9/25/2014. Ricki Loar, Ph.D., APN, FNP-BC, GNP-BC. Disclosure: No Disclosures

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1 Ricki Loar, Ph.D., APN, FNP-BC, GNP-BC 1 Dr. Ricki S. Loar, Ph.D., FNP-BC, GNP-BC Clinical Director, Be Well Partners in Health Nurse Practitioner, South Naperville Family Practice Faculty, Advanced Practice Education Specialists President, Strategic Nurse Practitioner Solutions, LLC Disclosure: No Disclosures 2 The information presented in this program is for educational purposes to help learn about joint/bursa aspiration and injection and is not intended to represent the only method appropriate Check specific details such as drug dosages and contraindications prior to clinical application In addition to this program, supervised clinical experience is highly encouraged 3 1

2 Identify the clinical indications and contraindications for glenohumeral joint, subacromial bursa and acromioclavicular joint injections Identify anatomical landmarks as appropriate for correct injection technique Select appropriate equipment and medications for injection Demonstrate injection and aspiration techniques for glenohumeral joint, subacromial bursa and acromioclavicular joint injections 4 Injecting corticosteroid can provide significant relief of discomfort associated with osteoarthritis The goal of intraarticular and intrabursal corticosteroid injections is to decrease pain and improve function Corticosteroid injections are elective procedures, palliative in nature and should be done with or after other basic therapies It is all about decreasing pain and improving function and quality of life 5 Purpose: suppress inflammation Therapeutic rationale Suppresses prostaglandin production Decrease collagenase activity Reduces interleukin-1, TNF alpha and protease that can degrade cartilage 6 2

3 Painful joint fails to respond to conservative measures Diagnosis or exclusion of causes of musculoskeletal pain Diagnosis of septic joint Confirmation of suspected crystal induced arthropathy Symptomatic relief of large effusions 7 Absolute Active overlying cellulitis or broken skin Suspected septic joint or history of specific joint sepsis Suspected bacteremia Pregnancy Prosthetic joint Relative Lack of response to previous therapeutic joint injections Uncontrolled coagulopathy Poorly controlled diabetes Severe joint destruction or abnormality 8 Infection Bleeding/bruising at injection site Post-injection flare Lipoatrophy, hypopigmentation Tendon rupture Intravascular injection Nerve damage Transient hyperglycemia Mild discomfort during procedure 9 3

4 10 Know the indications, contraindications, complications to the procedure and medications Gather necessary equipment Obtain a signed informed consent Know the anatomy: landmark well Use sterile technique Cleanse the area thoroughly with povidone-iodine, chlorhexidine with or without alcohol Don t be afraid to refer difficult joints or if you are uncomfortable with technique 11 Glenohumeral joint Subacromial bursa Acromioclavicular joint 12 4

5 Anesthetic Xylocaine (Lidocaine) 1%, max 5 7 ml Bupivicaine (Marcaine) 0.25% or 0.5%, 2 3 ml Corticosteroid Methylprednisolone (Depomedrol ) 40mg/mL 1 2mL Betamethasone (Celestone Soluspan ) 6 mg/ml 1-2 ml Triamcinolone Acetonide (Kenalog ) 40 mg/ml 1 2 ml cc syringe, larger if aspiration is done 21, 22 or 25 gauge, 1 ½ inch needle Sterile gloves Skin prep Tube for specimen collection if aspiration is done Sterile hemostat (optional) Sterile bandage (e.g. Bandaid ) Chloroethane Hydrochloric Ether or Pentafluoropropane / tetrafluoroethane (optional) Skin marker (optional) 14 Osteoarthritis of shoulder Rheumatoid arthritis flare Adhesive capsulitis 15 5

6 of the Shoulder and Proximal Humerus 18 6

7 19 Easy access, avoid brachial plexus and cephalic vein Positioning: seated, flexed elbow, shoulder internally rotated Prep / drape shoulder 20 Palpate the lateral edge of the acromion process Locate 2 3 cm inferior and medial to the posteriolateral acromion process Palpate the coracoid process anteriorly Insert needle through the glenohumeral joint and aim for the coracoid process

8 Subacromial / Subdeltoid bursitis Rotator cuff tendinosis Rotator cuff impingement Adhesive capsulitis 22 Lies between the acromion process, deltoid muscle and supraspinatus muscle

9 Palpate lateral portion of acromion process Inferior to the lateral edge of acromion Insert needle just below mid portion of lateral acromion process, perpendicular to skin Aim needle toward opposite nipple Aspirate and inject Resistance? Withdraw and redirect 25 Seated with elbow flexed, shoulder externally rotated Palpate distal, lateral and posterior edge of acromion process Insert needle just below posterior/lateral edge of acromion process Needle should slide under acromion process Aspirate, inject Resistance? Withdraw and redirect 26 AC joint pain Sharp or dull Superior aspect of the shoulder Often point-tenderness Causes of pain Osteoarthritis Traumatic arthritis Osteolysis

10 Diagnostic and therapeutic Consider AC joint injection or Orthopedics referral after conservative treatments have failed to resolve pain Radiologic studies of shoulder with attention to AC joints should be done 28 Usual equipment as previously discussed 3 cc syringe gauge, 5/8 1 1/2 inch needle Anesthetic Xylocaine 1% cc Bupivicaine 0.25%.5-1 cc Steroid Methylprednisolone 0.25 cc 0.5 cc of 40 mg/ml Betamethasone ml Triamcinolone acetonide cc of 40 mg/ml 29 Superior/anterior method Seated or supine, arm at side Palpate clavicle laterally until it meets acromion process Soft spot is at the lateral edge of the clavicle a depression 30 10

11 31 Advise rest for a few days Expect soreness OTC analgesics PRN Notify office any worsening pain, fever, redness, etc. Ice the site for 24 hours Physical therapy 32 Think Green!!! Please complete your evaluation Have a great conference Don t forget the PAC Please volunteer for ISAPN Encourage your colleagues to join! 33 11

JOINT INJECTIONS: INDICATIONS AND TECHNIQUES

JOINT INJECTIONS: INDICATIONS AND TECHNIQUES I. Aspiration (Arthrocentesis) May confirm diagnosis and dictate treatment for suspected causes of joint, tendon sheath, or bursal lesions or poorly defined forms of arthritis Removal of fluid from a tense