerve damage Skin depigmentation Do not inject prosthetic joints Avoid general exertion for 24 hours. – 40mg (1ml) Depo-medrone (methylprednisolone acetate) plus approximately1-2mls of 1% lidocaine Knee - 80mg (2ml) Depo-medrone (methylprednisolone) plus approximately 2mls of 1% lidocaine Wrist 20mg (0.5ml) Depo-medrone plus 0.5ml 1% lidocaine Shoulder Frequency- evidence limited Inject very active large joints affected by rheumatoid arthritis as often as 3 injections per year for any given joint. For joints affected by osteoarthritis, can inject glucocorticoids as often as once every six months only if no other therapy is effective. needle – 21 gauge (knee and shoulder) Orange needle – 25 gauge (wrist) 10ml syringe for knee and shoulder 1ml syringe for wrist Universal container Alcohol swabs (with 70% isopropyl alcohol) Green Knee injection Superior Lateral Medial Inferior