Emil Heinze, MD Olive View UCLA Rheumatology Joint Injection Workshop Southern California Regional ACP Meeting, September 16-17, 2017 Emil Heinze, MD Olive View UCLA Rheumatology

Overview / Goals Review risks Preparing for injections Brief review of technique then hands on practice of 13 most common joint and soft tissue therapeutic injections Introduction to MSK U/S guidance Groups of 6 rotate through each of the five stations (15 minutes each). Ask questions, take from this what you specifically need

Risks Iatrogenic infection Tendon rupture Bleeding (hemarthrosis) Skin hypopigmentation / dimpling Post-injection flare

Preparation Consent patient Review X-rays if available Position patient comfortably Draw up medication in appropriate syringe/needle Localize landmarks / mark site Sterilize area Local and/or topical anesthetic

Injection Kit 1 ½ inch 25 G needle 3 ½ inch 22 G spinal needle 1 cc syringe with ½ inch 25 G needle (TB) 6 cc syringe 3 cc syringe 1% lidocaine Triamcinolone Acetonide 40 mg/cc Iodine Cleansing Scrub Ethyl Chloride topical anesthetic Gauze Sponges Alcohol wipes Bandage Gloves

Knee joint Supplies 1 ½ inch 25 G needle 3 cc syringe 2 cc 1% lidocaine 1 cc Triamcinolone Acetonide 40 mg/cc Iodine Cleansing Scrub Ethyl Chloride topical anesthetic Gauze Sponges Alcohol wipes Bandage Gloves Technique Inject 40 mg of Triamcinolone with 2 cc of lidocaine using 1 ½” 25-gauge needle inserting 1 cm inferior to the lower border of the patella medial to the patellar tendon.

Pes anserine bursitis Supplies 1 cc syringe with ½ inch 25 G needle (TB) 0.75 cc 1% lidocaine 0.25 cc Triamcinolone Acetonide 40 mg/cc Ethyl Chloride topical anesthetic Alcohol wipes Bandage Gloves Technique Inject 10 mg of Triamcinolone with 0.75 cc of lidocaine using ½” 25-gauge needle inserting perpendicular to skin approximately 2 cm below medial tibial condyle aiming towards point of maximal tenderness. Inject deeply, close to the surface of the tibia.

Subacromial bursitis Supplies 1 ½ inch 25 G needle 3 cc syringe 2.5 cc 1% lidocaine 0.5 cc Triamcinolone Acetonide 40 mg/cc Ethyl Chloride topical anesthetic Alcohol wipes Bandage Gloves Technique Inject 20 mg of Triamcinolone with 2 cc of lidocaine using 1 ½” 25-gauge needle inserting laterally 1-2 cm inferior to the undersurface of the mid-acromion process with 10-degree upward angle into the subacromial space.

Glenohumoral joint Supplies 1 ½ inch 25 G needle 3 cc syringe 2 cc 1% lidocaine 1 cc Triamcinolone Acetonide 40 mg/cc Iodine Cleansing Scrub Ethyl Chloride topical anesthetic Gauze Sponges Alcohol wipes Bandage Gloves Humoral head Technique Inject 40 mg of Triamcinolone with 2 cc of lidocaine using 1 ½” 25-gauge needle inserting 1 cm inferior and 1 cm medial to the posterior angle of the acromion process. Direct needle straight toward the coracoid process anteriorly. 1 cm 1 cm Glenoid

Acromioclavicular joint Supplies 1 cc syringe with ½ inch 25 G needle (TB) 0.75 cc 1% lidocaine 0.25 cc Triamcinolone Acetonide 40 mg/cc Iodine Cleansing Scrub Ethyl Chloride topical anesthetic Alcohol wipes Bandage Gloves Injection site Technique Inject 10 mg of Triamcinolone with 0.75 cc of lidocaine using ½” 25-gauge needle inserting perpendicular to the skin directly into the acromioclavicular joint space.

Biceps tendonitis Supplies 1 ½ inch 25 G needle 3 cc syringe 2.5 cc 1% lidocaine 0.5 cc Triamcinolone Acetonide 40 mg/cc Ethyl Chloride topical anesthetic Alcohol wipes Bandage Gloves Long head of the biceps tendon Technique Inject 20 mg of Triamcinolone with 2.5 cc of lidocaine using 1 ½” 25-gauge needle inserting at anterior shoulder toward biceps tendon sheath with 45-degree upward angle. Injection site Short head of the biceps tendon Biceps muscle

Trochanteric bursitis Supplies 1 ½ inch 25 G needle or 3 ½ inch 22 G spinal needle (if obese) 6 cc syringe 5 cc 1% lidocaine 1 cc Triamcinolone Acetonide 40 mg/cc Ethyl Chloride topical anesthetic Alcohol wipes Bandage Gloves Technique Inject 40 mg of Triamcinolone with 5 cc of lidocaine using 1 ½” 25-gauge needle The patient is positioned lying on the side with affected hip pointing up. Insert the needle perpendicular to skin, dropping needle down toward point of maximal tenderness in the center of the trochanter. When needle strikes the trochanter, withdraw 1 mm and inject. Can reposition and inject several times in half dollar sized distribution to ensure even coverage of corticosteroid.

Plantar fasciitis Supplies 1 ½ inch 25 G needle 3 cc syringe 2.5 cc 1% lidocaine 0.5 cc Triamcinolone Acetonide 40 mg/cc Ethyl Chloride topical anesthetic Alcohol wipes Bandage Gloves Technique Inject 20 mg of Triamcinolone with 2.5 cc of lidocaine using 1 ½” 25-gauge needle inserting at medial foot aiming towards the medial tubercle of the calcaneus. Inject into space just above proximal insertion of plantar fascia. Injection site

Lateral epicondylitis Supplies 1 ½ inch 25 G needle or 1 cc syringe with ½ inch 25 G needle (TB) 1 cc syringe 0.75 cc 1% lidocaine 0.25 cc Triamcinolone Acetonide 40 mg/cc Ethyl Chloride topical anesthetic Alcohol wipes Bandage Gloves Technique Inject 10 mg of Triamcinolone with 0.75 cc of lidocaine using ½” 25-gauge needle inserting at point of maximal tenderness just distal to lateral epicondyle perpendicular to skin. Injection site

Trigger finger Supplies 1 cc syringe with ½ inch 25 G needle (TB) 0.75 cc 1% lidocaine 0.25 cc Triamcinolone Acetonide 40 mg/cc Ethyl Chloride topical anesthetic Alcohol wipes Bandage Gloves Technique Inject 10 mg of Triamcinolone with 0.75 cc of lidocaine using ½” 25-gauge needle inserting just beyond to proximal flexor crease of digit towards tender nodule using a 30-degree angle.

1st Carpometacarpal Supplies 1 cc syringe with ½ inch 25 G needle (TB) 0.75 cc 1% lidocaine 0.25 cc Triamcinolone Acetonide 40 mg/cc Ethyl Chloride topical anesthetic Iodine Cleansing Scrub Alcohol wipes Bandage Gloves Technique Inject 10 mg of Triamcinolone with 0.75 cc of lidocaine using ½” 25-gauge needle inserting directly in the 1st CMC joint space. Injection site

DeQuervain’s Tenosynovitis Supplies 1 cc syringe with ½ inch 25 G needle (TB) 0.75 cc 1% lidocaine 0.25 cc Triamcinolone Acetonide 40 mg/cc Ethyl Chloride topical anesthetic Alcohol wipes Bandage Gloves Technique Inject 10 mg of Triamcinolone with 0.75 cc of lidocaine using ½” 25-gauge needle inserting at lateral wrist using a 30 degree angle, just distal to radial styloid aiming towards the inflamed extensor tendon.

Occipital neuralgia Supplies 1 cc syringe with ½ inch 25 G needle (TB) 0.75 cc 1% lidocaine 0.25 cc Triamcinolone Acetonide 40 mg/cc Ethyl Chloride topical anesthetic Alcohol wipes Bandage Gloves Technique Inject 10 mg of Triamcinolone with 0.75 cc of lidocaine using ½” 25-gauge needle inserting 2-3 cm lateral from midline at the point of maximal tenderness. 2-3 cm Injection site