Joint Injections in Primary Care

1. Joint Injections in Primary Care • Marc A. Aiken, MD • Watauga Orthopaedics

2. Objectives • Understand when it is appropriate to inject /aspirate a joint • Review common injection medications • review pertinent anatomy for safe injection technique • Review technique for injections in most common joints • When to refer

3. The Most Common Joints Injected • Knee • Shoulder (glenohumeral jt.) • Shoulder (subacromial bursa)

4. Indications - Diagnostic • Evaluate fluid aspirate for: • Infection • Inflammatory arthropathy • Trauma • Relief of pain immediately following injection indicates an intraarticular source

5. Indications - Therapeutic • Relief of pain/inflammation caused by: • Effusion • OA, RA, Gout • Bursitis • Selected tendonopathies

6. Absolute Contraindications • Local cellulitis • Prosthetic joint • Septicemia • Acute fracture • Patella and achilles tendonopathy • Allergy to injection medications

7. Relative Contraindications • Anticoagulated/coagulopathic patient • Diabetes • Immunocompromised patient • Minimal or no relief with 2 prior injections • Local osteoporosis • Inaccessible joints

8. Medications • Corticosteroid • Local anesthetic • Hyaluronic acid

9. Steroid • Betamethasone (Celestone Soluspan) • Agent of choice in my practice • Long acting • 6-12mg for large joint (knee, shoulder) • 1.5-6mg for small/intermediate joints

10. Other Steroids • Triamcinolone (Aristospan) • Dexamethasone (Decadron) • Methylprednisolone (Depo-Medrol)

11. Local • 1% Lidocaine (Xylocaine) without epi • useful for intraarticular injection and subcutaneous injection when aspirating • onset within minutes • can be diagnostic tool

12. Local • Bupivicaine (Marcaine) • Potential cause of chondrocyte death • Avoid intraarticular use

13. Hyaluronic Acid • “Lube job” for the knee • Replaces HA deficient arthritic knee fluid with thick viscous HA. • Expect 6 months of relief • Given in 3 injections 1 week apart • Relief may not be obtained for up to 8wks following last injection.

14. Adverse Reactions/Complications • 2-5% - Post injection (steroid) flare • 0.8% - Steroid arthropathy (AVN, Chondrolysis, etc.) • Iatrogenic infection • Flushing • Skin atrophy and depigmentation

15. Adverse Reactions/Complications • Loss of glucose control in DM • Increased appetite • Insomnia • Irritability

16. General Considerations • Evaluate the patient • Patient education • Consent • Patient Comfort • Sterile preparation and technique • Documentation

17. Evaluate the Patient!! • Avoid the “Knee hurt....me inject” mentality. • Get a complete history • Examine the patient including other joints • Obtain x-rays • MRI only if appropriate

18. Patient Education • What medications are being used • What is the injection expected to do for them • What it is not expected to do • When they will notice effects of injection • What if the expected results are not achieved

19. Consent • Written Vs. Verbal • Your choice

20. Patient Comfort • Lying down for knees (superolateral approach) • Sitting up for shoulders • Take your time • Use ethyl chloride (cold spray) immediately before injection • Explain the steps of the procedure as you do them

21. Patient Comfort • In patients with severe anxiety regarding needles, provide alternatives or allow them to schedule the injection on a different date. This may allow them time to mentally prepare for the injection. • Injections are usually far less painful than patient anticipate

22. Sterile Prep/Technique • Make sure injection site is fully exposed • Should not be visibly soiled • Use iodine or chlorhexidine prep over site to be injected • Alway use aseptic technique • Consider use of sterile gloves • Sterile drapes generally unnecessary

23. Documentation • Document the history and physical exam findings that support the decision to perform aspiration/injection • Site (which joint and which side) • Anatomic placement (med, lat, ant etc) • medications and doses injected • Expiration dates and lot numbers

24. Document • Amount of fluid aspirated • color, clarity and viscosity of fluid • purulent? • Blood? (trauma) • Lipid?(trauma/occult fx)

25. Send Fluid for Analysis • Labs ordered from fluid: • Cell Counts (stat if infection suspected) • Cultures • Gram stain (stat) • Polarized light microscopy

26. Post Injection Care • Remove visible prep solution • Bandaid • Pressure dressing on free bleeders • Rest and Ice for 24 hours • Warn about limitation of local anesthetic • Warn about steroid flare

27. Injection Technique • Intraarticular knee • Intraarticular Shoulder • Subacromial bursa

28. Supplies

29. Knee Aspiration/Injection • Superolateral approach most reliable • 93% accuracy vs. 71-75% with bent knee anteromedial/anterolateral approach

31. Superolateral Approach • Patient Supine with knee extended • Palpate bony landmarks • Patella • Lateral Femur

32. Palpate Patella

34. X Marks the Spot • Palpate lateral border of patella and Lateral femur at the PF joint • The space between these bony structures is your injection site

35. The Injection • Reassure patient • Relaxed quads = more space at PF jt • Needle Trajectory • 15-20 degrees • Toward trochlea of femur

36. Needle Trajectory

37. Anterior Approach (bent knee)

38. Anterior Approach • Less reliable/accurate than superolateral approach • Can be easier in the obese knee • Patient sitting with knee bent to 90 degrees

39. Anterior Approach • Palpate landmarks • Inferior pole of patella • Patella tendon • Tibial Plateau

40. Landmarks - Patella

41. Landmarks - Plateau

42. Landmarks

43. Injection Site • May inject medial or lateral to patella tendon • 1cm above tibial plateau or • Half the distance from plateau to inferior pole of patella • Trajectory of needle should be toward intercondylar notch

44. Trajectory

45. Shoulder (GH joint) • Anterior approach • Position patient sitting facing provider • Palpate bony landmarks • Clavicle • Coracoid

46. Landmarks

47. Palpate - Clavicle

48. Clavicle

49. Coracoid