Joint Injections

1. Joint Injections UAB/Selma Family Medicine Fema B. Aquino, M.D.

2. Joint Injections Knee joint Shoulder joint Elbow joint Lumbar Puncture

3. Indications Therapeutic 1. Provide pain relief. 2.Deliver pharmacologic agents. Diagnostic Obtain fluid for analysis

4. Contraindications 1.Broken skin over injection site. 2. Overlying skin showing signs of cellulitis. 3. Patient known to have bacteremia. 4. Patient on blood thinner or has major clotting disorder. 5. Prosthetic joint.

5. Complications Caused by injection: 1. Bleeding (rare). 2. Infection (1 in 10,000) 3. Joint injury

6. Complications Caused by steroid agents: 1.Acceleration of septic joint. 2. Subcutaneous fat atrophy (<1%) 3.Steroid flare with pain 6 to 12 hr after injection (2% to 5%). 4. Osteoporosis 5. Cartilage damage 6. Tendon rupture (<1%). 7. Asymptomatic pericapsular calcification (43%)

7. Supplies,equipment and medications 1.Antiseptic solution. 2.Sterile gloves. 3.Local anesthetics. 4. Therapeutic medication. 5. Syringes and needles. 6. Bandages, compression dressing.

8. Warning to Patient Before Procedure 1% risk of infection Site could be more symptomatic for 24-48 hours following injection Tissue atrophy could occur with use of injection into the joint more than 3x/year If patient is diabetic, will need to watch fingersticks

9. Overview • Knee injection • Medial, lateral and two anterior approaches • Shoulder injection • Anterior, posterior approaches • Sub-acromial bursa. • Elbow injection - Lateral approach • Lumbar puncture -Lateral decubitus –Right, Left -Sitting position

10. Knee Joint- Anatomy

11. Technique of knee injection on supine position • Flex the knee to 15 degrees. • Can be done medially or laterally, but lateral approach is preferred. • Draw a line horizontally one fingerbreadth above the superior border of patella and a vertical line along the lateral border . • The point of intersection of these two lines is the entry point for the needle directed towards the center of the patella.

12. From Joint & Soft tissue Injection & Aspiration. James W. Mc Nabb, MD

13. Technique when knee is flexed • Can be approached either medially or laterally 1cm below the lower margin on either side of the patellar ligament directed towards the center of patella.

15. Shoulder joint • The distal, lateral, and posterior edges of the acromion are palpated. • Mark the lateral and posterior edge of acromion with an ink pen and having identified the posterior lateral corner drop a line from that point and mark a spot 2 cm below the postero-lateral corner . • This is the target site for the needle tip. • The needle is directed toward the opposite nipple.

16. From Joint & Soft tissue Injection & Aspiration. James W. Mc Nabb, MD

17. Shoulder Joint-Sub acromial approach:

18. Elbow joint • The elbow joint is injected from a lateral approach, thereby avoiding the ulnar nerve. • The patient should be in a supine position with the elbow flexed to 45 degrees and the hand in a neutral position resting on the patient's thigh • The needle is inserted into the soft tissue within the triangle directed to the opposite (medial) epicondyle.

19. Elbow Joint • Essential landmarks to palpate before performing this injection are the soft tissue at the center of the triangle formed by the lateral olecranon, the head of the radius, and the lateral epicondyle.

20. Lumbar Puncture Indications Diagnostic Infectious disease – Viral, Bacterial, Fungal Encephalitis Inflammatory process – MS,GBS Oncologic procedures Metabolic processes – Pyruvate, lactate, glucose, protein levels.

21. Therapeutic indications For lower body analgesia Anesthesia– Narcotics, Bupivacaine. Antibiotic administration in ventriculitis and meningitis - Vancomycin, Gentamicin. Chemotherapy –in some leukemias and lymphomas.

22. LP - Contraindications Increased intracranial pressure , cerebral herniation. Uncorrected bleeding disorder Soft tissue infection at puncture site Cardiopulmonary instability

23. LP - Positions • Lateral decubitus assuming a fetal position. • Sitting position.

24. LP PROCEDURE 1.After adequate preparation, draping and anesthesia, advance needle slowly through spinous ligaments aiming toward umbilicus. 2. Advance slowly about 2 cm or until a "pop'' is heard. Then withdraw the stylet in every 2- to 3-mm advance of the needle to check for CSF return. If the needle meets the bone or if blood is aspirated then withdraw to the skin and redirect the needle.

25. LP – CSF collection • 3-4 sterile tubes with 1 cc/tube • Tube #1: Gram stain and culture • Tube #2: CSF glucose, protein • Tube #3: CSF cell count and diff • Additional tubes: viral culture, fungal culture, cytology, special chemistries • If subarachnoid hemorrhage, 4 tubes – 1st and 4th for cell count.

26. LP – Complications Post spinal headache (36.5% within 48 hrs) Subarachnoid Epidermal cysts. Infection Cerebral herniation. Subdural or epidural hematoma.

27. Post injection care To minimize pain and inflammation - apply ice to the injection site (for no longer than 15 minutes at a time, once or twice per hour), and NSAIDs may be used, especially for the first 24 to 48 hours . No strenuous activity of the injected joint for few days because of the small possibility of local tissue tears secondary to temporarily high concentrations of steroid . Patients should be educated to look for signs of infection .

28. Questions?????