120
Pearls in Injection Therapies for Musculoskeletal Disorders and Conditions Frank Caruso DMSc, PA-C, EMT-P Skin, Bones, Hearts & Private Parts 2019

Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

  • Upload
    others

  • View
    3

  • Download
    0

Embed Size (px)

Citation preview

Page 1: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Pearls in Injection Therapies for Musculoskeletal

Disorders and Conditions

Frank Caruso DMSc, PA-C, EMT-P

Skin, Bones, Hearts & Private Parts

2019

Page 2: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Educational Objectives

• Recognize signs, symptoms of musculoskeletal disorders that may require injection therapies– Using evidence-based medicine to decide when injection therapy

is indicated

• Understand what materials may be injected safely and where

• Learn the complications and precautions in providing injection therapies

• Understand how to perform a proper physical examination

• Review and reinforce proper technique for joint and soft tissue injections and aspirations

• Understand how to properly dispose and or analyze any aspirations performed to treat musculoskeletal conditions

Caruso 2

Page 3: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 3

Page 4: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Injection Therapy

Tools of the Trade!

Caruso 4

Page 5: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Injection Therapy

• Adjunctive therapy

• Short – intermediate pain/functional relief

• Describe indications and contraindications

• Select equipment/products for injection or

aspiration

Caruso 5

Page 6: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Injection:

• Illustrate pertinent anatomic

landmarks for each

procedure

• Demonstrate safe and

effective technique

• When to refer to a

subspecialist

Caruso 6

Page 7: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Injections/Aspirations

• Diagnostic

• Therapeutic treatment

Caruso 7

Page 8: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Therapeutic Injections

• Crystalloid arthropathies

• Synovitis

• Rheumatoid arthritis

• Osteoarthritis

Caruso 8

Page 9: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Soft Tissue Indications

• Bursitis

• Tendonitis/osis

• Epicondylitis

• Trigger Points

• Ganglion Cysts

• Neuromas

• Nerve entrapment syndromes

• Fasciitis

Caruso 9

Page 10: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

• Infected tissue/septic patients

• Critical weight bearing tendons

• Achilles tendon

• True allergy

• Uncooperative patient

• Lack of informed consent

• Prior severe steroid flare

• Joints with arthroplasty

Contraindications to Injection

Therapy

Caruso 10

Page 11: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Contra-Indications Injection

• Fracture site: can delay healing

• Children – injectable lesions that are not

due to systemic arthropathy are very rare

under the age of 18 years

• Reluctant patient – no informed consent

given

• Gut feeling!!

Caruso 11

Page 12: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Relative Contra-indications

• Stay away from arteries, nerves or pleural surfaces

• Brittle diabetes

• History of avascular necrosis

• Immunocompromised states

• Large tendinopathies: e.g. tendo-archilles, infra-patella tendon

• Psychogenic pain

Caruso 12

Page 13: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Safety

• Universal precautions

• Aseptic technique

• Know your landmarks

• Always attempt to aspirate

before injecting anything!

• Don’t inject tendons directly –

inject around the tendon

Caruso 13

Page 14: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Aseptic Technique

• Physical exam: mark injection site – check three times!!

• Clean injection site with appropriate cleanser and allow to dry

• Wash your hands/allow to dry

• Use pre-packed, in-date, sterile, disposable needles and syringes

• Use single-dose ampoules or vials, then discard

Caruso 14

Page 15: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Aseptic Technique

• Change needles after drawing up

• Place on gloves

• Do not touch the skin after marking and cleansing the site

• Do not guide the needle with your finger

• Always aspirate before injecting

• Wipe clean

• Sometimes massage the area

• Apply Band-Aid or pressure dressing

• Post injection instructions (especially diabetics)

Caruso 15

Page 16: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

What Does Tissue Types Feel

Like?

• Muscle : soft, spongy

• Tendon or ligament: fibrous and touch

• Capsule: slight resistance to needle as it

penetrates – poking a pin through a

balloon

• Cartilage: sticky

• Bone: hard and hurts when touched

Caruso 16

Page 17: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Complications: Steroid Injection• 1. Systemic

– Vasovagal, lidocaine allergy/toxocity, cardiac arrhythmias, seizures, facial flushing, increased blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired immune response, menstrual irregularity (usually post-menopausal), fall in ESR and CRP levels (see in patients with inflammatory arthritis), anaphylaxis

• 2. Local– Bleeding, post injection flare of pain, soft tissue

infection, ligament/tendon rupture, subcutaneous atrophy , depigmentation, soft-tissue calcification, steroid chalk or paste, steroid arthropathy, joint sepsis

Caruso 17

Page 18: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Rare Local Side Effects

• Nerve damage

• Transient paresis of an

extremity

• Needle fracture

• Delayed soft-tissue

healing

• Fat atrophy

Caruso 18

Page 19: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Corticosteroids

• Commonly used injectable corticosteroids are synthetic analogues of adrenal glucocorticoid hormone cortisol which is secreted by the adrenal cortex.

Caruso 19

Page 20: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Corticosteroids

• Suppressing inflammation

• Suppressing inflammatory flares in

degenerative joint disease

• Breaking up the inflammatory damage–

repair-damage cycle

• Possibly a direct chondro-protective effect

on cartilage metabolism

Caruso 20

Page 21: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Properties of Injectable

CorticosteroidsCorticosteroid Relative Anti-

inflammatory potency

Solubility Biological Half-life (hrs)

Hydrocortisone acetate

(Hydrocortone)

1 high 8-12

Triamcinolone

Acetonide (Kenalog)

5 intermediate 12-36

Triamcinolone

hexacetonide

(Artisospan)

5 intermediate 12-36

Methylprednisolone

acetate (Depo-Medrol)

5 intermediate 12-36

Betamethasone acetate

and sodium phosphate

(Celestone Soluspan)

25 low 26-54

Dexamethasone

acetate (Decadron-LA)

25 low 26-54

Caruso

21

Page 22: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Equivalent Dosages of Injectable

CortcosteroidsCorticosteroid Preparation Trade Name Equivalent dose/volume

(mg/ml)

Trimciolone acetonide Kenalog 40

Triamcinolone hexacetonide Aristospan 40

Methylprednisolone acetate Depomedrol 40

Dexamethasone acetate Decadron-LA 8

Betamethasone acetate and

sodium phosphate

Celestone Soluspan 6

Caruso 22

Page 23: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

InjectionSyringe

size

Needle

gauge

Needle

length

Anesthetic

(cc)

Knee 5-10 cc 22 1.5 in 3-5 cc

Subacromial bursa 10 cc 21-25 1.5 in 5 cc

Carpal tunnel 5 cc 21-25 1.5 in 2-3 cc

Greater trochanter bursa 5-10 cc 22-25 varies 4 cc

Lateral epicondylitis 5 cc 25 1 in 2-3 cc

1st MTP/CMC 3 cc 25-26 1 in 0.5-1 cc

de Quervain's 5 cc 25 1.5 in 1 cc

Caruso 23

Page 24: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Local Anesthetics

• Analgesic

• Diagnostic

• Dilution

• Distension

• Dispersion

Caruso 24

Page 25: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Commonly Used Local

Anesthesia

Agents

• Lidocaine

• Marcaine (avoid – except soft tissues)

• “Special Agents”

– ie: “the towel”

Caruso 25

Page 26: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Viscosupplementation

• Hyalauronan (sodium hyaluronate) is a natural complex sugar of the glycosaminoglycan family

• Concentration and size of endogenous hyalauronan are reduced in the joint fluid of patients with osteoarthritis

• Commercial replacement agents are high molecular weight derivative of hyalauronanwhich are synthetically derived from rooster combs or produced by bacterial fermentation and extraction

Caruso 26

Page 27: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Viscosupplementation

• Exact mechanism of action unknown

• Physical cushioning?

• Anti-inflammatory action?

• Stimulation of production of endogenous hyaluronan by synoviocytes

• Synvisc (Genzyme), Orthovisc (DepuyMitek), Hyalgan (Sanofi-Aventis), Supartz(Smith and Nephew), and Euflexa(Ferring)

Caruso 27

Page 28: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 28

Page 29: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

OK LET’S GET GOING!

So what can we do with a needle? Are you

scared yet?

Caruso 29

Page 30: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Aspiration

• Serous fluid streaked with fresh blood: related to trauma of the aspiration

• Frank blood: usually history of trauma –hemarthrosis of knee due to anterior cruciateligament injury occurs 40 % of the time.

Caruso 30

Page 31: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Aspiration

• Serous fluid of variable

viscosity: normal or

non-inflammatory

synovial fluid is

colorless or straw-

colored, contains few

cells (less than 500),

mainly mononuclear

Caruso 31

Page 32: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Aspiration

• Xanthochromic fluid: old blood that has broken down – appears orange in color –implies old trauma

• Turbid fluid: inflammatory fluid appears less viscous than normal joint flood –looks darker and more turbid due to the increase in debris, cells and fibrin, and clots may form – do not inject, await results of culture

Caruso 32

Page 33: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 33

Page 34: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 34

Page 35: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 35

Page 36: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 36

Page 37: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 37

Page 38: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 38

Page 39: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Aspiration

• Frank pus: aspirate

has a foul smell – true

emergency – appears

usually appear very ill

• Other: chemical

reactions, etc.

Caruso 39

Page 40: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 40

Page 41: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Injection Preparation Protocol

• Prepare patient – get

permission~!

• Prepare equipment

• Prepare site

• Assemble equipment

Caruso 41

Page 42: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

What Do You Do With The

Stuff Once You Aspirate??

When indicated culture, glucose, gram

stain, cell count, crystal analysis!

Caruso 42

Page 43: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Synovial Fluid Analysis

• String sign

• Cell count

• Glucose

• Gram stain

• Crystals

Caruso 43

Page 44: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Diagnosis Appearance WBCs Glucose %

blood level

Crystals Culture

Normal Clear <200 95+ None ---

DJD Clear <4000 95+ None ---

Traumatic

Arthritis

Straw, bloody,

xanthochromic

<4000 95+ None ---

Acute

Gout

Turbid 2000-

50,000

80-100 Needle

like

---

Pseudogo

ut

Turbid 2000-

50,000

80-100 Rhomboi

d like

---

Septic

Arthritis

Purulent/turbid 5000-

>50000

<50 None +

usually

Non-

traumatic

Arthritis

Turbid 2000-

50,000

75 None ---

Synovial Fluid Interpretation

Caruso 44

Page 45: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Lab Analysis of Fluid

• White blood cell count

– <50,000 inflammatory

– >50,000 infectious

• Polymorphonucleocyte percentage

• Crystals

• If fluid cloudy, culture

Caruso 45

Page 46: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Septic Arthritis

• Early diagnosis essential:

– Growth impairment

– Articular destruction

– Osteomyelitis

– Soft tissue expansion

Caruso 46

Page 47: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Injection Therapies: Problems

That May Arise

• An inappropriate drug is chosen

• Too large a dose or volume is given in the wrong area of the musculoskeletal system

• The drug is put into the wrong tissue

• Poor technique causes skin complications or possible tendon/nerve/none injuries

• Injections are given too frequently

• Folks don’t pay attention to what is causing the condition

• Little or no aftercare is provided

Caruso 47

Page 48: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Stuff You Need: Keep Your

Supplies Well Localized• A dedicated cabinet

• An injection tray

• An injection cart

• Plastic toolbox

Caruso 48

Page 49: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Items

• Gloves

• Blue Chuck Pads

• Alcohol pads

• Povidone-iodine pads

• Bandages

• Hemostat surgical clamp – for

those needle change outs!

Caruso 49

Page 50: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Items

• Syringes (3, 5, 10, 20 and 60cc)

• Needles (20 gauge, 1 inch – drawing up meds and aspiration of small joints), 18 gauge 1 ½ in for aspiration of large joints and bursa, 23 gauge ½, 1, and 1 ½ for injections)

• PainEase or Ethyl chloride

• Anesthetic of choice

• Steroid of choice

• Viscosupplementation of choice – always pre-authorize

Caruso 50

Page 51: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Ready?? Will focus on shoulder/knee today!

Caruso 51

Page 52: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Shoulder: Glenohumeral

Acute or Chronic Capsulitis

• Anatomy: shoulder joint

surrounded by large

capsule – easiest

approach is posterior.

• Coracoid process –

landmark

Caruso 52

Page 53: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired
Page 54: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

54

Page 55: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired
Page 56: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Glenohumeral Joint • Uncommon injection

• Difficult, especially with adhesive capsulitis

• Posterior approach usually preferred

• Landmark: lateral edge of acromion, coracoid process

Caruso 56

Page 57: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 57

Page 58: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 58

Page 59: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Shoulder

Sub-Acromial Bursa

• Landmark: lateral edge of

acromion or posterior

• Allow arm to “dangle”

along side

• Don’t inject if you have

tremendous resistance -

reposition

Caruso 59

Page 60: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 60

Page 61: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 61

Page 62: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 62

Page 63: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 63

Page 64: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Acromio-Clavicular joint

AC joint superficial

Be careful – common

place for skin atrophy

and hypopigmentation!

Caruso 64

Page 65: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 65

Page 66: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Shoulder

(Long Head of the Biceps)

• Anatomy: lies in a

sheath in the bicipital

groove between the

greater and lesser

tuberosities

Caruso 66

Page 67: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 67

Page 68: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Scapulothoracic Syndrome

• Anatomy: bursitis

medial superior

border of the

scapula

• Be careful of the

long thoracic nerve

Caruso68

Page 69: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 69

Page 70: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 70

Page 71: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Knee Joint

• Very common to aspirate and inject

• Anatomy: Suprapatellarapproach is probably the easiest (extra-articularbut still within the joint space.

• Easy to aspirate

• Supine positioning of the patient

Caruso 71

Page 72: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 72

Page 73: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 73

Page 74: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 74

Page 75: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 75

Page 76: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 76

Page 77: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 77

Page 78: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 78

Page 79: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 79

Page 80: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 80

Page 81: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 81

Page 82: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 82

Page 83: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 83

Page 84: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Knee

Pes Anseurine Bursa

• Anatomy: combined

tendon of insertion of

the sartorius, gracilis

and semi-tendinosus –

bursa lies under the

tendon

Caruso 84

Page 85: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Elbow

(Olecranon Bursitis)

• Anatomy:

olecranon bursa

• Aspiration (send

aspirate)

• Injection

• Side approach –

direct long axis

approach

Caruso 85

Page 86: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 86

Page 87: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Elbow:

Common Extensor Tendon

• Anatomy: lateral

epicondyle, find

maximum point of

tenderness –

adjacent to lateral

epicondyle.

Caruso 87

Page 88: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 88

Page 89: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 89

Page 90: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 90

Page 91: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 91

Page 92: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 92

Page 93: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Elbow

Medial Epicondylitis

• Anatomy: medial

epicondyle

• Be careful of ulnar

nerve – travels just

posterior and inferior

to the medial

epicondyle.

Caruso 93

Page 94: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 94

Page 95: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Hip

(Trochanteric Bursa)

• Anatomy:

bursa lies

over the

greater

trochanter of

the femur.

Caruso 95

Page 96: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired
Page 97: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 97

Page 98: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 98

Page 99: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Ankle Joint

Chronic Capsulitis

• Anatomy:

inflammation of

the joint

capsule

• Similar to

adhesive

capsulitis of the

shoulder

Caruso 99

Page 100: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 100

Page 101: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Toe Joints

Capsulitis• Anatomy: typically

around second toe,

sometimes third of

fourth –

• Abnormal foot

mechanics

• Pain ball of foot

(especially when

walking barefootCaruso 101

Page 102: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 102

Page 103: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Foot

Plantar Fasciitis

• Anatomy:

origin of the

plantar

aponeurosis at

the medial

tubercle of the

calcaneus

• Excessive foot

pronationCaruso 103

Page 104: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 104

Page 105: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Hallux Rigidus

• Common joint

first MTP,

osteoarthrits

and gout

• Inject directly

over the first

MTP

Caruso 105

Page 106: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 106

Page 107: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Foot

(Neuroma)

• Most common

between third

and fourth toes

• Anatomy:

inflammation of

interdigital

nerve by

compression

Caruso 107

Page 108: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 108

Page 109: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Wrist Joint

• Anatomy: wrist joint

capsule is not

continuous and has

septa dividing it into

separate

compartments

• Common injection in

patients with RA

Caruso 109

Page 110: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Thumb and Finger Joints

• Anatomy: The

first metacarpal

articulates with

the trapezium

• Rx: OA CMC

• Very painful

injection!

Caruso 110

Page 111: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Thumb Tendon

deQuervain’s tenosynovitis

• Anatomy:

abductor pollicis

longus and

extensor pollicis

brevis – run

together in a

single sheath of

the radial side of

the wrist.

Caruso 111

Page 112: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 112

Page 113: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Flexor Tendon Nodule

(Trigger Finger)

• Anatomy:

• nodule base of

finger (stenosing

tenosynovitis

• Nodule A-1

pulley of the

tendon sheath –

becomes

entrapped

Caruso 113

Page 114: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Caruso 114

Page 115: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Recommendations

• Consent for needle aspiration and or

injection – include possible risks,

complications and benefits

• Give patient aspiration and injection

aftercare handout

• Medical record documentation

Caruso 115

Page 116: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Billing and Coding

• 20526 -Injection, therapeutic, carpal tunnel

• 20550- Injection, single tendon sheath, or

ligament, aponeurosis (plantar fascia)

• 20551 – Injection –single tendon origin

/insertion

• 20552 – Injection, single or multiple trigger

point in one to two muscles

Caruso 116

Page 117: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

• 20553 Injection, trigger point in

three or more muscles

• 20600 – Arthrocentesis, aspiration,

and /or injection , small joint or

bursa

• 20605 – Arthrocentesis, aspiration

and /or injection intermediate joint

or bursa

• 20610 – Arthrocentesis, aspiration

and/or injection, major joint

Caruso 117

Page 118: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

• 20612 – Aspiration and/or injection

of ganglion cyst (s), any location

• 64450 – Injection, nerve block,

therapeutic, other peripheral nerve

or branch.

Caruso 118

Page 119: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

Resources:

• James W. McNabb: A Practical Guide to Joint

and Soft Tissue Injection and Aspiration –

Second Edition. Wolters, Kluwer.Lippincott

Williams and Wilkins 2010

• Stephanie Saunders; Steve Longworth:

injection Techniques in Orthopaedics and

Sports Medicine- Third Edition. Elsevier

2006

• Myriad of online sources

Caruso 119

Page 120: Pearls in Injection Therapies for Musculoskeletal ... · blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired

ANY QUESTIONS OR COMMENTS?

[email protected]

Thank you!

Caruso 120