INTRA-ARTICULAR AND ALLIED INJECTIONS

Third EditionSureshwar Pandey

MBBS (Hons) MS (Gen) FICS FIAMS MS (Ortho) FACFAC FACS FNAMS

Professor Emeritus, University of Ranchi

Founder and Founder Director, GNH Handicapped Children Hospital and

RJS Artificial Limb Centre

Founder and Consultant, Ram Janam Sulakshana

Institute of Orthopaedics and Research

Ranchi, Jharkhand, India

Founder and Emeritus President and Ex-Secretary General, Indian Foot and Ankle Society

[Affiliated to International Federation of Foot and Ankle Societies (IFFAS)]

Founder and Emeritus Editor, The Journal of Foot and Ankle Societies Surgery

Visiting Professor, Universities of Tokyo, Osaka, Teikyo, Adelaide, Flinders,

Ujung Pandang, Singapore

Ex-Chairman ASIA-CIP (IFFAS)

Founder and Chairman, Ram Janam Sulakshana Pandey Cancer Hospital

& Research and Rehabilitation Centre, Ranchi

Hon President, Asia-Pacific Society for Foot and Ankle Surgery

Anil Kumar Pandey MBBS CORM PhD Orth MAMS

Director and Consultant

Ram Janam Sulakshana Institute of Orthopaedics and Research (RJSIOR)

Associate Director and Consultant

GNH Handicapped Children Hospital and RJS Artificial Limb Centre

Executive Director and Consultant

Ram Janam Sulakshana Pandey Cancer Hospital and Research and Rehabilitation Centre

Ranchi, Jharkhand, India

Consultant, Kiran Centre for Education and Rehabilitation

Varanasi, Uttar Pradesh, India

Consultant, RAHA, Chhattisgarh, India

Reconstructive Surgeon, Rotary International Project, Government of Nigeria

Foreword

Padma Bhushan Dr B Mukhopadhaya

New Delhi | London | Panama

The Health Sciences Publisher

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Jaypee Brothers Medical Publishers (P) LtdHeadquarters

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Intra-articular and Allied Injections

First Edition: 1982First Japanese Edition: 1987Second Edition: 2005American Edition: 2007Third Edition: 2017

ISBN 978-93-5270-130-8

Printed at

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Dedicated toThe fond memory of my beloved parents

Sulakshana Pandey

and

Ramjanam Pandey

who were, are, and will be

always with me to love, teach and guide

who taught me to persue my

dreams—because nothing is impossible

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* This painting has been commissioned by Pfizer Ltd (India) based on an old painting belonging to the Late

Maharaja of Mysore, Krishnaraja Wodeyar II (South India).

“DHANVANTARI”*

The Hindu God of Medicine

the original exponent of Indian medicine. Dhanvantari has many myths and legends

Legends make him reappear as “Divodasa”, the prince of Banaras (Kasiraja), in the

is “the first G

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Intra-articular and Allied Injectionsviii

Dhanvantari also appears to have been an actual historical person, although his pre-

cise identity is hard to be ascertained. He taught surgery and other divisions of Ayurve-

da (Indian System of Medicine) at the instance of Susruta, to a group of sages among

Dhanvantari is regarded as the patron-God of all branches of medicine. While

to Dhanvantari.

Dhanvantari-Nighantu is considered the most ancient of the medical glossaries that

medicinal substances; their names, synonyms, and brief description of properties being

extensively relied upon, despite several more comprehensive glossaries that have been

be considered more as indicative.

(By courtesy Pfizer Limited)

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“kiFk ¼fpfdRld ds fy;s½u rks LokFkZ ds fy;sugha fdlh lalkfjd oLrq ;k ykHk dh iwfrZ ds fy;s]vfirq loZnk ihfMr ekuork ds dY;k.k ds fy;seSa vius jksxh dh fpfdRlk d:a vkSj bl dk;Z esa lcls vkxs jgwa

‘pjd’

Oath (for a Medical Practitioner)“Not for the self,

Charak Oath

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accepted method of treatment for a variety of painful conditions, although its exact

No monograph detailing the proper procedure of these injections is available. The

this method of treatment for their patients.

Padma Bhushan Dr B MukhopadhayaMBBS (Hons) FRCS (Eng) MCh Orth (L Pool) FAMS

Professor Emeritus, Patna University

Hunterian Professor, Department of Orthopaedics

Royal College of Surgeons, England

Vice-President, Medical Council of India

Chairman,

Artificial Limb Manufacturing Corporation of India

Foreword

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Intra-

articular and Allied Injections

and American editions. This proved to be a useful guide for the interns, registrars,

practitioners rheumatologist, acupuncture practitioners and orthopaedic surgeons.

In this third edition, besides updating the manuscript, here and there, small sections

have been added on acupressure and yoga and the role of platelet-rich plasma (PRP)

advices and guide to improve the monograph further.

Sureshwar PandeyAnil Kumar Pandey

Preface

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observations over the subjects—the patients. We are obliged to them for providing

To upgrade the Second E

Campbell’s Operative Orthopaedics,

12th Edition by S Terry Canale and James H Beaty (E

Orthopaedic Management in Cerebral Palsy, 2nd Edition by Helen M Horstmann and

Eugene E Bleet, Mac Keith P

Unless the users, the young orthopaedic and general surgeons, rheumatologists and

Arranging the manuscript and putting them in proper order and further printing it

out are really great annoying jobs. These all have been very gladly and patiently done

by my dear granddaughter Dr Pallavi. I (SP) cannot return her debt.

Shruti, and Satyam and my great grand child Atharva Pranjal Kanha have been real source

for me.

Mr Ankit Vij (Group President) of M/s Jaypee Brothers Medical Publishers (P) Ltd, and all

persons involved in producing such a nice monograph. We are really thankful to one

and all of Jaypee—The Health Sciences Publisher.

Acknowledgements

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1. Principles of Intra-articular and Allied Injections 1

Mode of Action of Glucocorticoids 2

Immune Responses 2

Anti-inflammatory Properties 2

Potency 5

2. How Frequently to Inject Corticosteroid? 6

Why should Intra-articular Corticosteroid not be Given

7

Whether Intra-articular Corticosteroid should be Given

7

3. How to Inject? 9

Word of Caution 9

Localisation of the Site of the Injection 9

4. Indications of Corticosteroid Injection 11

12

Relative Indications of Corticosteroid Injections 13

Tendons (Mostly Around the Tendon Cautiously, and

very Rarely into the Tendons) 13

Ligaments 13

Fibrofatty Nodules 14

Peripheral Nerves 14

14

Skin Conditions 14

Ophthalmic Condition 14

Gynaecological Conditions 15

Reflex Sympathetic Dystrophy Syndrome 15

Trial Indications 15

5. Contraindications for Local Corticosteroid Therapy 16

General Infections 16

Contents

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Intra-articular and Allied Injectionsxviii

6. Intra-articular Hyaluronic Acid and Platelet-rich Plasma Injection 17

Viscosupplementation 18

Role of Hyaluronic Acid in Osteoarthritis 19

Corticosteroids vs Hyaluronic Acid 19

Platelet-rich Plasma Injection 20

7. Methodology 22

Preparation 22

22

Position of the Patient 22

Soap Water Cleaning of the Part 23

Certain Considerations in Relation to

Intra-articular and Allied Injections 23

Sites for Injection 25

8. Shoulder Joint 27

Anterior Approach 27

Posterior Approach 27

28

Anterolateral Approach 30

9. Elbow Joint 32

Lateral Approach 32

Posterior Approach 32

33

Olecranon Bursitis 34

35

10. Wrist Joint 36

Approaches for Wrist Joint 36

37

Injection Approaches for Metacarpophalangeal Joints

and Interphalangeal Joints 40

Trigger Thumb/Finger 40

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Contents xix

11. Hip Joint 42

Anterior Approach 42

Lateral Approach 42

12. Knee Joint 45

Mode of Injection 45

Infrapatellar Approach 46

Suprapatellar Approach 47

Posterior Approach 48

Method of Injecting into the Anserinus Bursa 49

(Apophysitis of Tibial Tuberosity) 49

49

13. Ankle Joint and Foot 51

Indications 51

Approaches 51

51

Painful Heel Syndrome 53

Plantar Fasciitis 56

Symptomatic Accessory Navicular 58

Subtalar Joint 58

14. Spine, Peripheral Nerves, Sacroiliac Joint 59

59

Herpetic Neuritis 60

Lumbar Disc Disease 60

Epidural Steroid Injections 61

Complications of Epidural Injections 65

Selective Nerve Root Injection 65

Method of Nerve Root Injection 66

Vertebroplasty and Kyphoplasty 66

Injection into and Around the Peripheral Nerves 66

67

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Intra-articular and Allied Injectionsxx

Popliteal Nerve 67

Nerve of Thigh 67

Coccydodynia (Painful Coccyx) 67

69

Old Pelvic Fracture 69

Recurrent Fibrositis 69

Rheumatoid Spondylitis 70

SacroIliac Joint 70

15. Facial Region 71

Oral Cavity 71

16. Joints Around the Clavicle 73

Method 73

17. Occipital Region 75

Trigeminal Neuralgia 76

18. Complications of Intra-articular Injections 78

Complications due to Lack of Aseptic Procedure 78

Management of Infection 79

Complications due to Error on the Part of Clinicians 80

Corticosteroids can Produce General Complications 80

Complications due to the Drug 81

Rebound Phenomenon 81

Delayed Manifestations of Infections 81

19. Role of Botulinum Toxin Type A Injection in Spastics and Other Indications 82

Botulinum Toxin Type A 82

Mode of Working of Botulinum Toxin Type A

(BT—A—BOTOX) 83

20. Acupuncture 85

Complications of Acupuncture 86

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Contents xxi

Acupuncture in Arthritis 86

Acupuncture in Painful Shoulder Syndromes 87

Acupressure 87

Moxibustion 88

21. Reiki and Yoga 89

Reiki 89

Yoga 90

Appendix 97

Bibliography 101

Index 105

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Elbow is a composite joint having ulnohumeral, radiohumeral and radioulnar components. These have continuous and communicating synovial reflections. Therefore, if the drug is injected into one component, it easily spreads into other compartments, unless there is intra-articular adhesions.

LATERAL APPROACHLateral approach is through radiohumeral compartment. The patient lies supine. The arm is kept in slight internal rotation at shoulder. The elbow is flexed 30 to 40 degree from zero extension, with forearm is midprone position. A transverse slit can be felt at the posterolateral aspect just below the lateral epicondylar region. Further confirmation can be done by rotating the forearm in which radial head is felt rotating just beneath the slit. The needle is pushed into the slit having a direction anteriorly with about 20 degree upward inclination (Figure 9.1).

POSTERIOR APPROACHThe patient lies on the side with the affected limb above. Elbow is flexed about 45 degree with forearm in midprone position. The olecranon tip stands prominent. On either side of the olecranon process a vertical slit can be felt. At a convenient point along the slit, a needle can be pushed on either side of the olecranon, having a direction downwards and towards mid-line (Figure 9.2).

C H A P T E R 9Elbow Joint

Chapter Outline

� Lateral approach

� Posterior approach

� Lateral epicondylitis (extra-articular tennis

elbow)

� Olecranon bursitis

� Medial epicondylitis (golfer’s elbow,

pitcher’s elbow, little league elbow

syndrome)

‘Remain cool to reach your goal safe and fast.’

—PP Wangchuk

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Elbow Joint 33

Fig. 9.2: Elbow joint—posterior approach

LATERAL EPICONDYLITIS (EXTRA-ARTICULAR TENNIS ELBOW)Lateral epicondylitis (tennis elbow) has been recogonized for over 100 years. It is an enthesopathy of the common extensors origin in the lateral epicondylar region, however, its pathogenesis is not clear. It has been also recognized as an overuse syndrome (repetitive stress disorder) due to repetitive tension overloading of the wrist extensor origin at the lateral epicondylar region. First clinical description of lateral epicondylitis was given by Runge in 1873. More than 40 different types of treatment have been used alone or in combinations, e.g. anti-inflammatory drugs, steroids, physiotherapy techniques, cast immobilisation, orthosis, surgery and less conventional methods such

Fig. 9.1: Elbow joint—lateral approach

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Intra-articular and Allied Injections34

as radiotherapy, acupuncture and vitamins (Labelle et al. 1992). Recently, extracorporeal shock-wave therapy (ESWT) has been used in tennis elbow. The mobile lithotriper (2000 shock waves at 2.5 bars of air pressure with a frequency of 8–10 Hz—a total of three sittings at an interval of 2 weeks, each lasting for three to four minutes is an effective way of treating tennis elbow and plantar fascitis but it requires, further trials for authentication. However, it is much costly as compared to corticosteroids injection (100 times) and also less effective. By and large injection of corticosteroids alongwith hyaluronidase and local anaesthetic is more effective treatment of tennis elbow. In the elbow region, it is the commonest indication. Infiltration in such cases is done in and around the origin of common extensors from anteroinferior aspect of lateral epicondylar region. The patient lies supine. The elbow is kept in 45 degrees flexion in midprone position. The anteroinferior part of lateral epicondylar region is easily felt. Palpate over the bony region and its adjoining area for locating the maximum tenderness. The most tendor point is directly injected pushing the needle almost up to subperiosteal region. The adjoining areas should also be infiltrated (Figure 9.3). It is better to manipulate at the elbow in the same sitting. Hold the hand of the patient in your right hand in the handshake position. Support the elbow from behind by your left hand. While gently rotating the forearm and flexing/extending at elbow, give a sudden jerky extension to the elbow. You may hear a mild click. Quite often it gives good relief, probably by viture of breaking the fibrotic adhesions.

OLECRANON BURSITISOlecranon bursitis (Figure 9.4) is the inflammation of the bursa overlying the olecranon process caused by repetitive or even acute trauma. It presents as a more or less

Fig. 9.3: Elbow joint—approach of extra-articular tennis elbow

Fig. 9.4: Olecranon bursitis on left elbow

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Elbow Joint 35

round tense, fluctuant (may not be demonstrable), tender swelling. It should be aspirated from the nondependent side (to avoid leakage after withdrawing the needle). Usually no local anaesthetic is required. The aspiration needle is advanced while maintaining negative pressure in the syringe. When the fluid starts flowing in the syringe, the needle is no longer advanced further. If the fluid is clear, the needle should be left in situ and other syringe containing the steroid is changed to inject it slowly after the aspirate stopped flowing. It may prevent recurrence. The fluid should be sent for examination and culture, especially if the fluid is not clear.

MEDIAL EPICONDYLITIS (GOLFER’S ELBOW, PITCHER’S ELBOW, LITTLE LEAGUE ELBOW SYNDROME)It is an overuse syndrome, common in young persons and is caused by chronic tension stress injuries, repetitive tension overloading of the flexor-pronator muscles at or near its origin from the medial epicondyle. When the problem does not improve with non-invasive methods (as noted in lateral epicondylitis) local infiltration of the corticosteroid cocktail should be done in the flexor-pronator muscles origin complex just at and near the medial epicondyle.

MethodPatient lies supine with shoulder abducted (by 90°), elbow flexed by 40° and forearm supinated. The medial epicondyle is palpated and maximum tender point is spotted and marked by skin pencil or nail edge. After preparing the skin antiseptically, the needle is pushed from just below the medial epicondylar tip in the upward and anterior direction. Just before reaching the bone, the medicine is pushed infiltrating the zone.

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