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 – 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

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

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

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

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

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

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

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

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

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

Septic Arthritis • • • Neisseria

gonorrheoae

– Adolescents and young adults

Staphylococcus

– Patients> 40, medical illnesses

Streptococcus

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

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

Synovial Fluid Interpretation Diagnosis Appearance WBCs Glucose % blood level Crystals Culture

Normal Clear <200 95+ None -- DJD Clear Traumatic Arthritis Acute Gout Straw, bloody, xanthochromic Turbid <4000 <4000 95+ 95+ None None -- -- Pseudogout Turbid Septic Arthritis Non traumatic Arthritis Purulent/turbid Turbid 2000 50,000 2000 50,000 5000 >50000 2000 50,000 80-100 80-100 <50 75 Needle like Rhomboid like None None -- -- + usually ---

Joint Injection

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

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

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

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

Safety Precautions • Aseptic Technique • Adverse Reactions – Syncope – Anaphylaxis

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

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

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

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

Most Common Aspirations and Injections

The Knee

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

Knee Joint Lateral Medial Knee slightly flexed

The Elbow

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

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

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

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

Questions?