Rural and Remote Medicine Course 2016 May 5th - 7th 2016

1. Clinical MusculoskeletalClinical Musculoskeletal
InjectionsInjections
Chris Parfitt MD FRCS©Chris Parfitt MD FRCS©

2. DisclosuresDisclosures
►nonenone
►(I like giving injections)(I like giving injections)

3. Musculoskeletal InjectionsMusculoskeletal Injections
► A bit like mooseA bit like moose
huntinghunting
► Chasse l’orignalChasse l’orignal

4. Moose HuntingMoose Hunting
► Hunting licenceHunting licence
► Right animal (moose)Right animal (moose)
► Right caliber rifleRight caliber rifle
► Right type of bulletRight type of bullet
► YOU HAVE TO HITYOU HAVE TO HIT
THE TARGETTHE TARGET

5. Musculoskeletal InjectionsMusculoskeletal Injections
► Medical licenceMedical licence
► Right diagnosisRight diagnosis
► Right needleRight needle
► Right dose of medicineRight dose of medicine
► YOU HAVE TO HITYOU HAVE TO HIT
THE TARGETTHE TARGET

6. MSK Injections GeneralMSK Injections General
► Informed consentInformed consent
► ProcedureProcedure
► BenefitsBenefits
► RisksRisks
► In writing or verbalIn writing or verbal
► ALWAYS ASKALWAYS ASK
ABOUT ALLERGY!!ABOUT ALLERGY!!

7. MSK Injections GeneralMSK Injections General
► The equipmentThe equipment
► AntisepticsAntiseptics
► bandagesbandages

8. MSK Injections GeneralMSK Injections General
► EquipmentEquipment
► Assorted long andAssorted long and
short acting localshort acting local
anestheticsanesthetics
► With and withoutWith and without
epinephrineepinephrine

9. Types of CortisoneTypes of Cortisone
► Triamcinolone 40 mgTriamcinolone 40 mg
cc (potency 5)cc (potency 5)
► Methylprednisone 40Methylprednisone 40
mg/cc (potency 5)mg/cc (potency 5)
► Betamethasone 6Betamethasone 6
mg /cc ( Potency 25)mg /cc ( Potency 25)
► KenalogKenalog
► DepomedrolDepomedrol
► CelestoneCelestone

10. SAFETY of WHAT we INJECTSAFETY of WHAT we INJECT
► Currently no stronglyCurrently no strongly
stated rules aboutstated rules about
what we inject into awhat we inject into a
jointjoint
► BUT!!!BUT!!!

11. Steroid shots and blood sugarSteroid shots and blood sugar
► MethylprednisoloneMethylprednisolone
40 mg40 mg
► Triamcinolone 40 mgTriamcinolone 40 mg
► betamethasonebetamethasone
► No effectNo effect
► Increases blood sugarIncreases blood sugar
► Increases blood sugarIncreases blood sugar

12. PAIN PUMPSPAIN PUMPS
► Used post operativelyUsed post operatively
starting about 2002starting about 2002
► Marcaine with epiMarcaine with epi

13. Bupivacaine and ChondrolysisBupivacaine and Chondrolysis
► BupivocaineBupivocaine
epinephrine infusionepinephrine infusion
pumps caused highpumps caused high
rates of chondrolysisrates of chondrolysis
► 2005 to 20082005 to 2008

14. Bupivacaine ChondrolysisBupivacaine Chondrolysis
► Now a whole crop ofNow a whole crop of
pain pump lawsuitspain pump lawsuits

15. Injections and ChondrotoxicityInjections and Chondrotoxicity
► Apoptosis ofApoptosis of
chondrocytes is achondrocytes is a
validatedvalidated
measurement ofmeasurement of
chrondrocyte toxicitychrondrocyte toxicity

16. Injections and ChondrotoxicityInjections and Chondrotoxicity
► prednisolone causeprednisolone cause
chondrocyte death inchondrocyte death in
ex vivo chondrocytes,ex vivo chondrocytes,
betamethasone did notbetamethasone did not
► Farkas et al CORRFarkas et al CORR
20102010
► All local anestheticsAll local anesthetics
caused chondrocytecaused chondrocyte
deathdeath
► Dose and time relatedDose and time related
► Farkas et al CORRFarkas et al CORR
20102010

17. Injections and chondrotoxicityInjections and chondrotoxicity
► All local anestheticAll local anesthetic
toxicity totoxicity to
chondrocyteschondrocytes
potentiated withpotentiated with
epiniphrineepiniphrine

18. Injections and ChondrotoxicityInjections and Chondrotoxicity
► The combination ofThe combination of
cortisone and localcortisone and local
anesthetic is possiblyanesthetic is possibly
synergistic in causingsynergistic in causing
chondrotoxicitychondrotoxicity

19. Chondrotoxicity: currentChondrotoxicity: current
recommendationsrecommendations
► Although commonAlthough common
practice is to injectpractice is to inject
steroid and localsteroid and local
anesthetic togetheranesthetic together
► There are no specificThere are no specific
recommendations inrecommendations in
the literaturethe literature

20. Injections and ChondrotoxicityInjections and Chondrotoxicity
► Intuitively?Intuitively?
► Use .5% lidocaine, .Use .5% lidocaine, .
25% bupivocaine25% bupivocaine
► Use bupivocaine, alsoUse bupivocaine, also
prednisoloneprednisolone
► Inject steroid withInject steroid with
salinesaline

21. Injections and ChondrotoxicityInjections and Chondrotoxicity
► If joint already bone onIf joint already bone on
bone, there are nobone, there are no
chondrocytes to bechondrocytes to be
toxic to, thereforetoxic to, therefore
longer acting locallonger acting local
anesthetic can beanesthetic can be
used!used!

22. Injections: Tenocyte toxicityInjections: Tenocyte toxicity
► Some studies showSome studies show
tenocyte toxicity withtenocyte toxicity with
steroids and localsteroids and local
anestheticanesthetic
► More dilute localMore dilute local
anesthetic less toxicanesthetic less toxic

23. MSK Injections GeneralMSK Injections General
► Assorted syringesAssorted syringes
► Preneedled syringesPreneedled syringes
are time savingare time saving
► Draw up solution withDraw up solution with
larger needlelarger needle
► demodemo

24. MSK Injections Needle sizeMSK Injections Needle size
► 1.5 inch 25 gauge for1.5 inch 25 gauge for
fine injectionsfine injections
► 1.5 inch 21 gauge is1.5 inch 21 gauge is
optimal for larger jointsoptimal for larger joints
(shoulder and knee)(shoulder and knee)

25. MSK Injections GeneralMSK Injections General
► TriamcinoloneTriamcinolone
► 40 mg mil40 mg mil
► Methyl prednisoneMethyl prednisone
40 mg miL40 mg miL
► BetamethasoneBetamethasone
6 mg mil6 mg mil

26. MSK ViscosupplementationMSK Viscosupplementation
► Hyaluronic acid nowHyaluronic acid now
just over 200$just over 200$
► Approved for arthitisApproved for arthitis
(mostly knee studies)(mostly knee studies)

27. PLATELET RICH PLASMAPLATELET RICH PLASMA
► Becoming moreBecoming more
commoncommon
► Cost from 400 to 800$Cost from 400 to 800$

28. PRP Soft tissuePRP Soft tissue
► Cochrane review 2014Cochrane review 2014
► Insufficient evidence toInsufficient evidence to
support use for MSKsupport use for MSK
soft tissue injuries andsoft tissue injuries and
tendopathiestendopathies

29. PRP Knee arthritisPRP Knee arthritis
► General concensus isGeneral concensus is
that PRP injections asthat PRP injections as
goodgood
► Or slightly better thanOr slightly better than
Hyaluronic acid andHyaluronic acid and
saline injectionsaline injection
► More side effectsMore side effects
► AAOS March 2015AAOS March 2015

30. MSK Injections TechniqueMSK Injections Technique
► One needle (mixed)One needle (mixed)
► Two needlesTwo needles
(prefreezing)(prefreezing)
► Less experiencedLess experienced
should prefreezeshould prefreeze

31. MSK Injections TechniqueMSK Injections Technique
► Betadine best as youBetadine best as you
can see where it iscan see where it is
demodemo
► Wait until it dries (untilWait until it dries (until
the screaming stops)the screaming stops)
► Prep, then prepare thePrep, then prepare the
injectioninjection

32. Tricks of the tradeTricks of the trade
►Assess resistance for injections into spaceAssess resistance for injections into space
►DO NO HARMDO NO HARM
►Need large bore needle to draw up solutionsNeed large bore needle to draw up solutions
►demodemo

33. MSK Injections: New kid on theMSK Injections: New kid on the
blockblock
►Ultrasonically guided injectionsUltrasonically guided injections
►Rapidly becoming more commonRapidly becoming more common
►Need US machine and trainingNeed US machine and training
►Price of US machine decreasingPrice of US machine decreasing
►Not discussed todayNot discussed today

34. TRIGGER FINGER INJECTIONSTRIGGER FINGER INJECTIONS
► Evidence basedEvidence based
► ANN RHEM DIS 2008ANN RHEM DIS 2008
sept;7(9) 1262-1266sept;7(9) 1262-1266

35. Trigger FingerTrigger Finger
► .5cc steroid.5cc steroid
► 1 – 2 cc local1 – 2 cc local
anestheticanesthetic
► Don’t inject into theDon’t inject into the
tendontendon
► Inject into or aroundInject into or around
synovial sheathsynovial sheath

36. Trigger FingerTrigger Finger
► HOT OFF THEHOT OFF THE
PRESSPRESS
► Peri pulley injectionPeri pulley injection
had higher successhad higher success
rate than intra sheathrate than intra sheath
injectioninjection

37. Basal Joint arthritisBasal Joint arthritis
► CMC joint arthritisCMC joint arthritis

38. Basal Joint ArthritisBasal Joint Arthritis
► Slight tractionSlight traction
► Prefreezing veryPrefreezing very
helpfulhelpful
► .5 cc steroid (20mg).5 cc steroid (20mg)
1cc of local anesthetic1cc of local anesthetic
marcaine Emarcaine E

39. De Quervains DiseaseDe Quervains Disease
► Evidence basedEvidence based
► BMC MSK disordersBMC MSK disorders
2009 Oct 27;10;1312009 Oct 27;10;131
► .5 to 1 cc steroid (20 –.5 to 1 cc steroid (20 –
40 mg) 2cc to 3 cc40 mg) 2cc to 3 cc
local anestheticlocal anesthetic

40. De Quervain’s DiseaseDe Quervain’s Disease
► Inject into or aroundInject into or around
the sheaththe sheath

41. Tennis ElbowTennis Elbow
► Evidence thatEvidence that
cortisone is beneficialcortisone is beneficial
for at least short termfor at least short term
reliefrelief

42. Tennis ElbowTennis Elbow
► Use 3 to 5cc, marcaineUse 3 to 5cc, marcaine
with epi 40 mgwith epi 40 mg
cortisonecortisone
► Inject the extensorInject the extensor
originorigin
► Use single needleUse single needle
► Patient leaves officePatient leaves office
pain freepain free

43. Shoulder InjectionsShoulder Injections
► Cochrane summaryCochrane summary
says no better injectionsays no better injection
success with clinical vssuccess with clinical vs
ultrasound guidedultrasound guided
injectioninjection
► (for now)(for now)

44. Shoulder InjectionsShoulder Injections
► Rotator Cuff TendinitisRotator Cuff Tendinitis
or tear in elderlyor tear in elderly
► Evidence basedEvidence based
► Duration of benefitDuration of benefit
variable in differentvariable in different
studiesstudies

45. Shoulder InjectionsShoulder Injections
► Subacromial injectionSubacromial injection
► Use 2 cc of steroidUse 2 cc of steroid
(80) mg with 8 cc of(80) mg with 8 cc of
long acting locallong acting local
anestheticanesthetic
► Posterior, slide needlePosterior, slide needle
under acromionunder acromion

46. Shoulder InjectionsShoulder Injections
► Arthritis or frozenArthritis or frozen
shouldershoulder
► 8cc marcaine with epi,8cc marcaine with epi,
1-2 cc steroid (40 to1-2 cc steroid (40 to
80mg)80mg)

47. Shoulder InjectionsShoulder Injections
► Glenohumeral injectionGlenohumeral injection
► Posterior, in soft spotPosterior, in soft spot
► Arm internally rotatedArm internally rotated

48. Trochanteric Bursa injectionsTrochanteric Bursa injections
► Evidence basedEvidence based
► Journal rheum. 1996Journal rheum. 1996
► Dec;23;(12) 2104-6Dec;23;(12) 2104-6

49. Trochanteric bursitisTrochanteric bursitis
► Large jointLarge joint
► 2cc 80 mg steroid2cc 80 mg steroid
► 8cc marcaine with epi8cc marcaine with epi
► Lateral position, hipLateral position, hip
extendedextended
► Long needleLong needle
► Marcaine with epiMarcaine with epi
► Single needleSingle needle

50. Knee injectionsKnee injections
► Evidence basedEvidence based
► Cochrane databaseCochrane database
► Both steroids andBoth steroids and
viscosupplemtationviscosupplemtation

51. Knee injectionsKnee injections
► Large jointLarge joint
► Use 2 cc steroidUse 2 cc steroid
► (80 mg)(80 mg)
► 8cc anesthetic/saline .8cc anesthetic/saline .
5% lidocaine, .25%5% lidocaine, .25%
marcainemarcaine
► Lateral subpatellarLateral subpatellar
approachapproach

52. Knee InjectionKnee Injection
► Leg extendedLeg extended
► RelaxedRelaxed
► Pull kneecap laterallyPull kneecap laterally
► Needle goes under theNeedle goes under the
superior patellasuperior patella
► Great for aspirationGreat for aspiration

53. Knee injection: Preaspiration?Knee injection: Preaspiration?
► One study on RAOne study on RA
patients demonstratespatients demonstrates
better response withbetter response with
preaspiration forpreaspiration for
steroid injectionssteroid injections
► Weitoff, JournalWeitoff, Journal
rheumatic dis. 2000rheumatic dis. 2000

54. Hallux Rigidus InjectionHallux Rigidus Injection
► Arthritis great toeArthritis great toe
► No good studies onNo good studies on
thisthis
► Lots of personalLots of personal
positive experiencepositive experience

55. Hallux rigidus injectionHallux rigidus injection
► Better done with 2Better done with 2
needle (prefreeze)needle (prefreeze)
► 25 gauge needle25 gauge needle
► Small jointSmall joint
► 1cc marcaine E and1cc marcaine E and
less than one half ccless than one half cc
steroidsteroid

56. MSK InjectionsMSK Injections
► QuestionsQuestions