Joint Injections in Primary Care

Transcription

1 Joint Injections in Primary Care MARC AIKEN MD Watauga Orthopaedics

2 Objectives Understand when it is appropriate to inject /aspirate a joint Review common injection medications review pertinent anatomy for safe injection technique Review technique for injections in most common joints When to refer

3 The Most Common Joints Injected Knee Shoulder (glenohumeral jt.) Shoulder (subacromial bursa)

4 Indications - Diagnostic Evaluate fluid aspirate for: Infection Inflammatory arthropathy Trauma Relief of pain immediately following injection indicates an intraarticular source

5 Indications - Therapeutic Relief of pain/inflammation caused by: Effusion OA, RA, Gout Bursitis Selected tendonopathies

6 Absolute Contraindications Local cellulitis Prosthetic joint Septicemia Acute fracture Patella and achilles tendonopathy Allergy to injection medications

7 Relative Contraindications Anticoagulated/coagulopathic patient Diabetes Immunocompromised patient Minimal or no relief with 2 prior injections Local osteoporosis Inaccessible joints

8 Medications Corticosteroid Local anesthetic Hyaluronic acid

9 Steroid Betamethasone (Celestone Soluspan) Agent of choice in my practice Long acting 6-12mg for large joint (knee, shoulder) 1.5-6mg for small/intermediate joints

10 Other Steroids Triamcinolone (Aristospan) Dexamethasone (Decadron) Methylprednisolone (Depo-Medrol)

11 Local 1% Lidocaine (Xylocaine) without epi useful for intraarticular injection and subcutaneous injection when aspirating onset within minutes can be diagnostic tool

12 Local Bupivicaine (Marcaine) Potential cause of chondrocyte death Avoid intraarticular use

13 Hyaluronic Acid Lube job for the knee Replaces HA deficient arthritic knee fluid with thick viscous HA. Expect 6 months of relief Given in 3 injections 1 week apart Relief may not be obtained for up to 8wks following last injection.

14 Adverse Reactions/Complications 2-5% - Post injection (steroid) flare 0.8% - Steroid arthropathy (AVN, Chondrolysis, etc.) Iatrogenic infection Flushing Skin atrophy and depigmentation

15 Adverse Reactions/Complications Loss of glucose control in DM Increased appetite Insomnia Irritability

16 General Considerations Evaluate the patient Patient education Consent Patient Comfort Sterile preparation and technique Documentation

17 Evaluate the Patient!! Avoid the Knee hurt...me inject mentality. Get a complete history Examine the patient including other joints Obtain x-rays MRI only if appropriate

18 Patient Education What medications are being used What is the injection expected to do for them What it is not expected to do When they will notice effects of injection What if the expected results are not achieved

19 Consent Written Vs. Verbal Your choice

20 Patient Comfort Lying down for knees (superolateral approach) Sitting up for shoulders Take your time Use ethyl chloride (cold spray) immediately before injection Explain the steps of the procedure as you do them

21 Patient Comfort Lying down for knees (superolateral approach) Sitting up for shoulders Take your time Use ethyl chloride (cold spray) immediately before injection Explain the steps of the procedure as you do them

22 Patient Comfort In patients with severe anxiety regarding needles, provide alternatives or allow them to schedule the injection on a different date. This may allow them time to mentally prepare for the injection. Injections are usually far less painful than patients anticipate

23 Sterile Prep/Technique Make sure injection site is fully exposed Should not be visibly soiled Use iodine or chlorhexidine prep over site to be injected Alway use aseptic technique Consider use of sterile gloves Sterile drapes generally unnecessary

24 Documentation Document the history and physical exam findings that support the decision to perform aspiration/injection Site (which joint and which side) Anatomic placement (med, lat, ant etc) medications and doses injected Expiration dates and lot numbers

25 Document Amount of fluid aspirated color, clarity and viscosity of fluid purulent? Blood? (trauma) Lipid?(trauma/occult fx)

26 Send Fluid for Analysis Labs ordered from fluid: Cell Counts (stat if infection suspected) Cultures Gram stain (stat) Polarized light microscopy

27 Post Injection Care Remove visible prep solution Bandaid Pressure dressing on free bleeders Rest and Ice for 24 hours Warn about limitation of local anesthetic Warn about steroid flare

28 Injection Technique Intraarticular knee Intraarticular Shoulder Subacromial bursa

29 Supplies

30 Knee Aspiration/Injection Superolateral approach most reliable 93% accuracy vs % with bent knee anteromedial/anterolateral approach

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32 Superolateral Approach Patient Supine with knee extended Palpate bony landmarks Patella Lateral Femur

33 Palpate Patella

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35 X Marks the Spot Palpate lateral border of patella and Lateral femur at the PF joint The space between these bony structures is your injection site

36 The Injection Reassure patient Relaxed quads = more space at PF jt Needle Trajectory degrees Toward trochlea of femur

37 Needle Trajectory

38 Anterior Approach (bent knee)

39 Anterior Approach Less reliable/accurate than superolateral approach Can be easier in the obese knee Patient sitting with knee bent to 90 degrees

40 Anterior Approach Palpate landmarks Inferior pole of patella Patella tendon Tibial Plateau

41 Landmarks - Patella

42 Landmarks - Plateau

43 Landmarks

44 Injection Site May inject medial or lateral to patella tendon 1cm above tibial plateau or Half the distance from plateau to inferior pole of patella

45 Trajectory

46 Shoulder (GH joint) Anterior approach Position patient sitting facing provider Palpate bony landmarks Clavicle Coracoid

47 Landmarks

48 Palpate - Clavicle

49 Clavicle

50 Coracoid

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52 Needle Placement Inject just lateral to coracoid process 20 degree angle Reposition if you encounter resistance

53 Shoulder (SA Bursa) Given lateral or posterior Just beneath the angle of the acromion

54 Acromion

55 Subacromial Injection Direct needle under acromion

56 Thank-you for your attention!

57 Questions?

58 Suture Techniques in Primary Care Shawn A. Sutterlin, PA-C Watauga Orthopaedics

59 Objectives Review wound types and classification Understand the principles of wound healing Describe the 3 types of wound closure Overview of Suture materials Wound closure techniques

60 Wound Classification Four Classes Clean Clean-contaminated Contaminated Dirty/infected

61 Clean Wounds Most common is elective surgical incision Primary closure 1-5% rate of infection

62 Clean Contaminated Wounds contaminated by local flora despite aseptic technique Cholecystectomy, appendectomy and hysterectomy 3-11% infection rate

63 Contaminated Open traumatic wounds in nonsterile environment Surgical procedures in which there is a gross deviation from sterile technique (emergent open cardiac massage) 10-17% infection rate

64 Dirty or Infected Gross/heavy contamination or active infection Perforated viscera, abscess and traumatic wounds >27% infection rate

65 Wound Healing Four Phases Hemostasis Inflammatory Proliferative Remodeling

66 Phase I: Hemostasis Vasoconstriction stimulated by endothelial injury Platelet aggregation Coagulation cascade is activated and fibrin clot formed Platelets release pro inflammatory mediators and PDGF in preparation for subsequent phases

67 Hemostasis

68 Phase II: Inflammatory Inflammatory mediators released Vasodilation - provides increased blood supply to injury site Increase vascular permeability - allows plasma proteins, WBCs, into injured tissue Migration of WBCs from circulation into interstitium allows phagocytosis of debris/microbes

69 Inflammation

70 Phase III: Proliferative Angiogenesis Granulation fibroblasts deposit extracellular matrix including collagen/elastin Characteristic beefy red appearance

71 Phase III: Proliferative Epithelialization keratinocytes Contraction Fibroblast release of actin

72 Phase IV: Remodeling Collagen remodeled along tension lines Cells no longer needed are removed by apoptosis May take many months

73 Patient factors Age Weight Nutrition Dehydration Blood supply

74 Patient Factors Immunocompromised Chronic disease Radiation therapy

75 Wound Closure Primary closure Secondary closure Tertiary closure

76 Primary Closure Most common Preferred method when appropriate Wounds are re-approximated acutely Dermis-dermis apposition Best cosmetic outcome

77 Secondary Closure Known as healing by secondary intention Wound edges are left unapproximated Granulation tissue formed Migration of keratinocytes provide reepithelialization over granulation tissue Appropriate in wounds with soft tissue loss or severe contamination not closable by primary or tertiary means

78 Tertiary Closure Contaminated wound is I&D d and left open for several days Wound is then closed as in primary closure when risk of infection declines Preferred method for high energy and highly contaminated wounds

79 Suture Materials Traits needed by suture Tensile Strength Knot security Ease of handling Low tissue reactivity

80 Characteristics Size and Tensile Strength Monofiliment (nylon, prolene, monocryl) Multifiliment (vicryl, ethibond, Silk) Absorbable Non Absorbable

81 Characteristics Dyed Undyed Sizes 11-0 to 6

82 Absorbable Broken down in tissues by hydrolysis and inflammation Time to resorb varies by material and diameter includes vicryl, monocryl, PDS, gut.

83 Non Absorbable Not broken down by hydrolysis or inflammatory reaction Walled off in body by fibroblasts or physically removed Includes nylon, prolene, stainless steel, silk, polyester (ethibond)

84 Suture

85 Suture Sizing

86 Size by Location

87 Needles Cutting - skin and other tough/fibrous tissue Taper - softer tissues inside body (bowel,vessels). Dilates tissues Blunt - felt to pose less risk of needle sticks. Most useful in closure of fascia.

88 Before Closing Evaluate Hemostasis Irrigate Debride devitalized/contaminated tissues Should it be closed primarily?

89 Before Closing Evaluate the wound Time of injury Size and shape of wound Soft tissue loss Gross contamination/foreign body

90 Before Closing Wound depth Nerve, tendon, vascular involvement Bone involvement (open Fx) Joint involvement (traumatic arthrotomy) Uncontrolled hemorrhage

91 Wound Preparation Single most important step in preventing complications Remove all debris and devitalized tissue Irrigate copiously with NS Do not use iodine or hydrogen peroxide in the wound

92 When to Consult Specialist Deep/penetrating wounds to hands/feet, thorax, abdomen, or pelvis Full thickness lac to eyelids, lips or ears Lacerations which involve bone, joint, tendon, artery, muscle or nerve Markedly contaminated wounds Crush injuries Concerns about cosmesis You don t feel comfortable

93 When to Not Close active infection erythema/induration puncture wounds Human/animal bites Delayed onset of treatment 12 hours for body 24 hours for face

94 Anesthesia General/spinal Anesthesia Used for large wounds and more invasive procedures Regional Anesthesia Lidocaine/bupivicaine infiltrated near peripheral nerve to produce anesthesia distally in extremity Digital, wrist and ankle blocks most common

95 Anesthesia Local Most common method in outpatient setting Anesthetic agent infused directly into the tissues being treated

96 Lidocaine Sodium channel blocker Most common 1% should be adequate for most procedures Rapid onset Relatively short duration of action

97 Lidocaine Available with epinephrine Helps to control bleeding Prolongs duration of action

98 Bupivicaine Longer duration of action (8-12hrs) Useful in prolonged procedures as well as post procedure pain control Also available with epinephrine

99 Local Anesthetics

100 Caution!! Do not use epinephrine containing local anesthetic on structures with limited circulation Fingers, nose, penis, toes and ears

101 Equipment

102 General Considerations Handle tissues as little as possible Limit the time and force used in retracting tissues Do not pinch tissues with forceps, Gently lift wound edges to place suture Irrigate frequently to minimize contaminants and keep tissues moist Approximate, don t strangulate

103 Needle Position Needle should be secured 1/2-2/3 down the length needle from the tip

104 Always cross skin at 90 degree angle

105 Rule of Halves Allows better approximation of tissues Avoids dog ears

106 Rule of Halves 1

107 Rule of Halves 3 1 2

108 Basic Suture Methods Simple interrupted Simple running Locked running Horizontal mattress Vertical mattress Running Subcuticular Subcutaneous (buried knot)

109 Simple Interrupted Most common closure performed Used in superficial wounds with minimal tension. Nylon or prolene Be careful of knot security

110 Simple Interrupted

111 Simple Interupted

112 Simple Continuous Rapid Best in short lacerations with no tension Helps with hemostasis If one knot fails, the entire closure is compromised Contraindicated in infected tissues as infection can propagate along suture line

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115 Locked Continuous Used in wounds closed with moderate tension Offers resistance to loosening Helpful in obtaining hemostasis Similar concerns with knot security and integrity of closure

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118 Horizontal Mattress For fragile tissue Distributes tension over wider area Helps evert skin edges

119 Horizontal Mattress

120 Vertical Mattress Used for maximal edge eversion Minimizes deadspace in deeper tissues Helps minimize tension

121 Vertical Mattress

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123 Running Subcuticular Provides optimum cosmetic results Not for contaminated or infected wounds Not appropriate for high tension wounds or joint surfaces

124 Running Subcuticular

125 Subcutaneous Useful for minimizing deadspace in deeper wounds Buries the knot Helps to reduce tension on skin closure May be used in dermis as well

126 Subcutaneous

127 After Closure Apply antibiotic ointment Non adherant sterile dressing Splint if appropriate Tetanus Antibiotics Schedule follow up 2-3 days

128 Suture Removal Face: 3-5 days Scalp: 7 days Chest and extremities: 8-10 days Joints, palms, soles: days

129 Thank You