shoulder girdle joint injection workshop virginia osteopathic medical association 2011 fall cme...

Shoulder Girdle Joint Injection

Workshop

Virginia Osteopathic Medical Association2011 Fall CME Conference

Hotel Roanoke & Conference CenterRoanoke, Virginia

September 23, 2011

Bradley M. McCrady, DOFellow, Primary Care Sports Medicine

Edward Via College of Osteopathic Medicine- Virginia CampusVirginia Polytechnic Institute and State University

Objectives

• Identify indications and contraindications for joint injections of the shoulder girdle.

• Review necessary equipment of shoulder injections.• Discuss techniques to perform various shoulder

girdle injections.• Illustrate techniques of ultrasound-guided injections

of the shoulder girdle.• Demonstrate skills to perform various common

shoulder girdle injections.

Resources

Shoulder Complex

• Shoulder is a complicated anatomical and biomechanical joint– “Fragile Equilibrium”

• Multiple joints• Static and dynamic

stabilizersHoppenfeld, S. Physical Examination of the Spine and Extremities. Prentice Hall; 1976http://www.sportfit.com/tips/rotatorcuff/images/Z4rtrs.gif

What Providers Need to Know About Joint Injection and Aspiration

• Relatively simple procedure• Complications are uncommon• Injection/arthrocentesis can provide diagnosis, relieve

pain, decrease joint damage– “Liquid biopsy of joint”– Useful information can be provided by relatively inexpensive

tests– Can help differentiate inflammatory from non-inflammatory

arthritis

• Judicious use of anesthetics and steroids may be safer than systemic medications

• Summary There are often more reasons for doing than not in the right clinical scenario

Indications for Joint Injection/Aspiration• Diagnostic

– Acute inflammatory arthritis (24-48 hours) in a patient who has never had these symptoms before

– Acute effusion in the setting of fever, chills, or presence of infection at another site

– Acute effusion in the setting of trauma– Prior to committing patients to long-term, expensive or toxic therapy

• Therapeutic– Provide for a better musculoskeletal exam (i.e. pain control)– To suppress inflammation in one or two isolated joints– Adjuvant therapy to a few joints resistant to systemic therapy– To facilitate a rehabilitative therapy program– To support a patient with active joint inflammation pending the effects of

systemic therapy– To remove exudative fluid from a septic joint– To relieve pain in a swollen joint

Conditions Likely to be Improved by Joint or Periarticular Injections

• Rheumatoid arthritis

• Seronegative spondyloarthropathies

• Crystal induced arthritis

• Carpal tunnel

• Bursitis

• Tenosynovitis/tendinitis

• Adhesive capsulitis

• Osteoarthritis

Contraindication to Joint Injection/Aspiration

• Absolute– Uncooperative patient– Allergy to anesthesia or

steroid (very rare)– Lack of informed consent– Injection through infected

tissues– Previous severe steroid

flare– Injection of steroid into

critical weight-bearing tendons

• Relative– Injection near critical structures– Coagulation disorders– Uncontrolled diabetes– h/o AVN– Previous joint replacement at

injection site– More than 3 previous steroid

injections in a major weight bearing joint in the preceding year

– Concern to activate any latent disease

– Excessive anxiety

Equipment• Informed consent• Non-sterile exam gloves• Marking pen• Alcohol pads

+/- povidine-iodine

• Gauze pads• Syringe(s)• Needle• Anesthetic• Steroid• Adhesive bandages

McNabb, James. A Practical Guide to Joint & Soft Tissue Injection & Aspiration. 2nd Ed.LWW; 2010.

Safety First• Position for comfort!• Define anatomy• Universal precautions

– Vaccines– Gown and mask not necessary

• Clean vs sterile technique• Aspirate prior to injections• Do not recap needles• Proper disposal of equipment• Observe patient in office

following injection for 15-30 min

Baima, J.Curr Rev Musculoskelet Med (2008) 1:88–91Hemani, M. Rev Urol. 2009;11(4):190-195Darouiche, RO. N Engl J Med 2010;362:18-26

Topical Preparation

• Infection is not common– Actual reported incidence

is unknown, but is thought to vary from 1: 3,000 to 1:50,000

• 70% isopropyl alcohol vs 10% povidone-iodine

• Ethyl chloride fine spray may have antimicrobial activity

Baima, J.Curr Rev Musculoskelet Med (2008) 1:88–91Hemani, M. Rev Urol. 2009;11(4):190-195Darouiche, RO. N Engl J Med 2010;362:18-26Clinical Radiology, Volume 61, Issue 12, Pages 1055-1057

http://www.shopmedrx.com/qt_images/TRI_103201.jpghttp://sani-system.com/images/products/b15901.jpghttp://www.gebauerco.com/Images/picEthylChlorideLeft.gif

Steroids-History• Hydrocortisone acetate was first

introduced in the 1949 for Rheumatoid arthritis by Hollander – “No other form of treatment has

given such consistent local symptomatic relief in so many for so long with so few harmful effects.”

• Oriole baseball pitcher Jim Palmer– “…cortisone is a miracle drug ... for

a week!"

• Long history of use in athletics– Treat the secondary inflammation– Need to find the cause

Nepple, J. Sports Health: A Multidisciplinary Approach 2009 1: 396-404Leadbetter WB. Clin Sports Med.1995;14(2):353-410.

Steroids-Physiology• Stabilizing lysosomal

membranes of inflammatory cells

• Decreasing local vascular permeability

• Altering neutrophil chemotaxis and function

• Able to pass through cell membranes and bind to nuclear steroid receptors– Where they influence RNA

transcriptionNepple, J. Sports Health: A Multidisciplinary Approach 2009 1: 396-404

Steroids-Use• Hill et al surveyed members of the

American Academy of Orthopaedic Surgeons on use of corticosteroids– 90% of used corticosteroid injections– Performed an average of 150 intra-

articular and 193 extra-articular injections per year

• Conditions warranting injection– Epicondylitis (93%)– Shoulder bursitis (91%)– Greater trochanteric bursitis (91%)– DeQuervain’s tenosynovitis (87%)– Bicipital tendonitis (81%)Hill JJ Jr,. Contemp Orthop. 1989;18:39-45.


Anesthetics• Decrease nerve conduction through

the blockade of Na channels, which disrupts axonal nerve conduction

• Typically steroid agent is combined with a local anesthetic agent– Decrease the pain – Dilute the steroid– Increase the distribution of the agent to

the treated area

• Lidocaine– Rapid onset (minutes)– Short duration (60-90 minutes)

• Bupivicaine• Slower onset (30 minutes)• Longer duration (6-8 hours)

• Buffering– Sodium bicarbonate

Nepple, J. Sports Health: A Multidisciplinary Approach 2009 1: 396-404

What Patients (and Providers) Need to Know about Joint Injection

• Relief will typically last weeks or longer

• Avoid injecting ligamentous or tendon structure directly

• Activity modification following injections of steroids is uncertain

• Maximal number of injections and the required period between injections have not been determined

Nichols, A Clin J Sport Med 2005;15(5) : E370Pfenninger JL. Procedures for primary care physicians. St. Louis: Mosby, 1994.

What Patients (and Providers) Need to Know about Joint Injection

• In a meta-analysis summarizing 25+ studies, they noted a 5.5% complication rate– The most common side effects

included skin atrophy (2.4%), skin depigmentation (0.8%), localized erythema and warmth (0.7%), and facial flushing (0.6%)

– Post-injection pain was noted in up to 9% of patients

– Post injection flare (2-5%)– Prolonged and repeated usage may

increase the risk of complications and systemic side effects

• In diabetic patients, hyperglycemia has been shown to persist up to 5 days after a single soft tissue injection (very low risk)

Dietzel, D Current Sports Medicine Reports 2004, 3:310–315Nepple, J. Sports Health: A Multidisciplinary Approach 2009 1: 396-404Wang AA. J Hand Surg [Am]. 2006;31(6):979-981.Pfenninger, JL Procedures in Primary Care 2nd Ed. 2003: 1479-1499

Typical Injection/Aspiration Procedure• Determine the medical diagnosis and consider

relevant differential diagnoses• Discuss the proposed procedure and alternatives

with the patient• Obtain written informed consent from the patient• Collect and prepare the required materials• Correctly position the patient for the procedure• Identify and mark the anatomic landmarks and

injection site with ink– Do not allow the patient to move the affected area

from the time that the marks are placed until after the procedure is completed

• Press firmly on the skin with the retracted tip of a ballpoint pen to further identify the injection site

• Prepare the site for injection by cleansing with a topical antimicrobial agent (povidine-iodine and/or alcohol swab)– If using the povidone, allow to dry for full

antibacterial effect• Provide local anesthesia as indicated through use of

tactile distraction, vapocoolant spray (ethyl chloride or PainEase), and/or injected local anesthesia

McNabb, James. A Practical Guide to Joint & Soft Tissue Injection & Aspiration. 2nd Ed.LWW; 2010.Pfenninger, JL Procedures in Primary Care 2nd Ed. 2003: 1479-1499

Typical Injection/Aspiration Procedure• Using the no-touch technique, introduce the needle

at the injection site and advance into the treatment area

• Aspirate fluid (optional) using a 18 or 20-g needle and send it for laboratory examination if indicated

• If injecting corticosteroid immediately following aspiration, do not remove the needle from the joint or bursa; In this case, grasp the needle hub firmly (with a hemostat clamp if necessary), twist off the original syringe, and then immediately attach the second syringe that contains the corticosteroid

• Always aspirate before injection to avoid intravascular administration

• Inject corticosteroid solution into the treatment area– If not aspirating then use 25-g needle– Do not inject the medication against resistance

• Withdraw the needle• Apply direct pressure over the injection site with a

gauze pad• Apply an adhesive dressing• Provide the patient with specific post-injection

instructionsMcNabb, James. A Practical Guide to Joint & Soft Tissue Injection & Aspiration. 2nd Ed.LWW; 2010.Pfenninger, JL Procedures in Primary Care 2nd Ed. 2003: 1479-1499

Informed Consent

• Patient’s consent to allow provider (and his/her pupils) to perform the procedure.

• All alternative treatments discussed with the patient in lieu of procedure.

• Benefits and risks to the procedure.• Explanation of the procedure in lay language to the

patient.• Signature of the patient or authorized representative,

witness, and provider.

Shoulder Girdle Injections

• Subacromial– Posterior– Lateral

• Glenohumeral– Posterior– Anterior

• Acromioclavicular

• Sternoclavicular

• Biceps brachii long head

Subacromial Injection Lateral Approach

• Find lateral edge of acromion and mark

• Palpate soft spot below the acromion and above the humeral head

• Insert needle perpendicular through the deltoid towards the bursa

Subacromial Injection Posterior Approach

McNabb, James. A Practical Guide to Joint & Soft Tissue Injection & Aspiration. 2nd Ed.LWW; 2010.Seroyer, S. Sports Health 2009; 1 (2): 108-120

• Find lateral edge of the acromion and mark

• Palpate posterior edge of the acromion and mark

• Find posterolateral edge of the acromion and mark a spot 2 cm below the corner

Subacromial Injection Posterior Approach

• Position the needle at a 30 ° angle to the skin with the needle tip directed cephalad toward the acromion

• Insert the needle getting underneath the acromion and advance until the needle tip touches the undersurface of the acromion

• Once at the acromion, back off 1-2mm

Glenohumeral Injection Posterior Approach

• Find lateral edge of acromion

• Palpate the posterior edge of the acromion

• Mark spot 2 cm below posterior lateral corner

• Target is coracoid process

Glenohumeral Injection Posterior Approach

• Advance needle towards coracoid process until tip touches humeral head and retract needle 1-2mm

Glenohumeral Injection Anterior Approach

• Identify coracoid process

• Injection point is 1 cm lateral to the coracoid

Glenohumeral Injection Anterior Approach

• Insert needle perpendicular to the skin toward the target 2 cm caudad to the posterior lateral corner of the acromion

• Advance needle until it reaches the humeral head and retract 1-2mm

Long Head Biceps Injection

• Palpate course of biceps long head tendon with the patient flexing the elbow

• Palpate location of maximal tenderness which is usually under the edge of the pectoralis major

http://www.aafp.org/afp/2009/0901/afp20090901p470-f1.jpg

Long Head Biceps Injection

• Position needle at a 45° angle to the skin with needle directed proximally

• Advance needle until needle tip touches tendon, back needle off 1-2mm

• Medication should flow smoothly

Acromioclavicular Injection

• Identify AC joint by palpating the clavicle in a medial to lateral direction until reaching a small depression that may be tender

http://upload.wikimedia.org/wikipedia/commons/thumb/3/3b/Gray326.png/250px-Gray326.png


• Insert needle perpendicular to the skin with the needle tip directed caudad

Sternoclavicular Injection

• Identify SC joint by palpating the clavicle in a lateral to medial direction until reaching a small depression that will likely be tender


• Insert needle perpendicular to the skin and advance into SC space

Musculoskeletal Ultrasound

• The use of high-frequency sound waves (3-17MHz) to image soft tissues and bony structures in the body for the purpose of diagnosing pathology or guiding real-time interventional procedures

Pinzon, EG and Moore, RE. Musculoskeletal Ultrasound: a brief overview of diagnostic and therapeutic application in musculoskeletal medicine. Practical Pain Management. June 2009.

http://cdn.bleacherreport.com/images_root/image_pictures/0236/5499/39664_crop_340x234.jpg

Ultrasound Terminology

• Echogenecity- the ability of tissue to reflect ultrasound waves back toward the transducer and produce an echo. (The higher the echogenicity of tissues, the brighter they appear on ultrasound imaging)

• Hyperechoic- seen as brighter on ultrasound relative to surrounding tissues due to higher reflectivity of the US beam

• Isoechoic- structures are seen as bright as surrounding structures on conventional US imaging due to similar reflectivity to the US beam

Pinzon, EG and Moore, RE. Musculoskeletal Ultrasound: a brief overview of diagnostic and therapeutic application in musculoskeletal medicine. Practical Pain Management. June 2009.


• Hypoechoic- structures are seen as darker relative to the surrounding structures on US imaging due to the US beam being reflected to a lesser extent

• Anechoic- structures that lack internal reflectors fail to reflect the US beam to the transducer and are seen as homogenously black on imaging

• Anisotrophy- the effect of the beam not being reflected back to the transducer when the probe is not perpendicular to the structure being evaluated Pinzon, EG and Moore, RE. Musculoskeletal Ultrasound: a brief overview of diagnostic and

therapeutic application in musculoskeletal medicine. Practical Pain Management. June 2009.


• Transverse- cross sectional view

• Sagittal (Longitudinal)- long axis plane view

• Coronal- long axis plane view dividing anterior and posterior

http://www2.healthsci.tufts.edu/saif/Vevo2100/Ultrasound-Terminology.pdf

Ultrasound Equipment

• High Resolution Machine• Transducers– Linear 8-14 MHz– Curvilinear 2-5 MHz– “Hockey Stick”

• Printer• CD/DVD/USB unit

Schaefer, MP. Ultrasound Guided Interventions in PM&R. MRIO PM&R Grand Rounds. 9 November 2009.http://www.ucsdultrasound.com/yahoo_site_admin/assets/images/ultrasound_transducers.24673744_large.jpg

Ultrasound Guidance Advantages

• Real-time guidance• Assess anatomy• Soft tissue visualization• Visualize neurovascular structures• No radiation

Schaefer, MP. Ultrasound Guided Interventions in PM&R. MRIO PM&R Grand Rounds. 9 November 2009.

Ultrasound Guidance Limitations

• Obesity (depth ~6cm)• No contrast confirmation• No visualization deep to bony structures (very

limited use in spine injections)• Operator dependency• Superficial tenderness


Equipment for U/S Guided Injections

• Informed consent• Sterile vs non-sterile gloves?• Marking pen• Alcohol pads• Povidine-iodine• Gauze pads• Syringes• Needles (typically longer than non-guided injections)

– Echoblock needle?

• Sterile transducer cover?• Sterile gel• Anesthetic• Steroid• Adhesive bandages


Subacromial Injection

http://www.essr.org/html/img/pool/shoulder.pdf


Subacromial Injection


Glenohumeral Injection


Long Head Biceps Brachii Injection


Long Head Biceps Brachii Injection

http://www.ultrasoundpaedia.com/USP%20shoulder%20winner.html

http://dynamicultrasound.org/images/lsbiceps.jpg


http://emj.bmj.com/content/28/6/542.extracthttp://greatpiercingshop.com/blog/wp-content/uploads/2009/12/Clavicles.jpg

Post Injection Instructions

• Recurring Pain- anesthetic effect ending before steroid effect begins

• Rest Injection Area- further injury may be caused by numbness of the site

• Infection Observation- fever, increased warmth/redness, ascending redness, increased swelling

Injection Coding• CPT code– 20610 injection/aspiration of major joint or bursa

• Code for injectable used (J code)


Questions and Demonstration

http://www.shoulderdoc.co.uk/images/uploaded/sdoc_ultrasound_07.jpg

References

• Beggs, I., et al. Musculoskeletal Ultrasound Technical Guidelines: shoulder. European Society of Musculoskeletal Radiology. http://www.essr.org/html/img/pool/shoulder.pdf

• McNabb, James. A Practical Guide to Joint & Soft Tissue Injection & Aspiration. 2nd Ed. LWW; 2010.

• Pinzon, EG and Moore, RE. Musculoskeletal Ultrasound: a brief overview of diagnostic and therapeutic application in musculoskeletal medicine. Practical Pain Management. June 2009.

• Schaefer, MP. Ultrasound Guided Interventions in PM&R. MRIO PM&R Grand Rounds. November 2009.



shoulder girdle joint injection workshop virginia osteopathic medical association 2011 fall cme...

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