KAPA2017MusculoskeletalAspirationand

InjectionWorkshopW.ScottBlack,MD

PhysicianAssistantStudiesProgramUniversityofKentucky

Aspiration

• Relativelyquickandinexpensive• Canbeperformedintheoffice• Helpsdifferentiateinflammatoryfromnon-inflammatoryarthritis

• Helpsestablishdiagnosisofcrystal-depositionarthritisandsepticarthritis

ReasonstoAspirateaJoint

• Patientwithinflamedjoint(orjoints)whodoesnothaveanestablisheddiagnosis

• Anyacutemonoarthritis• Anytimethereisanysuspicionofaninfectedjoint

• Serialaspirationsforpainrelief• Priortoinjectionofcorticosteroidsorhyaluronicacidpreparation

ReasonsNot toAspirateaJoint

• Bacteremia(?)• JointProsthesis(?)• OverlyingSkinandSoftTissueInfection• UncontrolledCoagulopathy• SevereOverlyingDermatitis• UncooperativePatient(?)

Wouldyouaspiratethatknee?

• 27y/omale• 3dayh/oflu-likeillness– Fever– Chills– Bodyaches

• Kneered,hot,andswollenX24hours

• Fever102.5inyouroffice

Whataboutthatknee?

• 64y/omale• HypertensionandNIDDM

• Acuteonsetkneeswellingandpain

• Low-gradesystemicsymptoms

• Temp99.9

Goutvs.SepticJointvs.Other???

Isthatelbowinfected?

EvaluatingJointFluid

• PhysicalCharacteristics:Appearance,Color,Viscosity

• ChemicalAnalysis:Glucose,Protein• MicroscopicEvaluation:CellCountandDifferential,CrystalAnalysis

• MicrobiologicEvaluation:GramStainandCulture(mayneedtobeveryspecific)

• SerologicandCytologicalEvaluation

SynovialFluid

• Iusuallyaskfor:– CellCountandDifferential– CrystalAnalysis– GramStainandCultureif

suspiciousforsepticjoint

• Checkwithyourreferencelabforappropriatecollection,storage,andhandlingofsynovialfluid

SynovialFluidAnalysis

Palmer&Toombs.JAmBoardFam Pract 2004;17:S32-42.

CommonMusculoskeletalInjections

Cardone &Tallia.AFP2002;66:283.

CommonMusculoskeletalInjections

Cardone &Tallia.AFP2002;66:283.

CommonAdverseEffect:SkinHypopigmentationandSQTissueAtrophy

CommonMusculoskeletalInjections

• WhotoInject– ProperDiagnosis/Reason

• WhattoInject– UsingtheRightMedication/Combination

• HowtoInject– CorrectProcedure– GetMedicationWhere ItisSupposedtoGo

Foster,etal.AFP2015;92(8):694-699.

WhattoInject• Lesssolublecorticosteroidpreparationstendtohavea

longerdurationofactionbutagreaterincidenceofcutaneoussideeffects

• MostcommonlyusedcorticosteroidsatUKaretriamcinoloneandmethylprednisolone– Kenalog-10orKenalog-40andDepo-Medrol40orDepo-Medrol

80• Thecorticosteroidisfrequentlymixedwithalocal

anesthetic– Manufacturersoftenrecommendagainstmixing– Someconcernaboutcartilagetoxicity– Lidocaine (Xylocaine)1%or2%– Bupivacaine(Marcaine)0.25%or0.5%

Subacromial Injection

• Indications– Subacromial Impingement– ChronicRotatorCuff

Tendinopathy– Subacromial Bursitis– AdhesiveCapsulitis

• Evidenceisfair• Probablyshouldthinkof

thismoreasanadjuvanttoPhysicalTherapy

Subacromial Injection• 10mlsyringe• 23-25g1½”Needle• Kenalog orDepo-Medrol

(40– 80mg)• Around6-8ml1%

lidocaine,0.25%bupivacaineor50:50mix

• Posterolateral approach– Aboutonefingerbreadth

belowposteriorcornerofacromion

– DirecttowardACjoint

Ultrasound-GuidedSAInjection

TennisElbow• Chronicoveruseinjuryof

theECRBandEDC• Tendinosis vs.Tendinitis

– Tendinopathy– LateralEpicondylaglgia

• Lessfrequentlyanacuteinjury

• Injectionmayprovidebettershort-termpainreliefbutnoadvantagelong-term

• Again,probablybesttoconsiderasanadjuvanttotherapy

TennisElbow

• 5mlSyringe• 25g1”Needle• 40mgKenalog orDepo-Medrol

• 2-4ml1%lidocaine or0.25%bupivacaine

• Anybenefittofenestration?

• AutologousbloodandPRP?

US-GuidedTennisElbowInjection

TennisElbow

Smidt,etal.Lancet2002;359:657-62

OlecranonBursaAspiration/Injection

• Importanttoaspirateifconsideringsepticbursitis

• Shouldnotinjectcorticosteroidsintoasepticbursitis

• SterileTechnique• Findboggy/tenseareaof

bursa• Mayneed21gneedle(or

larger)foraspiration• Localanestheticinfiltration

reducesdiscomfort

ElbowJointAspiration/Injection

• Aspirateeffusionifsepticjointsuspected

• Aspiratehemarthrosisafterradialheadfracture

• Landmarks:– LateralEpicondyle– RadialHead– OlecranonProcess

DeQuervain’s Tenosynovitis

• Tendinopathy oftheAPLandEPBintheFDCofthewrist

• RespondswelltoCSI• FinkelsteinTest

InjectionforDeQuervain Syndrome

• Tuberculin/AllergySyringe(1ml)

• 27g½”needle• 0.25mlKenalog-40orDepo-Medrol40(10mgCS)

• 0.75ml1%lidocaine or0.25%bupivacaine

InjectionforDeQuervain Syndrome

TriggerFingerInjection

TriggerFingerPathophysiology

TriggerFingerInjection

• 3mlSyringe• 25gneedle(5/8”to1”)• 10– 20mgofKenalog orDepoMedrol

• 0.5– 1.5ml1%lidocaineor0.25%bupivacaine

GreaterTrochanter• GreaterTrochanteric“Bursitis”• GreaterTrochanterPain

Syndrome– 5-10mlsyringe– 22-25gneedleatleast1½”

long– Mayneedspinalneedle– 40mgDepo-MedrolorKenalog– 5-7ml1%lidocaine or0.25%

bupivacaine– Sometimesuseguideneedle

andspinalneedle– Insertatpointofmaximum

tendernessandgotobone

GreaterTrochanterPain

KneeJointAspiration/Injection

• ReasonstoAspirate– Undiagnosedeffusion– Suspicionforsepticjoint– Improvepainbydecompressinglargepost-traumaticeffusion

• ReasonstoInject– Arthritis

KneeJointAspiration/Injection• 10mlsyringeforinjection• Mayneedmuchlargersyringe

foraspiration(30-60ml)• 23-25g1½”needlefor

injection• 21gneedle(orlarger)for

aspiration• Kenalog /Depo-Medrol40-80

mg– DextroseProlotherapy?

• 1%lidocaine or0.25%bupivacaine5-8mlor50:50mix

KneeInjection/AspirationLateralApproach

KneeInjectionAnteriorApproach

AnkleJointAspiration/Injection• Aspirationismuchmore

usefulthaninjection• OAoftheanklemayhave

differentpathophysiologythanthatatthekneeandhip

• 10mlsyringe(mayneed30-60ifaspiratinglargeeffusion)

• 20– 25g1½”needle• 40mgKenalog orDepo-

Medroldilutedin3-5mlanesthetic

AnkleAspiration/Injection

• AnterolateralApproach– Betweenthelateralmalleolusandthelateralborderoftheextensordigitorum longus

• Anteromedial Approach– Betweenthemedialmalleolusandthemedialborderofthetibialis anterior

PlantarFasciaInjection• Plantarfasciaisrelatively

toughbandofconnectivetissuedescribedasoriginatingatthemedialcalcanealtuberosityandinsertingintofivebandssurroundingthedigitaltendons

• WindlassMechanismofFoot

• SupportsMedialLongitudinalArch

PlantarFasciaInjection• Plantarfasciitis?• ChronicHeelPain

Syndrome• 3-5mlsyringe• 25g1½’”needle• 20mgKenalog orDepo-

Medroldilutedin2½to3½mllocalanesthetic

• MedialApproach• Avoidinjectingthrough

plantarfoot

FirstMTPJoint

• Gout• OA• TurfToe• 1– 3mlSyringe• 25– 27g1”Needle• 10– 20mgKenalog orDepo-Medroldilutedin1– 2mllocalanesthetic

FirstMTPJoint

• Approachfromdorsomedial sideofjoint

• Angleneedleabout60degreesandenterfromproximaltodistaltofollowcontourofjoint

• Distractiononthegreattoecanhelpopenupjointmakingentryeasier

JointInjection&Aspiration

• Thanks• Questions???