Safe and Easy Joint Injections Mary Derlacki, FNP Drs. Cassell and - - PowerPoint PPT Presentation

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

• steophyte 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

• f 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 To 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