joint/bursa injection (knee injection, subacromial bursa injection)
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Indications
- pain relief: symptom improvement may last 24 weeks[4] number needed to treat 4.4 for 1 to benefit at 16-24 weeks
Contraindications
- absolute
- localized abscess or cellulitis at site of injection
- active Herpes simplex virus (HSV) or tuberculosis infection
- previous hypersensitivity to injectable anesthetic
- relative
- bleeding diathesis
- anticoagulant therapy
- safe in patients receiving direct oral anticoagulant therapy;
- no need to withhold anticoagulation before procedure[8]
- safe in patients receiving direct oral anticoagulant therapy;
- bacteremia
- partial tendon rupture at site of injection
- joint prosthesis
Procedure
Preparation:
- obtain informed consent
- identify landmarks
- wide-field skin cleaning
- sterile glove
- sterile drape may be indicated
Precautions:
- withdraw needle to subcutaneous tissue prior to redirecting needle
- avoid removing the needle completely when redirecting
- no single joint should be injected more that every 3-6 months
Injection by joint/bursa/disorder
- subacromial bursitis
- patient sitting arm at side
- locate subacromial bursa by palpating superiorly along spine of scapula to posterolateral portion of the acromion (acromial angle), superior to the humeral head
- insert 4 cm, 25 gauge needle 1 cm below acromial angle, direct anteromedially, staying close to the inferior border of acromion, insert approximately 2.5 cm, avoid rotator cuff tendon inferiorly
- inject anesthetic (1% lidocaine/0.25% bupivicaine 2-10 mL) & glucocorticoid serially from front to back (connective tissue acts as septae separating space into sections)
- move joint through full range of motion to distribute mixture
- lateral & anterior approaches better than posterior approach[5]
- lateral epicondylitis
- elbow flexed 90 degrees with hand pronated
- locate point of maximum tenderness near lateral epicondyle
- insert 1 cm, 25 gauge needle into point of maximum tenderness parallel to the tendon
- inject anesthetic (lidocaine 1%, 0.5 mL) & corticosteroid
- knee (video[11])
- flex knee 10-15 degrees
- a rolled towel may be place in the popliteal fossa to support the knee & allow the quadriceps to relax
- insert 4 cm 25 gauge needle laterally beneath the patella
- inject anesthetic (lidocaine 1%, 2-4 mL) & corticosteroid
Glucocorticoids for joint injection:
- triamcinolone acetonide or hexacetonide (Kenalog) 40 mg/mL
- methylprednisolone acetate (Depo-Medrol) 80 mg/mL
- knee 0.5-1.0 mL (20-40 mg)
- large joints: 0.25-0.5 mL (10-20 mg)
- small joints: 0.25 mL (5-10 mg)
- tendons: 0.1 mL (4 mg)
Complications
- seizures from local anesthetic:
- localized cutaneous depigmentation & atrophy from leaking of injectable steroids onto skin
- subcutaneous swelling & pain after procedure:
- ice may attenuate
- post procedural infection
- knee injections given within 3 months of knee arthroplasty associatated with risk for periprosthetic infection[9]
- damage to tendons: avoid strenuous activity for 1 week after procedure
- post-injection steroid flairs 6-12 hours after injection (post-injection synovitis)
- phagocytosis of glucocorticoid ester crystals
- generally resolve in 48-72 hours
- relieved by NSAIDs & ice
- repeated injections do NOT accelerate joint narrowing[3][4]
- high dose hip joint injection 80 mg dexamethasone or repeated injections confer a risk of rapidly destruction hip disease[10]
- a single hip joint injection of 40 mg triamcinolone confers low risk[10]
More general terms
More specific terms
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 779-781
- ↑ Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 506
- ↑ 3.0 3.1 Journal Watch 23(8):65, 2003 Raynauld J-P et al, Arthritis Rheum 48:370, 2003
- ↑ 4.0 4.1 4.2 Journal Watch 24(11):86, 2004 Arroll B, Goodyear-Smith F. Corticosteroid injections for osteoarthritis of the knee: meta-analysis. BMJ. 2004 Apr 10;328(7444):869. Epub 2004 Mar 23. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/15039276 <Internet> http://bmj.bmjjournals.com/cgi/content/full/328/7444/869
- ↑ 5.0 5.1 Marder RA et al. Injection of the subacromial bursa in patients with rotator cuff syndrome: A prospective, randomized study comparing the effectiveness of different routes. J Bone Joint Surg Am 2012 Aug 15; 94:1442 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/22992814 <Internet> http://jbjs.org/article.aspx?articleid=1306117
- ↑ Gaujoux-Viala C, Dougados M, Gossec L. Efficacy and safety of steroid injections for shoulder and elbow tendonitis: a meta-analysis of randomised controlled trials. Ann Rheum Dis. 2009 Dec;68(12):1843-9. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19054817
- ↑ Courtney P, Doherty M. Joint aspiration and injection and synovial fluid analysis. Best Pract Res Clin Rheumatol. 2013 Apr;27(2):137-69 PMID: https://www.ncbi.nlm.nih.gov/pubmed/23731929
- ↑ 8.0 8.1 Yui JC, Preskill C, Greenlund LS. Arthrocentesis and joint injection in patients receiving direct oral anticoagulants. Mayo Clin Proc 2017 Aug; 92:1223 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28778256 <Internet> http://www.mayoclinicproceedings.org/article/S0025-6196(17)30310-5/fulltext
- ↑ 9.0 9.1 Richardson SS, Schairer WW, Sculco TP, Sculco PK. Comparison of infection risk with corticosteroid or hyaluronic acid injection prior to total knee arthroplasty. J Bone Joint Surg Am 2019 Jan 16; 101:112 PMID: https://www.ncbi.nlm.nih.gov/pubmed/30653040
- ↑ 10.0 10.1 10.2 Okike K, King RK, Merchant JC et al. Rapidly destructive hip disease following intra-articular corticosteroid injection of the hip. J Bone Joint Surg Am 2021 Nov 17; 103:2070. PMID: https://www.ncbi.nlm.nih.gov/pubmed/34550909 https://journals.lww.com/jbjsjournal/Abstract/2021/11170/Rapidly_Destructive_Hip_Disease_Following.2.aspx
- ↑ 11.0 11.1 Kelly N In-Office Knee Injection Technique: Tips for Success SANFORD HEALTH - THE UNIVERSITY OF SOUTH DAKOTA SCHOOL OF MEDICINE: ORTHOPAEDICS AND SPORTS MEDICINE. https://www.vumedi.com/video/in-office-knee-injection-technique-tips-for-success/