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JOINTS & SOFT TISSUE

INJECTIONS OF THE UPPERLIMB

V Rajaratnam vraj@rcsed.ac.uk

Royal Orthopaedic Hospital &

University Hospital Birmingham

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Why?

Very useful modality and immensely

appreciated by patientsMinimal systemic effect

Maximal Local effects

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PREPARATIONS

soluble - little role in infiltration(e.g., hydrocortisone)

depot - crystalline, bulky, andrelatively impervious to degradingenzymes (methylprednisoloneacetate, triamcinolone acetonide,

triamcinolone hexacetonide)

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Potencies

methylprednisolone acetate has a shorterduration of action (is relatively more soluble) thantriamcinolone hexacetonide.cost of triamcinolone hexacetonide, however, is3-4 times that of methylprednisoloneMethylprednisolone reserved for superficialstructures such as subcutaneous bursae andflexor tendon sheaths, and when there is concernabout tendon rupture, e.g., rotator cuff tendinitis

and retrocalcaneal (Achilles) bursa injections.Triamcinolone hexacetonide - more effective inreducing stubborn synovitis in a rheumatoid knee,wrist, elbow, or shoulder .

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ADVERSE EFFECTS

Post-injection flare

5% of articular infiltrations and a muchlarger proportion of soft tissueinfiltrations .

Rx - single dose of a nonsteroidal anti-

inflammatory drug or with the use of cold packs

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ADVERSE EFFECTS -cont.

Skin atrophy,hypopigmentation,fat pad atrophy, andtendon rupture

All above generally due to poor technique .

Infection rareVasovagalAnaphylaxis rare Rx - epinephrine

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General side effects

Diabetics - transienthyperglycemia,Arterial hypertension,Chronic adrenal suppression,Iatrogenic Cushing's syndrome,Menstrual irregularities,Osteoporosis,Avascular necrosis of bone femoral head, Kienbochs etc

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Technique

Effective sterilization - 70-92%ethyl alcohol or povidone-iodinesolution (Betadine)local anesthetic, e.g., lidocaine 1%or 2%, can be used concomitantlyResting an injected joint for 24-48hours following infiltration helps toconfine the corticosteroid to theinjected site and enhances local

action

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Guidelines for dosage/volume of infiltration

Knee 40-80 mg 3-10mlGlenohumeral joint 40-80 mg 3-10 mlSubacromial bursa 20-40 mg 3-5mlAcromioclavicular joint 10 mg 1-2 mlOlecranon bursa 20 mg 2 ml

Trochanteric bursa 20-40 mg 2-5mlTrigger finger 10 mg 1 ml

Region Dosage (methylprednisolone acetate or triamcinoloneRegion Dosage (methylprednisolone acetate or triamcinoloneacetonide)acetonide)Volume (corticosteroid + lidocaine)Volume (corticosteroid + lidocaine)

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Indications

Chronic tenosynovitisTrigger finger De Quervain`s tenosynovitisGangliaTennis elbowOlecranon bursitisCubital Tunnel SyndromeOA Hand jointsRotator cuff tendinitisSubacromial impingementFrozen shoulder AC joint disease

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Continued

Trochanteric bursitisOA hipAnserine bursitisInfrapatellar bursitisOA kneeAchilles bursaPlantar fasciitisMetatarsalgiaOA Foot and Ankle

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De Quervain`s tenosynovitis

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video

http://dequervans.wmv/http://dequervans.wmv/

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OA Hands

http://f/VIAO%20D%20drive/My%20Documents/My%20Videos/cmc5.WMVhttp://f/VIAO%20D%20drive/My%20Documents/My%20Videos/cmc5.WMV

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CMC OA

CMC Injection video

http://cmc2inj.wmv/http://cmc2inj.wmv/

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Wrist OA

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Carpal Tunnel Syndrome

http://f/VIAO%20D%20drive/My%20Documents/My%20Videos/ctinjection.WMVhttp://f/VIAO%20D%20drive/My%20Documents/My%20Videos/ctinjection.WMV

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Cubital Tunnel Syndrome

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Tennis Elbow

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Differential Diagnosis

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Paraesthesia

CTS video 2Cubital tunnel video

Thoracic outlet syndromeCervical Disc degenerative disease

http://ctinj.wmv/http://ctinj_0001.wmv/http://cubitalinj_0001.wmv/http://cubitalinj_0001.wmv/http://ctinj_0001.wmv/http://ctinj.wmv/

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Traumatic Synovitis PIP J

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ECU Tendinitis

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Trigger Digits

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Trigger finger TRIGGERDIGITS

http://f/VIAO%20D%20drive/My%20Documents/My%20Videos/trigger.WMVhttp://f/VIAO%20D%20drive/My%20Documents/My%20Videos/trigger.WMVhttp://f/VIAO%20D%20drive/My%20Documents/My%20Videos/trigger.WMVhttp://f/VIAO%20D%20drive/My%20Documents/My%20Videos/trigger.WMVhttp://f/VIAO%20D%20drive/My%20Documents/My%20Videos/trigger.WMVhttp://f/VIAO%20D%20drive/My%20Documents/My%20Videos/trigger.WMVhttp://f/VIAO%20D%20drive/My%20Documents/My%20Videos/trigger.WMVhttp://f/VIAO%20D%20drive/My%20Documents/My%20Videos/trigger.WMVhttp://f/VIAO%20D%20drive/My%20Documents/My%20Videos/trigger.WMVhttp://f/VIAO%20D%20drive/My%20Documents/My%20Videos/trigger.WMVhttp://f/VIAO%20D%20drive/My%20Documents/My%20Videos/trigger.WMVhttp://f/VIAO%20D%20drive/My%20Documents/My%20Videos/trigger.WMVhttp://f/VIAO%20D%20drive/My%20Documents/My%20Videos/trigger.WMVhttp://f/VIAO%20D%20drive/My%20Documents/My%20Videos/trigger.WMVhttp://f/VIAO%20D%20drive/My%20Documents/My%20Videos/trigger.WMVhttp://f/VIAO%20D%20drive/My%20Documents/My%20Videos/trigger.WMV

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Digits

Trigger Digits videoOA PIP and DIP video

Synovitis RA, gout

http://triggerrelease_0001.wmv/http://pipjinj.wmv/http://pipjinj.wmv/http://triggerrelease_0001.wmv/

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Ganglion

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Ganglion

AspirateSurgery

Digital BlockDigital Tourniquet

http://aspiration%20ganglion.wmv/http://ganglion.wmv/http://digitalblock.wmv/http://digitaltx.wmv/http://digitaltx.wmv/http://digitalblock.wmv/http://ganglion.wmv/http://aspiration%20ganglion.wmv/

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Thank You

www.handsurgerymanual.com

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