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Joint Injections in
Primary Care
MARC AIKEN MD
Watauga Orthopaedics
Objectives
Understand when it is appropriate
to inject /aspirate a joint
Review common injection
medications
review pertinent anatomy for safe
injection technique
Review technique for injections in
most common joints
When to refer
The Most Common Joints
Injected
Knee
Shoulder (glenohumeral jt.)
Shoulder (subacromial bursa)
Indications - Diagnostic
Evaluate fluid aspirate for:
Infection
Inflammatory arthropathy
Trauma
Relief of pain immediately following
injection indicates an intraarticular
source
Indications - Therapeutic
Relief of pain/inflammation caused by:
Effusion
OA, RA, Gout
Bursitis
Selected tendonopathies
Absolute
Contraindications
Local cellulitis
Prosthetic joint
Septicemia
Acute fracture
Patella and achilles tendonopathy
Allergy to injection medications
Relative
Contraindications
Anticoagulated/coagulopathic
patient
Diabetes
Immunocompromised patient
Minimal or no relief with 2 prior
injections
Local osteoporosis
Inaccessible joints
Medications
Corticosteroid
Local anesthetic
Hyaluronic acid
Steroid
Betamethasone (Celestone Soluspan)
Agent of choice in my practice
Long acting
6-12mg for large joint (knee, shoulder)
1.5-6mg for small/intermediate joints
Other Steroids
Triamcinolone (Aristospan)
Dexamethasone (Decadron)
Methylprednisolone (Depo-Medrol)
Local
1% Lidocaine (Xylocaine) without epi
useful for intraarticular injection and
subcutaneous injection when aspirating
onset within minutes
can be diagnostic tool
Local
Bupivicaine (Marcaine)
Potential cause of chondrocyte death
Avoid intraarticular use
Hyaluronic Acid
“Lube job” for the knee
Replaces HA deficient arthritic knee
fluid with thick viscous HA.
Expect 6 months of relief
Given in 3 injections 1 week apart
Relief may not be obtained for up
to 8wks following last injection.
Adverse
Reactions/Complications
2-5% - Post injection (steroid) flare
0.8% - Steroid arthropathy (AVN,
Chondrolysis, etc.)
Iatrogenic infection
Flushing
Skin atrophy and depigmentation
Adverse
Reactions/Complications
Loss of glucose control in DM
Increased appetite
Insomnia
Irritability
General Considerations
Evaluate the patient
Patient education
Consent
Patient Comfort
Sterile preparation and technique
Documentation
Evaluate the Patient!!
Avoid the “Knee hurt....me inject”
mentality.
Get a complete history
Examine the patient including other
joints
Obtain x-rays
MRI only if appropriate
Patient Education
What medications are being used
What is the injection expected to do for
them
What it is not expected to do
When they will notice effects of injection
What if the expected results are not
achieved
Consent
Written Vs. Verbal
Your choice
Patient Comfort
Lying down for knees (superolateral
approach)
Sitting up for shoulders
Take your time
Use ethyl chloride (cold spray)
immediately before injection
Explain the steps of the procedure
as you do them
Patient Comfort
Lying down for knees (superolateral
approach)
Sitting up for shoulders
Take your time
Use ethyl chloride (cold spray)
immediately before injection
Explain the steps of the procedure
as you do them
Patient Comfort
In patients with severe anxiety
regarding needles, provide alternatives
or allow them to schedule the injection
on a different date. This may allow them
time to mentally prepare for the
injection.
Injections are usually far less painful
than patients anticipate
Sterile Prep/Technique
Make sure injection site is fully
exposed
Should not be visibly soiled
Use iodine or chlorhexidine prep
over site to be injected
Alway use aseptic technique
Consider use of sterile gloves
Sterile drapes generally
unnecessary
Documentation
Document the history and physical
exam findings that support the
decision to perform
aspiration/injection
Site (which joint and which side)
Anatomic placement (med, lat, ant
etc)
medications and doses injected
Expiration dates and lot numbers
Document
Amount of fluid aspirated
color, clarity and viscosity of fluid
purulent?
Blood? (trauma)
Lipid?(trauma/occult fx)
Send Fluid for Analysis
Labs ordered from fluid:
Cell Counts (stat if infection suspected)
Cultures
Gram stain (stat)
Polarized light microscopy
Post Injection Care
Remove visible prep solution
Bandaid
Pressure dressing on free bleeders
Rest and Ice for 24 hours
Warn about limitation of local anesthetic
Warn about steroid flare
Injection Technique
Intraarticular knee
Intraarticular Shoulder
Subacromial bursa
Supplies
Knee Aspiration/Injection
Superolateral approach most reliable
93% accuracy vs. 71-75% with bent knee
anteromedial/anterolateral approach
Superolateral Approach
Patient Supine with knee extended
Palpate bony landmarks
Patella
Lateral Femur
Palpate Patella
X Marks the Spot
Palpate lateral border of patella and
Lateral femur at the PF joint
The space between these bony
structures is your injection site
The Injection
Reassure patient
Relaxed quads = more space at PF jt
Needle Trajectory
15-20 degrees
Toward trochlea of femur
Needle Trajectory
Anterior Approach
(bent knee)
Anterior Approach
Less reliable/accurate than superolateral
approach
Can be easier in the obese knee
Patient sitting with knee bent to 90
degrees
Anterior Approach
Palpate landmarks
Inferior pole of patella
Patella tendon
Tibial Plateau
Landmarks - Patella
Landmarks - Plateau
Landmarks
Injection Site
May inject
medial or
lateral to
patella tendon
1cm above
tibial plateau
or
Half the
distance from
plateau to
inferior pole of
patella
Trajectory
Shoulder (GH joint)
Anterior approach
Position patient sitting facing provider
Palpate bony landmarks
Clavicle
Coracoid
Landmarks
Palpate - Clavicle
Clavicle
Coracoid
Needle Placement
Inject just lateral to coracoid process
20 degree angle
Reposition if you encounter resistance
Shoulder (SA Bursa)
Given lateral or posterior
Just beneath the angle of the acromion
Acromion
Subacromial Injection
Direct needle under acromion
Thank-you for your
attention!
Questions?
Suture Techniques in Primary Care
Shawn A. Sutterlin, PA-C
Watauga Orthopaedics
Objectives
Review wound types and classification
Understand the principles of wound
healing
Describe the 3 types of wound closure
Overview of Suture materials
Wound closure techniques
Wound Classification
Four Classes
Clean
Clean-contaminated
Contaminated
Dirty/infected
Clean Wounds
Most common is elective surgical
incision
Primary closure
1-5% rate of infection
Clean Contaminated
Wounds contaminated by local flora
despite aseptic technique
Cholecystectomy, appendectomy and
hysterectomy
3-11% infection rate
Contaminated
Open traumatic wounds in nonsterile
environment
Surgical procedures in which there is a
gross deviation from sterile technique
(emergent open cardiac massage)
10-17% infection rate
Dirty or Infected
Gross/heavy contamination or active
infection
Perforated viscera, abscess and
traumatic wounds
>27% infection rate
Wound Healing
Four Phases
Hemostasis
Inflammatory
Proliferative
Remodeling
Phase I: Hemostasis
Vasoconstriction stimulated by
endothelial injury
Platelet aggregation
Coagulation cascade is activated
and fibrin clot formed
Platelets release pro inflammatory
mediators and PDGF in preparation
for subsequent phases
Hemostasis
Phase II: Inflammatory
Inflammatory mediators released
Vasodilation - provides increased
blood supply to injury site
Increase vascular permeability allows plasma proteins, WBCs, into
injured tissue
Migration of WBCs from circulation
into interstitium allows phagocytosis
of debris/microbes
Inflammation
Phase III: Proliferative
Angiogenesis
Granulation
fibroblasts deposit extracellular matrix
including collagen/elastin
Characteristic beefy red appearance
Phase III: Proliferative
Epithelialization
keratinocytes
Contraction
Fibroblast release of actin
Phase IV: Remodeling
Collagen remodeled along tension lines
Cells no longer needed are removed by
apoptosis
May take many months
Patient factors
 Age
Weight
Nutrition
Dehydration
Blood supply
Patient Factors
Immunocompromised
Chronic disease
Radiation therapy
Wound Closure
Primary closure
Secondary closure
Tertiary closure
Primary Closure
Most common
Preferred method when appropriate
Wounds are re-approximated acutely
Dermis-dermis apposition
Best cosmetic outcome
Secondary Closure
Known as healing by secondary
intention
Wound edges are left unapproximated
Granulation tissue formed
Migration of keratinocytes provide reepithelialization over granulation tissue
Appropriate in wounds with soft
tissue loss or severe contamination
not closable by primary or tertiary
means
Tertiary Closure
Contaminated wound is I&D’d and left
open for several days
Wound is then closed as in primary
closure when risk of infection declines
Preferred method for high energy and
highly contaminated wounds
Suture Materials
Traits needed by suture
Tensile Strength
Knot security
Ease of handling
Low tissue reactivity
Characteristics
Size and Tensile Strength
Monofiliment (nylon, prolene, monocryl)
Multifiliment (vicryl, ethibond, Silk)
Absorbable
Non Absorbable
Characteristics
Dyed
Undyed
Sizes 11-0 to 6
Absorbable
Broken down in tissues by hydrolysis
and inflammation
Time to resorb varies by material and
diameter
includes vicryl, monocryl, PDS, gut.
Non Absorbable
Not broken down by hydrolysis or
inflammatory reaction
Walled off in body by fibroblasts or
physically removed
Includes nylon, prolene, stainless steel,
silk, polyester (ethibond)
Suture
Suture Sizing
Size by Location
Needles
Cutting - skin and other tough/fibrous tissue
Taper - softer tissues inside body
(bowel,vessels). Dilates tissues
Blunt - felt to pose less risk of needle sticks.
Most useful in closure of fascia.
Before Closing
Evaluate
Hemostasis
Irrigate
Debride devitalized/contaminated
tissues
Should it be closed primarily?
Before Closing
Evaluate the wound
Time of injury
Size and shape of wound
Soft tissue loss
Gross contamination/foreign body
Before Closing
Wound depth
Nerve, tendon, vascular involvement
Bone involvement (open Fx)
Joint involvement (traumatic arthrotomy)
Uncontrolled hemorrhage
Wound Preparation
Single most important step in preventing
complications
Remove all debris and devitalized tissue
Irrigate copiously with NS
Do not use iodine or hydrogen peroxide in
the wound
When to Consult Specialist
Deep/penetrating wounds to hands/feet,
thorax, abdomen, or pelvis
Full thickness lac to eyelids, lips or ears
Lacerations which involve bone, joint,
tendon, artery, muscle or nerve
Markedly contaminated wounds
Crush injuries
Concerns about cosmesis
You don’t feel comfortable
When to Not Close
active infection
erythema/induration
puncture wounds
Human/animal bites
Delayed onset of treatment
12 hours for body
24 hours for face
Anesthesia
General/spinal Anesthesia
Used for large wounds and more
invasive procedures
Regional Anesthesia
Lidocaine/bupivicaine infiltrated near
peripheral nerve to produce anesthesia
distally in extremity
Digital, wrist and ankle blocks most
common
Anesthesia
Local
Most common method in outpatient setting
Anesthetic agent infused directly into the
tissues being treated
Lidocaine
Sodium channel blocker
Most common
1% should be adequate for most
procedures
Rapid onset
Relatively short duration of action
Lidocaine
Available with epinephrine
Helps to control bleeding
Prolongs duration of action
Bupivicaine
Longer duration of action (8-12hrs)
Useful in prolonged procedures as well
as post procedure pain control
Also available with epinephrine
Local Anesthetics
Caution!!
Do not use epinephrine containing local
anesthetic on structures with limited
circulation
Fingers, nose, penis, toes and ears
Equipment
General Considerations
Handle tissues as little as possible
Limit the time and force used in
retracting tissues
Do not “pinch” tissues with forceps,
Gently lift wound edges to place suture
Irrigate frequently to minimize
contaminants and keep tissues moist
Approximate, don’t strangulate
Needle Position
Needle should be secured 1/2 - 2/3 down
the length needle from the tip
Always cross skin at 90 degree angle
Rule of Halves
Allows better approximation of tissues
Avoids “dog ears”
Rule of Halves
1
Rule of Halves
3
1
2
Basic Suture Methods
Simple interrupted
Simple running
Locked running
Horizontal mattress
Vertical mattress
Running Subcuticular
Subcutaneous (buried knot)
Simple Interrupted
Most common closure performed
Used in superficial wounds with minimal
tension.
Nylon or prolene
Be careful of knot security
Simple Interrupted
Simple Interupted
Simple Continuous
Rapid
Best in short lacerations with no tension
Helps with hemostasis
If one knot fails, the entire closure is
compromised
Contraindicated in infected tissues as
infection can propagate along suture line
Locked Continuous
Used in wounds closed with moderate
tension
Offers resistance to loosening
Helpful in obtaining hemostasis
Similar concerns with knot security and
integrity of closure
Horizontal Mattress
For fragile tissue
Distributes tension over wider area
Helps evert skin edges
Horizontal Mattress
Vertical Mattress
Used for maximal edge eversion
Minimizes deadspace in deeper tissues
Helps minimize tension
Vertical Mattress
Running Subcuticular
Provides optimum cosmetic results
Not for contaminated or infected wounds
Not appropriate for high tension wounds
or joint surfaces
Running Subcuticular
Subcutaneous
Useful for minimizing deadspace in
deeper wounds
Buries the knot
Helps to reduce tension on skin closure
May be used in dermis as well
Subcutaneous
After Closure
Apply antibiotic ointment
Non adherant sterile dressing
Splint if appropriate
Tetanus
Antibiotics
Schedule follow up 2-3 days
Suture Removal
Face: 3-5 days
Scalp: 7 days
Chest and extremities: 8-10 days
Joints, palms, soles: 10-14 days
Thank You