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Shoulder Girdle Joint Injection Workshop. Virginia Osteopathic Medical Association 2011 Fall CME Conference Hotel Roanoke & Conference Center Roanoke, Virginia September 23, 2011 Bradley M. McCrady, DO Fellow, Primary Care Sports Medicine

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shoulder girdle joint injection workshop

Shoulder Girdle Joint InjectionWorkshop

Virginia Osteopathic Medical Association

2011 Fall CME Conference

Hotel Roanoke & Conference Center

Roanoke, Virginia

September 23, 2011

Bradley M. McCrady, DO

Fellow, Primary Care Sports Medicine

Edward Via College of Osteopathic Medicine- Virginia Campus

Virginia Polytechnic Institute and State University

objectives
Objectives
  • Identify indications and contraindications for joint injections of the shoulder girdle.
  • Review necessary equipment of shoulder injections.
  • Discuss techniques to perform various shoulder girdle injections.
  • Illustrate techniques of ultrasound-guided injections of the shoulder girdle.
  • Demonstrate skills to perform various common shoulder girdle injections.
shoulder complex
Shoulder Complex
  • Shoulder is a complicated anatomical and biomechanical joint
    • “Fragile Equilibrium”
  • Multiple joints
  • Static and dynamic stabilizers

Hoppenfeld, S. Physical Examination of the Spine and Extremities. Prentice Hall; 1976

http://www.sportfit.com/tips/rotatorcuff/images/Z4rtrs.gif

what providers need to know about joint injection and aspiration
What Providers Need to Know About Joint Injection and Aspiration
  • Relatively simple procedure
  • Complications are uncommon
  • Injection/arthrocentesiscan provide diagnosis, relieve pain, decrease joint damage
    • “Liquid biopsy of joint”
    • Useful information can be provided by relatively inexpensive tests
    • Can help differentiate inflammatory from non-inflammatory arthritis
  • Judicious use of anesthetics and steroids may be safer than systemic medications
  • Summary There are often more reasons for doing than not in the right clinical scenario
indications for joint injection aspiration
Indications for Joint Injection/Aspiration
  • Diagnostic
    • Acute inflammatory arthritis (24-48 hours) in a patient who has never had these symptoms before
    • Acute effusion in the setting of fever, chills, or presence of infection at another site
    • Acute effusion in the setting of trauma
    • Prior to committing patients to long-term, expensive or toxic therapy
  • Therapeutic
    • Provide for a better musculoskeletal exam (i.e. pain control)
    • To suppress inflammation in one or two isolated joints
    • Adjuvant therapy to a few joints resistant to systemic therapy
    • To facilitate a rehabilitative therapy program
    • To support a patient with active joint inflammation pending the effects of systemic therapy
    • To remove exudative fluid from a septic joint
    • To relieve pain in a swollen joint
conditions likely to be improved by joint or periarticular injections
Conditions Likely to be Improved by Joint or Periarticular Injections
  • Rheumatoid arthritis
  • Seronegativespondyloarthropathies
  • Crystal induced arthritis
  • Carpal tunnel
  • Bursitis
  • Tenosynovitis/tendinitis
  • Adhesive capsulitis
  • Osteoarthritis
contraindication to joint injection aspiration
Contraindication to Joint Injection/Aspiration
  • Absolute
    • Uncooperative patient
    • Allergy to anesthesia or steroid (very rare)
    • Lack of informed consent
    • Injection through infected tissues
    • Previous severe steroid flare
    • Injection of steroid into critical weight-bearing tendons
  • Relative
    • Injection near critical structures
    • Coagulation disorders
    • Uncontrolled diabetes
    • h/o AVN
    • Previous joint replacement at injection site
    • More than 3 previous steroid injections in a major weight bearing joint in the preceding year
    • Concern to activate any latent disease
    • Excessive anxiety
equipment
Equipment
  • Informed consent
  • Non-sterile exam gloves
  • Marking pen
  • Alcohol pads

+/- povidine-iodine

  • Gauze pads
  • Syringe(s)
  • Needle
  • Anesthetic
  • Steroid
  • Adhesive bandages

McNabb, James. A Practical Guide to Joint & Soft Tissue Injection & Aspiration. 2nd Ed.LWW; 2010.

safety first
Safety First
  • Position for comfort!
  • Define anatomy
  • Universal precautions
    • Vaccines
    • Gown and mask not necessary
  • Clean vs sterile technique
  • Aspirate prior to injections
  • Do not recap needles
  • Proper disposal of equipment
  • Observe patient in office following injection for 15-30 min

Baima, J.Curr Rev Musculoskelet Med (2008) 1:88–91

Hemani, M. Rev Urol. 2009;11(4):190-195

Darouiche, RO. N Engl J Med 2010;362:18-26

topical preparation
Topical Preparation
  • Infection is not common
    • Actual reported incidence is unknown, but is thought to vary from 1: 3,000 to 1:50,000
  • 70% isopropyl alcohol vs 10% povidone-iodine
  • Ethyl chloride fine spray may have antimicrobial activity

http://www.shopmedrx.com/qt_images/TRI_103201.jpg

http://sani-system.com/images/products/b15901.jpg

http://www.gebauerco.com/Images/picEthylChlorideLeft.gif

Baima, J.Curr Rev Musculoskelet Med (2008) 1:88–91

Hemani, M. Rev Urol. 2009;11(4):190-195

Darouiche, RO. N Engl J Med 2010;362:18-26

Clinical Radiology, Volume 61, Issue 12, Pages 1055-1057

steroids history
Steroids-History
  • Hydrocortisone acetate was first introduced in the 1949 for Rheumatoid arthritis by Hollander
    • “No other form of treatment has given such consistent local symptomatic relief in so many for so long with so few harmful effects.”
  • Oriole baseball pitcher Jim Palmer
    • “…cortisone is a miracle drug ... for a week!"
  • Long history of use in athletics
    • Treat the secondary inflammation
    • Need to find the cause

Nepple, J. Sports Health: A Multidisciplinary Approach 2009 1: 396-404

Leadbetter WB. Clin Sports Med.1995;14(2):353-410.

steroids physiology
Steroids-Physiology
  • Stabilizing lysosomal membranes of inflammatory cells
  • Decreasing local vascular permeability
  • Altering neutrophilchemotaxis and function
  • Able to pass through cell membranes and bind to nuclear steroid receptors
    • Where they influence RNA transcription

Nepple, J. Sports Health: A Multidisciplinary Approach 2009 1: 396-404

steroids use
Steroids-Use
  • Hill et al surveyed members of the American Academy of Orthopaedic Surgeons on use of corticosteroids
    • 90% of used corticosteroid injections
    • Performed an average of 150 intra-articular and 193 extra-articular injections per year
  • Conditions warranting injection
    • Epicondylitis (93%)
    • Shoulder bursitis (91%)
    • Greater trochanteric bursitis (91%)
    • DeQuervain’s tenosynovitis (87%)
    • Bicipital tendonitis (81%)

Hill JJ Jr,. ContempOrthop. 1989;18:39-45.

McNabb, James. A Practical Guide to Joint & Soft Tissue Injection & Aspiration. 2nd Ed.LWW; 2010.

anesthetics
Anesthetics
  • Decrease nerve conduction through the blockade of Na channels, which disrupts axonal nerve conduction
  • Typically steroid agent is combined with a local anesthetic agent
    • Decrease the pain
    • Dilute the steroid
    • Increase the distribution of the agent to the treated area
  • Lidocaine
    • Rapid onset (minutes)
    • Short duration (60-90 minutes)
  • Bupivicaine
      • Slower onset (30 minutes)
      • Longer duration (6-8 hours)
  • Buffering
    • Sodium bicarbonate

Nepple, J. Sports Health: A Multidisciplinary Approach 2009 1: 396-404

what patients and providers need to know about joint injection
What Patients (and Providers) Need to Know about Joint Injection
  • Relief will typically last weeks or longer
  • Avoid injecting ligamentous or tendon structure directly
  • Activity modification following injections of steroids is uncertain
  • Maximal number of injections and the required period between injections have not been determined

Nichols, A Clin J Sport Med 2005;15(5) : E370

Pfenninger JL. Procedures for primary care physicians. St. Louis: Mosby, 1994.

what patients and providers need to know about joint injection1
What Patients (and Providers) Need to Know about Joint Injection
  • In a meta-analysis summarizing 25+ studies, they noted a 5.5% complication rate
    • The most common side effects included skin atrophy (2.4%), skin depigmentation (0.8%), localized erythema and warmth (0.7%), and facial flushing (0.6%)
    • Post-injection pain was noted in up to 9% of patients
    • Post injection flare (2-5%)
    • Prolonged and repeated usage may increase the risk of complications and systemic side effects
  • In diabetic patients, hyperglycemia has been shown to persist up to 5 days after a single soft tissue injection (very low risk)

Dietzel, D Current Sports Medicine Reports 2004, 3:310–315

Nepple, J. Sports Health: A Multidisciplinary Approach 2009 1: 396-404

Wang AA. J Hand Surg [Am]. 2006;31(6):979-981.

Pfenninger, JL Procedures in Primary Care 2nd Ed. 2003: 1479-1499

typical injection aspiration procedure
Typical Injection/Aspiration Procedure
  • Determine the medical diagnosis and consider relevant differential diagnoses
  • Discuss the proposed procedure and alternatives with the patient
  • Obtain written informed consent from the patient
  • Collect and prepare the required materials
  • Correctly position the patient for the procedure
  • Identify and mark the anatomic landmarks and injection site with ink
    • Do not allow the patient to move the affected area from the time that the marks are placed until after the procedure is completed
  • Press firmly on the skin with the retracted tip of a ballpoint pen to further identify the injection site
  • Prepare the site for injection by cleansing with a topical antimicrobial agent (povidine-iodine and/or alcohol swab)
    • If using the povidone, allow to dry for full antibacterial effect
  • Provide local anesthesia as indicated through use of tactile distraction, vapocoolant spray (ethyl chloride or PainEase), and/or injected local anesthesia

McNabb, James. A Practical Guide to Joint & Soft Tissue Injection & Aspiration. 2nd Ed.LWW; 2010.

Pfenninger, JL Procedures in Primary Care 2nd Ed. 2003: 1479-1499

typical injection aspiration procedure1
Typical Injection/Aspiration Procedure
  • Using the no-touch technique, introduce the needle at the injection site and advance into the treatment area
  • Aspirate fluid (optional) using a 18 or 20-g needle and send it for laboratory examination if indicated
  • If injecting corticosteroid immediately following aspiration, do not remove the needle from the joint or bursa; In this case, grasp the needle hub firmly (with a hemostat clamp if necessary), twist off the original syringe, and then immediately attach the second syringe that contains the corticosteroid
  • Always aspirate before injection to avoid intravascular administration
  • Inject corticosteroid solution into the treatment area
    • If not aspirating then use 25-g needle
    • Do not inject the medication against resistance
  • Withdraw the needle
  • Apply direct pressure over the injection site with a gauze pad
  • Apply an adhesive dressing
  • Provide the patient with specific post-injection instructions

McNabb, James. A Practical Guide to Joint & Soft Tissue Injection & Aspiration. 2nd Ed.LWW; 2010.

Pfenninger, JL Procedures in Primary Care 2nd Ed. 2003: 1479-1499

informed consent
Informed Consent
  • Patient’s consent to allow provider (and his/her pupils) to perform the procedure.
  • All alternative treatments discussed with the patient in lieu of procedure.
  • Benefits and risks to the procedure.
  • Explanation of the procedure in lay language to the patient.
  • Signature of the patient or authorized representative, witness, and provider.
shoulder girdle injections
Shoulder Girdle Injections
  • Subacromial
    • Posterior
    • Lateral
  • Glenohumeral
    • Posterior
    • Anterior
  • Acromioclavicular
  • Sternoclavicular
  • Biceps brachii long head
subacromial injection lateral approach
Subacromial Injection Lateral Approach
  • Find lateral edge of acromion and mark
  • Palpate soft spot below the acromion and above the humeral head
  • Insert needle perpendicular through the deltoid towards the bursa
subacromial injection posterior approach
Subacromial Injection Posterior Approach
  • Find lateral edge of the acromion and mark
  • Palpate posterior edge of the acromion and mark
  • Find posterolateral edge of the acromion and mark a spot 2 cm below the corner

McNabb, James. A Practical Guide to Joint & Soft Tissue Injection & Aspiration. 2nd Ed.LWW; 2010.

Seroyer, S. Sports Health 2009; 1 (2): 108-120

subacromial injection posterior approach1
Subacromial Injection Posterior Approach
  • Position the needle at a 30 ° angle to the skin with the needle tip directed cephalad toward the acromion
  • Insert the needle getting underneath the acromion and advance until the needle tip touches the undersurface of the acromion
  • Once at the acromion, back off 1-2mm
glenohumeral injection posterior approach
Glenohumeral Injection Posterior Approach
  • Find lateral edge of acromion
  • Palpate the posterior edge of the acromion
  • Mark spot 2 cm below posterior lateral corner
  • Target is coracoid process
glenohumeral injection posterior approach1
Glenohumeral Injection Posterior Approach
  • Advance needle towards coracoid process until tip touches humeral head and retract needle 1-2mm
glenohumeral injection anterior approach
Glenohumeral Injection Anterior Approach
  • Identify coracoid process
  • Injection point is 1 cm lateral to the coracoid
glenohumeral injection anterior approach1
Glenohumeral Injection Anterior Approach
  • Insert needle perpendicular to the skin toward the target 2 cm caudad to the posterior lateral corner of the acromion
  • Advance needle until it reaches the humeral head and retract 1-2mm
long head biceps injection
Long Head Biceps Injection
  • Palpate course of biceps long head tendon with the patient flexing the elbow
  • Palpate location of maximal tenderness which is usually under the edge of the pectoralis major

http://www.aafp.org/afp/2009/0901/afp20090901p470-f1.jpg

long head biceps injection1
Long Head Biceps Injection
  • Position needle at a 45° angle to the skin with needle directed proximally
  • Advance needle until needle tip touches tendon, back needle off 1-2mm
  • Medication should flow smoothly
acromioclavicular injection
Acromioclavicular Injection
  • Identify AC joint by palpating the clavicle in a medial to lateral direction until reaching a small depression that may be tender

http://upload.wikimedia.org/wikipedia/commons/thumb/3/3b/Gray326.png/250px-Gray326.png

acromioclavicular injection1
Acromioclavicular Injection
  • Insert needle perpendicular to the skin with the needle tip directed caudad
sternoclavicular injection
Sternoclavicular Injection
  • Identify SC joint by palpating the clavicle in a lateral to medial direction until reaching a small depression that will likely be tender
sternoclavicular injection1
Sternoclavicular Injection
  • Insert needle perpendicular to the skin and advance into SC space
musculoskeletal ultrasound
Musculoskeletal Ultrasound
  • The use of high-frequency sound waves (3-17MHz) to image soft tissues and bony structures in the body for the purpose of diagnosing pathology or guiding real-time interventional procedures

http://cdn.bleacherreport.com/images_root/image_pictures/0236/5499/39664_crop_340x234.jpg

Pinzon, EG and Moore, RE. Musculoskeletal Ultrasound: a brief overview of diagnostic and therapeutic application in musculoskeletal medicine. Practical Pain Management. June 2009.

ultrasound terminology
Ultrasound Terminology
  • Echogenecity- the ability of tissue to reflect ultrasound waves back toward the transducer and produce an echo. (The higher the echogenicity of tissues, the brighter they appear on ultrasound imaging)
  • Hyperechoic- seen as brighter on ultrasound relative to surrounding tissues due to higher reflectivity of the US beam
  • Isoechoic- structures are seen as bright as surrounding structures on conventional US imaging due to similar reflectivity to the US beam

Pinzon, EG and Moore, RE. Musculoskeletal Ultrasound: a brief overview of diagnostic and therapeutic application in musculoskeletal medicine. Practical Pain Management. June 2009.

ultrasound terminology1
Ultrasound Terminology
  • Hypoechoic- structures are seen as darker relative to the surrounding structures on US imaging due to the US beam being reflected to a lesser extent
  • Anechoic- structures that lack internal reflectors fail to reflect the US beam to the transducer and are seen as homogenously black on imaging
  • Anisotrophy- the effect of the beam not being reflected back to the transducer when the probe is not perpendicular to the structure being evaluated

Pinzon, EG and Moore, RE. Musculoskeletal Ultrasound: a brief overview of diagnostic and therapeutic application in musculoskeletal medicine. Practical Pain Management. June 2009.

ultrasound terminology2
Ultrasound Terminology
  • Transverse- cross sectional view
  • Sagittal (Longitudinal)- long axis plane view
  • Coronal- long axis plane view dividing anterior and

posterior

http://www2.healthsci.tufts.edu/saif/Vevo2100/Ultrasound-Terminology.pdf

ultrasound equipment
Ultrasound Equipment
  • High Resolution Machine
  • Transducers
    • Linear 8-14 MHz
    • Curvilinear 2-5 MHz
    • “Hockey Stick”
  • Printer
  • CD/DVD/USB unit

Schaefer, MP. Ultrasound Guided Interventions in PM&R. MRIO PM&R Grand Rounds. 9 November 2009.

http://www.ucsdultrasound.com/yahoo_site_admin/assets/images/ultrasound_transducers.24673744_large.jpg

ultrasound guidance advantages
Ultrasound Guidance Advantages
  • Real-time guidance
  • Assess anatomy
  • Soft tissue visualization
  • Visualize neurovascular structures
  • No radiation

Schaefer, MP. Ultrasound Guided Interventions in PM&R. MRIO PM&R Grand Rounds. 9 November 2009.

ultrasound guidance limitations
Ultrasound Guidance Limitations
  • Obesity (depth ~6cm)
  • No contrast confirmation
  • No visualization deep to bony structures (very limited use in spine injections)
  • Operator dependency
  • Superficial tenderness

Schaefer, MP. Ultrasound Guided Interventions in PM&R. MRIO PM&R Grand Rounds. 9 November 2009.

equipment for u s guided injections
Equipment for U/S Guided Injections
  • Informed consent
  • Sterile vs non-sterile gloves?
  • Marking pen
  • Alcohol pads
  • Povidine-iodine
  • Gauze pads
  • Syringes
  • Needles (typically longer than non-guided injections)
    • Echoblock needle?
  • Sterile transducer cover?
  • Sterile gel
  • Anesthetic
  • Steroid
  • Adhesive bandages

Schaefer, MP. Ultrasound Guided Interventions in PM&R. MRIO PM&R Grand Rounds. 9 November 2009.

subacromial injection
Subacromial Injection

http://www.essr.org/html/img/pool/shoulder.pdf

Schaefer, MP. Ultrasound Guided Interventions in PM&R. MRIO PM&R Grand Rounds. 9 November 2009.

subacromial injection1
Subacromial Injection

Schaefer, MP. Ultrasound Guided Interventions in PM&R. MRIO PM&R Grand Rounds. 9 November 2009.

acromioclavicular injection2
Acromioclavicular Injection

http://www.essr.org/html/img/pool/shoulder.pdf

acromioclavicular injection3
Acromioclavicular Injection

Schaefer, MP. Ultrasound Guided Interventions in PM&R. MRIO PM&R Grand Rounds. 9 November 2009.

glenohumeral injection
Glenohumeral Injection

http://www.essr.org/html/img/pool/shoulder.pdf

glenohumeral injection1
Glenohumeral Injection

Schaefer, MP. Ultrasound Guided Interventions in PM&R. MRIO PM&R Grand Rounds. 9 November 2009.

long head biceps brachii injection
Long Head Biceps Brachii Injection

http://www.essr.org/html/img/pool/shoulder.pdf

long head biceps brachii injection1
Long Head Biceps Brachii Injection

http://www.ultrasoundpaedia.com/USP%20shoulder%20winner.html

http://dynamicultrasound.org/images/lsbiceps.jpg

sternoclavicular injection2
Sternoclavicular Injection

http://emj.bmj.com/content/28/6/542.extract

http://greatpiercingshop.com/blog/wp-content/uploads/2009/12/Clavicles.jpg

post injection instructions
Post Injection Instructions
  • Recurring Pain- anesthetic effect ending before steroid effect begins
  • Rest Injection Area- further injury may be caused by numbness of the site
  • Infection Observation- fever, increased warmth/redness, ascending redness, increased swelling
injection coding
Injection Coding
  • CPT code
    • 20610 injection/aspiration of major joint or bursa
  • Code for injectable used (J code)

McNabb, James. A Practical Guide to Joint & Soft Tissue Injection & Aspiration. 2nd Ed.LWW; 2010.

questions and demonstration
Questions and Demonstration

http://www.shoulderdoc.co.uk/images/uploaded/sdoc_ultrasound_07.jpg

references
References
  • Beggs, I., et al. Musculoskeletal Ultrasound Technical Guidelines: shoulder. European Society of Musculoskeletal Radiology. http://www.essr.org/html/img/pool/shoulder.pdf
  • McNabb, James. A Practical Guide to Joint & Soft Tissue Injection & Aspiration. 2nd Ed. LWW; 2010.
  • Pinzon, EG and Moore, RE. Musculoskeletal Ultrasound: a brief overview of diagnostic and therapeutic application in musculoskeletal medicine. Practical Pain Management. June 2009.
  • Schaefer, MP. Ultrasound Guided Interventions in PM&R. MRIO PM&R Grand Rounds. November 2009.