Steroid joint injections
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Steroid Joint injections . Updated 2010. Why inject joints?. Can be joint or soft tissue i.e. articular or periarticular Low risk e.g. septic arthritis occurs 1 in 40,000 Provide good symptom relief. Basic principles before you start. History and examination

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Why inject joints l.jpg
Why inject joints?

Can be joint or soft tissue i.e. articular or periarticular

Low risk e.g. septic arthritis occurs 1 in 40,000

Provide good symptom relief


Basic principles before you start l.jpg
Basic principles before you start

History and examination

Try conservative treatment first e.g. physio, NSAIDs, orthotics and continue after joint injection.

Careful patient selection

Consent & provide ARCUK PILeaflet

Know your anatomy!

Undertake as few injections as possible to settle the problem, max 3-4 monthly (no more than 3 for tennis elbow per lifetime)


Indications for injection l.jpg
Indications for injection

Osteoarthritis

Rheumatoid arthritis

Gouty arthritis

Synovitis

Bursitis

Tendonitis

Muscle trigger points

Carpal tunnel syndrome


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Inject with caution

Reducing the risk of infection

Never inject an infected joint.

Avoiding injecting through infected skin or psoriatic plaques.

Avoid injecting adjacent to infected skin/skin ulcers.

Avoid injecting patient on concurrent oral steroids.

Mediswabs or iodine should be used with a no touch or aseptic technique.

Reducing the risk of bleeding

If injecting weight bearing joints advise rest for 24 hours post injection.

Don’t inject patients on warfarin

Reducing the risk of tendon rupture

Don’t inject near the Achilles tendon.

Don’t inject into tendons.


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Contraindication to injection

Adjacent osteomyelitis or skin infection

Bacteraemia

Hemarthrosis

Impending (scheduled within 3 months) joint replacement surgery

Septic arthritis

Joint prosthesis

Osteochondral fracture

Periarticular cellulitis / severe dermatitis/ soft tissue infection

Plaque psoriasis at the injection point

Poorly controlled diabetes mellitus

Uncontrolled bleeding disorder or coagulopathy


Technique l.jpg
Technique

Complete the consent form and provide a Patient Information Leaflet prior to the procedure

Inject the corticosteroid with as little pain and as few complications as possible.

Do not attempt any injections in the vicinity of known nerve or arterial landmarks

e.g. lateral epicondyle of elbow ok, medial – beware ulnar nerve

Never inject into the substance of a tendon

Sterile technique


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Technique 2

ANTICIPATION!

Get your kit ready ie:

Needles, syringes, sterile container, LA, steroid, gloves, drapes, chlorhexidine, cotton wool, plaster.

1 or 2 needle technique (green to draw up and blue to give)

Clean area – ensure solution has DRIED (esp iodine) prior to injecting


Technique 3 l.jpg
Technique 3

Always withdraw syringe back first to ensure not injecting into blood vessel

Decide if you want to use lidocaine with the depomedrone

Use a different needle to draw up (green) to the one you use to inject (blue or orange).


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What doses of depo-medrone should you use?

  • Troc Bursitis 40-80mg

  • Knee 40-80mg

  • Shoulder 40mg

  • Tennis elbow 10-20 mg 9using a ‘peppering’ technique

  • +/- Lidocaine when injecting the shoulder or knee


What to warn the patient l.jpg
What to warn the patient

Pain returns after 2 hours, when the local anaesthetic wears off – may be worse than before.

If pain is severe or increasing after 48hrs, seek advice

Warn of local side effects

Advise to seek help if systemic s/es develop


Local side effects l.jpg
Local side effects

Infection, subcutaneous atrophy, skin depigmentation, and tendon rupture (<1%).

Post-injection ‘flare’ in 2-5%

Often are the result of poor technique, too large a dose, too frequent a dose, or failure to mix and dissolve the medications properly.

NB corticosteroid short duration of action – can be as short as 2-3 weeks relief.


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Knee injections

Patient on the couch, knee slightly bent

Palpate superior-lateral aspect of patella

Mark 1 fingerbreadth above + lateral to this site

Clean

LA, corticosteroid

Clean + bandage


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Plantar fasciitis

Procedure painful + no evidence for long-term benefit

Pt indicate tender spot

Approach from thinner skin + direct posterior-laterally

Small blelbs as near to bony insertion as possible

Do not inject fascia itself


Shoulder injection l.jpg
Shoulder injection

  • Glenohumeral joint

  • AC joint

  • Subacromial space

  • Long Head of Biceps

  • Older patients: 2-3 x/ year

  • Younger – consider surgery if no improvement (risk rotator cuff rupture)


Glenohumeral joint injection l.jpg
Glenohumeral joint injection

Pt sits, arm by side, externally rotated

Find sulcus between head of humerus and acromion

Posterolateral corner of acromion (2-3 cm inferior)

Direct needle anteriorly toward coracoid process

Insert needle to full length

Fluid should flow easily


Ac joint injection l.jpg
AC joint injection

Palpate clavicle to distal aspect

Slight depression where clavicle meets acromion

Insert needle from anterior and superior approach

Direct needle inferiorly


Sub acromial joint injection l.jpg
Sub-acromial joint injection

Posterior and lateral aspect of shoulder

Inferior to lower edge of posterolateral acromion

Insert inferior to acromion at lateral shoulder

Direct needle toward opposite nipple

Insert needle to full length

Fluid should flow easily


Elbow epicondyle injection l.jpg
Elbow epicondyle injection

Very effective in short term – 92%

Benefits do not normally persist beyond 6 weeks

Lateral (tennis elbow) + medial (golfer’s elbow) epicondylitis

Patient supine


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Tennis elbow (lateral)

Arm adducted at side

Elbow flexed to 45 degrees

Wrist pronated

Insert needle perpendicular to skin at point of maximal tenderness

Insert to bone, then withdraw 1-2 mm

Inject corticosteroid solution slowly


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Golfer’s elbow (medial)

Beware ulnar nerve!

Rest arm in comfortable abducted position

Elbow flexed to 45 degrees

Wrist supinated

Point of maximal tenderness - insert to bone, then withdraw 1-2 mm

Inject corticosteroid solution slowly


De quervain s tenosynovitis l.jpg
De Quervain’s tenosynovitis

Inflammation of thumb extensor tendons

-Extensor pollicis brevis

-Abductor pollicis longus

Occurs where tendons cross radial styloid


De quervain s tenosynovitis23 l.jpg
De Quervain’s tenosynovitis

Maximally abduct thumb (accentuates abductor tendon) Injection site

Snuffbox at base of thumb

Aim 30-45 degrees proximally toward radial styloid

Insert needle between the 2 tendons (not in tendon)

Do not inject if paraesthesias (sensory branch radial nerve)


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