Management Methods

Management Methods (81)

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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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Thứ hai, 17 Tháng 3 2014 20:55

Wrist Joint Injection

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Indications

Wrist joint injection is a useful diagnostic and therapeutic procedure for inflammation due to rheumatoid arthritis and other inflammatory arthritides.

Techniques

After informed consent is obtained, the patient is placed in the sitting position with the arm resting on the examination table. The hand is placed palm down with the wrist positioned over a rolled towel. The wrist joint is approached from the dorsal aspect. 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-gauge needle is inserted between the distal radius and ulna on the ulnar side of the extensor pollicis longus tendon. The needle is gently manipulated into the joint cavity to a depth of about 1 to 2 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- to 3-mL mixture of 10 mg of triamcinolone acetonide (or equivalent) and local anesthetic (Fig. 67-43).

FIGURE 67-43. Wrist joint injection. Approach for wrist joint aspiration and injection.

Comments

Many of the synovial joints of the wrists are interconnected. No significant resistance should be encountered. If resistance is encountered, the needle may not be in the joint cavity. Scapholunate dislocation, carpal instability, avascular necrosis, or other etiology of chronic conditions should be considered before injection. Elastic bandage or splint immobilization for 24 hours after injection may decrease discomfort.

Complications

Intraneural injection may result in nerve damage. Hematoma and intravascular injection are possible due to the close proximity of the 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, 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
Chủ nhật, 16 Tháng 3 2014 14:43

Carpal Tunnel Injection

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Indications

Injection of the carpal tunnel is used to treat inflammation of the tissue of the tunnel resulting in median nerve entrapment.

Techniques

After informed consent is obtained, the patient is placed in the sitting position with the arm resting on the examination table. The wrist is positioned with the hand dorsiflexed over a towel. The injection site is on the volar wrist surface just proximal to the distal wrist crease between the palmaris longus and flexor carpi radialis tendons. 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 directed distally at an angle of 60 degrees to the skin and gently manipulated through the flexor retinaculum ligament into the carpal tunnel. The tunnel is about 1 to 2 cm from the skin in this position. After negative aspiration, the carpal tunnel is injected with a 1-mL mixture of 10 mg of triamcinolone acetonide acetate (or equivalent) and local anesthetic (Fig. 67-42).

FIGURE 67-42. Carpal tunnel injection. Approach for carpal tunnel aspiration and injection.

Comments

Anesthesia in the distribution of the median nerve verifies injection into the carpal tunnel. These paresthesias may last for 1 to 2 weeks.

Complications

The median nerve should not be injected. The patient will normally report a sharp, electrical sensation when the needle tip is against the median nerve, and excruciating pain if the needle tip pierces the median nerve. If either of the above occurs, withdraw slightly and continue the procedure. The volume injected into the carpal tunnel should be kept to a minimum to reduce postinjection discomfort.

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice

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Indications

Radiohumeral joint injection is used to diagnose and treat the painful and swollen elbow due to rheumatoid arthritis or nonspecific inflammatory arthritides.

Techniques

After informed consent is obtained, the patient is placed in the sitting position with the elbow flexed to 90 degrees. The lateral epicondyle and posterior olecranon 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), 21- to 23-gauge needle is inserted into the groove just above and lateral to the olecranon process, just below the lateral humeral epicondyle, and posterior to the head of the radius. The needle is gently manipulated into the joint. 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 5-mL mixture of 10 mg of triamcinolone acetonide (or equivalent) and local anesthetic (Fig. 67-41).

FIGURE 67-41. Radiohumeral joint injection. Approach for radiohumeral joint aspiration and injection.

Comments

The connective tissue surrounding the elbow joint should be evaluated as a possible source of pain before injection of the radiohumeral joint.

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

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Indications

Olecranon bursa injection is a useful diagnostic and therapeutic procedure for olecranon bursitis. This condition is usually secondary to trauma or rheumatoid arthritis.

Techniques

After informed consent is obtained, the patient is placed in the sitting position with the hand on the lap. The olecranon process of the ulna is palpated for swollen bursa. The point of maximum swelling 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 at the most prominent part of the olecranon bursa. Aspiration is attempted until the needle has entered the synovial space. If there is an effusion of the bursa, the aspiration is completed. After negative aspiration or if the aspirated fluid is noninflammatory (clear and viscous), the bursa is injected with a 3-mL mixture of 10 mg of triamcinolone acetonide (or equivalent) and local anesthetic (Fig. 67-40).

FIGURE 67-40. Olecranon injection. Approach for olecranon aspiration and injection.

Comments

This procedure may require an 18-gauge needle to aspirate the bursa with highly viscous fluid.

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

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Indications

Medial epicondyle injection is a useful diagnostic and therapeutic procedure for medial epicondylitis (golfer’s elbow or tortilla elbow).

Techniques

After informed consent is obtained, the patient is placed in the sitting position, with the arm resting on the examination table, palm up, and the elbow flexed to 45 degrees. The elbow is palpated at the junction of the forearm extensor group at its attachment to the bone at the lateral epicondyle to determine the point of maximal tenderness. 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-gauge needle is inserted at the point of maximal tenderness. After negative aspiration, a 5-mL mixture of 10 mg of triamcinolone acetonide acetate (or equivalent) and anesthetic agent is injected at the point of maximal tenderness.

Comments

The point of maximal tenderness is usually just lateral and distal to the medial epicondyle over the common tendon of the forearm flexor group at its attachment to the bone.

Complications

Avoid injecting the ulnar nerve in the groove just behind the medial epicondyle.

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice

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Indications

Lateral epicondyle injection is a useful diagnostic and therapeutic procedure for lateral epicondylitis of the elbow (tennis elbow). The condition is usually secondary to occupational or sports-related trauma or recurrent trauma.

Techniques

After informed consent is obtained, the patient is placed in the sitting position, with the arm resting on the examination table, palm down, and the elbow flexed to 45 degrees. The elbow is palpated at the junction of the forearm extensor group at its attachment to the bone near the lateral epicondyle to determine the point of maximal tenderness. 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-gauge needle is inserted at the point of maximal tenderness. After negative aspiration, a 5-mL mixture of 10 mg of triamcinolone acetonide acetate (or equivalent) and anesthetic agent is injected at the point of maximal tenderness (Fig. 67-39).

FIGURE 67-39. Lateral epicondyle injection. Approach for lateral epicondyle aspiration and injection.

Comments

The point of maximal tenderness is usually just medial and distal to the lateral epicondyle over the common tendon of the forearm extensor group at its attachment to the bone.

Complications

Serious complications are uncommon with injection of the lateral epicondyle of the elbow.

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice
Thứ năm, 13 Tháng 3 2014 22:13

Bicipital Tendon Injection

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Indications

Peritendinous injection of the bicipital tendon is a useful diagnostic and therapeutic procedure for bicipital tenosynovitis.

Techniques

After informed consent is obtained, the patient is placed in the seated position with the arm externally rotated and lateral to the medial edge of the humeral head. The bicipital groove is located and the bicipital tendon palpated to determine the area of marked tenderness. 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- to 23-gauge needle is inserted along the border of the bicipital tendon. A 6-mL mixture of 20 mg of triamcinolone acetonide (or equivalent) and anesthetic agent is injected 2 mL at a time at the point of maximal tenderness and 1 in. above and below this point along the border of the bicipital tendon sheath (Fig. 67-38).

FIGURE 67-38. Bicipital peritendonous injection. Approach for bicipital peritendonous aspiration and injection.

Comments

There should be no significant resistance encountered when injecting the tenosynovium. Resistance suggests that the tip of the needle is within the body of the tendon. Steroid injection into the tendon should be avoided.

Complications

Injecting directly into the tendon rather than into the peritendinous region may result in damage to the bicipital tendon.

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice

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Indications

Corticosteroid injection procedures are used to diagnose and treat rotator cuff tendonitis or subacromial bursitis. These conditions are often due to nonspecific irritation of the subacromial bursa, lesions of the rotator cuff, calcific tendonitis, or rheumatoid arthritis.

Techniques

After informed consent is obtained, the patient is placed in a sitting position with the arm in the lap. The lateral aspect of the shoulder is palpated for the point of maximal tenderness, usually 1 to 2 cm inferiorly and 1 to 2 cm anteriorly to the angle of the acromion. 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 below the acromion at the point of maximal tenderness. The needle is gently manipulated under the acromion. Aspiration is attempted until the needle has entered the synovial space. The subacromial bursa is about 1 to 2 cm below the skin between the tip of the acromion process and the head of the humerus. If there is an effusion of the bursa, the aspiration should be completed. After negative aspiration, or if the aspirated fluid is noninflammatory (clear and viscous), a 5-mL mixture of 20 mg of triamcinolone acetonide (or equivalent) and local anesthetic is injected. Half of the mixture should be injected under the acromion in the bursa. The needle should be slightly withdrawn and redirected toward the anterior part of the rotator cuff, and the remainder of the mixture infiltrated (see Fig. 67-37B).

FIGURE 67-37. Shoulder joint injections. A: Approach for shoulder joint aspiration and injection. Acromioclavicular joint injection. B: Approach for shoulder joint aspiration and injection. Rotator cuff tendon/subacromial bursa injection.

Comments

Shoulder x-rays may show the locations of calcific deposits. If noted, a 1½-in. (4-cm), 16- to 18-gauge needle is directed to this area and aspiration attempted. Three mL of the mixture is injected at this location. The needle is withdrawn slightly and redirected toward the anterior part of the rotator cuff, and the remainder of the mixture infiltrated. This type of injection is usually uncomfortable, and premedication with codeine or oxycodone should be considered.

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 năm, 13 Tháng 3 2014 09:10

Acromioclavicular Joint Injection

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Indications

Intraarticular injection of the acromioclavicular joint is used to treat an inflamed or painful joint, as well as pain secondary to acromioclavicular joint separation.

Techniques

After informed consent is obtained, the patient is placed in the sitting position. The acromioclavicular joint is palpated by placing the fingers at the tip of the distal clavicle and medial to the tip of the acromion. 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 1-in. (2-cm), 25-gauge needle is inserted at the joint and advanced to the proximal margin of the joint surface. After negative aspiration, the periarticular area is injected with 2 mL of 1% lidocaine for diagnostic purposes. If the local anesthetic provides significant pain relief, the periarticular area should be injected with a 2-mL mixture of 10 mg of triamcinolone acetonide (or equivalent) and local anesthetic (Fig. 67-37A).

FIGURE 67-37. Shoulder joint injections. A: Approach for shoulder joint aspiration and injection. Acromioclavicular joint injection. B: Approach for shoulder joint aspiration and injection. Rotator cuff tendon/subacromial bursa injection.

Comments It is not necessary to advance the needle into the acromioclavicular joint. Infiltration of the superficial tissue over the interosseous groove of the joint at the point of maximal tenderness is usually adequate.

Complications

Serious complications are uncommon with injection of the acromioclavicular joint.

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice
Thứ tư, 12 Tháng 3 2014 19:08

Glenohumeral Joint Injection

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Indications

Intraarticular injection of the glenohumeral joint can be used to treat rheumatoid arthritis, inflammatory arthropathy, or adhesive capsulitis.

Techniques

After informed consent is obtained, the patient is placed in the sitting position, with the shoulder internally rotated. The glenohumeral joint is palpated by placing the fingers between the coracoid process and humeral head. The joint space can be felt as a groove just lateral to the coracoid process. 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- to 23-gauge needle is inserted 1 fingerbreadth inferiorly and laterally to the tip of the coracoid process. The needle is directed in the anteroposterior plane just lateral to the coracoid process and is advanced into the groove. The needle is very gently manipulated through the joint capsule into the synovial cavity. Aspiration is attempted until the needle has entered the synovial space. If there is an effusion of the joint, the aspiration should be completed. After negative aspiration, or if the aspirated fluid is noninflammatory (clear and viscous), a 2- to 3-mL mixture of 20 mg triamcinolone acetonide (or equivalent) and local anesthetic should be administered (Fig. 67-36).

FIGURE 67-36. Glenohumeral joint injection aspiration and injection. (From Gatter RA. Arthrocentesis technique and intrasynovial therapy. In: Koopman WJ, ed. Arthritis and Allied Conditions: AA Textbook of Rheumatology. 13th ed. Baltimore, MD: Williams & Wilkins; 1997:753, with permission.)

Comments

Care is required not to direct the needle medially into the neurovascular structures in the axilla.

Complications

Hematoma and intravascular injection are possible, owing to the close proximity of the axillary 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
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