joint injection workshop - kentucky academy of physician ...kentuckypa.org › ... ›...
TRANSCRIPT
![Page 1: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/1.jpg)
KAPA2017MusculoskeletalAspirationand
InjectionWorkshopW.ScottBlack,MD
PhysicianAssistantStudiesProgramUniversityofKentucky
![Page 2: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/2.jpg)
Aspiration
• Relativelyquickandinexpensive• Canbeperformedintheoffice• Helpsdifferentiateinflammatoryfromnon-inflammatoryarthritis
• Helpsestablishdiagnosisofcrystal-depositionarthritisandsepticarthritis
![Page 3: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/3.jpg)
ReasonstoAspirateaJoint
• Patientwithinflamedjoint(orjoints)whodoesnothaveanestablisheddiagnosis
• Anyacutemonoarthritis• Anytimethereisanysuspicionofaninfectedjoint
• Serialaspirationsforpainrelief• Priortoinjectionofcorticosteroidsorhyaluronicacidpreparation
![Page 4: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/4.jpg)
ReasonsNot toAspirateaJoint
• Bacteremia(?)• JointProsthesis(?)• OverlyingSkinandSoftTissueInfection• UncontrolledCoagulopathy• SevereOverlyingDermatitis• UncooperativePatient(?)
![Page 5: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/5.jpg)
Wouldyouaspiratethatknee?
• 27y/omale• 3dayh/oflu-likeillness– Fever– Chills– Bodyaches
• Kneered,hot,andswollenX24hours
• Fever102.5inyouroffice
![Page 6: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/6.jpg)
Whataboutthatknee?
• 64y/omale• HypertensionandNIDDM
• Acuteonsetkneeswellingandpain
• Low-gradesystemicsymptoms
• Temp99.9
![Page 7: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/7.jpg)
Goutvs.SepticJointvs.Other???
![Page 8: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/8.jpg)
Isthatelbowinfected?
![Page 9: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/9.jpg)
EvaluatingJointFluid
• PhysicalCharacteristics:Appearance,Color,Viscosity
• ChemicalAnalysis:Glucose,Protein• MicroscopicEvaluation:CellCountandDifferential,CrystalAnalysis
• MicrobiologicEvaluation:GramStainandCulture(mayneedtobeveryspecific)
• SerologicandCytologicalEvaluation
![Page 10: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/10.jpg)
SynovialFluid
• Iusuallyaskfor:– CellCountandDifferential– CrystalAnalysis– GramStainandCultureif
suspiciousforsepticjoint
• Checkwithyourreferencelabforappropriatecollection,storage,andhandlingofsynovialfluid
![Page 11: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/11.jpg)
SynovialFluidAnalysis
Palmer&Toombs.JAmBoardFam Pract 2004;17:S32-42.
![Page 12: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/12.jpg)
CommonMusculoskeletalInjections
Cardone &Tallia.AFP2002;66:283.
![Page 13: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/13.jpg)
CommonMusculoskeletalInjections
Cardone &Tallia.AFP2002;66:283.
![Page 14: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/14.jpg)
CommonAdverseEffect:SkinHypopigmentationandSQTissueAtrophy
![Page 15: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/15.jpg)
CommonMusculoskeletalInjections
• WhotoInject– ProperDiagnosis/Reason
• WhattoInject– UsingtheRightMedication/Combination
• HowtoInject– CorrectProcedure– GetMedicationWhere ItisSupposedtoGo
![Page 16: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/16.jpg)
Foster,etal.AFP2015;92(8):694-699.
![Page 17: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/17.jpg)
WhattoInject• Lesssolublecorticosteroidpreparationstendtohavea
longerdurationofactionbutagreaterincidenceofcutaneoussideeffects
• MostcommonlyusedcorticosteroidsatUKaretriamcinoloneandmethylprednisolone– Kenalog-10orKenalog-40andDepo-Medrol40orDepo-Medrol
80• Thecorticosteroidisfrequentlymixedwithalocal
anesthetic– Manufacturersoftenrecommendagainstmixing– Someconcernaboutcartilagetoxicity– Lidocaine (Xylocaine)1%or2%– Bupivacaine(Marcaine)0.25%or0.5%
![Page 18: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/18.jpg)
Subacromial Injection
• Indications– Subacromial Impingement– ChronicRotatorCuff
Tendinopathy– Subacromial Bursitis– AdhesiveCapsulitis
• Evidenceisfair• Probablyshouldthinkof
thismoreasanadjuvanttoPhysicalTherapy
![Page 19: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/19.jpg)
Subacromial Injection• 10mlsyringe• 23-25g1½”Needle• Kenalog orDepo-Medrol
(40– 80mg)• Around6-8ml1%
lidocaine,0.25%bupivacaineor50:50mix
• Posterolateral approach– Aboutonefingerbreadth
belowposteriorcornerofacromion
– DirecttowardACjoint
![Page 20: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/20.jpg)
Ultrasound-GuidedSAInjection
![Page 21: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/21.jpg)
TennisElbow• Chronicoveruseinjuryof
theECRBandEDC• Tendinosis vs.Tendinitis
– Tendinopathy– LateralEpicondylaglgia
• Lessfrequentlyanacuteinjury
• Injectionmayprovidebettershort-termpainreliefbutnoadvantagelong-term
• Again,probablybesttoconsiderasanadjuvanttotherapy
![Page 22: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/22.jpg)
TennisElbow
• 5mlSyringe• 25g1”Needle• 40mgKenalog orDepo-Medrol
• 2-4ml1%lidocaine or0.25%bupivacaine
• Anybenefittofenestration?
• AutologousbloodandPRP?
![Page 23: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/23.jpg)
US-GuidedTennisElbowInjection
![Page 24: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/24.jpg)
TennisElbow
Smidt,etal.Lancet2002;359:657-62
![Page 25: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/25.jpg)
OlecranonBursaAspiration/Injection
• Importanttoaspirateifconsideringsepticbursitis
• Shouldnotinjectcorticosteroidsintoasepticbursitis
• SterileTechnique• Findboggy/tenseareaof
bursa• Mayneed21gneedle(or
larger)foraspiration• Localanestheticinfiltration
reducesdiscomfort
![Page 26: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/26.jpg)
ElbowJointAspiration/Injection
• Aspirateeffusionifsepticjointsuspected
• Aspiratehemarthrosisafterradialheadfracture
• Landmarks:– LateralEpicondyle– RadialHead– OlecranonProcess
![Page 27: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/27.jpg)
DeQuervain’s Tenosynovitis
• Tendinopathy oftheAPLandEPBintheFDCofthewrist
• RespondswelltoCSI• FinkelsteinTest
![Page 28: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/28.jpg)
InjectionforDeQuervain Syndrome
• Tuberculin/AllergySyringe(1ml)
• 27g½”needle• 0.25mlKenalog-40orDepo-Medrol40(10mgCS)
• 0.75ml1%lidocaine or0.25%bupivacaine
![Page 29: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/29.jpg)
InjectionforDeQuervain Syndrome
![Page 30: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/30.jpg)
TriggerFingerInjection
![Page 31: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/31.jpg)
TriggerFingerPathophysiology
![Page 32: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/32.jpg)
TriggerFingerInjection
• 3mlSyringe• 25gneedle(5/8”to1”)• 10– 20mgofKenalog orDepoMedrol
• 0.5– 1.5ml1%lidocaineor0.25%bupivacaine
![Page 33: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/33.jpg)
GreaterTrochanter• GreaterTrochanteric“Bursitis”• GreaterTrochanterPain
Syndrome– 5-10mlsyringe– 22-25gneedleatleast1½”
long– Mayneedspinalneedle– 40mgDepo-MedrolorKenalog– 5-7ml1%lidocaine or0.25%
bupivacaine– Sometimesuseguideneedle
andspinalneedle– Insertatpointofmaximum
tendernessandgotobone
![Page 34: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/34.jpg)
GreaterTrochanterPain
![Page 35: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/35.jpg)
KneeJointAspiration/Injection
• ReasonstoAspirate– Undiagnosedeffusion– Suspicionforsepticjoint– Improvepainbydecompressinglargepost-traumaticeffusion
• ReasonstoInject– Arthritis
![Page 36: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/36.jpg)
KneeJointAspiration/Injection• 10mlsyringeforinjection• Mayneedmuchlargersyringe
foraspiration(30-60ml)• 23-25g1½”needlefor
injection• 21gneedle(orlarger)for
aspiration• Kenalog /Depo-Medrol40-80
mg– DextroseProlotherapy?
• 1%lidocaine or0.25%bupivacaine5-8mlor50:50mix
![Page 37: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/37.jpg)
KneeInjection/AspirationLateralApproach
![Page 38: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/38.jpg)
KneeInjectionAnteriorApproach
![Page 39: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/39.jpg)
AnkleJointAspiration/Injection• Aspirationismuchmore
usefulthaninjection• OAoftheanklemayhave
differentpathophysiologythanthatatthekneeandhip
• 10mlsyringe(mayneed30-60ifaspiratinglargeeffusion)
• 20– 25g1½”needle• 40mgKenalog orDepo-
Medroldilutedin3-5mlanesthetic
![Page 40: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/40.jpg)
AnkleAspiration/Injection
• AnterolateralApproach– Betweenthelateralmalleolusandthelateralborderoftheextensordigitorum longus
• Anteromedial Approach– Betweenthemedialmalleolusandthemedialborderofthetibialis anterior
![Page 41: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/41.jpg)
PlantarFasciaInjection• Plantarfasciaisrelatively
toughbandofconnectivetissuedescribedasoriginatingatthemedialcalcanealtuberosityandinsertingintofivebandssurroundingthedigitaltendons
• WindlassMechanismofFoot
• SupportsMedialLongitudinalArch
![Page 42: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/42.jpg)
PlantarFasciaInjection• Plantarfasciitis?• ChronicHeelPain
Syndrome• 3-5mlsyringe• 25g1½’”needle• 20mgKenalog orDepo-
Medroldilutedin2½to3½mllocalanesthetic
• MedialApproach• Avoidinjectingthrough
plantarfoot
![Page 43: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/43.jpg)
FirstMTPJoint
• Gout• OA• TurfToe• 1– 3mlSyringe• 25– 27g1”Needle• 10– 20mgKenalog orDepo-Medroldilutedin1– 2mllocalanesthetic
![Page 44: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/44.jpg)
FirstMTPJoint
• Approachfromdorsomedial sideofjoint
• Angleneedleabout60degreesandenterfromproximaltodistaltofollowcontourofjoint
• Distractiononthegreattoecanhelpopenupjointmakingentryeasier
![Page 45: Joint Injection Workshop - Kentucky Academy of Physician ...kentuckypa.org › ... › Black-JointInjectionWorkshop.pdf · Tennis Elbow • Chronic overuse injury of the ECRB and](https://reader034.vdocuments.net/reader034/viewer/2022042316/5f049b407e708231d40ecdde/html5/thumbnails/45.jpg)
JointInjection&Aspiration
• Thanks• Questions???