Common Injections of the Hand/Wrist & Foot/Ankle General Principles and Specific Techniques

1. Common Injections of the Hand/Wrist & Foot/AnkleGeneral Principles and Specific Techniques Jeff Leggit, MD

2. Objectives • Review the general indications, contraindications, benefits, and risks of injections • Discuss consent, equipment, anesthesia, corticosteroid choice and technique • Discuss specific anatomic injections detailing indications, clinical landmarks, technique, needle size and dosage

3. Diagnostic: Synovial fluid analysis Therapeutic trial Imaging studies Synovial biopsy Therapeutic: Remove tense effusions Remove blood or pus Therapeutic lavage Injection of steroids or other intra-articular therapies Indications

4. Risks/Complications • Tendon rupture • Post-injection flare • Cartilage degeneration • Local trauma • Infection: 1/20,000 - 50,000 injections • Atrophy/hypo or hyperpigmentation • Hyperglycemia

6. Contraindications • Cellulitis or broken skin over needle entry site • Anticoagulation or a coagulopathy (relative) • Intra-articular fractures (for steroids) • Septic effusion (for steroids) • Lack of response to prior injections • More than 3 prior injections in the last year to a weight bearing joint • Inaccessible joints; joint prostheses

7. Evidence-Based Medicine There is currently insufficient quality data to provide a definitive answer on the efficacy of steroid injections.

8. General Principles • Consent • Equipment • Anesthesia • Corticosteroids • Alternate Compounds • Technique • Post-Procedure Care

9. Consent • Consent should be obtained on all diagnostic and therapeutic injections! • A detailed discussion of benefits, risks and the expected results should be covered. • Consent should be witnessed and documented.

10. Equipment • Controversies: • sterile prep vs. alcohol prep • sterile gloves vs. nonsterile • Injections: 21 - 27 gauge 1-10cc syringes • Aspirations: 18 - 20 gauge 3 - 50cc syringes • Anesthesia:1-2% lidocaine, 0.5% bupivicaine? and/or topical (Ethyl Chloride, EMLA, TAC) • Steroid: Celeston 6mg/cc, Triamcinolone 40mg/cc • Sponges, Band-Aids • Access to equipment for allergy/anaphylaxis

11. Anesthesia • Aids in providing pain relief, assisting in diagnosis, and providing a volume for the steroid. • Lidocaine: 0.5% to 2%; amide; 1 - 5 min onset of action; duration 1 hr. • Bupivicaine: 0.25 - 0.5%; amide; 30 min onset of action; duration 8 hr. • Ethyl chloride, EMLA, TAC

12. Anesthesia • Anesthetics work by causing a reversible block to impulse conduction along nerve fibers. Loss of Pain Sensation Loss of All Sensation Loss of Motor Power As Dose of Local Anesthetic Increases Max Dose of Lidocaine = 4/mg/kg

13. Corticosteroids • Treats the local inflammatory response (if present)- not the clinical problem. • Modify Pain Receptors • Goal is to maximize glucocorticoid effects; minimize mineralocorticoid effects. • Increased solubility = shorter duration = lower risk for post-injection steroid flare = lower risk for local atrophy. Celestone (6mg/ml)- Has Short & Long Acting Properties may be best all around agent (hard to find and keep) Triamcinolone (10/ml & 40mg/ml) – Low Solubility so last longer and may be better for Joint Injections

14. Alternate Compounds-Prolotherapy Theory of strengthening tendons or ligaments by injecting a noxious stimulus that cause a proliferation of new cells, but avoids the possible catabolism of steroids • Dextrose • Saline • Phenol • Calcium Gluconate • Autologus Blood • Aprotinin • Heparin Poorly studied, but gaining interest. May be worth a try

15. Technique • Be prepared! • Landmarks • Aseptic vs. Sterile technique • Local anesthesia • Needle insertion • Delivering the volume: • bolus vs. peppering “This is gonna hurt a lot”

16. Post-Procedure Care • Evaluation of relief in the office (>50% improvement = efficacious) • Discussion of steroid effects/expectations • Afterpain treatment • Ice vs. short course NSAID • Activity Recommendations • Follow-up visit!

17. Pain Relief and Injection Therapy Corticosteroid Anesthetic Pain Pain Threshold 48hrs Time

18. Evidence-Based Medicine There is currently insufficient quality data to provide a definitive answer on the efficacy of steroid injections.

19. Specific Injections • deQuervain’s Tenosynovitis • Carpal Tunnel Syndrome • Trigger Finger/Thumb • 1st Carpometacarpal • Plantar Fascia Pain • Morton’s Neuroma • Tarsal Tunnel Syndrome • Ankle Joint

20. deQuervain’s Tenosynovitis • Indications: • Recalcitrant deQuervain’s stenosing tenosynovitis (may be initial tx of choice) • Diagnosis of radial wrist pain • Needle size and dosage: • 25 - 27 gauge 1 inch needle • 0.5-1ml of Anesthesia w/ 0.5ml of Celestone 6mg/ml or Kenalog 40mg/cc Abd Pollicus Longus Extensor Pollicus Brevis

21. Carpal Tunnel Syndrome (CTS) • Indications: • CTS recalcitrant to conservative tx • Needle size and dosage: • 25 - 27 gauge 1 inch needle • 1ml of Anesthesia w/ 1 ml of Celestone 6mg/ml or Kenalog 40mg/cc

22. Trigger Finger/Thumb • Indications: • Stenosing Tenosynovitis • Needle size and dosage: • 25 - 27 gauge 1 inch needle • 0.5 ml of Anesthesia w/ 0.5 ml of Celestone 6mg/ml or Kenalog 40mg/cc

23. 1st Carpometacarpal Injection • Indications: • Persistent Pain from Arthritic conditions (OA) • Diagnosis of 1st MCP Pain • Needle size and dosage: • 25 - 27 gauge 1 inch needle • 0.5-1ml of Anesthesia w/ 0.5ml of Celestone 6mg/ml or Kenalog 40mg/cc

24. Other Wrist Injections • Ganglion Cyst • Intersection Syndrome • Triangular Fibrocarilage Complex • Wrist Joint • Gamekeeper’s Examination

25. Plantar Fascia • Indications: • Recalcitrant plantar fascial pain • Diagnostic • Needle size and dosage: • 25 to 27 gauge 1 inch needle • 1ml of Anesthesia w/ 1 ml of Celestone 6mg/ml or Kenalog 40mg/cc

26. Morton’s Neuroma (perineural fibrosis of an interdigital nerve) • Indications: • Pain refractory to conventional treatment • Needle size and dosage: • 25 to 27 gauge 1 inch needle • 0.5ml of Anesthesia w/ 0.5 ml of Celestone 6mg/ml or Kenalog 40mg/cc

27. Tarsal Tunnel Syndrome • Indications: • Diagnostic • Persistent Pain • Needle size and dosage: • 25 to 27 gauge 1 inch needle • 0.5ml of Anesthesia w/ 0.5 ml of Celestone 6mg/ml or Kenalog 40mg/cc

28. Ankle Joint • Indications: • Persistent pain from OA or posttraumatic arthritis • Needle size and dosage: • 25 to 27 gauge 1 ½” needle • 1-2 ml of Anesthesia w/ 1 ml of Celestone 6mg/ml or Kenalog 40mg/cc Anterior Tibial Tendon

29. 1st MTP • Indications: • Aspiration- Confirmation of crystal induced arthropathy • Injection-Acute treatment of above and OA and traumatic arthritis • Needle size and dosage: • 25 to 27 gauge 1 inch needle • 0.5ml of Anesthesia w/ 0.5 ml of Celestone 6mg/ml or Kenalog 40mg/cc

30. Sinus Tarsi Syndrome • Indications: • Persistent Pain in Sinus Tarsi • Needle size and dosage: • 25 to 27 gauge 1 ½” needle • 1-2 ml of Anesthesia w/ 1 ml of Celestone 6mg/ml or Kenalog 40mg/cc

31. Conclusion • Injections are very satisfying and rewarding for both the patient and the Family Physician. • Indications and Contraindications must be known. • An appreciation for the mostly anecdotal evidence must be kept in mind.