Upper Extremity Injections

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Upper ExtremityInjections
Wren V. McCallister, MD
Surgery of the Hand Upper Extremity
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Edmonds Orthopedic CenterEdmonds,
Washington425-673-3900
Jeffrey P. Remington, MD Brian D. Cameron,
MD James R. Alberts, MD Wren V. McCallister,
MD
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Upper Extremity Injections

• Trigger Finger
• Carpal Tunnel
• Thumb CMC joint
• DeQuervians tenosynovitis
• FCR tendonitis
• Radial tunnel
• Elbow Medial and lateral epicondylitis
• Shoulder Subacromial and glenohumeral

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Fundamentals of Injections

• Risks
• Nerve injury
• Superficial branch of radial nerve when injecting
  1st dorsal compartment (DeQuervains
  tenosynotivitis)
• Intraneural injection of median nerve (Carpal
  Tunnel syndrome)
• Skin depigmentation
• Fat atrophy
• Tendon rupture
• Repeated injections of flexor carpi radialis
  (FCR) tendon sheath

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Fundamentals of Injections

• What you inject
• For intra-articular injections, can use
  longer-acting, less soluble steroids
• For soft tissue injections, use shorter-acting,
  water soluble sodium dexamethasone
• Sodium dexamethasone has also been shown to be
  the least toxic in the event of intraneural
  injection
• In general, single injections are well tolerated.
  With multiple injections the risk of
  complications increases.

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Trigger finger

• Technique
• Sterile skin preparation
• 25g or smaller needle (use diabetic needle)
• Can anesthetize skin with cold spray or
  subcutaneously with 1 lidocaine
• Injection delivered near A1 pulley
• evidence shows that you do not need to inject the
  pulley/tendon sheath itself

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Trigger finger (continued)

• Injection solution
• 11 mixture 1 lidocaine without epinephrine and
  sodium dexamethasone (10mg/ml)
• Anticipate numbness
• in the digit after
• injection

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Carpal tunnel syndrome

• Technique
• Sterile skin preparation
• 25g or smaller needle (use diabetic needle)
• Can anesthetize skin with cold spray or
  subcutaneously with 1 lidocaine

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Carpal tunnel (continued)

• Injection delivered just ulnar to palmaris longus
  tendon
• To identify the palmaris longus tendon, ask the
  patient to oppose thumb to small finger and flex
  wrist

Depiction of test to identify palmaris
longus (please disregard needle placement)
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Carpal tunnel (continued)

• Injection delivered just ulnar to palmaris longus
• Asking patient to flex and extend fingers
• will produce needle movement confirms
• needle placement within carpal tunnel
• (flexor tendon bounce test)
• Ask patient to immediately inform you
• of any electrical shocks or sensations
• that would suggest intraneural needle
• placement
• Palpate distal edge of carpal tunnel with
• opposite index finger to confirm filling

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Carpal tunnel (continued)

• Injection solution
• 21 mixture 1 lidocaine without epinephrine and
• sodium dexamethasone (10mg/ml)
• Anticipate short duration of numbness in median
  nerve distribution

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Thumb CMC joint arthritis

• Technique
• Sterile skin preparation
• 25g or smaller needle (use diabetic needle)
• Can anesthetize skin with cold spray or
  subcutaneously with 1 lidocaine
• Injection delivered from dorsal approach into CMC
  joint
• Can be challenging to locate joint, especially if
  there are large osteophytes

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Thumb CMC joint (continued)

• Injection solution
• 11 mixture 1 lidocaine
• without epinephrine and
• sodium dexamethasone
• (10mg/ml)
• Injection is often painful as
• joint is small and distends
• rapidly

CMC joint
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DeQuervains tenosynovitis

• Technique
• Sterile skin preparation
• 25g or smaller needle (use diabetic needle)
• Can anesthetize skin with cold spray or
  subcutaneously with 1 lidocaine
• Injection delivered into 1st dorsal compartment
• Palpate compartment filling with injection
• Some advocate redirecting needle within
  compartment but cannot be sure that additional
  subcompartments are being entered. Balance
  against risk of injury to superficial branch of
  radial nerve

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DeQuervains (continued)

• Injection solution
• 21 mixture 1 lidocaine without epinephrine and
  sodium dexamethasone (10mg/ml)
• Risk of injury to superficial branch of the
  radial nerve (SRBN)
• Patient may have a short duration of numbness in
  SBRN distribution if anesthetic is not contained
  in 1st dorsal compartment

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Flexor carpi radialis (FCR) tendonitis

• Technique
• Sterile skin preparation
• 25g or smaller needle (use diabetic needle)
• Can anesthetize skin with cold spray or
  subcutaneously with 1 lidocaine
• Injection delivered directly into FCR tendon
  sheath
• Can palpate filling of the FCR tendon sheath (see
  Figure next slide)

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FCR tendonitis (continued)

• Injection solution
• 11 mixture 0.5ml 1 lidocaine without
  epinephrine and 0.5ml sodium dexamethasone
  (10mg/ml)
• Repeated
• injections risk
• tendon rupture

FCR?
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Radial Tunnel

• Coming soon

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Medial epicondylitis

• Coming soon

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Lateral epicondylitis

• Coming soon

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Acromioclavicular (AC) joint

• Coming soon

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Glenohumeral joint

• Coming soon

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www.AskEdmondsHand.com
Stevens Orthopedic Group
Wren V. McCallister, MD