MODERN MEDICINE Joint injections: intra-articular and periarticular teciiniques MURRAY L INGPEN, FRACP, FRCP, DPhysMed, FACRM Local corticosteroid injection therapy is a simple delivery system which allows relatively small doses of the therapeutic substance to be applied to tissues in a manner which achieves local concentrations not possible by the systemic route. Since hydrocortisone became available over 40 years ago^ synthetic ana- logues have been developed which have greater potency and duration of effect. Over this period, joint injection has evolved as a safe and effective means of influencing inflammation in rheumatic and orthopaedic conditions provided fairly strict rules are adhered to. • General technique Injection procedures must be carried out with a thorough aseptic technique which includes skin preparation of both the doctor and the patient, preferably with alcoholic skin sterilization procedures. Infection is the most serious side-effect of these techniques and the requirement for hand- washing with antiseptics and avoidance of contact with nee- dles is fundamental. It is essential to use sterile dispos- able equipment. While the nee- dle involved needs to be long enough to achieve penetration of the joint, it should be of small bore unless aspiration Dr Ingpen is in private practice as a consultant rheumatoiogist in Melbourne, Victoria, Australia. This article was specially written forMoDERN MEDICINE. has to be carried out. Tissue damage is a major factor in the development of infection and if penetration of a joint is not effected easily, the procedure should be abandoned. It is essential that the anato- my of the area has been consid- ered, and in general terms joints are best approached through the extensor surfaces, thus avoiding neurovascular structures. Care should be taken to locate adjacent ten- dons and avoid penetration of the tendons with the needle and more particularly the corti- costeroid because tendon dam- age may result through cystic degeneration and subsequent rupture. Under most circumstances, it is not necessary to infiltrate the skin and subcutaneous tissues over a joint and, indeed, this can be imdesirable because the bony landmarks are more diffi- cult to feel. Muscles aroimd the joint should be relaxed or under very light passive tension and postured to open the joint on the side of penetration. If efiFusions are present, they should be aspirated as fiiUy as possible and a sample of the fluid sent for pathological examination. Under these cir- cumstances local anaesthetic infiltrated into the skin and subcutaneous tissues will result in less pain. One sample of the effusion should be sent for culture and Gram stain. A sec- ond sample should be collected in a plain tube for analysis for crystals and rheimiatoid factor if indicated, and a third sample should be coUected into EDTA for a cell coimt and differential coimt. Corticosteroid injections should not be given if there is any suggestion of skin infection and if there is any possibility on aspiration that there may be infection within the joint. In soft tissue injections, the anatomy of the joint must be defined by palpation and to do this it is necessary for ligaments or tendons to be placed under some tension, either actively or passively. It requires a know- ledge of the surface landmarks. 1 2 MODERN MEDICINE OF SOUTH AFRICA / NOVEMBER 1995 Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012)
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Joint injections: intra-articular and periarticular techniquesJoint injections: intra-articular and periarticular teciiniques
M U R R A Y L I N G P E N , F R A C P , F R C P , D P h y s M e d , F A C R M
Local corticosteroid injection therapy is a simple delivery system which allows relatively small doses of the therapeutic substance to be applied to tissues in a manner which achieves local concentrations not possible by the systemic route. Since hydrocortisone became available over 40 years ago^ synthetic ana- logues have been developed which have greater potency and duration of effect. Over this period, joint injection has evolved as a safe and effective means of influencing inflammation in rheumatic and orthopaedic conditions provided fairly strict rules are adhered to.
• General technique
Injection procedures must be carried out with a thorough aseptic technique which includes skin preparation of both the doctor and the patient, preferably with alcoholic skin sterilization procedures. Infection is the most serious side-effect of these techniques and the requirement for hand- washing with antiseptics and avoidance of contact with nee- dles is fundamental. It is essential to use sterile dispos- able equipment. While the nee- dle involved needs to be long enough to achieve penetration of the joint, it should be of small bore unless aspiration
Dr Ingpen is in private practice as a consultant rheumatoiogist in Melbourne, Victoria, Australia. This article was specially written forMoDERN MEDICINE.
has to be carried out. Tissue damage is a major factor in the development of infection and if penetration of a joint is not effected easily, the procedure should be abandoned.
It is essential that the anato- my of the area has been consid- ered, and in general terms joints are best approached through the extensor surfaces, thus avoiding neurovascular structures. Care should be taken to locate adjacent ten- dons and avoid penetration of the tendons with the needle and more particularly the corti- costeroid because tendon dam- age may result through cystic degeneration and subsequent rupture.
Under most circumstances, it is not necessary to infiltrate the skin and subcutaneous tissues
over a joint and, indeed, this can be imdesirable because the bony landmarks are more diffi- cult to feel. Muscles aroimd the joint should be relaxed or under very light passive tension and postured to open the joint on the side of penetration.
If efiFusions are present, they should be aspirated as fiiUy as possible and a sample of the fluid sent for pathological examination. Under these cir- cumstances local anaesthetic infiltrated into the skin and subcutaneous tissues will result in less pain. One sample of the effusion should be sent for culture and Gram stain. A sec- ond sample should be collected in a plain tube for analysis for crystals and rheimiatoid factor if indicated, and a third sample should be coUected into EDTA for a cell coimt and differential coimt. Corticosteroid injections should not be given if there is any suggestion of skin infection and if there is any possibility on aspiration that there may be infection within the joint.
In soft tissue injections, the anatomy of the joint must be defined by palpation and to do this it is necessary for ligaments or tendons to be placed under some tension, either actively or passively. It requires a know- ledge of the surface landmarks.
1 2 MODERN MEDICINE OF SOUTH AFRICA / NOVEMBER 1995
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In general terms joints are best approached through the extensor surfaces, thus avoiding neurovascular structures.
Steroid preparations
Hydrocortisone and the other soluble corticosteroid prepara- tions are rarely used now and have been replaced by prepara- tions with the acetate, tertiaiy butyl acetate or phosphate salts, which have a reduced sol- ubility and thus a prolonged therapeutic effect. Methyl- prednisolone acetate, beta- methasone acetate and betamethasone sodium phos- phate are crystalline sub- stances that may initially pro- duce a transient crystal synovi- tis. This side-effect appears to be reduced by the addition of local anaesthetic to the injec- tion.
The substances most com- monly used for intra-articular injection are: • methylprednisolone acetate (Depot-Medrol); • betamethasone acetate with betamethasone sodium phos- phate (Celestone-Soluspan); • triamcinolone acetonide.
No accurate dosage schedule has been evolved. It largely relates to the internal volume of the joint involved, which in a finger joint may be as little as 0,5ml, but in the larger joint 2 to 3ml can be accommodated without any difficulty. In prac- tice the ceiling dose tends to be one ampoule as presented by the manufacturer. It is rare to require more than this and of doubtful benefit. An admixture of local anaesthetic to the steroid injection will provide rapid confirmation of anatomi- cal accTiracy of the dose.
Aspiration of tlie Icnee
Aspirate the knee at the bisecting point of a vertical line 1cm proximal to the upper patellar border and a horizontal line 1cm below the inferior patellar border Direct the needle toward the centre of the patella.
Illustration for MODERN MEDICINE by Charles Boyter.
There is no particular rule as to the number of joints that may be injected at one time. However, it must be remem- bered that there is systemic absorption which may produce subsequent flushing and influ- ence the blood sugar levels of patients with diabetes. In prac- tice, it would be unusual to inject more than two or three joints at a time. Improvement will normally be noted within the first 24 hours with maxi- mal effect over three to four days. If improvement doesn't occTir it is usually because the joint wasn't entered satisfacto- rily or the joint was not
inflamed (although a transient benefit may still occur under these circumstances).
It is most important that local corticosteroid injection be con- sidered as an adjunct to the basic general management of the condition under considera- tion and not as a specific thera- py in its own right. There is no precise determination as to how often and for how long local cor- ticosteroid injection should be administered. This varies signif- icantly with the underlying cause of inflammation.
Currently there is great interest in the potential bene- fits of intra-articular pentosan
NOVEIVIBER 1995 / I\/IODERN I\/IEDICINE OF SOUTH AFRICA 23
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Joint injections continued I If corticosteroid is placed within
a tendon, cystic degeneration is common and the tendon may rupture
The acromion is the main landmark
Figure 1. TTje s/wofcferts bestmtered from the posterior a^)eawi»i the shOLH- der in tmem^ rotation. Tlie Mn should be penetrated some 3 cm txtow the acnsnnal tubemsitywrth the nee(^ angled 30'rne(Mlly and 3CP ipwards. The subacromial space is entered from the anterolateral approach usng the acromwn as the bor^ landmark.
polysulphate and hyaluronic acid, particularly in degenera- tive joint disease. If early reports are confirmed these may also be routinely used in the futxire.
Side-effects and contra- indications
The side-effects of intra-articu- lar and periarticular joint injec- tions are as foUows. • Bleeding into joint. This is usually very small but is a potential reason for a postinjec- tion flare of pain. • Crystal flare. Approximately 5% of intra-articular steroid injections wUl result in a flare of symptoms in the first one to
two days because of a crystal arthropathy. This seems to be diminished by the admixtxare of local anaesthetic. • Dermal atrophy. This occurs
TABLE
Contra-indications to joint injections Infection, eitiier systemic or local General disease activity Extensive joint damage W h e n prev ious in ject ions have not provided benelit In post-traumatic situations when the possibility of fracture exists Severe local osteoporosis Warfarin anticoagulant therapy
when corticosteroid is deposit- ed in the immediate subcuta- neous tissues. It is most com- mon following repeated injec- tions for lateral epicondylitis and around the wrist joint and small joints of the hands, and it is more common in women. Care should be taken to avoid subcutaneous corticosteroid injection. • Infection. Statistics on this are difficult to obtain. It would appear that the incidence is approximately one in 20 000 injections. All efforts should be made to minimize the potential for infection. • Allergy. This is not usually a major problem. One occasional- ly sees allergy to skin prepara- tions and more particularly to local anaesthetic preparations. As a routine at follow-up the patient should be asked about this and if it does occur the patient should be told about the possibility of it occurring in the future, particularly with respect to dental procedures. Some controversy exists over whether true allergy occurs to the steroid preparation; if so, it is probably rare.
The contra-indications to intra-articvdar and periarticu- lar joint injections are shown in the Table. Extensive joint dam- age is a relative contra-indica- tion because pain relief and improved function may allow excessive use and more rapid joint deterioration. However, with the availability of joint replacement, this potential side-effect is less important.
24 MODERN MEDICINE OF SOUTH AFRICA / NOVEMBER 1995
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Joint injections continued
Local corticosteroid injections are an adjunct to the basic general management of the condition under consideration; not a therapy in their own right.
Figure 2. The elbow should be ositioned at rest arKf at 90' flexion It may be enterad laterally into ttte rac6ohumeral joint or posterioityJust superior to the olecranon.
lUustratim for Modern Meqone byChnsWikoff.
Teciiniques for specific joints
Techniques for specific joints are outlined in the following sections. Injections of spinal joints and epidural injections have not been considered in this article. It is an extensive subject and injection relating to the spine should not be under- taken without adequate train- ing and knowledge of the potential hazards associated with the techniques.
The shoulder Injection of the shoulder is easi- est when approached from the posterior surface with the shoulder in internal rotation (Figure 1). The joint line is
Practice points
below the acromial tuberosity and if the skin is penetrated some 3cm below this and the needle angle 30° medially and 30° upwards, joint puncture rarely fails. The anterior approach to the shoulder is sig- nificantly more painful for the patient and is more difficult to achieve. It is thus better avoided.
Controversy exists over intra-articular injection for cap- sulitis of the shoulder. It is valid to inject the joint once or twice in the first six to eight weeks of this process as rapid pain relief may ensue. It is not valid to persist thereafter.
The rotator cuff tendon and the biceps tendon are common-
• Local corticosteroids injections must iae considered as an adjunct to tlie basic general management of tfie condition.
• Consider tiie anatomy of the area around the joint. • Do not inject if Infection is possibly present. • Inject corticosteroid only if inflammation is present. • If e f fus ion is present in the joint, aspirate to dryness before inject ing
corticosteroid. • Avoid penetration of tendons as cystic degeneration and rupture may occur. • Avoid traumatizing the cartilage surface. • Use of local anaesthetic gives rapid confirmation of anatomical accuracy. • A strict aseptic 'no-touch' technique should be used, including proper skin
preparation of both doctor and patient and the use of sterile disposable equipment.
• There is a strong case for the use of gloves in patients with HIV/AIDS.
ly involved and are best approached at an angle with the particular tendon under tension. The supraspinatus tendon and subdeltoid bursa are approached from the anterolateral aspect with the shoulder in internal rotation, and the long head of biceps is approached obliquely from below with the tendon under tension. In general, triamci- nolone is best used for soft tis- sue injections as it appears to produce significantly less postinjection pain.
The elbow The elbow should be positioned at rest and at 90° flexion. It may be approached laterally through the radiohumeral joint or posteriorly immediately above the olecranon (Figure 2). Tennis elbow may consist of lateral epicondylitis with pain at the extensor origin and may also include a sjmovial fringe in the radiohumeral joint which can be determined by forced rotation of this joint. Under these circumstances, both lesions should be infiltrat- ed with both corticosteroid and local anaesthetic.
Golfer's elbow is usually
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Joint injections continued I It is unwise to inject the hip as
a surgery procedure unless you are trained in this technique.
The superior point of the trochanter is the main landmarl<
Figure 3. The hip may be approached anteriorly (lateral to the neurovas- cular bundle) or laterally proximal to the greater trochanter The proximal neck of femur is Intra-articular and thus lo perwtrate the joint It is not nec- essary to place the acetabular structures at risk.
much more diffuse and while the epicentre of pain and ten- derness appears to be in the vicinity of the medial epi- condyle, tenderness may extend proximally and distaUy along the flexor tendon origin. Under these circumstances, it is necessary to infiltrate beyond the epicondyle and care needs to be taken with respect to the adjacent ulnar nerve.
The hand and wrist The wrist may be easily entered from the dorsal surface with the joint held in slight relaxed flexion. Injection is given distal to the bony ridge of the radius and extensor ten- dons should be first palpated to avoid pvmcture of these.
Finger joints are easily entered through the extensor
surface with the joint held in flexion and under slight ten- sion by pulling on the finger to widen the joint space.
The carpal tunnel syndrome may respond well to local cor- ticosteroid injection. The injection is given between the tendons of palmaris longus and flexor carpi radialis and the needle is inserted through the distal skin crease at an angle of about 40° distally. There is minor resistance as it penetrates the carpal liga- ment and the injection should flow easily without production of significant discomfort. If pain or paraesthesia occurs, the needle should be with- drawn as it may cause nerve damage.
Nodular tenosynovitis of either the flexor tendons or
the tendons of abductor polli- cis longus and extensor polli- cis brevis may be approached by placing the involved ten- dons under tension and advancing the needle at an oblique angle to touch but not penetrate the involved ten- dons. Subsequent infiltration should be associated with minimal resistance and the involved tendon sheath can be seen to expand as the fluid is injected slowly.
The hip joint In general terms it is unwise to inject the hip as a surgery pro- cedure unless trained in this technique.
It is necessary to vmderstand that the synovial cavity of the hip joint extends along the neck of the femur and thus to pene- trate the joint, it is not neces- sary to place the acetabular structures at risk. The joint may be approached anterolater- ally once the position of the neurovascular structures has been determined by palpation or laterally proximal to the greater trochanter (Figure 3). On occasions, it is difficult to determine whether hip pain arises from the joint or is referred from lumbar struc- tures. Under these circum- stances, injection of the joint under X-ray control for absolute confirmation of needle position may be desirable. It shoiald be noted that aseptic necrosis of the head of the femur has been reported following repeated intra-articular injections and this should modify the enthusi-
2 8 MODERN MEDICINE OF SOUTH AFRICA/ NOVEMBER 1995
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Joint injections continued
The ankle is not an easy joint to enter with confidence. It is best approached from the anterolateral or anteromedial aspect with the foot plantar flexed.
Figures 4a and 4b. The knee may be approached anteriody with the joint (a) relaxed and (b) at BCP. It is easiest to enter the knee from the anterome- dial aspect with the joint flexed at 9<T and to enter the suprapatella bursa with the knee relaxed In extension.
Illustration for MOQEBN MEDICINE by Chris Wlkoff.
asm with which this particular procedure is approached.
Trochanteric bursitis re- sponds well to local corticos- teroid infiltration, but if there is not a satisfactory and prolonged response it is probable that the pain in this region is referred fi"om the lumbar spine.
The knee The knee may be approached anteriorly with the joint relaxed and at 90° (Figures 4a and 4b). It is easiest approached medial to the patella tendon. It may also be approached by injection Tinder the superior pole of the patella with the knee relaxed in extension (Figure 5). This is the most favourable if the knee is to be aspirated.
Medial and lateral collateral ligaments may be infiltrated and respond well after strain. It
is important to determine the competence of the ligament because in the presence of sig- nificant tear further damage may ensue. PrepateUa bursitis, intrapatella bursitis and semi- membranosus bursitis respond well to local infiltration with corticosteroids, and triamci- nolone appears to be the most satisfactory preparation. The adjacent tendon structures should not be penetrated with the needle or injected with cor- ticosteroid.
The ankle and foot The ankle is not an easy joint to enter with confidence. It is best approached fi'om the anterolat- eral or anteromedial aspect with the foot plantar flexed (Figure 6). Ligament strains around the ankle joint are com- mon and, provided there is com-
petence of the involved liga- ments, they respond well to local infiltration with corticos- teroid and local anaesthetic. Tendon inflammation is com- mon around the ankle joint and involves particularly the Achilles tendon, tibialis posteri- or and peroneus longus and brevis. Pgirticular note should be taken when infiltrating around the Achilles tendon. Cystic degeneration is common and may precede rupture of the Achilles tendon. If thickening of the tendon can be palpated, then corticosteroid should be avoided and the tendon exam- ined either by ultrasovmd or CT scanning which wiU define the cystic degeneration within the tendon. Magnetic resonance imaging is most effective but too expensive for routine use.
Except in the setting of inflammatoiy arthritis, it is not practical to attempt injection of midtarsal joints and, indeed, efficacy is questionable as the pain syndromes most often relate to abnormal foot mechan- ics which require correction.
Metatarsophalangeal joints may be injected fi-om the dor- sal surface with the toes held lightly in plantar flexion; tmder these circumstances the joint is usually quite easy to palpate. Metatarsalgia, partic- ularly of the Morton's type between the fourth and fifth metatarsal heads, may also be infiltrated from the dorsal approach. The needle is advanced into the space between the metatarsal heads and…
M U R R A Y L I N G P E N , F R A C P , F R C P , D P h y s M e d , F A C R M
Local corticosteroid injection therapy is a simple delivery system which allows relatively small doses of the therapeutic substance to be applied to tissues in a manner which achieves local concentrations not possible by the systemic route. Since hydrocortisone became available over 40 years ago^ synthetic ana- logues have been developed which have greater potency and duration of effect. Over this period, joint injection has evolved as a safe and effective means of influencing inflammation in rheumatic and orthopaedic conditions provided fairly strict rules are adhered to.
• General technique
Injection procedures must be carried out with a thorough aseptic technique which includes skin preparation of both the doctor and the patient, preferably with alcoholic skin sterilization procedures. Infection is the most serious side-effect of these techniques and the requirement for hand- washing with antiseptics and avoidance of contact with nee- dles is fundamental. It is essential to use sterile dispos- able equipment. While the nee- dle involved needs to be long enough to achieve penetration of the joint, it should be of small bore unless aspiration
Dr Ingpen is in private practice as a consultant rheumatoiogist in Melbourne, Victoria, Australia. This article was specially written forMoDERN MEDICINE.
has to be carried out. Tissue damage is a major factor in the development of infection and if penetration of a joint is not effected easily, the procedure should be abandoned.
It is essential that the anato- my of the area has been consid- ered, and in general terms joints are best approached through the extensor surfaces, thus avoiding neurovascular structures. Care should be taken to locate adjacent ten- dons and avoid penetration of the tendons with the needle and more particularly the corti- costeroid because tendon dam- age may result through cystic degeneration and subsequent rupture.
Under most circumstances, it is not necessary to infiltrate the skin and subcutaneous tissues
over a joint and, indeed, this can be imdesirable because the bony landmarks are more diffi- cult to feel. Muscles aroimd the joint should be relaxed or under very light passive tension and postured to open the joint on the side of penetration.
If efiFusions are present, they should be aspirated as fiiUy as possible and a sample of the fluid sent for pathological examination. Under these cir- cumstances local anaesthetic infiltrated into the skin and subcutaneous tissues will result in less pain. One sample of the effusion should be sent for culture and Gram stain. A sec- ond sample should be collected in a plain tube for analysis for crystals and rheimiatoid factor if indicated, and a third sample should be coUected into EDTA for a cell coimt and differential coimt. Corticosteroid injections should not be given if there is any suggestion of skin infection and if there is any possibility on aspiration that there may be infection within the joint.
In soft tissue injections, the anatomy of the joint must be defined by palpation and to do this it is necessary for ligaments or tendons to be placed under some tension, either actively or passively. It requires a know- ledge of the surface landmarks.
1 2 MODERN MEDICINE OF SOUTH AFRICA / NOVEMBER 1995
R ep
ro du
ce d
by S
ab in
et G
at ew
ay u
nd er
li ce
nc e
gr an
te d
by th
e Pu
bl is
he r (
da te
d 20
12 )
In general terms joints are best approached through the extensor surfaces, thus avoiding neurovascular structures.
Steroid preparations
Hydrocortisone and the other soluble corticosteroid prepara- tions are rarely used now and have been replaced by prepara- tions with the acetate, tertiaiy butyl acetate or phosphate salts, which have a reduced sol- ubility and thus a prolonged therapeutic effect. Methyl- prednisolone acetate, beta- methasone acetate and betamethasone sodium phos- phate are crystalline sub- stances that may initially pro- duce a transient crystal synovi- tis. This side-effect appears to be reduced by the addition of local anaesthetic to the injec- tion.
The substances most com- monly used for intra-articular injection are: • methylprednisolone acetate (Depot-Medrol); • betamethasone acetate with betamethasone sodium phos- phate (Celestone-Soluspan); • triamcinolone acetonide.
No accurate dosage schedule has been evolved. It largely relates to the internal volume of the joint involved, which in a finger joint may be as little as 0,5ml, but in the larger joint 2 to 3ml can be accommodated without any difficulty. In prac- tice the ceiling dose tends to be one ampoule as presented by the manufacturer. It is rare to require more than this and of doubtful benefit. An admixture of local anaesthetic to the steroid injection will provide rapid confirmation of anatomi- cal accTiracy of the dose.
Aspiration of tlie Icnee
Aspirate the knee at the bisecting point of a vertical line 1cm proximal to the upper patellar border and a horizontal line 1cm below the inferior patellar border Direct the needle toward the centre of the patella.
Illustration for MODERN MEDICINE by Charles Boyter.
There is no particular rule as to the number of joints that may be injected at one time. However, it must be remem- bered that there is systemic absorption which may produce subsequent flushing and influ- ence the blood sugar levels of patients with diabetes. In prac- tice, it would be unusual to inject more than two or three joints at a time. Improvement will normally be noted within the first 24 hours with maxi- mal effect over three to four days. If improvement doesn't occTir it is usually because the joint wasn't entered satisfacto- rily or the joint was not
inflamed (although a transient benefit may still occur under these circumstances).
It is most important that local corticosteroid injection be con- sidered as an adjunct to the basic general management of the condition under considera- tion and not as a specific thera- py in its own right. There is no precise determination as to how often and for how long local cor- ticosteroid injection should be administered. This varies signif- icantly with the underlying cause of inflammation.
Currently there is great interest in the potential bene- fits of intra-articular pentosan
NOVEIVIBER 1995 / I\/IODERN I\/IEDICINE OF SOUTH AFRICA 23
R ep
ro du
ce d
by S
ab in
et G
at ew
ay u
nd er
li ce
nc e
gr an
te d
by th
e Pu
bl is
he r (
da te
d 20
Joint injections continued I If corticosteroid is placed within
a tendon, cystic degeneration is common and the tendon may rupture
The acromion is the main landmark
Figure 1. TTje s/wofcferts bestmtered from the posterior a^)eawi»i the shOLH- der in tmem^ rotation. Tlie Mn should be penetrated some 3 cm txtow the acnsnnal tubemsitywrth the nee(^ angled 30'rne(Mlly and 3CP ipwards. The subacromial space is entered from the anterolateral approach usng the acromwn as the bor^ landmark.
polysulphate and hyaluronic acid, particularly in degenera- tive joint disease. If early reports are confirmed these may also be routinely used in the futxire.
Side-effects and contra- indications
The side-effects of intra-articu- lar and periarticular joint injec- tions are as foUows. • Bleeding into joint. This is usually very small but is a potential reason for a postinjec- tion flare of pain. • Crystal flare. Approximately 5% of intra-articular steroid injections wUl result in a flare of symptoms in the first one to
two days because of a crystal arthropathy. This seems to be diminished by the admixtxare of local anaesthetic. • Dermal atrophy. This occurs
TABLE
Contra-indications to joint injections Infection, eitiier systemic or local General disease activity Extensive joint damage W h e n prev ious in ject ions have not provided benelit In post-traumatic situations when the possibility of fracture exists Severe local osteoporosis Warfarin anticoagulant therapy
when corticosteroid is deposit- ed in the immediate subcuta- neous tissues. It is most com- mon following repeated injec- tions for lateral epicondylitis and around the wrist joint and small joints of the hands, and it is more common in women. Care should be taken to avoid subcutaneous corticosteroid injection. • Infection. Statistics on this are difficult to obtain. It would appear that the incidence is approximately one in 20 000 injections. All efforts should be made to minimize the potential for infection. • Allergy. This is not usually a major problem. One occasional- ly sees allergy to skin prepara- tions and more particularly to local anaesthetic preparations. As a routine at follow-up the patient should be asked about this and if it does occur the patient should be told about the possibility of it occurring in the future, particularly with respect to dental procedures. Some controversy exists over whether true allergy occurs to the steroid preparation; if so, it is probably rare.
The contra-indications to intra-articvdar and periarticu- lar joint injections are shown in the Table. Extensive joint dam- age is a relative contra-indica- tion because pain relief and improved function may allow excessive use and more rapid joint deterioration. However, with the availability of joint replacement, this potential side-effect is less important.
24 MODERN MEDICINE OF SOUTH AFRICA / NOVEMBER 1995
R ep
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at ew
ay u
nd er
li ce
nc e
gr an
te d
by th
e Pu
bl is
he r (
da te
d 20
Joint injections continued
Local corticosteroid injections are an adjunct to the basic general management of the condition under consideration; not a therapy in their own right.
Figure 2. The elbow should be ositioned at rest arKf at 90' flexion It may be enterad laterally into ttte rac6ohumeral joint or posterioityJust superior to the olecranon.
lUustratim for Modern Meqone byChnsWikoff.
Teciiniques for specific joints
Techniques for specific joints are outlined in the following sections. Injections of spinal joints and epidural injections have not been considered in this article. It is an extensive subject and injection relating to the spine should not be under- taken without adequate train- ing and knowledge of the potential hazards associated with the techniques.
The shoulder Injection of the shoulder is easi- est when approached from the posterior surface with the shoulder in internal rotation (Figure 1). The joint line is
Practice points
below the acromial tuberosity and if the skin is penetrated some 3cm below this and the needle angle 30° medially and 30° upwards, joint puncture rarely fails. The anterior approach to the shoulder is sig- nificantly more painful for the patient and is more difficult to achieve. It is thus better avoided.
Controversy exists over intra-articular injection for cap- sulitis of the shoulder. It is valid to inject the joint once or twice in the first six to eight weeks of this process as rapid pain relief may ensue. It is not valid to persist thereafter.
The rotator cuff tendon and the biceps tendon are common-
• Local corticosteroids injections must iae considered as an adjunct to tlie basic general management of tfie condition.
• Consider tiie anatomy of the area around the joint. • Do not inject if Infection is possibly present. • Inject corticosteroid only if inflammation is present. • If e f fus ion is present in the joint, aspirate to dryness before inject ing
corticosteroid. • Avoid penetration of tendons as cystic degeneration and rupture may occur. • Avoid traumatizing the cartilage surface. • Use of local anaesthetic gives rapid confirmation of anatomical accuracy. • A strict aseptic 'no-touch' technique should be used, including proper skin
preparation of both doctor and patient and the use of sterile disposable equipment.
• There is a strong case for the use of gloves in patients with HIV/AIDS.
ly involved and are best approached at an angle with the particular tendon under tension. The supraspinatus tendon and subdeltoid bursa are approached from the anterolateral aspect with the shoulder in internal rotation, and the long head of biceps is approached obliquely from below with the tendon under tension. In general, triamci- nolone is best used for soft tis- sue injections as it appears to produce significantly less postinjection pain.
The elbow The elbow should be positioned at rest and at 90° flexion. It may be approached laterally through the radiohumeral joint or posteriorly immediately above the olecranon (Figure 2). Tennis elbow may consist of lateral epicondylitis with pain at the extensor origin and may also include a sjmovial fringe in the radiohumeral joint which can be determined by forced rotation of this joint. Under these circumstances, both lesions should be infiltrat- ed with both corticosteroid and local anaesthetic.
Golfer's elbow is usually
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Joint injections continued I It is unwise to inject the hip as
a surgery procedure unless you are trained in this technique.
The superior point of the trochanter is the main landmarl<
Figure 3. The hip may be approached anteriorly (lateral to the neurovas- cular bundle) or laterally proximal to the greater trochanter The proximal neck of femur is Intra-articular and thus lo perwtrate the joint It is not nec- essary to place the acetabular structures at risk.
much more diffuse and while the epicentre of pain and ten- derness appears to be in the vicinity of the medial epi- condyle, tenderness may extend proximally and distaUy along the flexor tendon origin. Under these circumstances, it is necessary to infiltrate beyond the epicondyle and care needs to be taken with respect to the adjacent ulnar nerve.
The hand and wrist The wrist may be easily entered from the dorsal surface with the joint held in slight relaxed flexion. Injection is given distal to the bony ridge of the radius and extensor ten- dons should be first palpated to avoid pvmcture of these.
Finger joints are easily entered through the extensor
surface with the joint held in flexion and under slight ten- sion by pulling on the finger to widen the joint space.
The carpal tunnel syndrome may respond well to local cor- ticosteroid injection. The injection is given between the tendons of palmaris longus and flexor carpi radialis and the needle is inserted through the distal skin crease at an angle of about 40° distally. There is minor resistance as it penetrates the carpal liga- ment and the injection should flow easily without production of significant discomfort. If pain or paraesthesia occurs, the needle should be with- drawn as it may cause nerve damage.
Nodular tenosynovitis of either the flexor tendons or
the tendons of abductor polli- cis longus and extensor polli- cis brevis may be approached by placing the involved ten- dons under tension and advancing the needle at an oblique angle to touch but not penetrate the involved ten- dons. Subsequent infiltration should be associated with minimal resistance and the involved tendon sheath can be seen to expand as the fluid is injected slowly.
The hip joint In general terms it is unwise to inject the hip as a surgery pro- cedure unless trained in this technique.
It is necessary to vmderstand that the synovial cavity of the hip joint extends along the neck of the femur and thus to pene- trate the joint, it is not neces- sary to place the acetabular structures at risk. The joint may be approached anterolater- ally once the position of the neurovascular structures has been determined by palpation or laterally proximal to the greater trochanter (Figure 3). On occasions, it is difficult to determine whether hip pain arises from the joint or is referred from lumbar struc- tures. Under these circum- stances, injection of the joint under X-ray control for absolute confirmation of needle position may be desirable. It shoiald be noted that aseptic necrosis of the head of the femur has been reported following repeated intra-articular injections and this should modify the enthusi-
2 8 MODERN MEDICINE OF SOUTH AFRICA/ NOVEMBER 1995
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Joint injections continued
The ankle is not an easy joint to enter with confidence. It is best approached from the anterolateral or anteromedial aspect with the foot plantar flexed.
Figures 4a and 4b. The knee may be approached anteriody with the joint (a) relaxed and (b) at BCP. It is easiest to enter the knee from the anterome- dial aspect with the joint flexed at 9<T and to enter the suprapatella bursa with the knee relaxed In extension.
Illustration for MOQEBN MEDICINE by Chris Wlkoff.
asm with which this particular procedure is approached.
Trochanteric bursitis re- sponds well to local corticos- teroid infiltration, but if there is not a satisfactory and prolonged response it is probable that the pain in this region is referred fi"om the lumbar spine.
The knee The knee may be approached anteriorly with the joint relaxed and at 90° (Figures 4a and 4b). It is easiest approached medial to the patella tendon. It may also be approached by injection Tinder the superior pole of the patella with the knee relaxed in extension (Figure 5). This is the most favourable if the knee is to be aspirated.
Medial and lateral collateral ligaments may be infiltrated and respond well after strain. It
is important to determine the competence of the ligament because in the presence of sig- nificant tear further damage may ensue. PrepateUa bursitis, intrapatella bursitis and semi- membranosus bursitis respond well to local infiltration with corticosteroids, and triamci- nolone appears to be the most satisfactory preparation. The adjacent tendon structures should not be penetrated with the needle or injected with cor- ticosteroid.
The ankle and foot The ankle is not an easy joint to enter with confidence. It is best approached fi'om the anterolat- eral or anteromedial aspect with the foot plantar flexed (Figure 6). Ligament strains around the ankle joint are com- mon and, provided there is com-
petence of the involved liga- ments, they respond well to local infiltration with corticos- teroid and local anaesthetic. Tendon inflammation is com- mon around the ankle joint and involves particularly the Achilles tendon, tibialis posteri- or and peroneus longus and brevis. Pgirticular note should be taken when infiltrating around the Achilles tendon. Cystic degeneration is common and may precede rupture of the Achilles tendon. If thickening of the tendon can be palpated, then corticosteroid should be avoided and the tendon exam- ined either by ultrasovmd or CT scanning which wiU define the cystic degeneration within the tendon. Magnetic resonance imaging is most effective but too expensive for routine use.
Except in the setting of inflammatoiy arthritis, it is not practical to attempt injection of midtarsal joints and, indeed, efficacy is questionable as the pain syndromes most often relate to abnormal foot mechan- ics which require correction.
Metatarsophalangeal joints may be injected fi-om the dor- sal surface with the toes held lightly in plantar flexion; tmder these circumstances the joint is usually quite easy to palpate. Metatarsalgia, partic- ularly of the Morton's type between the fourth and fifth metatarsal heads, may also be infiltrated from the dorsal approach. The needle is advanced into the space between the metatarsal heads and…
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