1 / 36

JOINTS

JOINTS. Injections & Aspirations. Rationale. Primary care providers should master the technique of joint aspiration and injection for many reasons: Diagnosing an inflamed joint Pain relief of a distended joint Injection of steroids for painful joint. Indications. Diagnostic

andrew
Download Presentation

JOINTS

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. JOINTS Injections & Aspirations

  2. Rationale • Primary care providers should master the technique of joint aspiration and injection for many reasons: • Diagnosing an inflamed joint • Pain relief of a distended joint • Injection of steroids for painful joint

  3. Indications • Diagnostic • To evaluate synovial fluid • Infections • Rheumatic • Traumatic • Crystal-induced etiology • Therapeutic • Remove exudate from septic joint • Relieve pain in grossly swollen joint • Inject lidocaine, saline, corticosteroids

  4. Contraindications • Cellulitis or broken skin over entry site • Anticoagulant therapy not well tolerated • Septic effusion of a bursa • More than 3 previous injections to weight bearing joint in last 12 months • Suspected bacteremia • Unstable joint • Inaccessible joint

  5. Absolute Local sepsis Suspicion of infection Sepsis Hypersensitivity Early trauma Hemarthrosis Prosthetic joint Very unstable joint Reluctant patient Children Contraindications

  6. Contraindications • Diabetic • Anticoagulated • Bleeding disorder • Immunosuppressed • Psychogenic pain • Severe anxiety • Gut feeling

  7. Equipment • Betadine • Sterile gloves • 22- to 27-gauge needle for injections • 18-gauge needle for aspirations • 10cc syringe • 30cc syringe is aspirating large amount • Lidocaine • Culture tubes

  8. Pre-procedure Patient Education • Risks • Benefits • Possible complications • Pain • Infection • Bleeding • Tendon damage

  9. Technique • Before injection, consider differential. • X-rays if tumor or fracture possible • Identify entry site and mark • Prep with betadine • Inject wheel of lidocaine and advance for deeper anesthesia with 27-gauge needle • Use 18-gauge needle inserted into desired location and aspirate or 22-gauge and inject medication

  10. Lab Analysis of Fluid • White blood cell count • <50,000 inflammatory • >50,000 infectious • Polymorphonucleocyte percentage • Crystals • If fluid cloudy, culture

  11. Septic Arthritis • Infection occurs by : • Hematogenous spread • Contiguous source • Direct implantation • Postoperative complication

  12. Septic Arthritis • Early diagnosis essential: • Growth impairment • Articular destruction • Osteomyelitis • Soft tissue expansion

  13. Septic Arthritis • Neisseria gonorrheoae • Adolescents and young adults • Staphylococcus • Patients> 40, medical illnesses • Streptococcus

  14. N. gonorrhoeae • Majority in women • With or without anogenital symptoms • Occurs during menstruation/pregnancy • Positive culture 25%-60% • Positive Gram stain 65% • WBC and glucose helpful

  15. Synovial Fluid Analysis • String sign • Cell count • Glucose • Gram stain • Crystals

  16. Synovial Fluid Interpretation

  17. Joint Injection

  18. The Drugs Corticosteroids Rationale for Using Steroid Injection • Suppressing inflammation Short acting: Hydrocortisone Intermediate acting: Methylprednisone/Triamcinolone Long acting: Dexamethasone

  19. Side Effects • Systemic • Facial flushing • Uterine bleeding • Deterioration of Diabetic glycemic control • Significant falls in the ESR and CRP levels • Other rare side effects • Anaphylaxis

  20. Side Effects • Local • Post-injection flare of pain • Subcutaneous atrophy • Bleeding or bruising • Soft-tissue calcification • Steroid arthropathy • Tendon rupture • Joint sepsis • Soft tissue infection

  21. Local Anesthetics • Rationale for using • Diagnostic • Analgesic • Dilution • Distension • Commonly used • Lidocaine • Bupivacaine

  22. Safety Precautions • Aseptic Technique • Adverse Reactions • Syncope • Anaphylaxis

  23. Aspiration • Frank blood • Serous fluid • Serous fluid streaked • Xanthochromic fluid • Turbid fluid • Frank pus • Other

  24. Injection Technique • Equipment • Syringes • Needles • Corticosteroids • Local anesthetic • Dosage and volume

  25. Injection Technique • Technique • Tissues • Bursa and joint • Tendons and ligaments • Tendons with sheaths • Blood vessels • Aspirations

  26. Preparation Protocol • Prepare patient • Prepare equipment • Prepare site • Assemble equipment • Sterile technique

  27. Most Common Aspirations and Injections

  28. The Knee

  29. The Knee • Landmarks: • Medial patella – middle to superior portion • Insertion • 1 cm medial to anteromedial patella edge. Directed between posterior surface of patella and intercondylar femoral notch

  30. Knee Joint Lateral Medial Knee slightly flexed

  31. The Elbow

  32. The Elbow • Landmarks • Lateral epicondyle and radial head • With elbow extended – the depression is palpated • Insertion • 22-ga needle from lateral aspect just distal to lateral epicondyle and direct medially

  33. The Elbow Lateral Epicondylitis (Tennis Elbow) Symptoms: pain with elevation of third digit against resistance, with wrist and elbow held in extension Approach: Point of Max Tenderness

  34. The Elbow Olecranon Bursitis Diagnosis obvious Approach: 20-ga needle into dependent aspect of sac

  35. The Wrist De Quervain’s Synovitis Injection: The needle is placed into the first extensor compartment and directed proximally toward the radial styloid.

  36. Questions?

More Related