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JOINTS

JOINTS. Injections & Aspirations. Rationale. Primary care providers should master the technique of joint aspiration and injection for many reasons: Diagnosing an inflamed joint Pain relief of a distended joint Injection of steroids for painful joint. Indications. Diagnostic

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JOINTS

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  1. JOINTS Injections & Aspirations

  2. Rationale • Primary care providers should master the technique of joint aspiration and injection for many reasons: • Diagnosing an inflamed joint • Pain relief of a distended joint • Injection of steroids for painful joint

  3. Indications • Diagnostic • To evaluate synovial fluid • Infections • Rheumatic • Traumatic • Crystal-induced etiology • Therapeutic • Remove exudate from septic joint • Relieve pain in grossly swollen joint • Inject lidocaine, saline, corticosteroids

  4. Contraindications • Cellulitis or broken skin over entry site • Anticoagulant therapy not well tolerated • Septic effusion of a bursa • More than 3 previous injections to weight bearing joint in last 12 months • Suspected bacteremia • Unstable joint • Inaccessible joint

  5. Absolute Local sepsis Suspicion of infection Sepsis Hypersensitivity Early trauma Hemarthrosis Prosthetic joint Very unstable joint Reluctant patient Children Contraindications

  6. Contraindications • Diabetic • Anticoagulated • Bleeding disorder • Immunosuppressed • Psychogenic pain • Severe anxiety • Gut feeling

  7. Equipment • Betadine • Sterile gloves • 22- to 27-gauge needle for injections • 18-gauge needle for aspirations • 10cc syringe • 30cc syringe is aspirating large amount • Lidocaine • Culture tubes

  8. Pre-procedure Patient Education • Risks • Benefits • Possible complications • Pain • Infection • Bleeding • Tendon damage

  9. Technique • Before injection, consider differential. • X-rays if tumor or fracture possible • Identify entry site and mark • Prep with betadine • Inject wheel of lidocaine and advance for deeper anesthesia with 27-gauge needle • Use 18-gauge needle inserted into desired location and aspirate or 22-gauge and inject medication

  10. Lab Analysis of Fluid • White blood cell count • <50,000 inflammatory • >50,000 infectious • Polymorphonucleocyte percentage • Crystals • If fluid cloudy, culture

  11. Septic Arthritis • Infection occurs by : • Hematogenous spread • Contiguous source • Direct implantation • Postoperative complication

  12. Septic Arthritis • Early diagnosis essential: • Growth impairment • Articular destruction • Osteomyelitis • Soft tissue expansion

  13. Septic Arthritis • Neisseria gonorrheoae • Adolescents and young adults • Staphylococcus • Patients> 40, medical illnesses • Streptococcus

  14. N. gonorrhoeae • Majority in women • With or without anogenital symptoms • Occurs during menstruation/pregnancy • Positive culture 25%-60% • Positive Gram stain 65% • WBC and glucose helpful

  15. Synovial Fluid Analysis • String sign • Cell count • Glucose • Gram stain • Crystals

  16. Synovial Fluid Interpretation

  17. Joint Injection

  18. The Drugs Corticosteroids Rationale for Using Steroid Injection • Suppressing inflammation Short acting: Hydrocortisone Intermediate acting: Methylprednisone/Triamcinolone Long acting: Dexamethasone

  19. Side Effects • Systemic • Facial flushing • Uterine bleeding • Deterioration of Diabetic glycemic control • Significant falls in the ESR and CRP levels • Other rare side effects • Anaphylaxis

  20. Side Effects • Local • Post-injection flare of pain • Subcutaneous atrophy • Bleeding or bruising • Soft-tissue calcification • Steroid arthropathy • Tendon rupture • Joint sepsis • Soft tissue infection

  21. Local Anesthetics • Rationale for using • Diagnostic • Analgesic • Dilution • Distension • Commonly used • Lidocaine • Bupivacaine

  22. Safety Precautions • Aseptic Technique • Adverse Reactions • Syncope • Anaphylaxis

  23. Aspiration • Frank blood • Serous fluid • Serous fluid streaked • Xanthochromic fluid • Turbid fluid • Frank pus • Other

  24. Injection Technique • Equipment • Syringes • Needles • Corticosteroids • Local anesthetic • Dosage and volume

  25. Injection Technique • Technique • Tissues • Bursa and joint • Tendons and ligaments • Tendons with sheaths • Blood vessels • Aspirations

  26. Preparation Protocol • Prepare patient • Prepare equipment • Prepare site • Assemble equipment • Sterile technique

  27. Most Common Aspirations and Injections

  28. The Knee

  29. The Knee • Landmarks: • Medial patella – middle to superior portion • Insertion • 1 cm medial to anteromedial patella edge. Directed between posterior surface of patella and intercondylar femoral notch

  30. Knee Joint Lateral Medial Knee slightly flexed

  31. The Elbow

  32. The Elbow • Landmarks • Lateral epicondyle and radial head • With elbow extended – the depression is palpated • Insertion • 22-ga needle from lateral aspect just distal to lateral epicondyle and direct medially

  33. The Elbow Lateral Epicondylitis (Tennis Elbow) Symptoms: pain with elevation of third digit against resistance, with wrist and elbow held in extension Approach: Point of Max Tenderness

  34. The Elbow Olecranon Bursitis Diagnosis obvious Approach: 20-ga needle into dependent aspect of sac

  35. The Wrist De Quervain’s Synovitis Injection: The needle is placed into the first extensor compartment and directed proximally toward the radial styloid.

  36. Questions?

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