Back to home pageNeedle Syringe Drug ARTHRITIS STEROID INJECTION PowerPoint Presentation on CD
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All derivative (i.e. change in media; by compilation) work from this underlying U.S. Government public domain/public release data is COPYRIGHT © GOVPUBS $3.00 first class shipping in U.S. and rest of world. Includes the Adobe Acrobat Reader for reading and printing publications.
Numerous illustrations and matrices.
Contains the following key public domain (not copyrighted) U.S. Government publication(s) on one CD-ROM in both Microsoft PowerPoint and Adobe Acrobat PDF file formats: TITLE: Injection Directions, 49 pages (slides)
SLIDE TOPICS, SUBTOPICS and CONTENTS:
Injection Directions Jon Roebuck August 5, 2008 Rheumatology AM lecture Series Overview Indications Education Tools Special considerations Techniques Joints Soft tissues TSP and L funds
Indications Aspiration of fluid Diagnosis Relieve pressure/pain Drain badness
Injection of anesthetic +/- steroid Relieve pain and suffering Education Post-injection care Decreased activity
Complications Infection/ bleeding Local pain Post-injection flare Flushing reaction Education Patient expectation Cure? Alleviation of symptoms No response Need for repeat injection Frequency of re-injection Adjunctive measures Arthrocentesis technique Considerations Needle and syringe size
Skin sterilization
Local anesthesia
Equanimity of patient Needle size “It’s not the size of the wand, but how you wave it”
22 gauge for most taps 18-20 for knee Viscous pus 25 for IP joints Inflammatory fluid is LESS viscous Syringe size What are you trying to accomplish? Large syringe for large effusion Small syringe for tendon sheath injection
5-10 cc is ideal Large enough for vacuum Small enough to avoid debris
Hair removal Shaving is NOT recommended Remove top layer of epidermis Expose more staph Increase risk of infection?
If gorilla like: Clip hair shafts Sterile preparation 3 separate concentric spirals Iodine disinfectant
Landmarks before preparation Sterile gloves are not necessary Don’t touch the prepared site Universal precautions CRUCIAL question Swipe the alcohol pad? Dab the alcohol pad?
Who’s a swiper Who’s a dabber
Anesthesia Bleb of SQ lidocaine Burst of ethyl chloride Before or after preparation? EMLA cream
Mix lidocaine with steroid Reduce post injection flare Anesthesia Theoretical concerns
Methylparaben preservatives Decrease culture sensitivity Bad technique with spray Splatter from non-sterile field Multi-dose vials not optimal For sterile technique
Switching syringes Why do it? First syringe fills Gross inspection prior to injection Only one stick Make sure needle is loose enough! Use a hemostat Grab proximal round end Why aspirate before inject? Reducing size of effusion before injection improves outcome
50% reduction in reaccumulation of fluid Principles Comfortable position You and patient
Easy access to joint capsule
Avoidance of neurovascuar bundles
Avoidance of abnormal overlying skin In general… Kenalog 40mg large joints 20-30mg medium joints 10-20 small joints As much as can fit for tiny joints
Be liberal with anesthetic MYTH Corticosteroid injections accelerate cartilage destruction Antiquated data
May even be chondroprotective Suppression of metalloproteases? Animal studies
Site specifics Shoulder Joints: Glenohumeral Acromioclavicular Sternoclavicular
Soft tissues: Subacromial bursitis Biceps tendonitis JOINTS Temporomandibular Palpate during jaw movement
Mark target with mouth open
Small joint principles apply Shoulder
Posterior
Anterior
Large joint Elbow Elbow joint proper Radiohumeral articulation
Elbow flexed to 90 degrees Medium joint Wrist Distal to radius Ulnar to anatomic snuffbox Interconnecting synovial spaces Medium joint First Carpometacarpal Thumb flexed across palm Dorsal side of extensor pollicis brevis Avoid radial artery
Small joint Interphalangeal joints Lateral, medial or dorsal Beneath extensor tendon Penetration of joint space is overrated
Small joint Knee Rheumatology Medial anesthesia Orthopedics Lateral Superior
Large joint
Why dry? You missed
It’s in the bursa
Gelatinous effusion Panacea?! Ankle Hollow between medial malleolus and articulation of tibia on talus
Just lateral to medial malleolus
Medium joint Ankle/ subtalar joint Many small joints Communicate Cluster attacks
One inch below lateral malleolus
Small joint Medium amount SOFT TISSUES
Subacromial bursa Scapulohumeral groove posteriorly Aim for the acromion
Anterior or lateral approach Supraspinatus tendon Lateral groove between humerus and acromion
Straight shot 2.5 cm Biceps tendon Palpate bicipital groove Area of point tenderness May be tender along tendon
Penetrate sheath and bath tendon Resistance is bad Wrist ganglion Carpal tunnel Radial side of palmaris longus Diagnostic as well as therapeutic
Medium joint principles apply DeQuervain’s Dupuytren’s Nodular fibrosing lesions Ulnar preference Intralesional injection Softening and flattening of nodules Best early in course Trochanteric bursitis
Bursa bursa everywhere Anserine bursa Sartorius Gracilis Semitendinosis
Very amenable to injection Don’t inject this Inject this Financial smarts How much will college cost for our kids Best methods to save Trusts Educational IRA 529 plans
Don’t let financial advisors tell you to use TSP– that's yours Summary Best thing we do Patients better by the time they leave Patient education/expectations Paramount to good response Don’t get too cavalier Bad things happen rarely Very few absolute contraindications TSP L funds Any questions about TSP in general? L funds Automated diversification Automated re-balance Automated shifting based on retirement timeline For the truly dedicated and disconnected Questions Did you sign up for TSP?
  
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