Peggers Super Summary of Articular Injections & Aspirations

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!

· 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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