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Joint Injections in Primary Care
Marc A. Aiken, MD Watauga Orthopaedics
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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
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The Most Common Joints Injected
Knee Shoulder (glenohumeral jt.) Shoulder (subacromial bursa)
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Indications - Diagnostic
Evaluate fluid aspirate for: Infection Inflammatory arthropathy Trauma Relief of pain immediately following injection indicates an intraarticular source
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Indications - Therapeutic
Relief of pain/inflammation caused by: Effusion OA, RA, Gout Bursitis Selected tendonopathies
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Absolute Contraindications
Local cellulitis Prosthetic joint Septicemia Acute fracture Patella and achilles tendonopathy Allergy to injection medications
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Relative Contraindications
Anticoagulated/coagulopathic patient Diabetes Immunocompromised patient Minimal or no relief with 2 prior injections Local osteoporosis Inaccessible joints
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Medications Corticosteroid Local anesthetic Hyaluronic acid
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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
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Other Steroids Triamcinolone (Aristospan) Dexamethasone (Decadron)
Methylprednisolone (Depo-Medrol)
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Local 1% Lidocaine (Xylocaine) without epi
useful for intraarticular injection and subcutaneous injection when aspirating onset within minutes can be diagnostic tool
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Local Bupivicaine (Marcaine) Potential cause of chondrocyte death
Avoid intraarticular use
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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.
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Adverse Reactions/Complications
2-5% - Post injection (steroid) flare 0.8% - Steroid arthropathy (AVN, Chondrolysis, etc.) Iatrogenic infection Flushing Skin atrophy and depigmentation
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Adverse Reactions/Complications
Loss of glucose control in DM Increased appetite Insomnia Irritability
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General Considerations
Evaluate the patient Patient education Consent Patient Comfort Sterile preparation and technique Documentation
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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
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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
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Consent Written Vs. Verbal Your choice
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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
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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 patient anticipate
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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
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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
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Document Amount of fluid aspirated
color, clarity and viscosity of fluid purulent? Blood? (trauma) Lipid?(trauma/occult fx)
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Send Fluid for Analysis
Labs ordered from fluid: Cell Counts (stat if infection suspected) Cultures Gram stain (stat) Polarized light microscopy
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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
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Injection Technique Intraarticular knee Intraarticular Shoulder
Subacromial bursa
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Supplies
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Knee Aspiration/Injection
Superolateral approach most reliable 93% accuracy vs % with bent knee anteromedial/anterolateral approach
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Superolateral Approach
Patient Supine with knee extended Palpate bony landmarks Patella Lateral Femur
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Palpate Patella
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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
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The Injection Reassure patient Relaxed quads = more space at PF jt
Needle Trajectory 15-20 degrees Toward trochlea of femur
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Needle Trajectory
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Anterior Approach (bent knee)
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Anterior Approach Less reliable/accurate than superolateral approach
Can be easier in the obese knee Patient sitting with knee bent to 90 degrees
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Anterior Approach Palpate landmarks Inferior pole of patella
Patella tendon Tibial Plateau
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Landmarks - Patella
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Landmarks - Plateau
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Landmarks
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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 of needle should be toward intercondylar notch
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Trajectory
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Shoulder (GH joint) Anterior approach
Position patient sitting facing provider Palpate bony landmarks Clavicle Coracoid
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Landmarks
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Palpate - Clavicle
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Clavicle
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Coracoid
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Needle Placement Inject just lateral to coracoid process
20 degree angle Reposition if you encounter resistance
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Shoulder (SA Bursa) Given lateral or posterior
Just beneath the angle of the acromion
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Acromion
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Subacromial Injection
Direct needle under acromion
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Questions?
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