Common Injections for the Family Physician : General Principles and Specific Techniques

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Common Injections for the Family Physician
General Principles and Specific Techniques

• The
• Primary Care Sports Medicine
• Fellows

2
Indications

• Therapy
• remove tense effusions
• remove blood or pus
• therapeutic lavage
• injection of steroids or other intra-articular
  therapies

• Diagnosis
• synovial fluid analysis
• therapeutic trial
• imaging studies
• synovial biopsy

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Risks/Complications

• Infection one infection per 20,000 to 50,000
  injections.
• Tendon rupture
• Post-injection flare
• Atrophy/hypo-hyperpigmentation
• Cartilage degeneration
• Hyperglycemia
• Local trauma

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Contraindications

• Cellulitis or broken skin over needle entry site
• Anticoagulation or a coagulopathy
• Intra-articular fractures
• Septic effusion
• Lack of response to prior injections
• More than three prior injections in the last year
  to a weight bearing joint.
• Inaccessible joints joint prostheses.

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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.

6
Equipment

• Controversies
• sterile prep vs. alcohol prep
• sterile gloves vs. nonsterile
• 21 to 27 gauge needles for aspiration 18 to 20
  gauge for aspirations
• 1 to 10cc syringes for injections 3 to 50cc for
  aspirations
• ethyl chloride, 1 and 2 lidocaine, 0.5
  bupivicaine
• sponges, Band-Aids
• access to equipment for allergy/anaphylaxis

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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
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Corticosteroids

• Treats the local inflammatory response, not the
  clinical problem.
• Increased solubility shorter duration lower
  risk for post-injection steroid flare lower
  risk for local atrophy.

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Technique

• Patient
• Be prepared!
• Landmarks
• Aseptic vs. Sterile technique
• Local anesthesia
• Needle insertion
• Delivering the volume
• bolus vs. peppering

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Pain Relief and Injection Therapy
Corticosteroid
Anesthetic
Pain Threshold
48hrs
Time
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Specific Injections
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Shoulder
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Subacromial Space

• Indications
• relief of pain in subacromial impingement
  syndrome
• diagnostic to help r/o adhesive capsulitis or
  rotator cuff tear, or confirm RTC impingement

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Subacromial Space

• Clinical anatomy landmarks
• AC joint
• posterolateral recess between the humeral head
  and the acromion

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Subacromial Space

• Technique
• seated patient
• arm relaxed with other arm used for passive
  traction
• ethyl chloride or 1 lidocaine anesthesia
• inferior to posterolateral acromion
• needle bevel up oriented cephalad and directed
  toward the anterior acromion
• bolus insertion

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Subacromial Space

• Needle size and dosage
• 1 ml of corticosteroid (celestone soluspan or
  kenalog) with 50/50 mix of 6 to 9 ml of lidocaine
  and marcaine in a 10ml syringe.
• 18 gauge needles for medicine draw 21 gauge 11/2
  needle for injection

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Acromioclavicular Joint

• Indications
• acromioclavicular degenerative disease
• evaluation of acromioclavicular pathology as an
  etiology for shoulder pain

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Acromioclavicular Joint

• Clinical anatomy/landmarks
• lateral clavicle
• acromion
• appreciated by
  circumducting
  the shoulder

19
Acromioclavicular Joint

• Technique
• seated or supine position
• arm slightly adducted across the chest
• needle inserted directly inferiorly
• with resistance the needle should be redirected
• slight pressure may be encountered as this is a
  small joint

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Acromioclavicular Joint

• Needle size and dosage
• a 1/2 to 1 inch 25 gauge needle is appropriate
• .5ml of anesthetic 50/50 with .5ml of celestone
  is adequate
• Happy if .5 of it goes in.

21
Elbow
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Lateral Tennis Elbow

• Indications
• lateral tennis elbow that fails to improve with
  conservative therapy

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Lateral Tennis Elbow

• Clinical anatomy/landmarks
• radial head, appreciated by pronation/supination
• humeral lateral epicondyle
• extensor carpi radialis brevis

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Lateral Tennis Elbow

• Technique
• supine or seated
• elbow in 90 degrees of flexion and pronated
• area of maximal tenderness found usually
  1fingerbreadth distal and medial to the lateral
  epicondyle
• needle inserted into a triangular fatty recess
  near the common extensor origin

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Lateral Tennis Elbow

• Needle size and dosage
• 25 to 27 gauge 1 inch needle
• .5ml of celestone with 1ml of 1 or 0.5 lidocaine

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Medial Epicondylitis (Golfers Elbow)

• Indications
• Medial golfers elbow that fails to improve with
  conservative therapy

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Medial Epicondylitis (Golfers Elbow)

• Landmarks
• Medial Epicondyle
• Common flexor-pronator insertion

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Medial Epicondylitis (Golfers Elbow)

• Technique
• supine or seated
• elbow in 70 90 degrees of flexion supinated
• area of maximal tenderness found usually right
  on insertion of flex/sup tendons
• needle inserted onto bone, then withdrawn
  slightly
• Wagonwheel technique, but be careful of ulnar
  nerve

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Medial Epicondylitis (Golfers Elbow)

• Needle size and dosage
• 25 to 27 gauge 1 inch needle
• .5ml of celestone with 1ml of 1 or 0.5 lidocaine

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Hand
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DeQuervains Tenosynovitis

• Indications
• recalcitrant DeQuervains stenosing tenosynovitis
• diagnosis of radial wrist pain

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DeQuervains Tenosynovitis

• Clinical anatomy/landmarks
• anatomic snuff box bordered anteriorly by the
  first dorsal compartment (abductor pollicis
  longus and the extensor pollicis brevis tendons)
  and posteriorly by the extensor pollicis longus
• radial styloid

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DeQuervains Tenosynovitis

• Technique
• administered in the seated or supine position
• wrist in the vertical position, rested over a
  towel
• needle at a low angle of inclination, cephalad
  direction
• needle inserted 1/4 to 3/8 inch if needle moves
  with thumb flexion , back off the needle
• injection should fill the sheath like a balloon

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DeQuervains Tenosynovitis

• Needle size and dosage
• 25 to 27 gauge 1 inch needle
• .5ml of celestone with .5ml 1 or .0.5 lidocaine

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Carpal Tunnel Syndrome

• Indications
• carpal tunnel syndrome
  
  recalcitrant to conventional
  therapy

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Carpal Tunnel Syndrome

• Clinical anatomy landmarks
• palmaris longus tendon
• flexor carpi radialis tendons
• distal wrist crease
• median nerve

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Carpal Tunnel Syndrome

• Technique
• supine position or seated
• dorsum of hand should rest on a folded towel
• needle inserted just proximal to the distal wrist
  crease at a 45 degree angle just ulnar to the
  palmaris longus
• needle is felt to pop thru the dense carpal
  ligament

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Carpal Tunnel Syndrome

• Needle size and dosage
• 25 to 27 gauge 1 inch needle
• 1ml of celestone with 1ml of 1 or 0.5 lidocaine

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Trigger Finger

• Indications
• stenosing tenosynovitis

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Trigger Finger

• Clinical anatomy/landmarks
• flexor tendons
• metacarpal head
• flexor digitorum superficialis

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Trigger Finger

• Technique
• supine or seated position
• hand resting on a folded towel
• finger should be extended
• the needle is inserted just proximal to the MP
  joint oblique angle,parallel to the tendon
• resistance indicates tendon and the needle should
  be withdrawn

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Trigger Finger

• Needle size and dosage
• 25 to 27 gauge 1 inch needle
• .5ml of celestone with .5ml 1 or 0.5 lidocaine

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Hip
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Trochanteric Bursitis

• Indications
• recalcitrant trochanteric bursitis

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Trochanteric Bursitis

• Clinical anatomy
  landmarks
• greater trochanteric
  prominence
• iliac crest
• sciatic nerve

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Trochanteric Bursitis

• Technique
• patient in the lateral decubitus position
• point of maximal tenderness identified
• needle perpendicular to the skin
• depth of insertion 1/2 to 3 inches
• gentle peppering of the bursa

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Trochanteric Bursitis

• Needle size and dosage
• 22 to 25 gauge 11/2 inch needle
• 1ml of celestone with 5-7ml of 0.5 lidocaine

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Foot
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Plantar Fascia

• Indications
• recalcitrant plantar fasciitis
• diagnostic

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Plantar Fascia

• Clinical anatomy/landmarks
• medial calcaneal tubercle
• posterior tibial nerve
• plantar fascia

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Plantar Fascia

• Technique
• patient in the prone or supine position
• point of maximal tenderness identified
• on side of foot (where footprint begins) needle
  is inserted medial to lateral toward the point of
  tenderness
• avoid going thru the fat pad

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Plantar Fascia

• Needle size and dosage
• 25 to 27 gauge 1 inch needle
• 1ml of celestone with 1ml of 1 or 2 lidocaine

Avoid fat pad atrophy!! Inject here (on dorsal
surface of plantar fascia) NOT on plantar surface
(between fascia fat pad)
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Mortons Neuroma

• Indications
• Mortons neuroma refractory to conventional
  therapy
• Mortons neuroma is thought to be the result of
  perineural fibrosis of an interdigital nerve

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Mortons Neuroma

• Clinical anatomy/landmarks
• metatarsal heads
• common digital
  (interdigital nerves)

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Mortons Neuroma

• Technique
• the neuroma is typically between and slightly
  plantar to the metatarsal heads
• the patient should be supine with several pillows
  under the knee to insure the foot can be plantar
  flexed
• the needle is advanced dorsal to plantar,
  perpendicular to and thru the transverse tarsal
  ligament
• depth of insertion is approximately 1/2 inch

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Mortons Neuroma

• Needle size and dosage
• 25 to 27 gauge 1 inch needle
• .5ml of celestone with .5ml of 1 or 0.5 lidocaine

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Conclusion

• Injections, when done properly and with the right
  indications, are a tremendous asset to the
  practice of the family physician.