techniques of itechniques of intra-articular injections and peri articular...

7/17/2019 Techniques of ITechniques of Intra-Articular Injections and Peri Articular Infiltrationsntra-Articular Injections and Peri Articular Infiltrations

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DIPROFOS'

'l

ml contains:

2

mg

of betamethasone

in

the

form of the

phosphate

+

5

mg of betamethasone

in the form of the

dipropionate

7 mgof betamethasone

EQUIVALENCE

OF

SYSTEMIC

CORTICOSTEROI

DS

(from

GOOD|/AN & GIIMAN'S

'

EIGHTH

EDITION

-CHP.

60,31

-

I

's

=

sHoRT

(biolosicol

hol{'lile

ol

s to

I

2 hours)

|

-

ll..'ltRrrlEDlAlt

lbioloskol

hollli{e ol

I

2

b 36

ho,ll)

|

=

LO|IG

lbiolosiol

holl-lile of 36

b

72

hounl

FA/.s /f*/r"f /sn/r{/f

20 mg 5mg

25 mg

4mg

4mg

2rg

0,75 mg 0,75

mg

53

m9 13 mg 66,5

mg

10,5

mg

10,5 mg

5rg

2rg

2mg

80 mg

20mg 100 mg

l6

mg

16 mg

8rg

3mg

3mg

133 mg

33

mg 166,5

mg 26,5 mg 26,5

mg

13 rng 5rg 5rg

160 mg 40 mg

200

mg

32

mg

32 mg l6

ntg 6mg

619

186,5

mg

46,5

mg

233

mg

37

mg 37

ng

18,5

mg

7ng

7^g

200

mg 50 mg 250 mg

40 mg

40

mg

20

mg

7,5 ng

7,5

nW

ANII

INTIAMMATORY ACIION

tl

0,8

5

5

t0

25

25

SOUUM REIENTION

0,8 0,8

0

0,5 0

0

0

DURAIION' OT ACTION

s

5

t



INJECTIONS

AND INFITTR/NTIONS

OF

THE

KNEE-

Afthough

a

painful

and

pxsibly

swollen

knee will readily

evoke a diagnosis of

inflammatory

infective,

or degenerative

joint

di-

sease, it

should

be

remembered that the

knee

is

a

common

site

of

abafticular or soft

tissue

rheumatic

dinrders of

various

types

because

it

is

prone

to

injuriu

that

may

affect

its tendons, iE

synovial bursae, or

iE

ligaments. This must not be ignored

despite

the

complexity

and

the

variety

of symptoms

presented

by various

clinical

picturu.

.

From

the

preventive

point

of

view

it

is

important

to detect general

disorders

or

static constitutional or

funclional

abnormali-

ties that

could

lead

to degenerative processes

in

the

tr'ssueE

or

recent

traumatic

lesions

which,

however

slighg

could

have the

same consequenc

es

if neglected.

.

From

the curative

point

of

view, an

accurate

clinical

and radiological diagnosis

of

the

chronic

lesion

is

needed in order

to

d*

termine the most appropriate

treatnenL

'Theseinfihrationsmunalwaysbecarriedoliunderrgorouslyasepticconditons.

A

.

MEDIAT ROUTE

Indications

:

very suitable for

joint

cf{usion.

IECHNIQUE

Needle

:50

mm needle

of 8/10 diameter.

Dose

to inject :

1

ml,

Infiltration :patient,

layingon

his backwith knee s lightly flexed.

This

route

is

often

painful

because

of

mechanical rubbing

of the

kneecap.

The

injection site

is

located:

.

in the intercondylopatellar

sulcus midway betrveen

the tip

and he base

of

he ptella. The nedle

is insefied tl a

hth

of 2 cm.



.i

B

-

ANTERIOR ROUTE

Indications

:

osteoarthrjtis

of the knee,

rheumatoid anhritls.

TECHNTQUE

Needle

:

50

mm needle of B/10 diameter.

Dose to inject :

I ml

Infiltration

:

the anleromedia

routc

is

usuallv prel.erred, often

facilitated by slight latefal subluxation oi the

patella. The pa

tient

is

placed in the sitting pos tion rvith the

leg pendent,

or

laying

on

his

back

with the knee flexed

at

about 80".

The

injection

site

is located:

.

1.5

cm

or 2

cm

inside and be

ow

thc apex oi the

patell.t

according to ihe thickness of the

pannicul s

adiposus.

The needle is inserted perpendicu ar to thc skin or at

a

slight

ang

e,

posteriorly and medially.

The

needle

is

insertcd

to

a

depth

oi 2 to 3 cm accofding to

the ihickness of the

pannicuLus

adiposus.



C.

IATERAL

ROUTE

lndications : hydrarthrosis or eiusior.

TECHNIQUE

l'{eedle :50 mm needle

of

B/l0

diameter.

Dose to iniert :

1 ml.

Infikration :the

patient

is

laying

on

his

back

with

the

knee

very

slightly flexed.

Ihe injection

site

is

located:

.

L Suprapatellar injection

(fairly

difficult and painful): ln thc in-

tercondylopatellar sulcus about 1 cm above thc patella, accor-

ding to the thickness

ofthe

panniculus adiposus.

The needie is inserled

to

a

depth oi2 cm.

.

2. Subpatellar injection : in the ntercondylopatellarsulcus,

mid way beh\een the apex and

the

base of the patella.

The needle

is

inserted

to

a

depth of

2

cm.

D

.

POSTERIOR

ROUTE

Ind

icatio ns : popl itea

L

cyst

-

eiiuslon

(monarth

ritls,

osteoarth

ritis).

TECHNTQUE

N

eedle :50 nm

needle of B/10 diametcr.

Dose

to

inject : 1 ml.

Infiltration :lhe patient

is

placed laying

on the abdomen

with

the

knce

slightly

flexed.

The

inieftion

sjte is located :

.

in

the medial

part

of the

pop

iteal space,

just

medial

to the

tendons oithe semimembranosus and

thc

scmllcrdinosus.

.

the needleBrazes the

medla

border

oithe

condyle and

is

pu'

shed doivn to the floor oithc pop ileal space

.

the

needle

is

irserted to

a depth

ofabout2 cm perpendicular

to

the skin Check lhat no

blood

runs back

through the

necdle

as

thcrc

is

,r

risk of puncluring

lhe

popliteal

vein or arlery

(aneurysm).

,,...-..'.-.--.--

ry:-L

I



INJECTIONSAND

INFIUTR/ATIONS

OFTHE

SHOULDER

Soft

tissue rheumatism

:

"This

most

commonly

takes

the

form

of local

symptoms

which can

be

app.reciably

or

completely

re-

lieved

by

tocat

injection.

However

this

simple

procedure

mustbe carefully

thought

out and

carried

out

safely

and

with

the

ut-

most care

: it

should

not

be

a

reflex

ruponseio

all

localised

disorders

carried

out

indiscriminately,

without

technical

know-

ledge, and

anywhere,

in

a

place that

is

not

pefectly

clean

or

on

the sports

field..Local

infiltrations

must

only

be

adiinktered

by

qualified

peisonnel

under

rigorously

aseptic

conditions;

to ignore

this

rule

is

to

expose

the

patient

to the

risk

of

local or

perhaps even

general

infection."

Professor

A.M.

RECORDIER

1.

lrrfiltrqtion

of

rhe

qcromioclqviculqr

ioinr

Ind

itations

:sequelae

of

acromioclavicular

dislocation

or sprain,

acromioclavicular osteoarthritis.

Needle

:25

mm

needle of 5/10

diamcter

with

long bevel

Dose to

inje(t:

1/2 ml.

.lnfiltration

:the

patient

is placed

in

the

sitting

position

Ihe injettion

site

is located:

'in

the acromioclavicular

joint

space

: this

joint

space

is

easily

identified

if

the

ioint

js

dislocated

or

affected

by

osteoarthritis.

Thc infiltration

is

made

into this

joint

space

with

the

needle

inscrtcd

obliquely

downwards

and

medially.

The needle

must

not be

inserted to a depth

of

morethan

1

cm.

I



,.,1.

lndications :

frrzcn shouklt'r. r,r;rsrr

tis,

rhrunt,ttocl

rrlhrits,

ll0st

tr,t nr.rl

(

l)

(x

k.

f, tcdlt:

l5

nll

,ltr:l

;'10

rli,lrrtf r)

a(l

nrnt

an,:l

11,10

tlimcicr

ntd

r,,r

r

oril n

1(

)

lx,lh

fl(x,i5

(

)l

thr

lt,tnnrr

uhs

adl-

P0s i.

Dlsc io injert

:

nt

rliltratior:lhcpalicntirlr,uul

I

tlrt:ift

ng

|Lrsition

u tth

lrnr

,rhd cl.d

,ri

l;'. The

nleLtLon sttr :

IrL,rlrr1

.

nttrfll

,ll(,

\

lloste

iLrl

to

thf .,1(

rottr

or

l,tl'ir

Lr

,rr

1o

nl.

.

,rl lhe .rpf\ oi thL' ,rr lle

,,rU

e

ionl(l l)\

thr,

Posler

or

boxler

'i

l'

1.''

l.

''.r

l'.,f

.

'.'

'r'r

'r

lhr: lt't

rl[' r

ifselleL]

,lt ln .r0'l

r,, ilotnrr,rrds ,lr1

slighl

v

,rler,r l\

(lo\

n

k) t

rc r.ll1

l.r

1'

(t

thi

hf,rtl

d

tht'

hlnx'r us.

.

.1,,

:|

ii

i,rl

"''

w:

."I

\

I

j;qllr,ris1'1

lt,t)r(,n

5ll)Lt

tlli

ri\|l ,lto

(ln

lltfili

,trrf/ri,I r\rr ,

"'

ii\

''lrr:Lllt .l;

f

Ir,Ix1li,1i[]

(lix|rt0

{rr

5[)nnlr

ar](l

11/l0al

antctcr

rmclr,rr

r orrl

nq Lr-r llte Lltrr

'rtcss

ot lltr

p,rilt

tt

us,tdiposls.

l-lo c

lrr Ujr[l . I m.

'r'liiL:.rtr5.

:

lhf

iIlttittis

p,rrrr I llrIsill nqlx)s to| \\'

ill

llrl

srou tlcr

s

,qhl

\

lit('r,r

r

fr)l,rlffl.

Thf

ini('ctio

r s

l|

s

(x alr'fl

:

.

I

(_nt

,rl)r)\f

thf,tcfont

|( ,r\'r | ,r

Jt)|rl.

f lrt

neer Jle

.

ilscrlccl,rl,r

il

qlrt

rI

ru

rl,,,rri

l,tng

c

unt

l l clnltcs

rlr r

L rrrrl,u I ri

itlr the

he,rrl

or

iltt hLrnl,rus

{

t

I

t

I

I

\l

I

I

,

t

I

I

I

l

I

I

I

I

I

t

I



r'

iilIp|d:'lt]]ffidlll

frlr{:11}rt]J'll

i ;l

Indications:

frozen shoulder

(all

qvpes),

capsulitis,

fhcumak)id arthrltis.

Needle

:

25

mm

needle of

5110

dhmeter with

a shod

bevel.

Dose to

inje(t

:

I

ml.

lnfiltration :

thc

paticnt

s

plaled

1n

thc

sining position

with

lhe

f nr.

i hllr,rbdu(1rrl l{)

i.

The

iniection

sit€ is

located

:

o

rt lh.

f[,r5r'.iion

l]{rlrr'eer

a

pcrpcndlcular line2

cm

mcdial

to

ihe

ateral

lnrdcr of

the

acronlon

and

a horizonta

line2

cm

belorv the

in1.er

or

horclerofthe

lateral

part

oithe

acromion.

The need

e s

inserted

pcrpendlcular

to th-"

skin

until

it comes

iftii

contact

$'ith

the

head of the humerus.

,'i.,i'lir;';-iril i,ir,il,. ili{i::fll li

ii'il;

Indications :

irozen shou

cler.

Needle :

15

nrm

reed

e

r-rf5/10

diameter.

Dose

ro inject :

I

ml.

lniiltration :thc

paticnt is

placed

jf

the

sllling

positi0n

$'Lth arrn

pefdent.

.

1

cm

beloi,,;

thc

nlcrior

lnrcler

oi

the

acrr)rrion

on the

lalern

.rspccl

oi

thc shoulder

{s

ightlv posterior

y).

Ilrc needlc

is

lnserLed

at a

slight anglc, upwards

ancl antetiot

y,

l)etweef

the

great

t berositv

oi thc

humerus ard

the

intcfior

aspeci ot the a[nm]of .

ffi

-

|

{r4

ir

:ir

ri'r

;l

i

}

t;l

I

j\l

[.i

lljliili_iliii

[

1.ili]d|,,]}

::liF

fF'll[i],;,lii1ii,:il'iilril;1.:l;

d0ltrldltis

detded

l)t

palpation, alicr the patlentcom

pla

ns

oispont,rncous pa

n

on alrdLrction

ofthc anr

be),ond

45').

2l

mm needlc

oi

5i l0 dlanre'tir.

I ml.

tl

e

prtient

rs

placecl

in

thc

silting

pos tlon

W

th

afm

pen(1Lilt.

\liNlrr opp(,s

(r(

to,rbdr(llof

0ilhcamrircilltates

iderntficationoi

lhl

r

orvlrglnr

l oi

thc iibfcs oi the delkrid

musr

e towads

thc

r Iito rl\, lrlwtu

lhc

b ccps

alrt$ior),

rnd

thc trircl]s posterlnl]'.

Irl

rrrrlr''

irr:r'

lcti,rl

lhispo

rtperpendiculartothe5l(if

Lrrrtil

It(1)r)ir,\nlorrlrl,r(1

$'ilhlhcbonealadepth0il,

to I cnr.

'/-

ti,--

I

t

I

I

I

I

I

tl

ll

/

I

lr

I

\



I

NJECTIONS

AN

D

INFI

TTRATIONS

OFTHE

ELBOW

Dr.

F. Comrnandrc

The elbow is

the

maior

site

of soft

tissue

rheumatic

disease.

Many

forms

of inflammation of

aftachment of

muscle

or ligament to bone or dinrders

of the

muscle

insertions can affect

the

elbow

(C.

la

Cava). Epicondylitis is

the

predominant form

of tendon

disease,

but

bursitis

and nerve

compression syndromes

are also

observed.

The

suruey carried outby

J.

Cenety

(1975)

indicated

the

relative incidences

of

disorders

at this site:

epicondylitis

66%

dinrders

of the

headofradius 20%

epitrochleaitis 9%

olecranon

pain

2%

misc.

bone

disorders

the radial

insertion

of biceps

medial humeral radial

tunnel syndrome

(i

nterosseus

nerve) about

2%

1%

1%

A.

TAIERAT ROUTE

Indications :Tennis elbow

or

Eicondylitis,

epicondylalgi4

sprairy

pulled ligamenr

TECHNIQUE

l{eedle

:25

mm needle

of5/10

diameter.

Dose to inject :

1

ml.

Infiltration :

the pain

can be

located

by opposing movement of

the

wrist

and

fin8e6

with the elbow flexed

at

90' and the

hand

supinated.

a. epicondylitis

-

epicondylalgia

The injection is made into

the site

ofthe

pain

:

.

either by

a

fanning movement

of

the needle in order to distri-

bute

the liquid without

excessive

increase

of

prcsure

at the site

(butthere

is a

risk ofcausing further

damage to the musculoten-

dinous tissues),

.

or at a single point,

with

fairly deep insertion

ofthe

needle

until

it

comes into contact with the

periosteum.

b.

sprain

-

pulled

ligament

(radial

collateral ligament)

The injection

site is located

just

above the

epicondylg

mid

way

between

this and the lateral aspect of the

olecranon,

and

the

injection

is made at an angle,

pinting

upwards, slightly anteriorly

and medially.



B.ANIERIOR

AND

MEDIAT

ROT,IE

a Indications: osteoarthritis

of the

elbow,

involvement

of

elbow in rheumatoid

arthritis,

diseaseofthe

head

ofthe radius,

painful

supination

in

the adult. Intra-articular

injection.

TECHNIQUE

Needle :25 mm and 5/10

diameteror 50 mm and

B/10

diameter

needle with

short

bevel.

Dose

to

inject

:

I ml.

Infilnation:

with

the elbow

extended, the

injection

site

is

l.cated

along

the distal

part

olthe

lateral margin ofthe

tendon

ofthe

biceps.

The needle is

inserted

perpendicular

to the skin

until it is felt

to encounter

the bone

of

the

head

ofthe

radius.

b.

Indiation :

inflammation

of

the

teodon

of

the biceps.

TECHNIQUE

l,leedle

:

25 mm needle

of 5l10 diameter.

Dose

to

inject

:

1

rnl.

Infihration

:with

the

elbow flexed

at90',

thetendon

standsout

on supination

of the hanrj.

The

needle

is

inserted parallel

to

the tendon

alon8

its

lateral

sudace untjl

it

makes contact with

bone.

c. Indication

:

Colfers

elbor:, or medical

humeral epicondylitis

anle'rrr

and ncdial

route.

TECHNIQUE

Needle

:25

mm needle

of5/10

diameter.

Dose

to inject :

1

nrl.

Infiltration

:

the site of pain rs

identified

by

palpation

with the

elbow flexed

at90'.

The

injection is

made

into$issiteof muscle

pain,

the needlebeing

insertd

until itencountersthe

periosteum.

This

ensures

that the needle

remains clear

ofthe

ulnar

nerve

in

the sulcusformed

by

the

medial epicondyle

of the humerus

and

the

olecranon.

d-

Indication:

infiltration

of the ulnar collateral ligament.

TECHNIQUE

Needle

:25

mm nccdle

of5/10

diameter.

Dose

to

inject

:

1 ml.

Infiltration :

great

care

is

needed

here because

of the

proximi-

.

ty

oi

the ulnar

nerve

on the posterior

aspect

0fthe medial

epi-

condylc

of

$c

humerus. The

elbow

is

flexed at

90'.

The injec-

tion sitc is locikd

directly

anterior to and slightly inferior

to

the

tip oithc rnediai

epicondyle

ofthe

humerus. The infiltration

is

mad('between

the skin

and the

surface

ofthe ligament.



C.

POSTERIOR

AND IATERAT

ROUTE

Indications:

tendonitis

and bursitis

ofthe

triceps,

hygromas

of the

elbow.

TECHNtQUt

Needle:25 mn

needle

oi

srlg6;rr.,.r.

Dose

to

injert

:

1 ml,

Infiltration :ivith

the elbow

extended

a nd

the

triceDs

tensed,

the

sites

ofpain

are located

by palpation

aboveand

alongthesides

ofthe

olecranon.

Ihe

injection

site

is

located:

a.

for

tricipital

tendon

rtis

: arou

nd

the

sites

of

pain,

avoiding the

lendon.

b.

for

tricipital

bursitis

: with

the elbow

flexed

at 90'

identili),

the

epicondyle and olecranon. The injection

s'te

is

located beneath

theepicondyle.

The needle

is

inserted

perpendicular

tothe

skin,

pointing

downwards,

posteriorly

and medially.

c.

avoid

infiltration

for

hygrcmas

of thc

elbow. li this

is

not

possible,

asthe

hygroma

is

essentialiy

subcutaneous,

inject

l ml

directly

beneath

the

skin.

D. POSTEROIATERAI

ROUTE

Indications

:

disorders affecting the

head

of the

r

adius

(epicon-

-

dylalgia),

osteoarthritis

of

the

elbow,

involvement

of the

elbow

in rheumatoid

monarthritis

0roJigoarthritis.

TECHNIQUE

Needle

:25

mm

needle

of5/10

di;meter.

Dose

to

inject

:

1

ml.

Infiltration

:

the

elbow is

flexed

at

about

90'.

The

injection

is

made

intothe

radio-ulnarsulcus

perpendicu

lar to

the

skin,

i

cm

beneath

and anterior

to

the inferior

border of

the

epicondyle.

The needlc

is

inserted

1.5

to 2

cm

into

the superior

radio-ulnar

joint

c.rpsule.



B.WRISTJOINT

lltliraiions

:

sequelae of injUry

(sprain,

injury

to the

wristor wrist

joint),

synovitis, rheumatoid

anhritis.

Osteoafthritis

ofthe wrist

(very

rare).

TECHNIQUE

,nli.edle

:

25 mm

needle

o{ 5/10

diameter.

oJ I to iiiioci : l/2 to I ml.

liiirlurticii :the

wristjointspace

is identified through the skin on

the dorsal aspect

ofthe wrist, with the hand pronated and

resting

on

a

table

or

hard

surlace.

e.

stylold process

of

radius

A compressible region, which is

ollen swollen

(acute

0r

chronjc

inflammation) is usually readily identified by touch, behveen the

distalextremity oithe

radius, the lunate and

thescaphoid

bones.

The

lnjection

is

nrade about 2

cm

(one

finger's

width)

from

the

styloid

proces

ofthe ulna.

The needle is inserled perpendicular

to the skin and then ang ed upwards with the hand kept

pronate

lo opcn

the

joint.

f,gi..il]0F.I :care nrust be taken to avoid the veins in the dorsal

side of the

wrist

and the

hand. Painful reactions

are

fairly

com-

mon because

ofthe

distension

ofthe

joint

capsule

lthe

injected

amoift

plays a

part

here).

[.

st,vloid

proccss of the

ulna

Same principlc, but

in

this instancethe injection

is

nude

bt'l^/een

thc distal extrcmiry ofthc ulna

and

thc

triquetral

bone.

C

.

DISTAL

RADIO.UTNAR

JOINT

,,r1{ri olrs :

osteoaft

hritis,

sprain.

TECHNIQUE

fifldjr

:25

mm needle of 5/10 diameter.

l:e rr; rnlcri :

1

ml.

rliriir:iilr

: the hand is p aced

flaton

a hard surface.

After locating

the base

of the stvloid

process

of the ulna

and the

radius, the injection is made about 2 crn irom the border of

thc

ulna. The need e is inserted perperdicular to the skrn.

4



D

-

CARPOMFTACARPAT

JOIT{TOFffETTIUMB

Indications

:

osteoarthritis

oithe

base

oithe

thumb,

lr,ery

rarely)post-

traumatic sequelae

LspIa

n, dis

ocation...).

TECHN

QUE

Needle

:25

mm

needleoi5/10

diarneter

Dose

ro inlcct

:

li2

to

1 mL.

Infrllration:

the

iirsllretacarpaibasc

is ocated

on

thcback ofthe

hand. The osteo-articu

ar intersection

formed bv

the

fint

and se-

cond

mchcarpal

bones and

the

napezium

is then

identiiied

by pal

pation,

ivhich

s

oiten

painfLrl.

The

n1,"cl0n is made

Frpendlcu

arto

the skin,

graz ng the atera

J

border

oi the

i r(

nreLicarpa

L

The

necdle

passes

lleh{een

the lrapezlLrm and

the heads

ofthc

first ard second

metacarpals. The

injcction s

olten

palniul.

ffi

',"

fffi ETACARPOPHAJhNGEAT

AI{D

II{TERFT{A,TANGEAI-

JOINTS

lnditations :

osteoarthr

tis

oithe

fingers;

metacapophalargeal

i0ints

irare)

and

distJl

interPhaLafgeal

]oirrts

: I

ieberden's

nodes;

proximal

intcrphaLangeaL

joinls

:

Bouchdrd's

nodes,

iheuma

toid

arthritls,

l)osftraunratic

seqlelae.

IECHNIQUE

N

eed

le

:

15

nnr

needlc ot

5/

l0

diameter.

Dose

ro

injeri :

l/l

ml.

Infiltration :

the

iniection

is nrade

irto lhe

joint

spare

or

the

dorsal sidc

of the finger, to the

side oi

thc cxtcnsor

tendon

ilate

ral

y

r-rr

nrcdiallvlgrazingthc

mctacarpalor

phalangeal head.

fhe

necdle s lnserted

at an

angletowards

the d

stalextrcmitles

oithe

fingen.

Thls

injection

is i,ery pa

niul.

Cryoanaesthesia

($,ilh

cryo

iluorane)

is

rcconrnrendecl.

f iff4: flffith,fi",

ll]h[AlAl{GFAt

pADS

lndications :

lrr

ht

of, fllanrmat

of,

bursitls.

TICHNIQUE

Needle

:

2i

mnr nced

e oi

5/10

dianreler or

vcry

f

ne

and short

intradcflrir

need r.

Do5t

to

inj3ct

:

lll

ntl.

lrfiitration

: lhc prds aie on the dorsal

irce

c-ri

the proxinral

irtcrphrhngr',rl

loinls

Ihe.v are oi

soitcr consistencv

than

lirLr lr,rrrl's rrr xlcs, irrlr

wh ch

thev

should

be

distinguishcd.

The

in

jt'r

t

r

n

s

rr,rr['

l,rteralLr',,rl thc base

oi thc

pad, n

ihe

region

of

lr'

;.

,.rr

r.r

'

.r'l

;.

|

.

.

il

t

"l

7

I

f

.-'.;--:,'.'::,



2.

Lqlerol

ospecf

A

.

SIYIOD

rc(ESOFIHE

MDII'S

Indi(ations

:

radial

styloiditis,

TECHNIQUE

Needle

:25

mm

needle

of5/10

diameter.

Dose

to inje(t:12

to

1

ml.

Infiltration

:

identify

the contour

ofthe

styloid process

ofthe

radius

on the lateralaspect

ofthe hand;

jt

is

painfulto

pressure

dnd_somerimes

shows

signs

of inflammarory

sweljilg.

siloiditjs

is

otlen

dsso(iated

with

inflammation

ofthe

lendon

ofthe

lorg

fleror

oflhethumb

or De

Quervain

s

lenosynovrtis.

The

injeaioi

rs

made

dtrertly

againsl the

bone where

rhe

pain

is

localised.

B

.

TENDON

SHEAI}IS

OF

ME

TONGABDUOORANDTHE

SHORT

DfiENSOR

OF THE

THUMB

Indications

: De

Quervain's

tenosynovitis.

TECHNIQUE

Needle

:25

mm

needle

of5/10

diameter.

Dose

to inject:

1/2

ml.

In[iltlation

:it

is

essential

to recognise

the outline

of the anato-

mical

snuffbox

:

r

anteriorly

it

is

bounded

by the

tendons

of the

abductor polli_

cis longus

and the

extensor pollicis

brevis in

their

common

synovialsheath;

in

cases

ofabarticular

inflammation

there

is

:

.

swelling

with

or without

crepitation

on palpation

and

on

active

movement

of the

thumb,

.

orsimply

stenosis

and pain,

.

posteiiorly

the snullbox

is lmunded

by the

extensor pol)icis

longus,

.

and its

base is

formed

by

the styloid proces

of the radius

ind

the

scaphoid.

It

js

important

not

to forget

that the radialartery

and

is

branches

pass

through

the

distal

part

of the

anatomical

snufibox.

The injection

is made

into

the lateralface

of the

wrist

and hand

at the

tip

ofthe

styloid process

of the radius,

the needle

being

angled

upwards

in

order

to

pas

into

the synovialsheath.



3. Pclmqr

A.

CARPAITI., f{NEI.

cr

rP,r I

tun

ne

svnd

ranre,

reiracklry acfoparrcslhesia.

TECH\QUE

li mnr nccdle oi ir'l0

diamctc'r.

tnt.

the

hnnd

Jfd wf

(

are exam

nfd

n

the

r,rnter

or or

n

ll

,l

.l

n,

Ln

r'

tt

.l

l

r

"

t.n.i,

. ln,

.,t'

:

.

c ther the aftefiof llrberclc oi thc scaphoicl,

.

ot the second I

errrc

inc on

thc skln

frorn

the palnt on

lhc

dfter/or ispccl

ot

ilre

wrlsl,

.

orthcs(rlo

d

process

oithe radius.

Ihrtc nr(,tlrods

oi irjertion ma

lr

usccl

:

re alive

to thc Jnterior tulrrclc oi trc

scapho d.

Alons;r

horizontal fc I()m

lhe

ffter or tLrbefc c to

thc

pisr-

tonr

bone,

thc injelion

is macle

one i n,ter's lviclth nrcdhl

to the

tul)ercie, rnal

just

fredial

to

the

palmlr s longus rvhrah Iorms

one

sidcoilhechanne

ior the r,rclhl artcn,. Tho

need e

is

nserted al

.rn angLc

po

nt

ng

cloivnu,ads,

nx,dh

ly

and postcfloriv to\\,ar[]s

lhc

ilrrs{'r5,

ti).r d0pth oi I i to 2

cnr.

relat l,e to

thr

mcili,rl

flexlre line on

the

anlerior

sud.tce of

the \\,ri\1.

Th-" inje,ctiirn

is

nrarlt,nt-"diit Iothc lnterse(lol oithisilt'rrrrc

line

.rnrlthepalnraris

brtvis Theneedle s angkrlvet

shar'p v doivn

rurrrh, redlal

,,

and posteriorlv tovr.rrcls thc

tingcr

in

ofilef to

J\roi.lihf

nrrcliar

f0r c. lt

js

ijtcedcd to

i

depth oi

l.;

k) 2

(jm.

ft. .r1 \,(' lo

tlrc

.pe\ oilhe

stv o d p

ocess

ol the

fadius.

llrf

nif(tlon i

m,tdr.J to,1 mn p()rim,rl

totheaperoithc

slr

o

11

prori,ss

oi thc r,rdius, in

lhe su cus iornted Lry thc

tcrdons oi thc palnr,rris ongus

rnd

the palnr,rris hrcvis. I he

reecl

e

is nscrtc,cl

,rt ,rn lnqle, ntccliallv. rllrnwarrls

lncl

po(crior

\'.

N.fl.

:

\('l'or

cls onallv lhe rccd

c

prnft res

the med

af

r(' t'

a.ru5

r1t sharp

pl

r

i

this slrould hrppen

do

nol

Irrxr&

u th thc injeLt

or

L)ui

mo\c thc fccdlo lo,tnotlter

l)o

lior.



B. UTNAR

NERVE COMPRESSION

I

.irit

l:r

ulnar

nerve

compression.

TECHNIQUE

li mm

needleol

5/

uoramelcr.

l/2

to

1

ml.

,

"

identiry the

plsitbrm

bone,

the

tendon

ofthe

flexor

carpi ulnaris and

lts

insertion.

The

lnjection

is

made

at a sharp

angle later;1ly to the

tendon

of

the

flexor

carpi

ulnaris, clownwards

and slightlv

posteriorly.

The needle

is inserted

to

a

depth

of 1.5

cm.

lf the

ulnar

nerveorthe ulnarartery

is accidentally

punctured

do

not proceed rvith the

lnjcction but

move the

needle to another

posilron.



C.

TRIGGER

FINGER

Indications

:

tenosynovitis

of the flexor

muscles

of the

finger.

"Trigger

finger".

TECHNIQUE

Needle :25

mm

needle

of5/j0 diameter.

D

ose

to inje(r :

1/2

to'l ml.

Infilnation

:

the nodule

on

the tendon

of the flexor

is

detected

by

palpatiOn,

lsually

in front

of the metacarpophalangealjoint,

and

on

active movement

ofthe finger.

The finger

is

very

slightly

flexed.

The

needle is

inserled

opposite

the metacarpophalangeal joint

at a sharp

angle, posteriorly

and downwards

until it reaches

the nodule to be infiltrated.

D

.

DUPUYTREN'S

CONTRACTURE

Indicatioul

:

lLtpgytrgn's

contracture.

TECHNIQUE

lleedle

:25

mm

needle

of 5/i 0 dianreter.

0ose

io irle(t

.l/2

to

I ml.

infii

ra ti0

n

:

pa

lpation reveals

the

aponeurotic

bands

and nodu les

oi

i

e'0'elr.rL

'ile

paln

dr

aponeuro'irrs

DupLrl

tren s direa.er.

The injection

is made

into the

nodules and

bands. lt is

often

difficult

and painful.

Aponeurotomy

has

rendered

this treatment

ress

useruL.

The injection

must

be followed

by

vigorous

but controlled

extension

of

the

retracted

fingers.

s".



DIPROFOS-

lbtomet|oonediorooionole

ond betqmeAoone

disodium

phosphote)

indtot nr,

doroq"

dnd

odtinirhclion

:

DIPcOFOS

i5

rcco.nmended

b

{

I

I

nno-uscl o'

r

edior

ir

oolierh

rcourng

rv:temic

co-icovet

d

{eropv

l2l

dreo

rni*tion

iro

$e

ollectd soh

fitsues,

{3)

ilro-

or pef-or'cJlor

inlec

or

lo' lhp

reot

r""

"i"it,

'i.,

faf

ai'*i

'ii"i'ion

ro

J i. bsio"s: ond

(5)

ocol odmiristrot

or

lor the

treo-enl ol

vorious

cvslic

ord

,nllommotor diorderr

of the

fooi

l.

5dt

tirsue ond

mus(ubrl&toldircrder: Rheumotoid

odhritis,

osteoodhritis,

bursitis,

onkylosing

spon-

dvlitis, epicondylitis,

rodiculiiis, coccydynio.

lorlicollis, sciotico

lumbogo, gonglion

cysf, e-xosirsis,

fosciiris.

'Dosoqe

'

I

o

2 ml by deep

lM

iriec'on.

'ntro-orticulor

nieo,or

0 25

n

2 mi

ctording

b

he size

ol he orl

2. Alkok diroid"" Ch'ont bronchiil

os'h.o

linciudinq

odi,rnctive

theropv

for

stottrs

osrhmoticus),

ho' feJer. onoioneurotic

edemo,

ollerqic

bronchitis,

seo-sonol

o'

perenniol

olle'gic

rhinilis drug

reoc-

rions.

serum

ilckness,

insea b;res.

llo hnefic

olos

odincnil|eropy

n slotus or*rmoticLrs.

Dosoge:

I

lo 2

mlby

deep lM

iniecflon.

i. ili"

a;tl"t",

ar"oi. a"rrnoliis

lnvmmuloreczemo),

neurodermotiiis

(circumscribed

lichen simplex),

necrobiosis

liooidico dioheticorum,

olopecio oreolo,

discoid

lupr-rs ery*'emotosr,'s,

psoriosir,

keloids,

oemohiqus

dermotitis

heroetibrmis

uricorio,

\ypertrophic

lic\en

Plonus,

conlocl

dermofiris,

seve'

i" iJf"r"a"ir"riti.,

"r'f.

ocne

Dosoge o

? ml by deep

lr'r irir on

Di'ecl

rrrooeric

ir

iec

or

irb

Ae

les

on

of 0 2 ml/cm?

uo to

o moximum

of

I

ml

per

week.

l, ia.g""

ai*"

Disseminoted

lupus

eryhemol,cs,-rs,

sclerodermo, dermotomyosilis,

Polyorleriis

no-

doso. Dosaoe:lb?m

bv deep

Mlnleclion

i.

otlriil;"tu"r,ti;;""irol

syndrome,

ulceroiive

colitis, regionol

ileitis, sprue,

podiotric

condi-

t'ons

{bursilis

under

helo#o durum,

hollux

'igidus,

digiti

quinlivorus)

drsorden

requiring

subcon

i*.i,i.i

i"i*ri.".

-'ri.osteroid

responsiuellood

dv"scrosios

nephri[s ond

nep\rolic

syndrome

brimorv o,

'econdorv

cdrenocortitol

ins,,fficiencv

nov be

treoted

with

DIPROI-OS

Sterile

Aqueous

Susoeision

bur should

be s,.,pple'nenhd

wi$ r'rinerclocorticords

Dooge

b

2 ml bv deep

M

n

ector

'

Lcro]ry

0.25 o

-l

odm

.

st'eo

oy

ruhrcul'n syr nge

'l'e

do'oqe

m,rsl

& b

lo€d b

fie

ooierf5

dridLol lE'rierenrs,

$"

,.',e,

1

ol{e

d oroe,.

{" ,"pne

ono

{e po[irr

s oo lirv

i

olerole

hp cor

oseroid

llre*

of$e

p'oPemes ol Dl

PPOFOS'corc"re"

ocoiono.,iles,o"i.lhreqr,edorlT-orelyfcolcJ'Ierluseoforonoslrercisdesirobe

DIPRO

fOS

mov

h

-ixeo

n

tle

sv;rqe

lro

r *e

ompoulel

-iF

procorre hC

r%

or

'rdoco

n" HCI

I

%

C"J-'

O,|,CO;OS

-"r*'

& odr"

sre'"d

inr,o"eno

ny.

.r...rsr

oe

oo-inisrr"d

urcer

.

gorcr.

y

oseptic

.ondi

ons

Si*-"tt*tt , r".""i

c|l"i.a

r'ioh

hcue

sfo*n

thot locol oi

qenercl

rreotmenr

w fi D

PROFOS

s

*ell

toleroied

There

ls

o

*ovso r

{o

side

eFe.rc\o'ocle

isric or{"

co-

cosrelo'd

dr,gs -01de'eop

howeue-

The

s'ile.eff*ts

retoted

u

dole ond durolion

of heolmenl

ixlude

Cush'rg's

syndrome,

od,enol suppresion

(specio

precou.ors

o'e

rxessory

d.:.rnq

drets adLcdby5rge]

-oumo

or se''our

diseo,e)

osleotoosis

gosl'(uke'w'\

;

+

of

pcro'olio

r o1d

.oenorrroq"

d'sr,rbo

rce o[ glucose

m€ obo[sm

wilh

$

ocerbo'on ol

diob€'es -e

li'us: e

'ocer

borlo"'.,

:""

^o

o,;i*'i".

poie.r

cotobo.nm

,il

r

eqotrye

na.ogel oo or(e

go*h

e.odo o"

rr

cl,Ldren

poly'

ohoo'oossociori"rr*eqfq"nordoed.r"o,''e*or{ep'oong"docriorolDoROFOSordthe'esitirgrhlb

tron iferooqeroL

s

od'e.olixie

or

the

'"

-oy

lr okop"i

o{

feodrerolco-e,

ol-e'

t'eo'-erolo

le*

-eeLs

ord

t

s

mov oenislbr

some

monlhs or even

lor up

loone

yeor

L"t"

ku-i

tid"*fi".rt

. r"ntl disorders,

spontoneous

hocbres,

mus.le diseose,

rolsed

nho oculor pressure'

olrophy

ol

tle

s[]n or subcutneous

lissue,

ord

menstruol

disir:rhonces

Controindkdio :

wi$r lhe exceplion

of o few spec

ol

s

tuot ons

fiol

hove o senous

prognosis

tuch os

5p

no blod,

hypo

rension ond dyspnoeo,

fie corticosteroids

ore os o

generol

ru e conlrondicokd

in

qolienlr

w

tl

i Lbercrlosir

l{

tfiey

hove to

h

urcd

tr.rbiculostotic cover

musl

o

wovs be

qiven

concLirrm

y

HeFes simple, ol

lhe

eye

ond ocul€

psychosrs ore

gEne

ro lv considered

to be onrroindicotions

16r

coriiiosteroid

r|eropy. DIPROFOS

is

conlro

ndicoied

Ln

polienh

olle€

c

lo one o.

moie of

its

inqredienis Otlrer

conko

ndicotlons

:

oclive

or

olenl goslr'c

lkerolion

primory

gloucomo

re€ni

nle$ no ono

,toros,s.

o'ue_'c.,

lis

lyp€lerso.

rl'o'bopl

ebit'

o'reopo

osis d oberes

C"J^

rg

s

'yndtome

reno

iorlLre oy

cl'oti

croer

r

o.do.:"o'

c. onc

oo

eror

u'o or t"qol

rle.ior' br

*\,c1"

oopoonoo,'mf_err

s

rotovoiloble

h

rreornn.y

col

cossod

*e'opy

m,"s

h

et-ceo

I,ero.,s

disordes

or

d

gva

r tle

'i

_'-

efle'a€

do5e

MTn

51olor

o{DPIO-O)

ro

p

eqnon'

-o-"^

m,;

oe

ouod.d

e,peciolfdu'"grfeIr'tet

L

coni'

oieroid

lh"roPl

wos

1"'

ceso',

d.

'.q

p'eqio.

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techniques of itechniques of intra-articular injections and peri articular...

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