Peggers’ Super Summary of Articular Injections & Aspirations
Principles:
STERILITY
· No touch aseptic technique
· Sterile gloves
· 70% alcohol wipe
FREQUENCY
· 4 weekly intervals
· No more than 3 times a year
· If no benefit review the diagnosis
STEROID CHOICE
· Hydrocortisone acetate 25mg/ml (hydrocortistab)
· Methylprednisolone acetate 40mg/ml (Depo-Medrone)
· Triamcinolone hexacetonide 20mg/ml (Aristispan)
· Triamcinolone acetonide 40mg/ml (Kenalog)
NB tennis elbow can painful therefore the use of a stronger steroid to use less volume is advisable
NB only Both hydrocortisone and Triamcinolone are licenced to mix with LA
CI TO STEROID USE
· Prosthetic joint
· Patient awaiting joint replacement < 6 months
· Infected joint
· Overriding skin infection
Relative CI
· Diabetes
· Hypertension
· Hyperthyroidism
· Osteoporosis
· Pregnancy certainly in first 16 weeks!
LA
· Lignocaine 1%
· Bupivicaine (Marcaine) 0.25% or 0.5% longer lasting
POST INJECTION ADVICE
· Pain may increase between days 1-3
· Relative rest over days 1-3
· Avoid carrying heavy objects or aggrevating activities for 1-3 days
Medical Legal Issues:
PAIN POST INJETION & COMPLICATIONS
· 48HR TO 72 HRS OF PAIN take paracetamol
· Lipodytrophy and dimpling due to s/c injection of steroid
· Loss of skin pigmentation
· Tendon rupture
· OA (though evidence suggests that 4 annula injections for 2 years did not increase joint space narrowing)
INFORMED CONSENT
· Diagnosis of condition and natural time course
· Effect of injection with benefits and risks
SPECIFIC INDICATION
· Specific injection for a specific condition
FULL RECORDS
· History, subjective findings, examination findings, diagnosis and past management
TECHNIQUE
· Aseptic washing hands and sterility
Shoulder:
ACJ
Diagnosis
· Direct pain
· Scalf test or abduction painful
Anatomy
· Lateral end of clavicle, mark the end of clavicle and start of acromium
· Osteophyte in OA may obscure joint
Approach
· Anterior or vertically though pushing too far will cause injection into joint capsule
Apparatus
· 2ml syringe and orange needle
· Max volume 0.5ml triamcinolone no LA
Bicipital Tendinopathy
Diagnosis
· Local tenderness
· Yergasons resisted supination test
Anatomy
· Found between the greater and lesser tubercle of the shoulder
Approach
· Inject at level of groove, if there is resistance this is due to injection into the tendon, pull back to inject into the sheath
Apparatus
· 2ml syringe orange needle
· 1ml of triamcinolone (Kenalog) + 1ml 1% lignociane
Subacromial space
Diagnosis
· Painful arc
· Hawkin’s Kennedy sign positive
Anatomy
· Space between humeral head and acromium
Approach
· Palpate most lateral part of acromium
· Mark 1.5cm below and aim horizontally and slightly posteriorly
Apparatus
· 2ml syringe blue or green needle
· 1ml of kenalog
· 1ml of lignocaine
Glenohumeral Joint
Diagnosis
· Frozen shoulder limited ER
· None of the following ACJ, rotator cuff tears, impingement, biceps tendinopathy
Anatomy
· Line of injection is between posterior tip of acromion and coracoid process anteriorly
Approach
· 2.5cm inferior to acromion and medial to humeral head posteriorly
Apparatus
· Green needle 2ml syringe
· 1ml of lignocaine and triamcinolone
Hand and Wrist:
OA 1st CMCj
Diagnosis
· Aching in region and pain on passiv backward movement of thumb
· OA changes on x ray
Anatomy
· Joint between metacarpal and trapezium
Approach
· Directly for joint draw it on
· Between the extensor tendon of the thumb
Apparatus
· 2ml syringe and orange needle
· 0.5ml of triamcinolone not space for lignocaine
Carpal tunnel:
Diagnosis
· Wasting of thenar muscles tingling
· Phalens or tinel’s test positive
Anatomy
· Median nerve lies radial side of Palmaris longus
Approach
· Superficial anaesthetic aim at distal wrist crease aiming distally
· Enter ulnar side of PL and once feeling pop in the carpal tunnel
Apparatus
· 2ml syringe and blue needle
· 1ml of triamcinolone
De Quervain’s:
Diagnosis
· Tendon pain
· Exacerbated by Finklesteins test
Anatomy
· Tendinopathy of abductor pollicis longus and extensor pollicis brevis
Approach
· Insert needle pointing proximally DISTAL to site of maximum pain along line of tendon/sheath
Apparatus
· 2ml syringe and orange needle
· 1ml of each lignocaine and methyprednisolone
Trigger finger:
Diagnosis
· Tender nodule in the palm
· Which locks having to painfully extend the finger with help
Anatomy
· A1 pulley is where the nodule gets stuck
Approach
· The A1 pulley is the same distance of the P1 skin creases into the palm from the volar MCPJ skin crease
Apparatus
· 2ml syringe and orange needle
· 1ml of lignocaine and methyprednisolone into this region
The Elbow:
Tennis elbow/lateral
Diagnosis
· Lateral elbow pain in racket sports or house activities
· Painful resisted wrist extension
Anatomy
· Common extensor origin for brachioradialis, extensor carpi radialis, extensor carpi ulnaris, digitorum muscles
Approach
· Fan technique into all the tender areas of the lateral elbow
Apparatus
· 2ml syringe blue needle
· 1ml of methyprednisolone NB anaesthetic may mask all the tender areas
Golfers Elbow/medial
Diagnosis
· Medial elbow pain
· Resisted flexion of the wrist exacerbates pain
Anatomy
· Close proximity to the ulnar nerve (ask patient to tell you if any little finger tingling
Approach
· Place patients hand behind their back and pinpoint tender region and use a fanning technique
Apparatus
· As above
Knee Joint:
Diagnosis
· Diagnosis or therapeutic reasons
· Diagnosis
o Traumatic effusion to relieve swelling and pain
o Gout or pseudogout
o Septic arthritis
· Therapeutic
o OA or RA relief
Anatomy
· Aim for the space underneath the patella bone
Approach
· Knee flexed with a pillow underneath
· Lateral approach under the superior pole of the patella
· Tilting the opposite pole with increase the gap
· Aim the needle horizontally
Apparatus
· Aseptic apparatus
· 20ml syringe and white need if aspirating or grey venflom
· Local anaesthetic can be infiltrated initially
· If injecting can use either
o 2ml of triamcinolone
o Viscosupplementation i.e. hyaluronic acid preparation 3 courses 1 week apart
Aspiration of Joints
NB Always use green/white needle or grey venflom
Wrist
Anatomy
· Listers tubercle is the boundary between the extensor compartments 2/3 of the wrist
Approach
· Distal to Lister’s tubercle
Ankle
Anatomy
· The n/v structures lie between Tibialis anterior and EHL at the ankle joint.
Approach
· Medial to Tibialis anterior tendon in sulcus of ankle joint
Elbow
Anatomy
· The safe zone over the radial head changes depending on the rotation of the forearm
· The radial nerve crosses the radius 3.8cm distal to the joint margin in pronation (2.2cm in supination)
Approach
· In full pronation with hand flat on the table the ‘safe zone’ is 900 vertically with a 450 angled zone either side
Shoulder
Anatomy
· The shoulder joint can be approached either anteriorly or posteriorly
· Inferiorly and posteriorly is the quadrangle space where the axillary nerve and circumflex humeral artery exits
Approach
· 2.5cm down from the acromion and 2.5 medial to the humerus posteriorly
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