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ORTHOPEDIC OFFICE INTERVENTIONS

By Steve Benz M.D.

Objectives of this discussion

•  Learn about injections and castings that you can perform in your clinic setting.

•  Learn about the agents that you can inject. •  Learn about the specific diagnosis and

treatment options that are amenable to injections.

•  Practice injection and casting techniques.

Why me?

•  Board certified orthopedic surgeon. •  Went to medical school here at St. Louis U. •  President of Tesson Heights Orthopedics in

south St. Louis County. •  My wife is on faculty here and is on the

planning committee for this conference.

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Injectible agents

•  Cortisone (Corticosteroids) •  Local anesthetics •  Viscosupplementations (Hyaluronic Acids) •  PRP (Platelet Rich Plasma)

Cortisone

•  A very close derivative of cortisol. Cortisol is a glucocorticoid that is produced in the adrenal gland. Two of its effects; suppression of the immune system and increase blood sugar.

•  May be PO (Prednisone), IV (Solu Medrol), or injectible (Depo Medrol, Dexamethesone)

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Cortisone continued

•  Are they just a pain reliever? NO!!! They are treatment to reduce an inflammatory response.

•  Are they just temporary? Sometimes like when used to treat an arthritic joint. But they can be a permanent fix for things like bursitis or tendonitis.

Cortisone advantages

•  Remove and analyze fluid when combined with aspiration.

•  Avoid the generalized side effects of NSAIDS.

•  Rapid, dependable onset of action.

Cortisone side effects

•  Cortisone flair – a crystallization of the cortisone causing a 1-2 day worsening of the pain. Seen mostly when injected into tendons.

•  Depigmentation if injected into the dermal layer •  Infection (rare if you use an alcohol pad) •  Transient increase in the blood sugar of diabetics •  Repeated injections can cause necrosis of subdermal

tissue, rupture of tendons, or injury to articular cartilage. Never give more than 2-3 injections.

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Local anesthetics

•  Lidocaine (Xylocaine) •  Marcaine (Bupivacain)

Lidocaine

•  Very old…First made in 1945 and been available for clinical use since 1949.

•  Use the 0.5 – 1.0% and don’t use epi with it.

•  Half life is 90 minutes to 2 hours. •  The chance of systemic side effects are very

rare if used locally in modest amount. •  Can be mixed with the cortisones.

Marcaine

•  Also called sensorcaine •  Use the 0.25 – 0.50% without epi. •  Can be very cardiotoxic which is why the

don’t use it for iv regional anesthetic. •  Has a long half life (2-7 hours). •  Can be mixed with the cortisones.

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Viscosupplementations

•  These are injections in the knee joint. •  Also known as Hyaluronic Acids. •  Five brand names: Synvisc, Euflexa,

Hyalgen, Orthovisc, and Supartz. •  Derived from rooster’s combs.

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Visco (cont.)

•  How do they work? •  In patients with osteoarthritis the synovial

fluid has a lower concentration of Hyaluronan. This is a polymer that increase the lubrication and viscosity of the fluid. This medication will reverse that somehow for a period of time,

Visco (cont.)

•  They’ve been around since 1997. •  May take up to one month for it to work and

should last for 6 months to a year. •  Minimal side effect except for some

instances of psuedo infections especially with Synvisc.

PRP

•  Platelet Rich Plasma •  This is plasma that has a high concentration

of platelets. It is taken from the patient’s own blood that is centefuged down. This fluid has a high concentration of growth factors. It can be injected into tendons or joints.

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PRP

•  Usually takes 1-6 visits for a treatment •  The literature is somewhat ambiguous as to

its support of prp’s results. •  Most insurance companies don’t pay for it. •  I believe there will be a lot of research

favoring its use and that it will become main stream.

Sites of Injections

•  Tendons – tennis elbow, trigger fingers •  Bursas – shoulder, greater trochanter •  Inflamed bursas – olecranon, pre patella •  Joints – knee •  Ganglion Cysts •  Nerves – Morton’s neuromas, CTS

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Generalities

•  Always use sterile technique – either alcohol or betadine.

•  Draw the fluid into the syringe with an 18 gauge needle, then switch to the needle you will inject. It is easier and more sterile.

•  You can mix the anesthetic agent and the cortisone.

Subacromial Bursitis

•  Also known as impingement syndrome •  Inflammation of the bursa between the

acromium and the supraspinatis tendon of the rotator cuff.

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Subacromial Bursitis (cont.)

•  Usually middle age, insidious onset of pain to the anterior lateral aspect of shoulder and deltoid, no history of trauma, pain with sleeping and overhead use.

•  Physical exam shows FROM of shoulder, positive impingement tests, possible rotator cuff weakness.

•  MRI shows some rotator cuff tendonitis but no tear and some bursitis.

Subacromial Bursitis (cont.)

•  Treatment: •  First try NSAIDs and physical therapy. •  If no better try an injection of cortisone.

Injection Technique •  Use 1 ml of depomedrol (40mg.) and 2 ml of 0.5%

Lidocaine in a 5 ml syringe with a 21 gauge needle.

•  Have the patient sitting up on the table and stand behind her/him.

•  Find the posterior lateral corner of the acromium. Go 1-2 cm inferior and 1-2 cm medial to it. You should feel a soft spot. Insert the needle pointing to what you think is the center of the acromium (point the needle a little up).

•  Inject. It should flow smoothly.

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Lateral Epicondylitis

•  “Tennis elbow” – can be very painful •  Usually insidious onset without trauma •  Point tenderness to the lateral epicondyle,

made worse when they extend the elbow and dorsiflex the wrist.

Lateral Epicondylitis

•  Treatment: •  NSAIDs and bracing (give it time) •  Cortisone injection.

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Injection Technique

•  Use 1 ml of Depomedrol (40mg.) and 1 ml of 0.5% lidocaine in a 5 ml syringe with a 21 gauge needle.

•  Have the patient supine with the elbow flexed at her side resting on the table with her hand across her abdomen.

•  Palpate the spot that hurts the most. Inject right to the bone and then extend distal down the proximal 2 cm of the extensor tendon.

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Olecranon Bursitis

•  Inflamed and swollen bursa on back of elbow. •  Differentiate between inflamed and infected. •  If you think it is inflamed you can treat with

activity modification and NSAIDs. •  If you think it is infected, aspirate and culture, •  If it is inflamed and the patient wants

something done. Aspirate and inject with cortisone.

Technique for asp/inj

•  Have patient prone on the table with the involved arm at his side and the elbow hanging over the table. This will make it very accessible to you.

•  Aspirate where you feel the fluid with an 18 gauge needle (for thicker fluid) and a 20 ml syringe. Once all the fluid is out you can add some cortisone if you feel there is no infection. Just undo the syringe while you leave the needle in place. Put on a 3 ml syringe that you have 1 ml of Depo in and inject.

•  Hold pressure on it. It will bleed. •  Fluid should be sent for gram stain, c and s, and crystals

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Dorsal wrist ganglion

•  Swelling on the dorsal side of the wrist. Typically between the lunate and the radius.

•  It will feel firm but not hard like a bone. •  Treatment is to leave it alone, aspirate, or excise. •  Aspiration is very safe but the recurrence rate is

about 90%. •  Don’t aspirate the volar ones because of the

proximity of the radial artery.

Technique for aspiration

•  Have the patient supine. •  Infuse about 1 ml of 0.5% lidocaine with a 25

gauge needle just under the skin next to the cyst. •  Hold the hand and piece it with an 18 gauge

needle on a 10 ml syringe. You can feel it pierce the cyst. As you pull back on the syringe, push down on the cyst. It will fill the syringe with clear jelly like substance.

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De Quervain’s Tendonitis

•  Point tender to the first extensor compartment at the wrist (at the radial styloid).

•  Positive Finkelstein’s test. •  Treat with NSAIDs. If not better in three

weeks, inject with cortisone.

Injection Technique •  Draw up 1 ml of Depomedrol (40mg) and 1 ml of 0.5%

lidocaine in a 3 ml syringe. Use a 25 gauge needle to inject.

•  Have the patient supine with her arm at her side. •  Infuse the cortisone/lidocaine right into the tendon

sheath. You may feel a pop as it travels up the sheath. •  After you finish, test the Finkelstein’s again. This

should now be neg because of the lidocaine. That will be diagnostic.

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Trigger finger

•  Usually middle age or older patient. •  Presents with a catching of the finger or thumb.

It will seem like the PIP joint is not working. •  Will have pain at the volar side of the MP joint. •  Treat with NSAIDs and after three weeks if that

doesn’t work give a cortisone injection. •  The shot will have a 50/50 chance of working.

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Injection Technique

•  Draw up 1 ml of Depomedrol (40mg) and 1 ml of 0.5% Lidocaine in a 3 ml syringe with a 25 gauge needle on it.

•  Have the patient supine with the arm at the side. •  Give the shot right where it hurts over the MP joint. It

will feel firm when you hit the tendon and the sheath. Inject it all over there. Tell the patient that the finger may get numb because the digital nerve is so close, but it’s only temporary.

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Trochanteric Bursitis

•  Usually a middle age or older patient. •  c/o insidious onset of pain to the lateral

aspect of the greater trochanter. •  May radiate a bit down the illiotibial band. •  Very painful when you lay on it. •  Initially treat with NSAIDs and PT. •  Cortisone shots may help the difficult ones.

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Injection Techniques

•  Draw up 1-2 ml of Depomedrol and 3-4 ml of 0.5% lidocaine in a 10 ml syringe with a 21 gauge needle on it.

•  Have the patient lie lateral decubitus on the table with the painful side up.

•  Inject right into the painful site all the way to the bone if you can and then spread it around.

•  For obese patients, you may need a spinal needle.

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Knee arthritis

•  Middle age to older. •  Insidious onset of pain with no specific trauma. •  May be generalized pain or greater on one side. •  No locking or giving out. More painful with

activity. •  May have an effusion, may see genu varus or

valgus.

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Knee DJD

•  Always obtain a weight bearing AP, weight bearing AP with flex, lateral, and Sunrise x-rays.

•  MRI is not needed all the time. •  Treat initially with NSAIDs. Then progress

to aspiration and injection.

Asp/Inj Techniques

•  You will need 3 syringes: •  1st – empty 60 ml syringe with 18 gauge

needle. •  2nd – 3 ml syringe and 25 gauge needle with

0.5% lidocaine. •  3rd – 3 ml syringe with 1 ml of Depomedrol

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Knee Asp/Inj

•  Have the patient supine on the table. •  Your target will be just posterior to the patella going mid

lateral. •  Inject the lidocaine in the area of the stick. Then inject

the 60 ml syringe and aspirate as much as you can (you may need to get a second 60 ml syringe). Save some fluid.

•  Keep the needle in the joint switch to the depomedrol and inject it in.

•  Send the fluid for c and s, gram stain, crystals, cell count

Prepatellar Bursitis

•  Inflamed or infected swelling of the prepatellar bursa.

•  Often times some history of trauma. •  If there is no indication of infection, you

can just observe it.

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Asp/Inj Techniques

•  Have the patient supine on the table. •  Aspirate with an 18 gauge needle and a 20

or 60 ml syringe. •  Milk the fluid out. Send for c and s, gram

stain, and crystals. •  If no infection, switch needles and inject 1

ml of Depomedrol

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Morton’s Neuroma

•  Inflammation of the digital nerve just proximal to the mp joint of the foot.

•  Presents as foot pain in middle age or older patient •  It will occur in either the web space between toes

2-3 or between toes 3-4. It is VERY point specific pain. May have distal numbness.

•  Lidocaine and cortisone injections are perfect.

Injection Technique

•  Have the patient supine. •  Have 1 ml of Depomedrol 40 mg and 1 ml of 0.5%

Lidocaine in a 3 ml syringe with a 25 gauge needle. •  With your left thumb feel the spot of maximum

tenderness on the dorsal side and inject there. Have your left index finger on the plantar side and stop advancing when you can feel the pressure.

•  The anesthetic should give you 100% of pain relief for a short time. (this is diagnostic)

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Plantar Fasciitis

•  Point tender under the calcaneus, •  Feels like a dull nail •  Bad when you first get up in the morning and after

you’ve been sitting for a while. •  Treat with NSAIDs, stretching first and heel cups •  If that doesn’t help, do an injection.

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Injection Technique

•  In 3 ml syringe with a 25 gauge needle have 1 ml of depomedrol (40 mg) and 1 ml of 0.5% lidocaine.

•  Inject it into the most painful spot on the plantar aspect of the foot.

•  Don’t be afraid to go all the way to bone.

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CPT Codes and Reimbursements

•  Aspirations and/or injections are the same •  Fingers/toes #20800 $50 •  Wrist/ankles/elbow #20805 $56 •  Shldr/hip/knee #20810 $75

•  Ultrasonic Guidance #76942 $142-$198

CPT Codes and Reimbursements

•  Dopo Medrol J1030 $4 •  Orthovisc J7324 cost is $98

reimbursement is $195 •  Synvisc One J7325 cost is $488

reimbursement is $750

Break Time

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Casting

•  Short arm – distal to the elbow. •  Short leg – distal to the knee.

Short arm cast

•  Have the patient sitting upright on the table with his arm extended. Have him hold his wrist like he had a quarter in his open palm that he didn’t want to drop.

•  Put on plenty of stockinet (cover the fingers and go to the elbow, it will be folded back).

•  Cover evenly with web roll (2 inch). Don’t impinge the elbow and make sure the MP joint is free.

•  Use 2 2inch rolls. Put the first one on, fold down the stockinet and then put the second one on.

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Short leg cast

•  Have the patient on the table on his stomach with his knee flexed at 90 degrees. This will put the foot in the air. Have an assistant hold the foot and ankle in a neutral position.

•  Put on a stockinet from the knee to the toes. •  Use 3 inch web roll. Make sure you cover the

metatarsal heads. There is a tendency to not cover enough of the foot.

Short leg cast (cont.)

•  Start with a 3 inch roll around the foot and ankle. Next roll a 4 inch roll from the ankle up the entire leg. Then fold the stockinet down. Finish with a four inch roll from the top all the way to the bottom.

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Thank you for your attention

Let’s try some casting