SLIDE TOPICS, SUBTOPICS and CONTENTS:

Injection Directions

Jon Roebuck

August 5, 2008

Rheumatology AM lecture Series

Overview

Indications

Education

Tools

Special considerations

Techniques

Joints

Soft tissues

TSP and L funds

 

Indications

Aspiration of fluid

Diagnosis

Relieve pressure/pain

Drain badness

 

Injection of anesthetic +/- steroid

Relieve pain and suffering

Education

Post-injection care

Decreased activity

 

Complications

Infection/ bleeding

Local pain

Post-injection flare

Flushing reaction

Education

Patient expectation

Cure?

Alleviation of symptoms

No response

Need for repeat injection

Frequency of re-injection

Adjunctive measures

Arthrocentesis technique

Considerations

Needle and syringe size

 

Skin sterilization

 

Local anesthesia

 

Equanimity of patient

Needle size

“It’s not the size of the wand, but how you wave it”

 

22 gauge for most taps

18-20 for knee

Viscous pus

25 for IP joints

Inflammatory fluid is LESS viscous

Syringe size

What are you trying to accomplish?

Large syringe for large effusion

Small syringe for tendon sheath injection

 

5-10 cc is ideal

Large enough for vacuum

Small enough to avoid debris

 

Hair removal

Shaving is NOT recommended

Remove top layer of epidermis

Expose more staph

Increase risk of infection?

 

If gorilla like:

Clip hair shafts

Sterile preparation

3 separate concentric spirals

Iodine disinfectant

 

Landmarks before preparation

Sterile gloves are not necessary

Don’t touch the prepared site

Universal precautions

CRUCIAL question

Swipe the alcohol pad?

Dab the alcohol pad?

 

Who’s a swiper

Who’s a dabber

 

 

Anesthesia

Bleb of SQ lidocaine

Burst of ethyl chloride

Before or after preparation?

EMLA cream

 

Mix lidocaine with steroid

Reduce post injection flare

Anesthesia

Theoretical concerns

 

Methylparaben preservatives

Decrease culture sensitivity

Bad technique with spray

Splatter from non-sterile field

Multi-dose vials not optimal

For sterile technique

 

Switching syringes

Why do it?

First syringe fills

Gross inspection prior to injection

Only one stick

Make sure needle is loose enough!

Use a hemostat

Grab proximal round end

Why aspirate before inject?

Reducing size of effusion before injection improves outcome

 

50% reduction in reaccumulation of fluid

Principles

Comfortable position

You and patient

 

Easy access to joint capsule

 

Avoidance of neurovascuar bundles

 

Avoidance of abnormal overlying skin

In general…

Kenalog

40mg large joints

20-30mg medium joints

10-20 small joints

As much as can fit for tiny joints

 

Be liberal with anesthetic

MYTH

Corticosteroid injections accelerate cartilage destruction

Antiquated data

 

May even be chondroprotective

Suppression of metalloproteases?

Animal studies

 

Site specifics

Shoulder

Joints:

Glenohumeral

Acromioclavicular

Sternoclavicular

 

Soft tissues:

Subacromial bursitis

Biceps tendonitis

JOINTS

Temporomandibular

Palpate during jaw movement

 

Mark target with mouth open

 

Small joint principles apply

Shoulder
(It’s all in the approach)

 

 

Posterior

 

Anterior

 

Large joint

Elbow

Elbow joint proper

Radiohumeral articulation

 

Elbow flexed to 90 degrees

Medium joint

Wrist

Distal to radius

Ulnar to anatomic snuffbox

Interconnecting synovial spaces

Medium joint

First Carpometacarpal

Thumb flexed across palm

Dorsal side of extensor pollicis brevis

Avoid radial artery

 

Small joint

Interphalangeal joints

Lateral, medial or dorsal

Beneath extensor tendon

Penetration of joint space is overrated

 

Small joint

Knee

Rheumatology

Medial

anesthesia

Orthopedics

Lateral

Superior

 

Large joint

 

 

Why dry?

You missed

 

It’s in the bursa

 

Gelatinous effusion

Panacea?!

Ankle

Hollow between medial malleolus and articulation of tibia on talus

 

Just lateral to medial malleolus

 

Medium joint

Ankle/ subtalar joint

Many small joints

Communicate

Cluster attacks

 

One inch below lateral malleolus

 

Small joint

Medium amount

SOFT TISSUES

 

Subacromial bursa

Scapulohumeral groove posteriorly

Aim for the acromion

 

Anterior or lateral approach

Supraspinatus tendon

Lateral groove between humerus and acromion

 

Straight shot 2.5 cm

Biceps tendon

Palpate bicipital groove

Area of point tenderness

May be tender along tendon

 

Penetrate sheath and bath tendon

Resistance is bad

Wrist ganglion

Carpal tunnel

Radial side of palmaris longus

Diagnostic as well as therapeutic

 

Medium joint principles apply

DeQuervain’s

Dupuytren’s

Nodular fibrosing lesions

Ulnar preference

Intralesional injection

Softening and flattening of nodules

Best early in course

Trochanteric bursitis

 

Bursa bursa everywhere

Anserine bursa

Sartorius

Gracilis

Semitendinosis

 

Very amenable to injection

Don’t inject this

Inject this

Financial smarts

How much will college cost for our kids

Best methods to save

Trusts

Educational IRA

529 plans

 

Don’t let financial advisors tell you to use TSP– that's yours

Summary

Best thing we do

Patients better by the time they leave

Patient education/expectations

Paramount to good response

Don’t get too cavalier

Bad things happen rarely

Very few absolute contraindications

TSP L funds

Any questions about TSP in general?

L funds

Automated diversification

Automated re-balance

Automated shifting based on retirement timeline

For the truly dedicated and disconnected

Questions

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