Articular injections Guide

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Articular injections Guide
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Arthrocentesis, intra-articular injection therapy in soft tissue
Maestro Javier Saavedra. Family physician. C.S. Noia. A Coruña (Spain) Enrique N
ieto Pol family physician. C.S. C. Arenal. Santiago. A Coruña (Spain) Carlos Eir
e Eiras. Family physician. C.S. Bueu. Pontevedra (Spain) Castano Ana Carou. Fami
ly physician. Transfusion Centre. Porto (Portugal) Juan José Díaz Garel. Rheumat
ologist. C. Hospital of Santiago de Compostela. A Coruña (Spain
Updated on 27/03/2007. Contents: Injections in ...
Overview and objectives. Justification General Information Directions Directions
intraarticular infiltration periarticular infiltration Instrumental Drug Contra
indications General rules How many injections side effects we do? Bibliography
Shoulder Elbow Hand Knee Foot
More
Cortisone Injection of Soft Tissues and Joints (MedicineNet) Corticosteroid Inje
ctions of Joints and Soft Tissues - (eMedicine)
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Articular injections Guide
Overview and objectives. Justification arthrocentesis is a relatively straightfo
rward procedure with few side effects is joint puncture and removal of joint flu
id for diagnostic or therapeutic. The local administration or intra-articular so
ft tissues of drugs, chemicals or radioisotopes is one of the therapeutic modali
ties of rheumatic diseases, which generally produces a relief of symptoms, with
few side effects, and is in many cases the treatment of choice, primarily in sof
t tissue inflammation. The main objectives of the workshop are, first, acquire t
he ability to diagnose periarticular inflammatory conditions or to articulate th
at is a subsidiary of local treatment and, secondly, promoting the acquisition o
f technical skills for the primary care physician to perform this therapy. There
are several reasons for conducting infiltration into the primary care field, am
ong which we would highlight:
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The technique is simple, requiring a learning that is acquired quickly and only
require training, practice and caution the clinician. It requires few resources,
feasible in any office or health center. Greater accessibility for patients abo
ut specialized care. Very favorable clinical results and short term. Very rare c
omplications. Aval years of experience on the part of primary care physicians. P
rofessional motivation: learning and problem-solving.
Epicondylitis
Epitrocleítis
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General information on a steroid injection. Monofocal or oligofocal inflammatory
joint or soft tissue. 2. Polifocal inflammatory disease, but more severely mono
focal or oligofocal. 3. Failure of drug treatment and / or rehabilitation. 4. Wh
en other treatments are contraindicated. 5. Need quick functional recovery.
Bursitis
Indications for intra-articular infiltration with glucocorticoids
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Rheumatoid arthritis (adult and juvenile) microcrystals deposit arthropathies (g
out and pseudogout) Lupus erythematosus and other connective acute traumatic art
hritis Arthritis / Osteoarthritis Inflammatory Joint Diseases from another sourc
e (inflammatory bowel disease, ankylosing spondylitis with peripheral involvemen
t, psoriatic arthritis, disease Reiter, etc.
N. Morton
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Articular injections Guide
Heel spur
Indications for periarticular infiltration with glucocorticoids
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SHOULDER
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Subacromial bursitis bicipital tendinitis supraspinatus tendinitis adhesive caps
ulitis suprascapular neuropathy olecranon bursitis Epicondylitis Epitrocleitis c
ubital tunnel syndrome Ganglion De Quervain's Tenosynovitis Carpal Tunnel Syndro
me Trigger finger Meralgia paresthetica trochanteric bursitis anserina bursitis
ischial bursitis Bursitis Bursitis prepatellar iliopectineal Achilles Tendinitis
Achilles Bursitis Calcaneal Bursitis Neurinoma of Morton tarsal tunnel syndrome
calcaneal spur plantar fasciitis
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ELBOW
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Wrist and hand
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HIP
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KNEE
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PELVIS
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PIE
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To follow a therapeutic regimen. 2. 3. 4. Local measures rest on NSAIDs / analge
sics (5-7 days) Assess local infiltration
Contraindications for an infiltration with glucocorticoids. Lack of accurate dia
gnosis. 2. Coagulation disorders 3. Presence of infection intraarticular or peri
articular tissues, or in case of bacteremia. 4. Injections repeated previous ine
ffective. 5. Adverse drug reaction in previous infiltration. 6. Chronic polyarth
ritis, including rheumatoid arthritis, multiple actively inflamed joints. Genera
l rules for infiltration with glucocorticoids 1. Carried out by trained personne
l. 2. Anatomical knowledge of the joint structures and soft tissue infiltrate. 3
. Choose the path more comfortable and safer, if necessary marking the entry poi
nt. 4. Always have all materials ready before starting the technique. 5. Always
follow a strict hygiene. 6. Choosing the proper needle home joint or soft tissue
. 7. Insert the needle gently, not violently, without making untimely or multidi
rectional movements without necessity. 8. No unexpected overcome resistance to t
he introduction of the needle. 9. If in the joint cavity, aspirate before all th
e synovial fluid that may exist. 10. Before injecting the drug, with suction ens
ure that you are not in the vascular access. 11. If infiltrates within proximity
of nervous tissue, ask the patient if you notice numbness or lancinating pains
to avoid injury. 12. Managing the volume does not exceed that supports each join
t. 13. After infiltration, carefully remove the needle and a protective dressing
to the puncture site. 14. Tell the rest of the joint for 24-48 hours after infi
ltration. Apparatus necessary for carrying out infiltration Always use sterile d
isposable single use only. It states:
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1. 2. 3. 4. 5. 6.
Disposable needles, various models by location and pathology. Disposable syringe
s. Sterile gauze. Sterile surgical drapes. Sterile gloves. Antiseptics.
Drugs used in the infiltration 1. Corticosteroids: The use of steroids via intra
articular or soft tissue requires delayed or deposit formulations in the form of
esters in crystalline suspension, giving them a lower solubility and greater pe
rsistence and duration of local effect, necessary to achieve clinical efficacy .
There are several synthetic analogues, with similar efficacy but different pote
ncy such as betamethasone acetate and betamethasone sodium phosphate (Celestone
cronodose) parametasona acetate (cortidene depot) and triamcinolone acetonide (T
rigon depot), probably the latter is the best result has contributed, probably b
ecause of its low solubility and the effect lasts longer local. Some authors rec
ommend as mixed formulations of Celestone cronodose (poorly soluble steroids - d
elayed-action corticoid-soluble fast). 2. Local anesthetics: They can be used si
ngly or in combination with corticosteroids when infiltrated soft tissues. It is
also possible that mixtures of both in intraarticular infiltrations decrease th
e frequency of arthritis steroids microcrystals, since its concentration decreas
es. Examples of local anesthetics used are: mepivacaine, lidocaine, xylocaine. A
dverse effects of infiltration with glucocorticoids 1. Joint infection: is the m
ost serious complication. Infiltration occurs in approximately 1:10,000. 2. Post
injection arthritis (arthritis steroids microcrystals). It occurs in 1-3% of cas
es and is characterized by acute arthritis within 48 hours after infiltration. 3
. Tendon ruptures: not to do intratendinosas infiltration. 4.€Corticosteroid art
hropathy: the repeated infiltration of a single joint may produce a like arthrop
athy neuropathic arthropathy. 5. Vasovagal syncope, by intense pain during the p
rocedure or in those predisposed or apprehensive.
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6. Hematoma in the area infiltrated. 7. The adverse effects of its dissemination
to the systemic circulation. How many injections can be performed with the same
disease? The patterns of use, relatively arbitrary, they recommend: 1. Infiltra
tion Spacing between 7 days and 1 month. 2. Do not inject the same joint more th
an four times a year, or more than two consecutive if they are ineffective. 3. D
o not inject more than 3 joints in one sitting. 4. Keep infiltrated the joint at
rest 24-48 hours. 5. Do not use in accompanying which could aggravate condition
s (eg diabetes). References 1. Arribas JM. Minor surgery and procedures in famil
y medicine. Madrid: Jarpio Publishers, 2000. 2. St John A, Graber J. Articular i
njection techniques. Barcelona: Termis, 1989. 3. Mazzucheli R, Quiros J, Zarco P
. Emergencies in the Locomotive (II): Pain in soft tissue. Medicine 2001, 8 (35)
: 1832-1839. 4. Palomino B, Peña A. Effectiveness of corticosteroid and anesthet
ic infiltration in epicondylitis. Rheuma 2000; 4: 44-47. 5. Fernandez A, Povedan
o J, Campos S, García A. Clinical efficacy of steroid injections. Rev Esp Reumat
ol 1998, 25: 361-370. [Full Text] 6. Benito S, Lopez JA. Arthrocentesis and inje
ction techniques of local. In: Eliseo Pascual, Vicente Rodríguez, Jordi Carbonel
l, Juan J: Gomez-United. Treaty of Rheumatology. Vol II. Madrid: Aran, 1998: p.2
447-2453. 7. Vidal J, Turner J. Intraarticular therapy. In: Gabriel Herrero-Beau
mont, Emilio Martín, José Luis Riestra, Jesus Tornero. Manual of rheumatic disea
ses. Madrid: Doyma, 1992: p.21-127. 8. S. Duncan Owen, Jr. Aspiration and inject
ion Of joints and soft tissues. In: William N. Kelley, M.D., Edward D. Harris, J
r, MD, Shaun Ruddy, MD, Clement B. Sledge, MD Textbook of rheumatology. Vol II.
4th ed. Philadelphia: W. B. Saunders Company, 1993: 545-561. 9. Frank H. Netter,
M.D. Bones and joints of the shoulder and arm. In: Russell T, Woodburne MA, Edm
und S, Crelin PhD, Frederick S, Kaplan MD. Musculoskeletal System Volume VIII. N
ew Barcelona: Salvat, 1990: p.30-34. 10. JJ Rodriguez, Tristan M, Escribano E. G
irdle: anatomic remember. History and physical examination. In: Juan Jose Rodrig
uez, Valverde Lis. Manual trauma in primary care. Spain:
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11.
12.
13. 14.
Smithkline Beecham, 1996: p.125-131. Rotes Querol J. Exploration of the musculos
keletal system. In: Eliseo Pascual, Vicente Rodríguez, Jordi Carbonell, Juan J.
Gómez-United. Treaty of Rheumatology Vol I. Madrid: Aran, 1998: p.177-208. Grana
dos J, Soler R. Local and regional syndromes of the upper extremities. In: Elise
o Pascual, Vicente Rodríguez, Jordi Carbonell, Juan J. Gomez-United. Rheumatolog
y Vol II Treaty. Madrid: Aran, 1998: p.1783-1789. Seamus ED. The Shoulder. In: J
ohn H. Klippel, Paul. A. Dieppe. Rheumatology. London: Mosby, 1994. MacKenney E.
Manual basic exploration of the hand. Madrid. Jarpio, 2001.
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