Management Methods

Management Methods (81)

Children categories

Injection Procedures

Injection Procedures (81)

The injection procedures outlined in this chapter are appropriately used in conjunction with other aspects of rehabilitation to reduce pain and increase function. Sterile technique and knowledge of anatomic relationships are required. Aspiration is performed before injecting and is repeated as necessary throughout administration of medication to prevent intravascular injection. For optimal results and safety with injection techniques, the practitioner needs the necessary skill, training, and education to perform the procedures. Haste and failure to observe the necessary precautions by the practitioner increase the risks for any procedure. Knowledge of the anatomy pertaining to each injection procedure is a requirement for safe and successful outcomes in even the simplest injection. 

 

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Chủ nhật, 30 Tháng 3 2014 14:27

Retrocalcaneal Bursa Injection

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Indications

Retrocalcaneal bursa injection is a useful therapeutic procedure for bursitis secondary to repetitive overuse disorder or rheumatoid arthritis.

Techniques

After informed consent is obtained, the patient is situated in the side lying position. The lateral malleolus and the Achilles tendon are palpated. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. A 1½-in. (4-cm), 23- to 25-gauge needle is inserted between the lateral malleolus and the Achilles tendon perpendicular to the skin. The needle is advanced slowly to about half the thickness of the width of the Achilles tendon. After negative aspiration, a 2-mL mixture of 2 mg of triamcinolone acetonide (or equivalent) and local anesthetic is injected (Fig. 67-57).

FIGURE 67-57. Retrocalcaneal bursa injection. Approach for retrocalcaneal bursa aspiration and injection.

Comments

This disorder may be seen in runners as they increase mileage early in the season or from an improperly fitting running shoe.

Complications

Corticosteroids should not be injected if there is any suspicion that the bursa is infected. If the fluid appears infected, then it should be sent for culture and sensitivity and the patient treated appropriately for the infection.

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice

Indications

Subtalar joint injection is used to treat inflammation secondary to rheumatoid arthritis and other inflammatory arthritides.

Techniques

After informed consent is obtained, the patient is placed in the prone position with the feet extending over the end of the examination table and the foot flexed to about 90 degrees. The location of the subtalar joint, about 1 to 2 cm distal to the tip of the lateral malleolus and posterior to the sinus tarsus, should be palpated and marked. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. A 1½-in. (4-cm), 21-gauge needle is inserted perpendicular to the skin at the mark and advanced medially into the subtalar joint. Aspiration is attempted until the needle has entered the synovial space. If there is an effusion of the joint, the aspiration is completed. If the aspirated fluid is noninflammatory (clear and viscous), the joint should be injected with a 2-mL mixture of 10 mg of triamcinolone acetonide (or equivalent) and local anesthetic (Fig. 67-56).

FIGURE 67-56. Subtalar (talocalcaneal) joint injection. Approach for subtalar (talocalcaneal) joint aspiration and injection.

Comments

Injection of this joint is usually secondary to osteoarthritis resulting from trauma or from repetitive overuse injury such as from ballet dancing. Gout is not an indication for injecting this joint.

Complications

Corticosteroids should not be injected if there is any suspicion that the joint is infected. If the fluid appears infected, then it should be sent for culture and sensitivity and the patient treated appropriately for the infection.

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice
Thứ sáu, 28 Tháng 3 2014 08:23

Tibiotalar Joint Injection

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Indications

Tibiotalar joint injection is a useful therapeutic procedure with inflammation secondary to osteoarthritis, rheumatoid arthritis, or chronic pain from instability. Pain most often occurs with ankle extension and flexion with weight bearing.

Techniques

After informed consent is obtained, the patient is placed in the supine position with the leg extended and the ankle extended over the end of the examination table. The area just anterior to the medial malleolus at the articulation of the tibia and the talus should be palpated and marked. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. A 1½-in. (4-cm), 21-gauge needle is inserted at the mark perpendicular to the skin. The needle is advanced slightly laterally, penetrating the capsule of the joint. The needle is directed into the tibiotalar joint to a depth of about 2 to 3 cm. Aspiration is attempted until the needle has entered the synovial space. If there is an effusion of the joint, the aspiration is completed. After negative aspiration or if the aspirated fluid is noninflammatory (clear and viscous), the joint is injected with a 2-mL mixture of 10 mg of triamcinolone acetonide (or equivalent) and local anesthetic (Fig. 67-55).

FIGURE 67-55. Tibiotalar joint injection. Approach for tibiotalar joint aspiration and injection.

Comments

Injection of this joint is usually secondary to osteoarthritis resulting from trauma or from repetitive overuse injury such as from ballet dancing. If the swelling and tendonitis are around the lateral aspect of the joint, entry is accomplished just below the lateral malleolus. Gout is not an indication for injecting this joint.

Complications

Corticosteroids should not be injected if there is any suspicion that the joint is infected. If the fluid appears infected, then it should be sent for culture and sensitivity and the patient treated appropriately for the infection.

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice
Thứ năm, 27 Tháng 3 2014 20:16

Anserine Bursa Injection

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Indications

Anserine bursa injection is a useful diagnostic and therapeutic procedure in bursitis resulting from osteoarthritis or direct trauma. Pain is noted inferior to the anterior medial surface of the knee when climbing stairs. Pain is reproduced with the knee in flexion-extension while internally rotating the leg.

Techniques

After informed consent is obtained, the patient is placed in the supine position with the knee in extension. The knee is palpated for the point of maximal tenderness over the medial tibial flare. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. A 1½-in. (4-cm), 21-gauge needle is inserted perpendicular to the skin and at the point of maximal tenderness. The needle is advanced to the periosteum and withdrawn slightly. After negative aspiration, a 4-mL mixture of 2 mg of triamcinolone acetonide (or equivalent) and local anesthetic is injected (Fig. 67-54).

FIGURE 67-54. Anserine bursa injection. Approach for anserine bursa aspiration and injection.

Comments

The anserine bursa is one of the most common bursae to become inflamed in the lower extremity. Kneepads are recommended for athletes with anserine bursitis secondary to trauma.

Complications

Serious complications are uncommon with injection of the anserine bursa.

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice
Thứ tư, 26 Tháng 3 2014 02:14

Knee Joint Injection

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Indications

Intraarticular corticosteroid injection of the knee joint is used to treat noninfective inflammatory joint disease secondary to rheumatoid arthritis, seronegative spondyloarthritides, or the chondrocalcinosis inflammatory phase of osteoarthritis.

Techniques

After informed consent is obtained, the patient is placed in the sitting position with the knee flexed to 90 degrees. The patellar tendon is palpated and the middle of the patellar tendon is marked. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. A 1½-in. (4-cm), 21-gauge needle is inserted horizontally and advanced to the intercondylar notch. Aspiration is attempted until the needle has entered the synovial space. If there is an effusion of the joint, the aspiration is completed. After negative aspiration or if the aspirated fluid is noninflammatory (clear and viscous), the joint is injected with a 2-mL mixture of 10 mg of triamcinolone acetonide (or equivalent) and local anesthetic (Fig. 67-52).

FIGURE 67-52. Knee joint injection. Approach for knee joint aspiration and injection. Anterior approach.

Comments

An alternate approach may be used to access the suprapatellar pouch, which is continuous with the synovial space of the knee. The patient is placed in the supine position with the leg fully extended. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. Throughout the procedure, the patella should be grasped between the examiner’s thumb and forefinger and should be able to be moved from one side to another to ensure that the quadriceps muscle is relaxed. A 1½-in. (4-cm), 21-gauge needle is inserted horizontally into the suprapatellar pouch at a point lateral and posterior to the patella at the level of the cephalad edge. A small amount of pressure is placed on the patella, pushing it to the side of needle insertion. This improves the ability to direct the needle during advancement (Fig. 67-53). The patient should be advised to minimize walking activity for 24 hours after injection, to minimize dispersion of the corticosteroid from the joint. If fluid is exceptionally viscous, a 1½-in., 18-gauge needle may be required to aspirate the joint.

FIGURE 67-53. Knee joint injection. Medial approach to suprapatellar pouch for knee joint aspiration and injection. Note connection between suprapatellar pouch and main synovial cavity.

Complications

Corticosteroids should not be injected if there is any suspicion that the joint is infected. If the fluid appears infected, then it should be sent for culture and sensitivity and the patient treated appropriately for the infection. It is contraindicated to inject the joint in a person with hemophilia, unless the risk for intraarticular bleed has been minimized. Corticosteroid injection into the knee joint may impair epiphyseal growth in children, resulting in a significant leg-length discrepancy.

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice
Thứ ba, 25 Tháng 3 2014 08:14

Abductor Tendon Injection

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Indications

Injection of the abductor tendon is a useful diagnostic and therapeutic procedure for tendonitis at the insertion of the gluteal musculature into the greater trochanter.

Techniques

After informed consent is obtained, the patient is positioned lying on the side facing the clinician with the painful hip exposed. The hips and knees are flexed and the affected hip adducted. The hip is palpated above the tip of the trochanter to determine the point of maximal tenderness. A 3.5-in. (9-cm), 21-gauge needle is inserted at the point of maximal tenderness and directed toward the tip of the greater trochanter, approximating the insertion of the gluteal fasciae. The needle is advanced vertically to a depth that would reach the hip abductor tendon. This depth would vary from one patient to another, which is estimated by palpation of the hip abductor tendon. In obese patients, a lumbar puncture needle would have to be used to reach the tendon area. After negative aspiration, the area of maximal tenderness is injected with a 10-mL mixture of 10 mg of triamcinolone acetonide (or equivalent) and local anesthetic.

Comments

The injection is not placed into the tendon but rather into the peritendinous region. Wide infiltration with a corticosteroid and local anesthetic mixture is recommended. Tender points in the vicinity of the hip joint are often associated with osteoarthritis of the hip. Injection of these sites may provide significant pain relief.

Complications

Injecting directly into the tendon rather than into the peritendinous region may result in damage to the abductor tendon of the hip.

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice
Thứ ba, 25 Tháng 3 2014 08:11

Trochanteric Bursa Injection

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Indications

Trochanteric bursa injection is used to diagnose and treat bursitis of the hip. This often presents as pain in the lateral thigh during ambulation. Pain may be elicited by placing the hip in external rotation and abduction.

Techniques

After obtaining informed consent, the patient is positioned lying on the side and facing the clinician, with the painful hip exposed. The hips and knees are flexed and the affected hip adducted. The protuberance of greater trochanter on the lateral aspect of the thigh is palpated for the point of maximal tenderness. This is usually two fingerbreadths below the tip of the trochanter. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. A 3-in. (8-cm), 21-gauge needle is inserted perpendicular to the skin at the point of maximal tenderness. The needle is advanced with aspiration attempted until the needle has entered the synovial space. If there is an effusion of the joint, the aspiration is completed. If the aspirated fluid is noninflammatory (clear and viscous), the bursa should be injected with a 3-mL mixture of 20 mg of triamcinolone acetonide (or equivalent) and local anesthetic. If unable to enter the synovial space, the needle is advanced to the bone and then withdrawn 2 mm. After negative aspiration, a 3 mL mixture of 20 mg of triamcinolone acetonide (or equivalent) and local anesthetic is injected (Fig. 67-51).

FIGURE 67-51. Trochanteric bursa injection.

Comments

The clinician should consider other causes of pain if the problem persists after bursa injection and appropriate rehabilitation.

Complications

Corticosteroids should not be injected if there is any suspicion that the bursa is infected. If the fluid appears infected, it should be sent for culture and sensitivity and the patient treated appropriately for the infection.

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice
Thứ hai, 24 Tháng 3 2014 20:10

Hip Joint Injection

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Indications

Hip joint intraarticular injection is used to treat inflammation of the hip secondary to rheumatoid arthritis or osteoarthritis.

Techniques

After informed consent is obtained, the patient is placed in the supine position with the leg straight and externally rotated. A point is marked at 2 cm below the anterosuperior spine of the ilium and 3 cm laterally to the palpated femoral pulse at the level of the superior edge of the greater trochanter. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. A 3.5-in. (9-cm), 21-gauge needle is inserted at the mark in the posterior medial direction at an angle 60 degrees to the skin. The needle is advanced through the tough capsular ligaments to the bone and slightly withdrawn. Under fluoroscopy, contrast medium is injected to confirm appropriate needle placement. Aspiration is attempted until the needle has entered the synovial space. If there is an effusion of the joint, the aspiration is completed. After negative aspiration or if the aspirated fluid is noninflammatory (clear and viscous), the joint is injected with a 2- to 4-mL mixture of 20 mg triamcinolone acetonide (or equivalent) and local anesthetic (Fig. 67-50).

FIGURE 67-50. Hip joint injection. Approach for hip joint aspiration and injection. Lateral approach.

Comments

The hip joint is difficult to aspirate or inject due to the depth and limited landmarks. Fluoroscopic guidance with the use of contrast media is recommended. It is rare to aspirate fluid from this joint.

Complications

Avascular necrosis of the hip has been reported as a result of repeated intraarticular injection of corticosteroids. Hematoma and intravascular injection are possible, owing to the close proximity of the femoral vessels. If an arterial puncture occurs, prolonged direct pressure is usually adequate to prevent the development of a hematoma. Corticosteroids should not be injected if there is any suspicion that the joint is infected. If the fluid appears infected, it should be sent for culture and sensitivity and the patient treated appropriately for the infection.

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice
Chủ nhật, 23 Tháng 3 2014 08:09

Coccygeal Junction Injection

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Indication

Infiltration of the coccyx region can be useful as a therapeutic procedure in coccydynia after exclusion of infection or other significant pathology.

Techniques

After informed consent is obtained, the patient is positioned in the lateral Sims’ position with the left side down for right-handed clinicians. With the upper leg flexed, the buttocks are separated, allowing easy access to the sacrococcygeal junction. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. The area of tenderness is localized by palpating from the tip of the coccyx to the sacrococcygeal junction. The palpating hand is kept in position, and a 1½-in. (4-cm), 21-gauge needle is inserted at the point of maximal tenderness perpendicular to the skin. After negative aspiration, a 3-mL mixture of 20 mg of methylprednisolone acetate or equivalent and local anesthetic is injected into the tender area using a fan pattern (Fig. 67-49).

FIGURE 67-49. Coccygeal junction injection. Approach for coccygeal junction injection.

Comments

It is not necessary to advance the needle into the sacrococcygeal junction. Infiltration of the superficial tissue at the point of maximal tenderness is usually adequate.

Complications

Perianal numbness may be noted for 24 hours after injection. Serious complications are uncommon with appropriate needle placement.

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice
Thứ bảy, 22 Tháng 3 2014 14:08

Sacroiliac Joint Injection

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Indications

Sacroiliac joint injection is used to treat inflammation of the sacroiliac joints secondary to trauma, rheumatoid arthritis, degenerative joint disease, or stress secondary to mechanical changes in posture or gait.

Techniques

After informed consent is obtained, the patient is placed in the prone position. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. A 6-in. (16-cm), 22-gauge needle is inserted. The needle is advanced under fluoroscopy to the joint. After negative aspiration, joint penetration is confirmed with 1 mL of diatrizoate meglumine injection USP 60% (Renografin-60). After needle location is confirmed, a 1.5 to 2.0 mL (64) mixture of 40 mg of methylprednisolone acetate (or equivalent) and local anesthetic is injected (Fig. 67-48).

FIGURE 67-48. Sacroiliac joint injection. A: Fluoroscopic approach for right sacroiliac joint. B: Approach for sacroiliac joint injection.

Comments

The sacroiliac joint is difficult to aspirate, owing to the depth and bony structures. Fluoroscopic guidance with the use of contrast media is recommended. It is rare to aspirate fluid from this joint.

Complications

Serious complications are uncommon with appropriate needle placement.

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice
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