Injections Injections for the Upper Extremity Treatment Tortures, - PowerPoint PPT Presentation

Injections Injections for the Upper Extremity � Treatment Tortures, Voodoo or Magic Bullet � Anti-inflammatory � Viscosupplementation C. Benjamin Ma, MD � Diagnostic � Lidocaine injection Professor in Residence � Differential injection Chief, Shoulder and Sports Medicine • Multiple locations University of California, San Francisco Department of Orthopaedic Surgery Injections Injections � Pearls � Shoulder � Glenohumeral joint � Use the same size needle each time � Bursa • Get comfortable with the � AC joint resistance. � Biceps tendinitis � Elbow � Don’t use a long long long needle � Intra-articular unless you have to � Epicondylitis � Volume is important, different � Wrist and Hand volume for different purpose � Intra-articular � Trigger finger

Shoulder Shoulder � Subacromial injection (22g needle � Intra-articular (22G needle - - 10ml) 10ml) � Rotator cuff tears � Frozen shoulder � Impingement syndrome/bursitis � Osteoarthritis � Feel the soft spot posteriorly � Can do it posteriorly or laterally � Aim for the coracoid process. � Go underneath the bone � Stay horizontal � Very easy injection, no pressure. � If it is hard to inject, think about � Best treatment for frozen moving the needle as it may be in shoulder muscle Shoulder Shoulder � Bicipital groove (1-2ml) � Acromioclavicular joint (1-2ml) � Biceps tendinitis � AC joint arthritis � Tough joint to inject � Feel the tender spot � Very superficial. � Go straight down � Touch bone and back up slightly � Can feel the space between the acromion � Should have very easy injection and distal clavicle and goes along the bicipital bursa � Don’t go too deep, only 1, at most 2 cm. � If tough to inject, maybe intra-tendinosus injection � If too deep, injecting into the subacromial space � Advice patient the risk of rupture and restrict lifting for first week

Elbow – hard! Elbow � Lateral epicondyle (1-2ml) � Intra-articular (3-5ml) � Tennis elbow � Medial epicondyle (1-2ml) � Osteoarthritis � Medial epicondylitis � Osteochondritis dessicans � Inject site of maximum tenderness � Soft Spot � 1cm distal to the epicondyle � Feel the other side for swelling � Warn patient of � Fat atrophy � Lateral side of the elbow � Hyper- or hypopigmentation � Border of radial head, ulna � Numbness of ulna nerve for medial epicondylitis and lateral epicondyle � Don’t use long-acting anesthetic! Wrist and Hand Trigger finger � Along tendon sheath � Intra-articular (2-3ml) � Osteoarthritis A1 pulley (1-2ml) � Cartilage injuries (TFCC) � Small caliber needle 25g � Difficult – more technical � Go right at the point of � Dorsal approach swelling and pain. � Withdraw to ensure not � Extensor compartment (1-2ml) in blood vessel � De Quervain’s syndrome

C. Benjamin Ma maben@orthosurg.ucsf.edu