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 năm, 20 Tháng 3 2014 20:05

Interphalangeal Joint Injection

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Indications

Interphalangeal joint injection is used as a therapeutic procedure to treat inflammation of the metacarpal phalangeal and interphalangeal joints 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 with the joint extended for approach from the lateral or medial aspect, with slight traction applied to the finger. 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. (2.5-cm), 25- to 27-gauge needle is inserted at the borders of the joint and advanced gently to the joint capsule. Pericapsular injection without attempting to enter the joint is appropriate. The pericapsular area is injected with a 1-mL mixture of 10 mg of triamcinolone acetonide (or equivalent) and local anesthetic (Fig. 67-46).

FIGURE 67-46. Interphalangeal joint injection. Approach for first metacarpal joint aspiration and injection.

Comments

No effort should be made to aspirate fluid unless infection is suspected.

Complications

Serious complications are uncommon with appropriate needle placement.

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice
Thứ tư, 19 Tháng 3 2014 02:03

First Metacarpal Joint Injection

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Indications

First metacarpal joint injection is used to treat pain and inflammation secondary to osteoarthritis.

Techniques

After informed consent is obtained, the patient is placed in a sitting position with the arm resting on the examination table. The forearm is placed on the ulnar side midway between supination and pronation, with the thumb adducted and held in flexion with the palm. The first metacarpal along the dorsal aspect to the groove at its proximal end is 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 1-in. (2.5-cm) needle is inserted at the point of maximal tenderness. The needle is advanced into the joint space. Aspiration is attempted until the needle has entered the synovial space. After negative aspiration or if there is an effusion of the joint, the aspiration is completed. If negative aspiration or if the aspirated fluid is noninflammatory (clear and viscous), the joint is injected with a 1- to 3-mL mixture of triamcinolone acetonide (or equivalent) and local anesthetic (Fig. 67-45).

FIGURE 67-45. First metacarpal joint injection. Approach for first metacarpal joint aspiration and injection.

Comments

Piercing the radial artery and extensor pollicis tendon should be avoided.

Complications

Radial artery injury, extensor pollicis tendon injury, and increased pain for 1 to 3 days are uncommon, but may result from this injection. Hematoma and intravascular injection are possible due 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

Indications

Abductor tendon of the thumb injection is a useful therapeutic procedure for tenosynovitis of extensor pollicis brevis and abductor hallicus longus (de Quervain’s syndrome) usually associated with repetitive trauma disorder. This procedure involves injection of common tendon sheath of the long abductor and short extensor tendons of the thumb.

Techniques

After informed consent is obtained, the patient is placed in the sitting position with the arm resting on the examination table. The forearm is placed on the ulnar side midway between supination and pronation. The wrist is held in ulnar deviation over a rolled towel, stretching the tendons over the radial styloid. Tendons are palpated for 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. (3-cm), 23-gauge needle is inserted in a proximal direction, parallel to the tendon at a tangential angle, aiming for the point of maximal tenderness. Once the needle is in the tenosynovium, 0.25 to 0.5 mL of local anesthetic can be injected with a tuberculin syringe without significant resistance. This results in a small sausage-shaped swelling along the length of the tendons. At this point, the syringe containing only local anesthetic is disconnected, and another syringe is used to inject the peritendinous area with a 2-mL mixture of 5 mg of triamcinolone acetonide (or equivalent) and local anesthetic (Fig. 67-44).

FIGURE 67-44. Abductor tendon sheath thumb injection. Approach for abductor tendon sheath of the thumb aspiration and injection.

Comments

There should be no significant resistance encountered in the tenosynovium. There will be resistance encountered by the plunger of the syringe if the needle is in the tendon. Steroid injection into the tendon should be avoided.

Complications

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

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice
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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