Steroid Joint Steroid Joint injectionsinjections

Updated 2010Updated 2010

Why inject joints?Why inject joints?

►Can be joint or soft tissue i.e. articular Can be joint or soft tissue i.e. articular or periarticularor periarticular

►Low risk e.g. septic arthritis occurs 1 in Low risk e.g. septic arthritis occurs 1 in 40,00040,000

►Provide good symptom reliefProvide good symptom relief

Basic principles before you Basic principles before you startstart

► History and examinationHistory and examination► Try conservative treatment first e.g. physio, Try conservative treatment first e.g. physio,

NSAIDs, orthotics and continue after joint NSAIDs, orthotics and continue after joint injection.injection.

► Careful patient selectionCareful patient selection► Consent & provide ARCUK PILeafletConsent & provide ARCUK PILeaflet► Know your anatomy!Know your anatomy!► Undertake as few injections as possible to Undertake as few injections as possible to

settle the problem, max 3-4 monthly (no settle the problem, max 3-4 monthly (no more than 3 for tennis elbow per lifetime)more than 3 for tennis elbow per lifetime)

Indications for injectionIndications for injection

►Osteoarthritis Osteoarthritis ►Rheumatoid arthritisRheumatoid arthritis►Gouty arthritisGouty arthritis►SynovitisSynovitis►BursitisBursitis►Tendonitis Tendonitis ►Muscle trigger points Muscle trigger points ►Carpal tunnel syndromeCarpal tunnel syndrome

Inject with cautionInject with caution

Reducing the risk of infectionReducing the risk of infection► Never inject an infected joint.Never inject an infected joint.► Avoiding injecting through infected skin or psoriatic plaques.Avoiding injecting through infected skin or psoriatic plaques.► Avoid injecting adjacent to infected skin/skin ulcers.Avoid injecting adjacent to infected skin/skin ulcers.► Avoid injecting patient on concurrent oral steroids.Avoid injecting patient on concurrent oral steroids.► Mediswabs or iodine should be used with a no touch or aseptic Mediswabs or iodine should be used with a no touch or aseptic

technique.technique.Reducing the risk of bleedingReducing the risk of bleeding► If injecting weight bearing joints advise rest for 24 hours post If injecting weight bearing joints advise rest for 24 hours post

injection.injection.► Don’t inject patients on warfarinDon’t inject patients on warfarinReducing the risk of tendon ruptureReducing the risk of tendon rupture► Don’t inject near the Achilles tendon.Don’t inject near the Achilles tendon.► Don’t inject into tendons.Don’t inject into tendons.

Contraindication to Contraindication to injectioninjection

► Adjacent osteomyelitis or skin infection Adjacent osteomyelitis or skin infection ► Bacteraemia Bacteraemia ► Hemarthrosis Hemarthrosis ► Impending (scheduled within 3 months) joint Impending (scheduled within 3 months) joint

replacement surgery replacement surgery ► Septic arthritis Septic arthritis ► Joint prosthesis Joint prosthesis ► Osteochondral fracture Osteochondral fracture ► Periarticular cellulitis / severe dermatitis/ soft tissue Periarticular cellulitis / severe dermatitis/ soft tissue

infectioninfection► Plaque psoriasis at the injection pointPlaque psoriasis at the injection point► Poorly controlled diabetes mellitus Poorly controlled diabetes mellitus ► Uncontrolled bleeding disorder or coagulopathy Uncontrolled bleeding disorder or coagulopathy

TechniqueTechnique

► Complete the consent form and provide a Complete the consent form and provide a Patient Information Leaflet prior to the Patient Information Leaflet prior to the procedureprocedure

► Inject the corticosteroid with as little pain Inject the corticosteroid with as little pain and as few complications as possible.and as few complications as possible.

► Do not attempt any injections in the vicinity Do not attempt any injections in the vicinity of known nerve or arterial landmarks of known nerve or arterial landmarks

►e.g. lateral epicondyle of elbow ok, medial – e.g. lateral epicondyle of elbow ok, medial – beware ulnar nervebeware ulnar nerve

► Never inject into the substance of a tendonNever inject into the substance of a tendon► Sterile techniqueSterile technique

Technique 2Technique 2

►ANTICIPATION!ANTICIPATION! Get your kit ready ie:Get your kit ready ie:

Needles, syringes, sterile container, LA, Needles, syringes, sterile container, LA, steroid, gloves, drapes, chlorhexidine, cotton steroid, gloves, drapes, chlorhexidine, cotton wool, plaster.wool, plaster.

►1 or 2 needle technique (green to 1 or 2 needle technique (green to draw up and blue to give)draw up and blue to give)

►Clean area – ensure solution has Clean area – ensure solution has DRIED (esp iodine) prior to injectingDRIED (esp iodine) prior to injecting

Technique 3Technique 3

►Always withdraw syringe back first to Always withdraw syringe back first to ensure not injecting into blood vessel ensure not injecting into blood vessel

► Decide if you want to use lidocaine Decide if you want to use lidocaine with the depomedronewith the depomedrone

►Use a different needle to draw up Use a different needle to draw up (green) to the one you use to inject (green) to the one you use to inject (blue or orange).(blue or orange).

What doses of depo-What doses of depo-medrone should you use?medrone should you use?

►Troc BursitisTroc Bursitis 40-80mg40-80mg►KneeKnee 40-80mg40-80mg►ShoulderShoulder40mg40mg►Tennis elbow Tennis elbow 10-20 mg 9using a 10-20 mg 9using a

‘peppering’ technique‘peppering’ technique►+/- Lidocaine when injecting the +/- Lidocaine when injecting the

shoulder or kneeshoulder or knee

What to warn the patientWhat to warn the patient

►Pain returns after 2 hours, when the Pain returns after 2 hours, when the local anaesthetic wears off – may be local anaesthetic wears off – may be worse than before.worse than before.

► If pain is severe or increasing after If pain is severe or increasing after 48hrs, seek advice48hrs, seek advice

►Warn of local side effectsWarn of local side effects►Advise to seek help if systemic s/es Advise to seek help if systemic s/es

developdevelop

Local side effectsLocal side effects

► Infection, subcutaneous atrophy, skin Infection, subcutaneous atrophy, skin depigmentation, and tendon rupture (<1%). depigmentation, and tendon rupture (<1%).

► Post-injection ‘flare’ in 2-5%Post-injection ‘flare’ in 2-5%► Often are the result of poor technique, too Often are the result of poor technique, too

large a dose, too frequent a dose, or failure large a dose, too frequent a dose, or failure to mix and dissolve the medications to mix and dissolve the medications properly.properly.

► NB corticosteroid short duration of action – NB corticosteroid short duration of action – can be as short as 2-3 weeks relief.can be as short as 2-3 weeks relief.

Knee injectionsKnee injections

► Patient on the couch, Patient on the couch, knee slightly bentknee slightly bent

► Palpate superior-Palpate superior-lateral aspect of lateral aspect of patellapatella

► Mark 1 fingerbreadth Mark 1 fingerbreadth above + lateral to above + lateral to this sitethis site

► CleanClean► LA, corticosteroidLA, corticosteroid► Clean + bandageClean + bandage

Plantar fasciitisPlantar fasciitis

► Procedure painful + Procedure painful + no evidence for long-no evidence for long-term benefitterm benefit

► Pt indicate tender Pt indicate tender spotspot

► Approach from Approach from thinner skin + direct thinner skin + direct posterior-laterallyposterior-laterally

► Small blelbs as near Small blelbs as near to bony insertion as to bony insertion as possiblepossible

► Do not inject fascia Do not inject fascia itselfitself

Shoulder injectionShoulder injection

•Glenohumeral joint •AC joint•Subacromial space•Long Head of Biceps

•Older patients: 2-3 x/ year•Younger – consider surgery if no improvement (risk rotator cuff rupture)

Glenohumeral joint Glenohumeral joint injectioninjection

1.1. Pt sits, arm by side, Pt sits, arm by side, externally rotatedexternally rotated

2.2. Find sulcus between Find sulcus between head of humerus and head of humerus and acromion acromion

3.3. Posterolateral corner of Posterolateral corner of acromion (2-3 cm acromion (2-3 cm inferior) inferior)

4.4. Direct needle anteriorly Direct needle anteriorly toward coracoid process toward coracoid process

5.5. Insert needle to full Insert needle to full length length

6.6. Fluid should flow easily Fluid should flow easily

AC joint injectionAC joint injection

1.1. Palpate clavicle to Palpate clavicle to distal aspect distal aspect

2.2. Slight depression Slight depression where clavicle meets where clavicle meets acromion acromion

3.3. Insert needle from Insert needle from anterior and superior anterior and superior approach approach

4.4. Direct needle Direct needle inferiorly inferiorly

Sub-acromial joint injectionSub-acromial joint injection

1.1. Posterior and lateral Posterior and lateral aspect of shoulder aspect of shoulder

2.2. Inferior to lower edge Inferior to lower edge of posterolateral of posterolateral acromion acromion

3.3. Insert inferior to Insert inferior to acromion at lateral acromion at lateral shoulder shoulder

4.4. Direct needle toward Direct needle toward opposite nipple opposite nipple

5.5. Insert needle to full Insert needle to full length length

6.6. Fluid should flow easily Fluid should flow easily

Elbow epicondyle injectionElbow epicondyle injection

►Very effective in short term – 92%Very effective in short term – 92%►Benefits do not normally persist Benefits do not normally persist

beyond 6 weeksbeyond 6 weeks►Lateral (tennis elbow) + medial Lateral (tennis elbow) + medial

(golfer’s elbow) epicondylitis(golfer’s elbow) epicondylitis►Patient supinePatient supine

Tennis elbow (lateral)Tennis elbow (lateral)

1.1. Arm adducted at side Arm adducted at side 2.2. Elbow flexed to 45 Elbow flexed to 45

degrees degrees 3.3. Wrist pronated Wrist pronated 4.4. Insert needle Insert needle

perpendicular to skin perpendicular to skin at point of maximal at point of maximal tenderness tenderness

5.5. Insert to bone, then Insert to bone, then withdraw 1-2 mm withdraw 1-2 mm

6.6. Inject corticosteroid Inject corticosteroid solution slowlysolution slowly

Golfer’s elbow (medial)Golfer’s elbow (medial)

1.1. Beware ulnar nerve!Beware ulnar nerve!2.2. Rest arm in Rest arm in

comfortable abducted comfortable abducted position position

3.3. Elbow flexed to 45 Elbow flexed to 45 degrees degrees

4.4. Wrist supinated Wrist supinated 5.5. Point of maximal Point of maximal

tenderness - insert to tenderness - insert to bone, then withdraw bone, then withdraw 1-2 mm 1-2 mm

6.6. Inject corticosteroid Inject corticosteroid solution slowly solution slowly

                                                                                                                        

                                        

De Quervain’s tenosynovitisDe Quervain’s tenosynovitis

► Inflammation of thumb extensor Inflammation of thumb extensor tendons tendons

-Extensor pollicis brevis -Extensor pollicis brevis

-Abductor pollicis longus -Abductor pollicis longus ► Occurs where tendons cross radial Occurs where tendons cross radial

styloid styloid

De Quervain’s De Quervain’s tenosynovitistenosynovitis

1.1. Maximally abduct thumb Maximally abduct thumb (accentuates abductor (accentuates abductor tendon) Injection site tendon) Injection site

2.2. Snuffbox at base of Snuffbox at base of thumb thumb

3.3. Aim 30-45 degrees Aim 30-45 degrees proximally toward radial proximally toward radial styloid styloid

4.4. Insert needle between Insert needle between the 2 tendons (not in the 2 tendons (not in tendon) tendon)

5.5. Do not inject if Do not inject if paraesthesias (sensory paraesthesias (sensory branch radial nerve)branch radial nerve)