Joint Injection

Joint Injection (30)

The joint is usually injected from the extensor surface at a point where the synovium is closest to the skin. This site minimizes the interference from major arteries, veins, and nerves. When the point of injection has been determined, it is best marked with the tip of a retracted ballpoint pen or a needle hub by pressing the skin to produce a temporary indentation to mark the point of entry. The skin is then prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure.

Thứ tư, 02 Tháng 4 2014 02:30

Metatarsal Joint Injection

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Indications

This injection procedure is used to diagnose and treat Morton’s metatarsalgia and Morton’s neuroma.

Techniques

After informed consent is obtained, the patient is positioned for optimal access to the dorsal aspect of the foot. The metatarsal joint interspaces are palpated for swelling and 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 1-in. (2-cm), 25-gauge needle is inserted at the point of maximal tenderness, perpendicular to the skin, and advanced about 1 cm. After negative aspiration, a 2-mL mixture of 5 mg of triamcinolone acetonide (or equivalent) and local anesthetic is injected (Fig. 67-59).

FIGURE 67-59. Metatarsal joint injection. Approach for metatarsal joint aspiration and injection.

Comments

Morton’s metatarsalgia often involves the first and second interdigital spaces. Morton’s neuroma is neuritis of the plantar digital nerves located between the third and fourth metatarsal heads and occasionally in the nerve between the second FIGURE 67-59. Metatarsal joint injection. Approach for metatarsal joint aspiration and injection. (From Katz J. Atlas of Regional Anesthesia. Norwalk, CT: Appleton & Lange; 1994:93, with permission.) and third metatarsal heads. This procedure is used to treat postoperative scar pain often present after surgical removal of a Morton’s neuroma.

Complications

Serious complications are uncommon with appropriate needle placement.

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice

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Indications

Metatarsophalangeal joint injection is a useful procedure in the treatment of joint inflammation secondary to rheumatoid arthritis.

Techniques

After obtaining informed consent, the patient is positioned for optimal access to the dorsal surface of the foot. The metatarsophalangeal joints are palpated for swelling and point 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. Light traction is applied to the toe of the joint to be injected. A ½- to 1-in. (1.5- to 2.5-cm), 25-gauge needle is inserted perpendicular to the skin, directly into the joint space. 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 the aspirated fluid is noninflammatory (clear and viscous), the joint is injected with a 0.5-mL mixture of 5 mg of triamcinolone acetate (or equivalent) and local anesthetic (see Fig. 67-58B).

FIGURE 67-58. Foot injections. A: Approach for plantar fasciitis or calcaneal bursitis injection. B: Approach for aspiration and injection of metatarsophalangeal joint.

Comments

These joints are often limited to 0.5 mL of solution. The first metatarsophalangeal joint may be approached from the medial side with the needle advanced tangentially under the extensor tendon.

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 hai, 31 Tháng 3 2014 20:27

Plantar Heel Fascia Injection

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Indications

Plantar heel fascia injection is used to treat inflammation at the insertion of the long plantar ligament at the anterior aspect of the calcaneus, secondary to chronic overuse disorder or spondyloarthritides.

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. The plantar aspect of the heel is palpated in the area of the attachment of the plantar fascia to the calcaneus 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- to 25-gauge needle is inserted at the point of maximum tenderness on the plantar surface of the heel, perpendicular to the skin. The needle is gently advanced until the tip touches the underlying bone and then is withdrawn 2 mm. After negative aspiration, a 2-mL mixture of 20 to 10 mg of triamcinolone acetonide (or equivalent) and local anesthetic is injected. If proper palpation of the point of maximal tenderness is difficult, one half of the mixture of local anesthetic and corticosteroid should be injected into the region of maximal tenderness and the remainder injected in a fanwise manner around the plantar fascia attachment (Fig. 67-58A).

FIGURE 67-58. Foot injections. A: Approach for plantar fasciitis or calcaneal bursitis injection. B: Approach for aspiration and injection of metatarsophalangeal joint.

Comments

This is a significantly painful procedure with or without cutaneous anesthesia. After injection, the patient is discouraged from excessive walking until the local anesthetic wears off and is encouraged to wear a heel cushion inside the shoe.

Complications

Serious complications are uncommon with appropriate needle placement.

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice
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
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