Joint Injections Workshop.RNZCGP Conference 2011

Dr Francesco LentiniFRNZCGP

CARPAL TUNNEL SYNDROMEANATOMY

The carpal tunnel is formed by the carpal bones dorsally, and the transverse carpal ligament (Flexor Retinaculum), ventrally. The contents of the tunnel include the Median Nerve and flexor tendons of the hand. The median nerve sensory and motor distribution includes the palmar aspect of the thumb and the index and middle fingers, and it allows opposition of the tip of the thumb with the tips of the fingers.

Carpal Tunnel syndrome-Diagnosis-

Diagnosis of carpal tunnel syndrome is clinical. Electro-diagnostic studies (nerve conduction and electromyography) may assist in confirming the diagnosis. Weakness of thumb abduction is a specific and reliable sign.

Tinel’s test: Percuss lightly over the Flexor Retinaculum with a tendon hammer between the Palmaris Longus and the Flexor Carpi Radialis > tingling sensation in Median nerve distribution.

Phelan’s test: Hold wrist in flexion for up to 1 min > Pain and paraesthesia

Carpal Tunnel SyndromeIndications for injection

The major indication for carpal tunnel injection is the syndrome of median nerve compression, which may result from osteoarthritis, rheumatoid arthritis, diabetes mellitus, hypothyroidism, repetitive use injury or other traumatic injuries to the area.

Carpal Tunnel SyndromeIndications

The use of local corticosteroid injection for CTS has been shown to provide greater clinical improvement in symptoms one month after injection, compared with placebo. Injection of the CT is considered a later modality after appropriate nonsurgical therapeutic interventions have been undertaken. These include the use of NSAIDs, splinting, and avoidance of precipitating activities.

Carpal Tunnel SyndromeInjection Landmarks

Essential landmarks to palpate before performing this injection include the proximal wrist crease and the Palmaris Longus Tendon when present. The Palmaris Longus Tendon is best identified by having the patient pinch all the fingertips together while the wrist is in a neutral position.

Carpal Tunnel SyndromeMaterials + Pharmaceuticals

Syringe: 5 Ml Needle: 25 gauge, 1.5 inch Anaesthetic: 2-3 Mls of 1% Lidocaine Cortico-steroid: 1 Ml

Methylprednisolone, 40 Mg in 1 Ml

Carpal Tunnel SyndromeApproach and needle entry

The injection is performed at a site just ulnar to the Palmaris Longus Tendon and at the proximal wrist crease. The needle is inserted at a 30-degree angle and directed toward the ring finger. If the needle meets obstruction or if the patient experiences paraesthesia, the needle should be withdrawn and re-directed in a more ulnar fashion.

Carpal Tunnel SyndromeInjection Site

1st Carpo-Metacarpal JointAnatomy

The movements of the thumb are dictated by the saddle-shaped articular surface of the base of the first metacarpal, which articulates with the trapezium.

1st CMC JointIndications and diagnosis

Pain associated with arthritis or overuse is the most common indication for injection of this joint. Diagnosis is determined by limitation of motion and palpation of crepitus and tenderness over the joint. Diagnosis may be confirmed by radiographs. Injection is usually performed after other more conservative therapies, including use of NSAIDs and a brief period of immobilization, have been tried. As with any arthritic joint, relief after injection may only be temporary, and surgical intervention may need to be considered.

1st CMC JointApproach and needle entry

Palpate the joint space between the Trapezium and the First Metacarpal.

The needle enters just proximal to the first metacarpal on the extensor surface. Care must be taken to avoid the Radial Artery and the Extensor Pollicis tendons. To avoid the radial artery, the needle should enter toward the dorsal (ulnar) side of the Extensor Pollicis Brevis tendon. The needle should fall into the joint space. Traction can be applied to the thumb to further open the joint space.

1st CMC JointMaterials + Pharmaceuticals

Syringe: 3 Mls Needle: 25 Gauge, 1 inch Anesthetic: 0.5 Ml of 1% Lidocaine Cortico-Steroid: 0.5 Ml of

Methylprednisolone 40 Mg/1 Ml

1st CMC Joint

de Quervain’s DiseaseAnatomy

This disorder, a stenosing tenosynovitis, involves the Abductor Pollicis Longus and Extensor Pollicis Brevis tendons.

de Quervain’s DiseaseIndications and Diagnosis

Usually occurs with repetitive use of the thumb. Thickening is noted, and tenderness is elicited just distal to the radial styloid process over the site of the involved tendon sheath. The Finkelstein test is performed by having the patient make a fist with the thumb inside while simultaneously ulnar deviating the hand. Pain over the affected area is elicited in dQD

de Quervain’s Disease

Immobilization and the use of NSAIDs should be tried before injection therapy is performed.

De Quervain DiseaseInjection Approach

With the thumb abducted and extended, palpate the course of the tendons distal to the radial styloid process. The needle is placed into the first extensor compartment, directed proximally toward the radial styloid process and sliding in parallel to the abductor and extensor tendons. Do not inject directly into a tendon.

de Quervain’s DiseaseMaterials + Pharmaceuticals

Syringe: 5 Ml Needle: 25 gauge, 1.5 inch Anaesthetic: 2 Mls of 1% Lidocaine Cortico-steroid: 1 Ml

Methylprednisolone, 40 Mg in 1 Ml

de Quervains Disease

Knee JointAnatomy

Two functional joints, the femoral-tibial and the femoral-patellar, make up the knee. Primary stabilizers of the knee are the anterior and posterior cruciate ligaments, the medial and lateral collateral ligaments, and the capsular ligaments.

Knee JointIndications for Aspiration

Unexplained effusion, possible septic arthritis and relief of discomfort caused by an effusion.

Knee JointIndications for injection

The use of intra-articular corticosteroids is reserved for patients with more advanced disease (osteoarthritis and other non-infectious inflammatory arthritides such as gout) and after other modalities have been tried.

Knee JointPosition and Landmarks

Position of Patient: The patient is in the supine position with the knee slightly flexed with a pillow or rolled towel in the popliteal space.

Palpation of Landmarks: Identify the medial, lateral, and superior borders of the patella.

Knee Joint Techniques

There are many different techniques for aspirating or injecting the knee. These include medial, lateral, and anterior approaches. Each has its own merit, but choice of approach is dependent on physician preference

Knee JointMaterials + Pharmaceuticals

Syringe: 50 Mls for Aspiration; 10 Mls for Injection

Needles: 18, 20 or 22 gauge. 1.5 inch Anaesthetics: 5 Mls 1% Lidocaine. Cortico-steroid: 2-3 Mls of

Methylprednisolone 40 Mg/1 Ml.

Knee JointApproach and needle entry

The lateral approach is most commonly used. For this approach, lines are drawn along the lateral and proximal borders of the patella. The needle is inserted into the soft tissue between the patella and femur near the intersection point of the lines, and directed at a 45-degree angle toward the middle of the medial side of the joint.

Knee JointApproach and needle entry

Knee JointApproach and needle entry

For the medial approach, the needle enters the medial side of the knee under the middle of the patella (midpole) and is directed toward the opposite patellar midpole.

Knee JointApproach and needle entry

In the anterior approach, the knee is flexed 60 to 90 degrees, and the needle is inserted just medial or lateral to the patellar tendon and parallel to the tibial plateau. This technique is preferred by some physicians for its ease of joint entry in advanced osteoarthritis. However, the anterior approach may incur greater risk for meniscal injury by the needle.

Joint injectionsFollow up care

Following injection, the joint or injected region may be put through passive range of motion. The patient should remain in the office for 30 minutes after the injection to monitor for any adverse reactions. Avoid strenuous activity involving the injected region for several days. Patients should be cautioned that they may experience worsening symptoms during the first 24 to 48 hours related to a possible steroid flare, which can be treated with ice and NSAIDs. Instruct against the application of heat. A F/u appointment should be scheduled within three weeks.

THANK YOU

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