Shoulder Girdle Joint Injection Workshop Virginia Osteopathic Medical Association 2011 Fall CME Conference Hotel Roanoke & Conference Center Roanoke, Virginia September 23, 2011 Bradley M.
Download ReportTranscript Shoulder Girdle Joint Injection Workshop Virginia Osteopathic Medical Association 2011 Fall CME Conference Hotel Roanoke & Conference Center Roanoke, Virginia September 23, 2011 Bradley M.
Shoulder Girdle Joint Injection Workshop Virginia Osteopathic Medical Association 2011 Fall CME Conference Hotel Roanoke & Conference Center Roanoke, Virginia September 23, 2011 Bradley M. McCrady, DO Fellow, Primary Care Sports Medicine Edward Via College of Osteopathic Medicine- Virginia Campus Virginia Polytechnic Institute and State University Objectives • Identify indications and contraindications for joint injections of the shoulder girdle. • Review necessary equipment of shoulder injections. • Discuss techniques to perform various shoulder girdle injections. • Illustrate techniques of ultrasound-guided injections of the shoulder girdle. • Demonstrate skills to perform various common shoulder girdle injections. Resources Shoulder Complex • Shoulder is a complicated anatomical and biomechanical joint – “Fragile Equilibrium” • Multiple joints • Static and dynamic stabilizers Hoppenfeld, S. Physical Examination of the Spine and Extremities. Prentice Hall; 1976 http://www.sportfit.com/tips/rotatorcuff/images/Z4rtrs.gif What Providers Need to Know About Joint Injection and Aspiration • Relatively simple procedure • Complications are uncommon • Injection/arthrocentesis can provide diagnosis, relieve pain, decrease joint damage – – – “Liquid biopsy of joint” Useful information can be provided by relatively inexpensive tests Can help differentiate inflammatory from non-inflammatory arthritis • Judicious use of anesthetics and steroids may be safer than systemic medications • Summary There are often more reasons for doing than not in the right clinical scenario Indications for Joint Injection/Aspiration • Diagnostic – Acute inflammatory arthritis (24-48 hours) in a patient who has never had these symptoms before – Acute effusion in the setting of fever, chills, or presence of infection at another site – Acute effusion in the setting of trauma – Prior to committing patients to long-term, expensive or toxic therapy • Therapeutic – – – – – Provide for a better musculoskeletal exam (i.e. pain control) To suppress inflammation in one or two isolated joints Adjuvant therapy to a few joints resistant to systemic therapy To facilitate a rehabilitative therapy program To support a patient with active joint inflammation pending the effects of systemic therapy – To remove exudative fluid from a septic joint – To relieve pain in a swollen joint Conditions Likely to be Improved by Joint or Periarticular Injections • Rheumatoid arthritis • Seronegative spondyloarthropathies • Crystal induced arthritis • Carpal tunnel • Bursitis • Tenosynovitis/tendinitis • Adhesive capsulitis • Osteoarthritis Contraindication to Joint Injection/Aspiration • Absolute – Uncooperative patient – Allergy to anesthesia or steroid (very rare) – Lack of informed consent – Injection through infected tissues – Previous severe steroid flare – Injection of steroid into critical weight-bearing tendons • Relative – Injection near critical structures – Coagulation disorders – Uncontrolled diabetes – h/o AVN – Previous joint replacement at injection site – More than 3 previous steroid injections in a major weight bearing joint in the preceding year – Concern to activate any latent disease – Excessive anxiety Equipment • • • • Informed consent Non-sterile exam gloves Marking pen Alcohol pads +/- povidine-iodine • • • • • • Gauze pads Syringe(s) Needle Anesthetic Steroid Adhesive bandages McNabb, James. A Practical Guide to Joint & Soft Tissue Injection & Aspiration. 2nd Ed.LWW; 2010. Safety First • Position for comfort! • Define anatomy • Universal precautions – Vaccines – Gown and mask not necessary • • • • • Clean vs sterile technique Aspirate prior to injections Do not recap needles Proper disposal of equipment Observe patient in office following injection for 15-30 min Baima, J.Curr Rev Musculoskelet Med (2008) 1:88–91 Hemani, M. Rev Urol. 2009;11(4):190-195 Darouiche, RO. N Engl J Med 2010;362:18-26 Topical Preparation • Infection is not common – Actual reported incidence is unknown, but is thought to vary from 1: 3,000 to 1:50,000 • 70% isopropyl alcohol vs 10% povidone-iodine • Ethyl chloride fine spray may have antimicrobial activity http://www.shopmedrx.com/qt_images/TRI_103201.jpg http://sani-system.com/images/products/b15901.jpg http://www.gebauerco.com/Images/picEthylChlorideLeft.gif Baima, J.Curr Rev Musculoskelet Med (2008) 1:88–91 Hemani, M. Rev Urol. 2009;11(4):190-195 Darouiche, RO. N Engl J Med 2010;362:18-26 Clinical Radiology, Volume 61, Issue 12, Pages 1055-1057 Steroids-History • Hydrocortisone acetate was first introduced in the 1949 for Rheumatoid arthritis by Hollander – “No other form of treatment has given such consistent local symptomatic relief in so many for so long with so few harmful effects.” • Oriole baseball pitcher Jim Palmer – “…cortisone is a miracle drug ... for a week!" • Long history of use in athletics – Treat the secondary inflammation – Need to find the cause Nepple, J. Sports Health: A Multidisciplinary Approach 2009 1: 396-404 Leadbetter WB. Clin Sports Med.1995;14(2):353-410. Steroids-Physiology • Stabilizing lysosomal membranes of inflammatory cells • Decreasing local vascular permeability • Altering neutrophil chemotaxis and function • Able to pass through cell membranes and bind to nuclear steroid receptors – Where they influence RNA transcription Nepple, J. Sports Health: A Multidisciplinary Approach 2009 1: 396-404 Steroids-Use • Hill et al surveyed members of the American Academy of Orthopaedic Surgeons on use of corticosteroids – 90% of used corticosteroid injections – Performed an average of 150 intraarticular and 193 extra-articular injections per year • Conditions warranting injection – – – – – Epicondylitis (93%) Shoulder bursitis (91%) Greater trochanteric bursitis (91%) DeQuervain’s tenosynovitis (87%) Bicipital tendonitis (81%) Hill JJ Jr,. Contemp Orthop. 1989;18:39-45. McNabb, James. A Practical Guide to Joint & Soft Tissue Injection & Aspiration. 2nd Ed.LWW; 2010. Anesthetics • Decrease nerve conduction through the blockade of Na channels, which disrupts axonal nerve conduction • Typically steroid agent is combined with a local anesthetic agent – Decrease the pain – Dilute the steroid – Increase the distribution of the agent to the treated area • Lidocaine – Rapid onset (minutes) – Short duration (60-90 minutes) • Bupivicaine • • Slower onset (30 minutes) Longer duration (6-8 hours) • Buffering – Sodium bicarbonate Nepple, J. Sports Health: A Multidisciplinary Approach 2009 1: 396-404 What Patients (and Providers) Need to Know about Joint Injection • Relief will typically last weeks or longer • Avoid injecting ligamentous or tendon structure directly • Activity modification following injections of steroids is uncertain • Maximal number of injections and the required period between injections have not been determined Nichols, A Clin J Sport Med 2005;15(5) : E370 Pfenninger JL. Procedures for primary care physicians. St. Louis: Mosby, 1994. What Patients (and Providers) Need to Know about Joint Injection • In a meta-analysis summarizing 25+ studies, they noted a 5.5% complication rate – The most common side effects included skin atrophy (2.4%), skin depigmentation (0.8%), localized erythema and warmth (0.7%), and facial flushing (0.6%) – Post-injection pain was noted in up to 9% of patients – Post injection flare (2-5%) – Prolonged and repeated usage may increase the risk of complications and systemic side effects • In diabetic patients, hyperglycemia has been shown to persist up to 5 days after a single soft tissue injection (very low risk) Dietzel, D Current Sports Medicine Reports 2004, 3:310–315 Nepple, J. Sports Health: A Multidisciplinary Approach 2009 1: 396-404 Wang AA. J Hand Surg [Am]. 2006;31(6):979-981. Pfenninger, JL Procedures in Primary Care 2nd Ed. 2003: 1479-1499 Typical Injection/Aspiration Procedure • • • • • • Determine the medical diagnosis and consider relevant differential diagnoses Discuss the proposed procedure and alternatives with the patient Obtain written informed consent from the patient Collect and prepare the required materials Correctly position the patient for the procedure Identify and mark the anatomic landmarks and injection site with ink – • • Press firmly on the skin with the retracted tip of a ballpoint pen to further identify the injection site Prepare the site for injection by cleansing with a topical antimicrobial agent (povidine-iodine and/or alcohol swab) – • Do not allow the patient to move the affected area from the time that the marks are placed until after the procedure is completed If using the povidone, allow to dry for full antibacterial effect Provide local anesthesia as indicated through use of tactile distraction, vapocoolant spray (ethyl chloride or PainEase), and/or injected local anesthesia McNabb, James. A Practical Guide to Joint & Soft Tissue Injection & Aspiration. 2nd Ed.LWW; 2010. Pfenninger, JL Procedures in Primary Care 2nd Ed. 2003: 1479-1499 Typical Injection/Aspiration Procedure • • • • • Using the no-touch technique, introduce the needle at the injection site and advance into the treatment area Aspirate fluid (optional) using a 18 or 20-g needle and send it for laboratory examination if indicated If injecting corticosteroid immediately following aspiration, do not remove the needle from the joint or bursa; In this case, grasp the needle hub firmly (with a hemostat clamp if necessary), twist off the original syringe, and then immediately attach the second syringe that contains the corticosteroid Always aspirate before injection to avoid intravascular administration Inject corticosteroid solution into the treatment area – – • • • • If not aspirating then use 25-g needle Do not inject the medication against resistance Withdraw the needle Apply direct pressure over the injection site with a gauze pad Apply an adhesive dressing Provide the patient with specific post-injection instructions McNabb, James. A Practical Guide to Joint & Soft Tissue Injection & Aspiration. 2nd Ed.LWW; 2010. Pfenninger, JL Procedures in Primary Care 2nd Ed. 2003: 1479-1499 Informed Consent • Patient’s consent to allow provider (and his/her pupils) to perform the procedure. • All alternative treatments discussed with the patient in lieu of procedure. • Benefits and risks to the procedure. • Explanation of the procedure in lay language to the patient. • Signature of the patient or authorized representative, witness, and provider. Shoulder Girdle Injections • Subacromial – Posterior – Lateral • Glenohumeral – Posterior – Anterior • Acromioclavicular • Sternoclavicular • Biceps brachii long head Subacromial Injection Lateral Approach • Find lateral edge of acromion and mark • Palpate soft spot below the acromion and above the humeral head • Insert needle perpendicular through the deltoid towards the bursa Subacromial Injection Posterior Approach • Find lateral edge of the acromion and mark • Palpate posterior edge of the acromion and mark • Find posterolateral edge of the acromion and mark a spot 2 cm below the corner McNabb, James. A Practical Guide to Joint & Soft Tissue Injection & Aspiration. 2nd Ed.LWW; 2010. Seroyer, S. Sports Health 2009; 1 (2): 108-120 Subacromial Injection Posterior Approach • Position the needle at a 30 ° angle to the skin with the needle tip directed cephalad toward the acromion • Insert the needle getting underneath the acromion and advance until the needle tip touches the undersurface of the acromion • Once at the acromion, back off 1-2mm Glenohumeral Injection Posterior Approach • Find lateral edge of acromion • Palpate the posterior edge of the acromion • Mark spot 2 cm below posterior lateral corner • Target is coracoid process Glenohumeral Injection Posterior Approach • Advance needle towards coracoid process until tip touches humeral head and retract needle 12mm Glenohumeral Injection Anterior Approach • Identify coracoid process • Injection point is 1 cm lateral to the coracoid Glenohumeral Injection Anterior Approach • Insert needle perpendicular to the skin toward the target 2 cm caudad to the posterior lateral corner of the acromion • Advance needle until it reaches the humeral head and retract 12mm Long Head Biceps Injection • Palpate course of biceps long head tendon with the patient flexing the elbow • Palpate location of maximal tenderness which is usually under the edge of the pectoralis major http://www.aafp.org/afp/2009/0901/afp20090901p470-f1.jpg Long Head Biceps Injection • Position needle at a 45° angle to the skin with needle directed proximally • Advance needle until needle tip touches tendon, back needle off 1-2mm • Medication should flow smoothly Acromioclavicular Injection • Identify AC joint by palpating the clavicle in a medial to lateral direction until reaching a small depression that may be tender http://upload.wikimedia.org/wikipedia/commons/thum b/3/3b/Gray326.png/250px-Gray326.png Acromioclavicular Injection • Insert needle perpendicular to the skin with the needle tip directed caudad Sternoclavicular Injection • Identify SC joint by palpating the clavicle in a lateral to medial direction until reaching a small depression that will likely be tender Sternoclavicular Injection • Insert needle perpendicular to the skin and advance into SC space Musculoskeletal Ultrasound • The use of high-frequency sound waves (3-17MHz) to image soft tissues and bony structures in the body for the purpose of diagnosing pathology or guiding real-time interventional procedures http://cdn.bleacherreport.com/images_root/image_pictures/0236/5499/39664_crop_340x234.jpg Pinzon, EG and Moore, RE. Musculoskeletal Ultrasound: a brief overview of diagnostic and therapeutic application in musculoskeletal medicine. Practical Pain Management. June 2009. Ultrasound Terminology • Echogenecity- the ability of tissue to reflect ultrasound waves back toward the transducer and produce an echo. (The higher the echogenicity of tissues, the brighter they appear on ultrasound imaging) • Hyperechoic- seen as brighter on ultrasound relative to surrounding tissues due to higher reflectivity of the US beam • Isoechoic- structures are seen as bright as surrounding structures on conventional US imaging due to similar reflectivity to the US beam Pinzon, EG and Moore, RE. Musculoskeletal Ultrasound: a brief overview of diagnostic and therapeutic application in musculoskeletal medicine. Practical Pain Management. June 2009. Ultrasound Terminology • Hypoechoic- structures are seen as darker relative to the surrounding structures on US imaging due to the US beam being reflected to a lesser extent • Anechoic- structures that lack internal reflectors fail to reflect the US beam to the transducer and are seen as homogenously black on imaging • Anisotrophy- the effect of the beam not being reflected back to the transducer when the probe is not perpendicular to the structure being evaluated Pinzon, EG and Moore, RE. Musculoskeletal Ultrasound: a brief overview of diagnostic and therapeutic application in musculoskeletal medicine. Practical Pain Management. June 2009. Ultrasound Terminology • Transverse- cross sectional view • Sagittal (Longitudinal)- long axis plane view • Coronal- long axis plane view dividing anterior and posterior http://www2.healthsci.tufts.edu/saif/Vevo2100/Ultrasound-Terminology.pdf Ultrasound Equipment • High Resolution Machine • Transducers – Linear 8-14 MHz – Curvilinear 2-5 MHz – “Hockey Stick” • Printer • CD/DVD/USB unit Schaefer, MP. Ultrasound Guided Interventions in PM&R. MRIO PM&R Grand Rounds. 9 November 2009. http://www.ucsdultrasound.com/yahoo_site_admin/assets/images/ultrasound_transducers.2467 3744_large.jpg Ultrasound Guidance Advantages • • • • • Real-time guidance Assess anatomy Soft tissue visualization Visualize neurovascular structures No radiation Schaefer, MP. Ultrasound Guided Interventions in PM&R. MRIO PM&R Grand Rounds. 9 November 2009. Ultrasound Guidance Limitations • Obesity (depth ~6cm) • No contrast confirmation • No visualization deep to bony structures (very limited use in spine injections) • Operator dependency • Superficial tenderness Schaefer, MP. Ultrasound Guided Interventions in PM&R. MRIO PM&R Grand Rounds. 9 November 2009. Equipment for U/S Guided Injections • • • • • • • • Informed consent Sterile vs non-sterile gloves? Marking pen Alcohol pads Povidine-iodine Gauze pads Syringes Needles (typically longer than non-guided injections) – Echoblock needle? • • • • • Sterile transducer cover? Sterile gel Anesthetic Steroid Adhesive bandages Schaefer, MP. Ultrasound Guided Interventions in PM&R. MRIO PM&R Grand Rounds. 9 November 2009. Subacromial Injection http://www.essr.org/html/img/pool/shoulder.pdf Schaefer, MP. Ultrasound Guided Interventions in PM&R. MRIO PM&R Grand Rounds. 9 November 2009. Subacromial Injection Schaefer, MP. Ultrasound Guided Interventions in PM&R. MRIO PM&R Grand Rounds. 9 November 2009. Acromioclavicular Injection http://www.essr.org/html/img/pool/shoulder.pdf Acromioclavicular Injection Schaefer, MP. Ultrasound Guided Interventions in PM&R. MRIO PM&R Grand Rounds. 9 November 2009. Glenohumeral Injection http://www.essr.org/html/img/pool/shoulder.pdf Glenohumeral Injection Schaefer, MP. Ultrasound Guided Interventions in PM&R. MRIO PM&R Grand Rounds. 9 November 2009. Long Head Biceps Brachii Injection http://www.essr.org/html/img/pool/shoulder.pdf Long Head Biceps Brachii Injection http://www.ultrasoundpaedia.com/USP%20shoulder%20winner.html http://dynamicultrasound.org/images/lsbiceps.jpg Sternoclavicular Injection http://greatpiercingshop.com/blog/wpcontent/uploads/2009/12/Clavicles.jpg http://emj.bmj.com/content/28/6/542.extract Post Injection Instructions • Recurring Pain- anesthetic effect ending before steroid effect begins • Rest Injection Area- further injury may be caused by numbness of the site • Infection Observation- fever, increased warmth/redness, ascending redness, increased swelling Injection Coding • CPT code – 20610 injection/aspiration of major joint or bursa • Code for injectable used (J code) McNabb, James. A Practical Guide to Joint & Soft Tissue Injection & Aspiration. 2nd Ed.LWW; 2010. Questions and Demonstration http://www.shoulderdoc.co.uk/images/uploaded/sdoc_ultrasound_07.jpg References • Beggs, I., et al. Musculoskeletal Ultrasound Technical Guidelines: shoulder. European Society of Musculoskeletal Radiology. http://www.essr.org/html/img/pool/shoulder.pdf • McNabb, James. A Practical Guide to Joint & Soft Tissue Injection & Aspiration. 2nd Ed. LWW; 2010. • Pinzon, EG and Moore, RE. Musculoskeletal Ultrasound: a brief overview of diagnostic and therapeutic application in musculoskeletal medicine. Practical Pain Management. June 2009. • Schaefer, MP. Ultrasound Guided Interventions in PM&R. MRIO PM&R Grand Rounds. November 2009.