Transcript Joint injection - Spire Healthcare, UK Private hospital

Joint injection
Dr Amit Saha
Consultant Rheumatologist & Clinical Lead for
Rheumatology- Maidstone and Tunbridge Wells
NHS Trust
Spire Tunbridge Wells- TALK
 Introduction
course Focus on 90% of injections- knee, wrists
shoulder
 When to inject and aspirate – need
diagnosis first
 Safety
Shoulder
 Frozen
shoulder (adhesive capsulitis)
 Subacromial impingement syndromes
Frozen Shoulder
 Stiffened
gleno-humeral joint that has lost
significant range of motion (abduction and
rotation).
 40-60s
 Dis-use – sling, recent operation, preexisting shoulder complaint
 50% reduction in all movements
(especially external rotation)
Frozen Shoulder
In SAI – though active movement reduced,
passively you can push full movement.
 Patients with frozen shoulder have varying
degrees of pain early in the disease course, but
complain primarily of joint stiffness. Symptoms
generally develop over the course of weeks to
months.
 No X-rays generally needed (exception if you
think there is gleno-humeral OA)
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Treatment
 Acute
(first 8 weeks)- NSAIDs and avoid
excessive activities
 Gentle exercises- Pendular exercises
(evidence weak) plus stretching exercises.
 Revaluate in 8 weeks – Continue or inject
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Randomized trial of 109 patients.
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At seven weeks, 40 of 52 patients randomly
assigned to glucocorticoid injection were
considered to have a treatment success
compared with 26 of 56 patients (46 percent)
treated with physiotherapy.
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van der Windt DA et al. BMJ. 1998;317(7168):1292.
 Glucocorticoid
injection may hasten
recovery, and the addition of supervised
physical therapy following glucocorticoid
injection may result in more rapid
improvement than injection alone.
However, the long-term outcome of
adhesive capsulitis may not be much
affected by either intervention.
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Four groups: steroid plus supervised physiotherapy (PT),
glucocorticoid injection alone, saline injection plus
supervised PT, or saline injection alone.
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Those who received a glucocorticoid injection and
supervised PT improved significantly more, and more
rapidly, than any other group at six weeks; those who
received glucocorticoid injections were better than those
who did not at three months.
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But by one year there was no discernible difference in
improvement among the four groups.

Carette et al. Arthritis Rheum. 2003;48(3):829.
 Injection
Approach - posterior approach
Subacromial impingement
syndromes

Rotator cuff may be compressed during
glenohumeral movement
 Painful daily activities may include putting on a
shirt or brushing hair.
 Patients may localize the pain to the lateral
deltoid and often describe pain at night,
especially when lying on the affected shoulder.
Inspection – Rotator cuff atrophy
Palpation- focal subacromial tenderness at the
lateral or posterior-lateral border of the
acromion.
 Painful ROM that occurs between 60 and 120
degrees of active abduction marks a positive arc
test
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 Normal
passive range of movement and
power
 Beyond 150 degrees possible acromioclavicular OA
Treatment
 X-rays
generally not needed
 Simple things first
 Injections- evidence weak. Systematic
review poor trials.
Knee
 OA
knees
 Aspirate- gout/pseudogout/infection
 Works – can be up to 6 months
 Certain patients better to use than others
Carpal Tunnel syndrome
 Median
nerve entrapment
 Classically 1-31/2 fingers
 Classic symptoms
 Tinel’s and phalens
 Splints first
 Surgery if severe damage
 Inject if splints fail
Injections
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Discussed benefits already
Risks – Bleeding and infection – less than 1 in 10,000
Aseptic
INR less than 3 for large joints
Post-injection flare- last few hours usually within 24-48 hours.
Tendon damage – Tendon rupture is most commonly encountered
when undiluted glucocorticoid is given very near or into tendon
Nerve damage
Skin depigmentation
Do not inject prosthetic joints
Avoid general exertion for 24 hours.
– 40mg (1ml) Depo-medrone
(methylprednisolone acetate) plus
approximately1-2mls of 1% lidocaine
 Knee - 80mg (2ml) Depo-medrone
(methylprednisolone) plus approximately
2mls of 1% lidocaine
 Wrist 20mg (0.5ml) Depo-medrone plus
0.5ml 1% lidocaine
 Shoulder
Frequency- evidence limited
 Inject
very active large joints affected by
rheumatoid arthritis as often as 3
injections per year for any given joint.
 For joints affected by osteoarthritis, can
inject glucocorticoids as often as once
every six months only if no other therapy is
effective.
needle – 21 gauge (knee and
shoulder)
 Orange needle – 25 gauge (wrist)
 10ml syringe for knee and shoulder
 1ml syringe for wrist
 Universal container
 Alcohol swabs (with 70% isopropyl
alcohol)
 Green
Knee injection
Superior
Lateral
Medial
Inferior