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Pearls in Injection Therapies for Musculoskeletal

Disorders and Conditions

Frank Caruso DMSc, PA-C, EMT-P

Skin, Bones, Hearts & Private Parts

2019

Educational Objectives

• Recognize signs, symptoms of musculoskeletal disorders that may require injection therapies– Using evidence-based medicine to decide when injection therapy

is indicated

• Understand what materials may be injected safely and where

• Learn the complications and precautions in providing injection therapies

• Understand how to perform a proper physical examination

• Review and reinforce proper technique for joint and soft tissue injections and aspirations

• Understand how to properly dispose and or analyze any aspirations performed to treat musculoskeletal conditions

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Injection Therapy

Tools of the Trade!

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Injection Therapy

• Adjunctive therapy

• Short – intermediate pain/functional relief

• Describe indications and contraindications

• Select equipment/products for injection or

aspiration

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Injection:

• Illustrate pertinent anatomic

landmarks for each

procedure

• Demonstrate safe and

effective technique

• When to refer to a

subspecialist

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Injections/Aspirations

• Diagnostic

• Therapeutic treatment

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Therapeutic Injections

• Crystalloid arthropathies

• Synovitis

• Rheumatoid arthritis

• Osteoarthritis

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Soft Tissue Indications

• Bursitis

• Tendonitis/osis

• Epicondylitis

• Trigger Points

• Ganglion Cysts

• Neuromas

• Nerve entrapment syndromes

• Fasciitis

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• Infected tissue/septic patients

• Critical weight bearing tendons

• Achilles tendon

• True allergy

• Uncooperative patient

• Lack of informed consent

• Prior severe steroid flare

• Joints with arthroplasty

Contraindications to Injection

Therapy

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Contra-Indications Injection

• Fracture site: can delay healing

• Children – injectable lesions that are not

due to systemic arthropathy are very rare

under the age of 18 years

• Reluctant patient – no informed consent

given

• Gut feeling!!

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Relative Contra-indications

• Stay away from arteries, nerves or pleural surfaces

• Brittle diabetes

• History of avascular necrosis

• Immunocompromised states

• Large tendinopathies: e.g. tendo-archilles, infra-patella tendon

• Psychogenic pain

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Safety

• Universal precautions

• Aseptic technique

• Know your landmarks

• Always attempt to aspirate

before injecting anything!

• Don’t inject tendons directly –

inject around the tendon

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Aseptic Technique

• Physical exam: mark injection site – check three times!!

• Clean injection site with appropriate cleanser and allow to dry

• Wash your hands/allow to dry

• Use pre-packed, in-date, sterile, disposable needles and syringes

• Use single-dose ampoules or vials, then discard

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Aseptic Technique

• Change needles after drawing up

• Place on gloves

• Do not touch the skin after marking and cleansing the site

• Do not guide the needle with your finger

• Always aspirate before injecting

• Wipe clean

• Sometimes massage the area

• Apply Band-Aid or pressure dressing

• Post injection instructions (especially diabetics)

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What Does Tissue Types Feel

Like?

• Muscle : soft, spongy

• Tendon or ligament: fibrous and touch

• Capsule: slight resistance to needle as it

penetrates – poking a pin through a

balloon

• Cartilage: sticky

• Bone: hard and hurts when touched

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Complications: Steroid Injection• 1. Systemic

– Vasovagal, lidocaine allergy/toxocity, cardiac arrhythmias, seizures, facial flushing, increased blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired immune response, menstrual irregularity (usually post-menopausal), fall in ESR and CRP levels (see in patients with inflammatory arthritis), anaphylaxis

• 2. Local– Bleeding, post injection flare of pain, soft tissue

infection, ligament/tendon rupture, subcutaneous atrophy , depigmentation, soft-tissue calcification, steroid chalk or paste, steroid arthropathy, joint sepsis

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Rare Local Side Effects

• Nerve damage

• Transient paresis of an

extremity

• Needle fracture

• Delayed soft-tissue

healing

• Fat atrophy

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Corticosteroids

• Commonly used injectable corticosteroids are synthetic analogues of adrenal glucocorticoid hormone cortisol which is secreted by the adrenal cortex.

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Corticosteroids

• Suppressing inflammation

• Suppressing inflammatory flares in

degenerative joint disease

• Breaking up the inflammatory damage–

repair-damage cycle

• Possibly a direct chondro-protective effect

on cartilage metabolism

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Properties of Injectable

CorticosteroidsCorticosteroid Relative Anti-

inflammatory potency

Solubility Biological Half-life (hrs)

Hydrocortisone acetate

(Hydrocortone)

1 high 8-12

Triamcinolone

Acetonide (Kenalog)

5 intermediate 12-36

Triamcinolone

hexacetonide

(Artisospan)

5 intermediate 12-36

Methylprednisolone

acetate (Depo-Medrol)

5 intermediate 12-36

Betamethasone acetate

and sodium phosphate

(Celestone Soluspan)

25 low 26-54

Dexamethasone

acetate (Decadron-LA)

25 low 26-54

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Equivalent Dosages of Injectable

CortcosteroidsCorticosteroid Preparation Trade Name Equivalent dose/volume

(mg/ml)

Trimciolone acetonide Kenalog 40

Triamcinolone hexacetonide Aristospan 40

Methylprednisolone acetate Depomedrol 40

Dexamethasone acetate Decadron-LA 8

Betamethasone acetate and

sodium phosphate

Celestone Soluspan 6

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InjectionSyringe

size

Needle

gauge

Needle

length

Anesthetic

(cc)

Knee 5-10 cc 22 1.5 in 3-5 cc

Subacromial bursa 10 cc 21-25 1.5 in 5 cc

Carpal tunnel 5 cc 21-25 1.5 in 2-3 cc

Greater trochanter bursa 5-10 cc 22-25 varies 4 cc

Lateral epicondylitis 5 cc 25 1 in 2-3 cc

1st MTP/CMC 3 cc 25-26 1 in 0.5-1 cc

de Quervain's 5 cc 25 1.5 in 1 cc

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Local Anesthetics

• Analgesic

• Diagnostic

• Dilution

• Distension

• Dispersion

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Commonly Used Local

Anesthesia

Agents

• Lidocaine

• Marcaine (avoid – except soft tissues)

• “Special Agents”

– ie: “the towel”

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Viscosupplementation

• Hyalauronan (sodium hyaluronate) is a natural complex sugar of the glycosaminoglycan family

• Concentration and size of endogenous hyalauronan are reduced in the joint fluid of patients with osteoarthritis

• Commercial replacement agents are high molecular weight derivative of hyalauronanwhich are synthetically derived from rooster combs or produced by bacterial fermentation and extraction

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Viscosupplementation

• Exact mechanism of action unknown

• Physical cushioning?

• Anti-inflammatory action?

• Stimulation of production of endogenous hyaluronan by synoviocytes

• Synvisc (Genzyme), Orthovisc (DepuyMitek), Hyalgan (Sanofi-Aventis), Supartz(Smith and Nephew), and Euflexa(Ferring)

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OK LET’S GET GOING!

So what can we do with a needle? Are you

scared yet?

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Aspiration

• Serous fluid streaked with fresh blood: related to trauma of the aspiration

• Frank blood: usually history of trauma –hemarthrosis of knee due to anterior cruciateligament injury occurs 40 % of the time.

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Aspiration

• Serous fluid of variable

viscosity: normal or

non-inflammatory

synovial fluid is

colorless or straw-

colored, contains few

cells (less than 500),

mainly mononuclear

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Aspiration

• Xanthochromic fluid: old blood that has broken down – appears orange in color –implies old trauma

• Turbid fluid: inflammatory fluid appears less viscous than normal joint flood –looks darker and more turbid due to the increase in debris, cells and fibrin, and clots may form – do not inject, await results of culture

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Aspiration

• Frank pus: aspirate

has a foul smell – true

emergency – appears

usually appear very ill

• Other: chemical

reactions, etc.

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Injection Preparation Protocol

• Prepare patient – get

permission~!

• Prepare equipment

• Prepare site

• Assemble equipment

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What Do You Do With The

Stuff Once You Aspirate??

When indicated culture, glucose, gram

stain, cell count, crystal analysis!

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Synovial Fluid Analysis

• String sign

• Cell count

• Glucose

• Gram stain

• Crystals

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Diagnosis Appearance WBCs Glucose %

blood level

Crystals Culture

Normal Clear <200 95+ None ---

DJD Clear <4000 95+ None ---

Traumatic

Arthritis

Straw, bloody,

xanthochromic

<4000 95+ None ---

Acute

Gout

Turbid 2000-

50,000

80-100 Needle

like

---

Pseudogo

ut

Turbid 2000-

50,000

80-100 Rhomboi

d like

---

Septic

Arthritis

Purulent/turbid 5000-

>50000

<50 None +

usually

Non-

traumatic

Arthritis

Turbid 2000-

50,000

75 None ---

Synovial Fluid Interpretation

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Lab Analysis of Fluid

• White blood cell count

– <50,000 inflammatory

– >50,000 infectious

• Polymorphonucleocyte percentage

• Crystals

• If fluid cloudy, culture

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Septic Arthritis

• Early diagnosis essential:

– Growth impairment

– Articular destruction

– Osteomyelitis

– Soft tissue expansion

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Injection Therapies: Problems

That May Arise

• An inappropriate drug is chosen

• Too large a dose or volume is given in the wrong area of the musculoskeletal system

• The drug is put into the wrong tissue

• Poor technique causes skin complications or possible tendon/nerve/none injuries

• Injections are given too frequently

• Folks don’t pay attention to what is causing the condition

• Little or no aftercare is provided

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Stuff You Need: Keep Your

Supplies Well Localized• A dedicated cabinet

• An injection tray

• An injection cart

• Plastic toolbox

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Items

• Gloves

• Blue Chuck Pads

• Alcohol pads

• Povidone-iodine pads

• Bandages

• Hemostat surgical clamp – for

those needle change outs!

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Items

• Syringes (3, 5, 10, 20 and 60cc)

• Needles (20 gauge, 1 inch – drawing up meds and aspiration of small joints), 18 gauge 1 ½ in for aspiration of large joints and bursa, 23 gauge ½, 1, and 1 ½ for injections)

• PainEase or Ethyl chloride

• Anesthetic of choice

• Steroid of choice

• Viscosupplementation of choice – always pre-authorize

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Ready?? Will focus on shoulder/knee today!

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Shoulder: Glenohumeral

Acute or Chronic Capsulitis

• Anatomy: shoulder joint

surrounded by large

capsule – easiest

approach is posterior.

• Coracoid process –

landmark

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Glenohumeral Joint • Uncommon injection

• Difficult, especially with adhesive capsulitis

• Posterior approach usually preferred

• Landmark: lateral edge of acromion, coracoid process

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Shoulder

Sub-Acromial Bursa

• Landmark: lateral edge of

acromion or posterior

• Allow arm to “dangle”

along side

• Don’t inject if you have

tremendous resistance -

reposition

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Acromio-Clavicular joint

AC joint superficial

Be careful – common

place for skin atrophy

and hypopigmentation!

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Shoulder

(Long Head of the Biceps)

• Anatomy: lies in a

sheath in the bicipital

groove between the

greater and lesser

tuberosities

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Scapulothoracic Syndrome

• Anatomy: bursitis

medial superior

border of the

scapula

• Be careful of the

long thoracic nerve

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Knee Joint

• Very common to aspirate and inject

• Anatomy: Suprapatellarapproach is probably the easiest (extra-articularbut still within the joint space.

• Easy to aspirate

• Supine positioning of the patient

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Knee

Pes Anseurine Bursa

• Anatomy: combined

tendon of insertion of

the sartorius, gracilis

and semi-tendinosus –

bursa lies under the

tendon

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Elbow

(Olecranon Bursitis)

• Anatomy:

olecranon bursa

• Aspiration (send

aspirate)

• Injection

• Side approach –

direct long axis

approach

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Elbow:

Common Extensor Tendon

• Anatomy: lateral

epicondyle, find

maximum point of

tenderness –

adjacent to lateral

epicondyle.

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Elbow

Medial Epicondylitis

• Anatomy: medial

epicondyle

• Be careful of ulnar

nerve – travels just

posterior and inferior

to the medial

epicondyle.

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Hip

(Trochanteric Bursa)

• Anatomy:

bursa lies

over the

greater

trochanter of

the femur.

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Ankle Joint

Chronic Capsulitis

• Anatomy:

inflammation of

the joint

capsule

• Similar to

adhesive

capsulitis of the

shoulder

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Toe Joints

Capsulitis• Anatomy: typically

around second toe,

sometimes third of

fourth –

• Abnormal foot

mechanics

• Pain ball of foot

(especially when

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Foot

Plantar Fasciitis

• Anatomy:

origin of the

plantar

aponeurosis at

the medial

tubercle of the

calcaneus

• Excessive foot

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Hallux Rigidus

• Common joint

first MTP,

osteoarthrits

and gout

• Inject directly

over the first

MTP

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Foot

(Neuroma)

• Most common

between third

and fourth toes

• Anatomy:

inflammation of

interdigital

nerve by

compression

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Wrist Joint

• Anatomy: wrist joint

capsule is not

continuous and has

septa dividing it into

separate

compartments

• Common injection in

patients with RA

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Thumb and Finger Joints

• Anatomy: The

first metacarpal

articulates with

the trapezium

• Rx: OA CMC

• Very painful

injection!

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Thumb Tendon

deQuervain’s tenosynovitis

• Anatomy:

abductor pollicis

longus and

extensor pollicis

brevis – run

together in a

single sheath of

the radial side of

the wrist.

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Flexor Tendon Nodule

(Trigger Finger)

• Anatomy:

• nodule base of

finger (stenosing

tenosynovitis

• Nodule A-1

pulley of the

tendon sheath –

becomes

entrapped

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Recommendations

• Consent for needle aspiration and or

injection – include possible risks,

complications and benefits

• Give patient aspiration and injection

aftercare handout

• Medical record documentation

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Billing and Coding

• 20526 -Injection, therapeutic, carpal tunnel

• 20550- Injection, single tendon sheath, or

ligament, aponeurosis (plantar fascia)

• 20551 – Injection –single tendon origin

/insertion

• 20552 – Injection, single or multiple trigger

point in one to two muscles

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• 20553 Injection, trigger point in

three or more muscles

• 20600 – Arthrocentesis, aspiration,

and /or injection , small joint or

bursa

• 20605 – Arthrocentesis, aspiration

and /or injection intermediate joint

or bursa

• 20610 – Arthrocentesis, aspiration

and/or injection, major joint

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• 20612 – Aspiration and/or injection

of ganglion cyst (s), any location

• 64450 – Injection, nerve block,

therapeutic, other peripheral nerve

or branch.

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Resources:

• James W. McNabb: A Practical Guide to Joint

and Soft Tissue Injection and Aspiration –

Second Edition. Wolters, Kluwer.Lippincott

Williams and Wilkins 2010

• Stephanie Saunders; Steve Longworth:

injection Techniques in Orthopaedics and

Sports Medicine- Third Edition. Elsevier

2006

• Myriad of online sources

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ANY QUESTIONS OR COMMENTS?

FCARUSO@WAKEHEALTH.EDU

Thank you!

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