1. Clinical Musculoskeletal Injections
Chris Parfitt MD FRCS©

2. Disclosures
none
(I like giving injections)

3. Musculoskeletal Injections
A bit like moose hunting
Chasse l’orignal

4. Moose Hunting Hunting licence Right animal (moose) Right caliber rifle
Right type of bullet
YOU HAVE TO HIT THE TARGET

5. Musculoskeletal Injections
Medical licence
Right diagnosis
Right needle
Right dose of medicine
YOU HAVE TO HIT THE TARGET

6. MSK Injections General
Informed consent
Procedure
Benefits
Risks
In writing or verbal
ALWAYS ASK ABOUT ALLERGY!!

7. MSK Injections General
The equipment
Antiseptics
bandages

8. MSK Injections General
Equipment
Assorted long and short acting local anesthetics
With and without epinephrine

9. Types of Cortisone Triamcinolone 40 mg cc (potency 5)
Methylprednisone 40 mg/cc (potency 5)
Betamethasone 6 mg /cc ( Potency 25)
Kenalog
Depomedrol
Celestone

10. SAFETY of WHAT we INJECT
Currently no strongly stated rules about what we inject into a joint
BUT!!!

11. Steroid shots and blood sugar
No effect
Increases blood sugar
Methylprednisolone 40 mg
Triamcinolone 40 mg
betamethasone

12. PAIN PUMPS
Used post operatively starting about 2002
Marcaine with epi

13. Bupivacaine and Chondrolysis
Bupivocaine epinephrine infusion pumps caused high rates of chondrolysis
2005 to 2008

14. Bupivacaine Chondrolysis
Now a whole crop of pain pump lawsuits

15. Injections and Chondrotoxicity
Apoptosis of chondrocytes is a validated measurement of chrondrocyte toxicity

16. Injections and Chondrotoxicity
prednisolone cause chondrocyte death in ex vivo chondrocytes, betamethasone did not
Farkas et al CORR 2010
All local anesthetics caused chondrocyte death
Dose and time related
Farkas et al CORR 2010

17. Injections and chondrotoxicity
All local anesthetic toxicity to chondrocytes potentiated with epiniphrine

18. Injections and Chondrotoxicity
The combination of cortisone and local anesthetic is possibly synergistic in causing chondrotoxicity

19. Chondrotoxicity: current recommendations
Although common practice is to inject steroid and local anesthetic together
There are no specific recommendations in the literature

20. Injections and Chondrotoxicity
Intuitively?
Use .5% lidocaine, .25% bupivocaine
Use bupivocaine, also prednisolone
Inject steroid with saline

21. Injections and Chondrotoxicity
If joint already bone on bone, there are no chondrocytes to be toxic to, therefore longer acting local anesthetic can be used!

22. Injections: Tenocyte toxicity
Some studies show tenocyte toxicity with steroids and local anesthetic
More dilute local anesthetic less toxic

23. MSK Injections General
Assorted syringes
Preneedled syringes are time saving
Draw up solution with larger needle
demo

24. MSK Injections Needle size
1.5 inch 25 gauge for fine injections
1.5 inch 21 gauge is optimal for larger joints (shoulder and knee)

25. MSK Injections General
Triamcinolone
40 mg mil
Methyl prednisone 40 mg miL
Betamethasone 6 mg mil

26. MSK Viscosupplementation
Hyaluronic acid now just over 200$
Approved for arthitis (mostly knee studies)

27. PLATELET RICH PLASMA
Becoming more common
Cost from 400 to 800$

28. PRP Soft tissue Cochrane review 2014
Insufficient evidence to support use for MSK soft tissue injuries and tendopathies

29. PRP Knee arthritis General concensus is that PRP injections as good
Or slightly better than Hyaluronic acid and saline injection
More side effects
AAOS March 2015

30. MSK Injections Technique
One needle (mixed)
Two needles (prefreezing)
Less experienced should prefreeze

31. MSK Injections Technique
Betadine best as you can see where it is demo
Wait until it dries (until the screaming stops)
Prep, then prepare the injection

32. Tricks of the trade Assess resistance for injections into space
DO NO HARM
Need large bore needle to draw up solutions
demo

33. MSK Injections: New kid on the block
Ultrasonically guided injections
Rapidly becoming more common
Need US machine and training
Price of US machine decreasing
Not discussed today

34. TRIGGER FINGER INJECTIONS
Evidence based
ANN RHEM DIS 2008 sept;7(9)

35. Trigger Finger .5cc steroid 1 – 2 cc local anesthetic
Don’t inject into the tendon
Inject into or around synovial sheath

36. Trigger Finger HOT OFF THE PRESS
Peri pulley injection had higher success rate than intra sheath injection

37. Basal Joint arthritis
CMC joint arthritis

38. Basal Joint Arthritis Slight traction Prefreezing very helpful
.5 cc steroid (20mg) 1cc of local anesthetic marcaine E

39. De Quervains Disease Evidence based
BMC MSK disorders 2009 Oct 27;10;131
.5 to 1 cc steroid (20 – 40 mg) 2cc to 3 cc local anesthetic

40. De Quervain’s Disease
Inject into or around the sheath

41. Tennis Elbow
Evidence that cortisone is beneficial for at least short term relief

42. Tennis Elbow Use 3 to 5cc, marcaine with epi 40 mg cortisone
Inject the extensor origin
Use single needle
Patient leaves office pain free

43. Shoulder Injections
Cochrane summary says no better injection success with clinical vs ultrasound guided injection
(for now)

44. Shoulder Injections Rotator Cuff Tendinitis or tear in elderly
Evidence based
Duration of benefit variable in different studies

45. Shoulder Injections Subacromial injection
Use 2 cc of steroid (80) mg with 8 cc of long acting local anesthetic
Posterior, slide needle under acromion

46. Shoulder Injections Arthritis or frozen shoulder
8cc marcaine with epi, 1-2 cc steroid (40 to 80mg)

47. Shoulder Injections Glenohumeral injection Posterior, in soft spot
Arm internally rotated

48. Trochanteric Bursa injections
Evidence based
Journal rheum. 1996
Dec;23;(12)

49. Trochanteric bursitis
Large joint
2cc 80 mg steroid
8cc marcaine with epi
Lateral position, hip extended
Long needle
Marcaine with epi
Single needle

50. Knee injections Evidence based Cochrane database
Both steroids and viscosupplemtation

51. Knee injections Large joint Use 2 cc steroid (80 mg)
8cc anesthetic/saline .5% lidocaine, .25% marcaine
Lateral subpatellar approach

52. Knee Injection Leg extended Relaxed Pull kneecap laterally
Needle goes under the superior patella
Great for aspiration

53. Knee injection: Preaspiration?
One study on RA patients demonstrates better response with preaspiration for steroid injections
Weitoff, Journal rheumatic dis. 2000

54. Hallux Rigidus Injection
Arthritis great toe
No good studies on this
Lots of personal positive experience

55. Hallux rigidus injection
Better done with 2 needle (prefreeze)
25 gauge needle
Small joint
1cc marcaine E and less than one half cc steroid

56. MSK Injections
Questions