“ The Art of the Injection”. By Jon C. Brillhart PA-C Daivd Lannik MD Portsmouth Orthopedics, Inc. Joint Injection Challenge. The art of good injection therapy is to place the appropriate amount of the appropriate medication into the exact site of the affected tissue.
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By Jon C. Brillhart PA-C
Daivd Lannik MD
Portsmouth Orthopedics, Inc
The art of good injection therapy is to place the appropriate amount of the appropriate medication into the exact site of the affected tissue.
“The right medicine”,
“in the right quantity”,
“given in the right stop”,
“at the right time”.
Quoted from David Lannik MD, 2005.
1.) Joint Aspiration (confirm nature fluid)
2.) Provide symptom relief of affected body part.
1.) Increase mobility and decrease pain.
Soft Tissue conditions
(avoid soft tissue injection)
crash cart, msds)
The skin should be prepared with
providone-iodine or similar antiseptic solution. (Alcohol)
The risk of infection with use of alcohol skin preparation alone is reportedly estimated at 1 in 10,000.
Synthetic analogues of the adrenal glucocorticocoid hormone “cortisol” (hydrocortisone) with is secreted by the innermost layer (zona reticularis) of the adrenal cortex.
*Suppress inflammation (RA, PA, Gout).
*Suppress inflammatory flares (OA/DJD).
Hydrocortisone acetate Low Short 10 to 25 mg for
(Hydrocortone) soft tissue and
50 mg large joints
Methylprednisolone Intermediate Intermediate 2 to 10 mg for
(Depo Medrol) soft tissue and
Triamcinolone small joints
(Aristocort) 10 to 80 mg for
Dexamethasone sodium High Long 0.5 to 3 mg for
(Decadron) soft tissue and small
2 to 4 mg large joints
Betametasone sodium High Long 1 to 3 mg for soft tissue
phosphate and acetate and small joints
(Celestone Soluspan) 2 to 6 mg large joints
Shoulder 30 mg 10 ml
Elbow 20 mg 5 ml
Wrist, Thumb 10 mg 2 ml
Fingers 5 mg 1 ml
Hip 40 mg 5 ml
Knee 40 mg 10 ml
Ankle, foot 20 mg 5 ml
Toes 10 mg 1ml
Use more concentrated solutions (ie 2%) of lidocaine hydrochloride for small joints that require small injection volumes. (MCPJ)
Conversely, use a less concentrated (ie 1%) lidocaine hydrochloride for large joints that need increased volume. (Knee)
Never use epinephrine / lidocaine solution on ears, nose, fingers and toes!!!
Drug Onset Duration Max Vol
1% 1-2 Min ~ 1 Hour 20 ml
2% 1-2 Min ~ 1 Hour 10 ml
0.25% 30 Min 8 hours 60 ml
0.50% 30 Min 8 Hours 30ml
CHANGES ASSOCIATED WITH OSTEOARTHRITIS
1. Brandt KD. In: Harrison’s Principles of Internal Medicine. 13th ed. New York, NY: McGraw-Hill; 1994:1692-1698.
2. Balazs EA, Denlinger JL. J Rheumatol. 1993;20(suppl 39):3-9.
hylan G-F 20MW 6 million
Reference: Lussier A, Cividino AA, McFarlane CA, et al. Viscosupplementation with hylan for the treatment of osteoarthritis: findings from clinical practice in Canada. J Rheumatol. 1996;23(9):1579-1585.
ACR 2000 GUIDELINES – Pharmacologic/Surgical Therapy
Adapted from American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Arthritis Rheum. 2000;43:1905-1915.
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