Safe and Easy Joint Injections Mary Derlacki, FNP Drs. Cassell and Braun 132 E. Broadway #830 Eugene, OR 97401 541.687.0816 mderlacki@comcast.net
History of Joint Injections 1930's saw formalin, glycerin, lactic acid and petroleum jelly injected with little effect. 1960's introduced Hydrocortisone acetate and tertiary-butyl acetate hydrocortisone which were superior in benefit.
Indications To reduce swelling and aid in recovery of soft tissue structures such as bursitis Decrease pain of weight bearing joints to preserve function and muscle mass in OA To induce long periods of near remission in joints with inflammatory arthritis
Contraindications Do not inject steroids into a monoarthritis ALWAYS THINK INFECTION! For patients on anticoagulation therapy, Low risk if INR is below 3.7 Nothing larger than a 22g needle
Frequency Knee joint once every 3 months Always pair with strengthening exercises Straight Leg Raises Shoulder bursa; 2 injections 3 months apart Inject first then PT or PT then inject
Safety of Steroid Injections 1950's and 1960's: multiple injections with higher concentrations of steroids had a catabolic effect on cartilage in rabbit knees 1990's: Chondroprotective effect by reducing cartilage damage and osteophyte formation
Adverse Effects FAT....atrophy FLUSH.....facial flushing, red and hot FLARE.....post injection flare Systemic effect on bone and blood sugar minimal and safer than oral Rate of infection 2/100,000 or less
Choice of Medication Lidocaine total volume equals 10% 5 cc of 2% or 10 cc of 1% Marcaine 0.25% add 1 cc to knee only Less soft tissue atrophy and chance of tendon rupture when steroid is mixed with local anesthetic
Choice of Medication Methylprednisolone (Depo-Medrol) 80mg/ml Very slow onset, less FLARE, slightly soluable Dexamethasone sodium phosphate 4mg/ml Rapid onset, protects against FLARE, very soluable Lidocaine 1%, 2% and Marcaine 0.25%
Supplies
Supplies Pes Anserine Bursa aka The Other Knee 3 cc syringe with 25g 1 1/4” needle 40mg Methylprednisolone ½ cc 1mg Dexamethasone ¼ cc 2 ½ cc Lidocaine 2% TOTAL=3cc
Supplies Shoulder Bursa 5 cc syringe with a 25g 1 1/4” needle 40mg Methylprednisolone ½ cc 1mg Dexamethasone ¼ cc 4 ¼ cc Lidocaine 1% TOTAL=5cc Sterile Prep with Betadine swab x 3 Ethyl Chloride Spray for 10 seconds
Drawing up the Medications 1. Dexamethasone 2. Methylprednisolone 3. Marcaine (for the knee only) 4. Lidocaine
Positioning of the Patient Knee Joint: Sitting on table. Palpate inferior lateral edge of the patella and superior edge of tibia. Stay lateral to the patellar tendon. Find the dimple. Enter lateral side. Target is superior, medial patella edge at a 45 degree angle. Anserine: Sitting on table. Palpate anserine bursa on the medial side just inferior to the tibial tubercles . Below Knee Joint line. Enter medial side.
Shoulder: Sitting on table, angle 45* away from you. Enter posteriorly at dimple below the acromium angle. Direct needle towards the sternoclavicular joint. https://www.youtube.com/watch?v=YXtQQAd4n1E RheumTutor.com 0:32-1:22 https://www.youtube.com/watch?v=4kvH7aG4WWE Shoulder Subacromial Injections by Dr. Ernest Roman - Empire Medical Training
Post Injection Flare 2-5% of joint injections, less with bursa Symptoms begin 2-4 hours after injection Painful with use, warm, swollen Often mistaken for infection RX is ice, rest, pain relievers Resolves in 24 hours T o prevent next time: Use more Dexamethasone
Infection Usually develops after 24-48 hours Painful with use and at rest Swollen, red, hot Often accompanied by fever, drenching sweats and/or shaking chills (rigor) Medical Emergency! Contact Ortho and send to the hospital. Potential loss of joint is high.
Aftercare Instructions Rest injected area for 24-48 hours Apply ice for 10-15 min, 2-3 times a day Acetaminophen 1000mg after injection Do not submerge in water for 24 hours Begin strengthening exercises on day 3
Good Luck! Mary Derlacki, FNP Drs. Cassell and Braun 132 E. Broadway #830 Eugene, OR 97401 541.687.0816 mderlacki@comcast.net
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