ORTHO INJECTIONS Flashcards
(43 cards)
INDICATIONS FOR INJECTIONS
⦁ Wound Anesthesia ⦁ Osteoarthritis ⦁ Rheumatoid arthritis ⦁ Gouty arthritis ⦁ Synovitis ⦁ Bursitis ⦁ Tendonitis ⦁ Muscle trigger points ⦁ Carpal tunnel syndrome
- injecting into subcutaneous tissue of open wounds
local infiltration
LOCAL INFILTRATION
- injecting into subcutaneous tissue of open wounds
- clean & sterilize wound
- avoid toxic doses of lidocaine
⦁ 4 mg/kg for plain lidocaine
⦁ 7 mg/kg for lido + epi - epi = decreases blood loss / controls bleeding
max doses of lidocaine
⦁ 4 mg/kg for plain lidocaine (jen says 4.5)
⦁ 7 mg/kg for lido + epi
FIELD BLOCKS
- good for superficial lesions, such as skin abscesses
⦁ local anesthesia is not effective and is painful. May spread the infection
- prep skin with betadine or chlorohexidine
- inject slowly while advancing the needle, only go thru the skin twice
DIGITAL BLOCKS
- use 25-27 gauge needle
- each digit is supplied by 4 nerves: 2 dorsal, 2 palmar / plantar
- start dorsally, inject straight down each side of proximal phalanx
⦁ inject as you go - change angle
⦁ Big toe - may need to make a 3rd pass on the dorsal aspect
- Do not use if there is vascular compromise
⦁ be cautious using EPI HERE**
STEROID INJECTIONS
- for inflamed tendon / bursa by a bony prominence (ex: subacromial bursitis - tendonitis)
- inject combo: Lidocaine + Steroid
- indicated for when conservative treatment fails and for diagnosis
Prep skin with betadine swab (3x) or chloroprep (1x) - let dry
- slowly inject into point of maximum tenderness
- advance the needle to bone, then withdraw 2mm
common areas for injections
- Tennis elbow = lateral epicondylitis (pain with resisted wrist dorsiflexion = extension)
- Greater trochanteric bursitis - pain with stretching of lateral side of hip
⦁ Ober’s test
⦁ may need spinal need if bigger pt - Ischial tuberosity bursitis = Weaver’s bottom - pain with resisted knee flexion
⦁ be careful of sciatic nerve
Ober’s test
to identify tightness of the iliotibial band (iliotibial band syndrome)
AFTERCARE FOR TENDONITIS / BURSITIS INJECTIONS
- Rest, Ice, Anti-inflammatories
- Resume conservative treatment, including stretching
TRIGGER POINT INJECTIONS
⦁ Smaller volume ⦁ Inject into areas of tenderness ⦁ Mostly located into upper neck and mid back areas ⦁ Usually just use Lidocaine ⦁ Small needle, and gauge depth. ⦁ Remember skin atrophy and blanching
trigger points are most commonly located
in upper neck and mid back areas
sensitive areas in the muscle or connective tissue (fascia) that becomes painful when compressed
JOINT INJECTIONS
- intra-articular injections with steroids are useful, safe, and cost-effective treatments
- most joint injections are for symptoms of arthritis
⦁ shoulder - also for rotator cuff tendonitis & subacromial bursitis
- for knee, shoulder, AC joint - must know your anatomy
- can also put needles into joints to aspirate (remove synovial fluid - analysis for arthritis or infection)
most joint injections are for symptoms of
arthritis
WHY INJECT JOINTS
- can be joint or soft tissue issue
- inflammation
⦁ could be from degenerative joint disease, bursitis, and tendonitis - corticosteroid injections help decrease inflammatory reaction - limits capillary dilatation & vascular permeability
BASIC PRINCIPLES TO JOINT INJECTIONS
- HX & PE
- try conservative treatment first - NSAIDS, RICE, etc. - continue these treatments after joint injection
- careful patient selection
- informed consent - get signature
- know your anatomy!
- undertake as few injections as possible to settle the problem: q3-4 months
RISKS OF JOINT INJECTIONS
⦁ infections
⦁ soft tissue infection
⦁ acceleration of a septic joint (missed septic joint)
⦁ SubQ atrophy & skin depigmentation - where steroid was injected subcutaneously
⦁ steroid flare: facial flushing in first 24-48 hrs
- clears in 1-2 days - not an allergic reaction!!!
⦁ Exacerbation of diabetes*** - warn patients to monitor their blood sugars (spikes)
⦁ Cartilage damage - happens with repeated serial injections
⦁ Tendon rupture - only if injecting around the tendon
⦁ Allergic reaction
⦁ Anaphylactic reaction - within 5-10 minutes of the injection
CONTRAINDICATIONS TO JOINT INJECTIONS
⦁ Adjacent osteomyelitis
⦁ Evidence of bacteremia or febrile illness
⦁ Hemarthrosis
⦁ Impending joint replacement surgery (scheduled within days)
⦁ Infectious arthritis
⦁ Joint prosthesis
⦁ Osteochondral fracture
⦁ Periarticular cellulitis / severe dermatitis/ soft tissue infection
⦁ Poorly controlled diabetes mellitus
⦁ Uncontrolled bleeding disorder or coagulopathy
⦁ Clotting disorder and anticoagulation(correct before injecting)
- Probably okay if INR < 1.8
⦁ Broken skin or cellulitis over injection site
⦁ Joint infection
⦁ Allergy to local anesthetic or steroid preservative
⦁ Immunosuppressed (by drugs or disease)
INJECT WITH CAUTION IN THE FOLLOWING PATIENTS
o Charcot joint (neuropathic sensory loss)
o Tumor
o Neurogenic disease
o Active infections (ex: TB)
o Hypothyroidism
o Blood dyscrasias
o Diabetics (likely to raise BG levels for several days)
EQUIPMENT NEEDED FOR INJECTONS
Sterile gloves and drapes
Retractable ball point pen
Alcohol wipes
5 Gauze pads (4x4)
Skin prep solution
Lidocaine 1%
Steroid of choice
Syringes….3ml,5ml, 20 ml, 30 ml, 60 ml
Needles….18 or 20 G and 25 or 27 G
- Morbidly obese patients may require a 21 G spinal needle for arthrocentesis
Hemostat
Specimen tubes
Bandage
INFORMED CONSENT - PATIENT EDUCATION
- Risks ⦁ infection ⦁ bleeding ⦁ allergic reaction ⦁ pain
- Benefits
⦁ simple office procedure
⦁ may provide relief for patients that are too frail for definitive treatment - Realistic Expectations
⦁ may not help or may only help for limited amount of time
⦁ may have increased pain for 1-2 days after injection
⦁ may take several days to take effect
ANESTHESIA PRIOR TO JOINT INJECTION
- often warranted - good idea!
- after skin prep / draping / identification of needle insertion site, use 25-27 gauge needle to inject 2-5 mL of local anesthetic into subcutaneous tissue
⦁ OK if you enter joint space; will have minimal effect to alter synovial fluid analysis results
⦁ Biggest concern = introducing bacteria while injecting anesthetic
biggest concern of anesthetic injection prior to steroid + lido injection
introducing bacteria while injecting anesthetic
STEROIDS FOR INJECTIONS
- some take effect faster, others take and therefore last longer
- short acting preparations (soluble)
⦁ Hydrocortisone
⦁ Prednisolone - long acting preparations (depot steroids)
⦁ Kenalog (triamcinolone acetonide): 40mg / large, 30mg / medium, 10mg / small
⦁ Depo-Medrol (methylprednisolone)
⦁ Decadron (dexamethasone) - Combination preparations (soluble + depot)
⦁ Celestone Soluspan - Half life of intra-articular injections - can give months of relief
⦁ Depo Medrol = 6 days
⦁ Kenalog = 22 days
