MNA Joint Injection Workshop

MNA Joint Injection Workshop
W. Todd Smith MD
Mary A. Smith, DNP, FNP-BC
Starkville Orthopedic Clinic
Purpose
To educate the APN on:
1. The evidence base for
injection therapy
2. The drugs used
3. The anatomy of
common joints
What are we actually doing?
• Treatment of musculoskeletal disorders by the
localized injection of a drug, usually a synthetic
steroid AND a local anesthetic
• Injection Therapy is safe, easy to perform and
cost effective
• Problems arise with
1. Too large volume
2. Non standardized use
3. Poor technique
4. No regard to aftercare
The Drugs
• Corticosteroids
• Local anesthetic
Corticosteroids
• Many types/Many combinations exist among
providers
• Long acting vs. short acting (Depo vs.
Celestone)
• Insoluble vs. Soluble
• Preference is to inject long acting insoluble
into joints/bursa and short acting soluble into
soft tissue areas (less skin changes and
subcutaneous fat atrophy
Corticosteroids
Solubility
Generic Name
Trade Name
Equivalent Dose,mg
Most Soluable
Betamethasone
Celestone
0.6
Soluable
Dexamethasone
Decadron
0.75
Slightly Soluable
Triamcinolone
diacetate
Aristospan
4
Slightly Soluable
Methylprednisolone
Depo-Medrol
4
Relatively
insoluable
Dexamethasone
Decadron LA
0.75
Relatively
insoluable
Triamcinolone
acetonide
Kenalog
4
Combination
Betamethasone
phosphatebetamethasone
acetate
CelestoneSoluspan
0.6
Corticosteroids
Local Anesthetics
• Rationale
1. Analgesic
2. Diagnostic- Pain relief confirms pathology
and correct administration
3. Dilution-Adding this to steroid helps disperse
the steroid into area
4. Best not to use anything with epinephrine
Local Anesthetics
Lidocaine
• Acts rapidly
• Stable
• Starts to work within
seconds and lasts up to one
hour or more
Marcaine
• Slow onset of action
• Stable as well but some
reports of chondrotoxicity
• Lasts up to 8-10 hours
Adverse Events
• Adverse Reactions
1. Anaphylactic reaction (Epipen, Oxygen, CPR)
2. Toxicity-Increased plasma concentrations
(Convulsions, CNS collapse)
3. Syncope
4. Joint sepsis: 1:17,000-1:77,000
5. Tendon rupture
Contraindications to Injection Therapy
Absolute
• Sepsis
• Hypersensitivity
• Fracture
• Arthroplasty
• Reluctant Patient
• “Gut” feeling
Relative
• Diabetes
• Immunosuppression
• Bleeding disorder
Technique: Preparation
• Discuss with patient options of injection and
alternative treatments applicable to condition
• Obtain the confidence in you
• Obtain informed consent
Technique: Equipment
• Place in comfortable position
• Check names on consent and expiration dates
• Appropriate syringes and needles
• Alcohol/Betadine/Ethyl Chloride
22 G
Technique: Site Prep
•
•
•
•
1.
2.
3.
Identify Site
Mark Site
Clean Site
Inject/Aseptic technique
Confident Approach
Stretch skin
Perpendicular insertion
then may direct to
pathology
18 G
Technique: Aftercare
• Avoid excessive activity for 24-48 hrs.
• Gradual return
• Apply ice to area 20 min per hour for first 1224 hrs.
• NSAIDS/Tylenol for first 12-24 hrs.
• Watch for “Steroid Flare”
• +/- follow up: Call, email etc…
Shoulder
• Bursitis, tendonosis, adhesive capsulopathy,
impingement syndrome, calcific tendonopathy
• Anatomy: No major arteries or nerves in
technique
• Approach: Posterior- 1cm inferior, 1 cm medial to
posterior lateral acromial border OR lateral- 1cm
inferior to lateral edge of acromion in line with
posterior AC joint
• My injection: 1cc Depomedrol, 3cc Lidocaine, 3cc
Marcaine
• AC Joint: 1cc Depomedrol, 1cc Lidocaine
Impingement
Shoulder injection
Posterior
Lateral
Knee injection
•
•
•
•
OA, RA, Gout, Synovitis, Effusion, Plica syndrome
Pain
Trauma-Rule out fracture
Anatomy: Large joint (120cc)/ No major arteries
or nerves with approach
• Approach: No posterior/Anterior OR
Suprapatellar
• My injection: 1cc Depomedrol, 3cc Lidocaine, 3cc
Marcaine
Knee injection
Anterior injection
Suprapatellar injection
Knee Arthrocentesis
• Aspiration of knee joint to obtain fluid for pain
relief, culture, cell count or cytology
• Anatomy: same as injection
• Approach: Anterior or Suprapatellar/ Inject 1cc
Lidocaine/ follow with 30 or 60cc syringe with 18
or 20 gauge needle. Synovial fluid/hematoma is
viscous so larger bore needle needed
• Aftercare: Rest, Ice: Treatment as directed by
aspirate
Elbow injection
• Lateral epicondylosis (tennis elbow) and Medial
epicondylosis (golfers’ elbow) !!!Ulnar nerve!!!!
• Anatomy: No major artery or nerves laterally/
medially is ULNAR NERVE
• Approach: Point of maximal tenderness usually
along the epicondyle, inject perpendicular to
skin, touch bone and pepper enthesis (tendonosseous origin
• My injection: 1cc Celestone, 1cc lidociane
Elbow injection
Radial
Head
Lateral
epicondyle
DeQuervain’s
• Tenosynovitis of 1st Extensor Compartment (6): AbPL
and EPB
• Finkelstein’s Test along with pain base of thumb and
radial styloid
• Anatomy: AbPL and EPB usually run together in a single
sheath but variations occur/ Superficial Radial Nerve at
risk with too dorsal
• Approach: 1cm proximal to radial styloid at 45 degrees
in direction of thumb
• My injection: 1cc Celestone, 1cc Lidocaine
• Aftercare: Rest, Ice, NSAIDS, +/- thumb spica splint
Wrist injection
1 cm
proximal to
radial
styloid
Trigger Finger
• “Catching or Locking” of digit with flexion: Painful
and sometimes requires manual unlocking
• Anatomy: Nodule on tendon is larger than
annular pulley which is the opening to flexor
tendon sheath. As digit is flexed, nodule if forced
into sheath causing “locking”
• Approach: Find distal palmar crease, palpate
nodule, aim at 45 degrees to tip. Visualize filling
of digit
• My injection: 1cc Celestone, 1cc Lidocaine
• Aftercare: As tolerated
Trigger Finger
Trigger Finger Injection
Distal
palmar
crease
Greater Trochanteric Bursitis
• Pain over Greater Trochanter
• Falls, thin patients
• Anatomy: Greater Trochanteric Bursa lies
between Greater Trochanter and Iliotibial Band.
No major artery or nerve with lateral approach
• Approach: Stand or lie on contralateral side;
Consider spinal needle in obese; inject
perpendicular to skin, touch bone and pull back
slightly
• My injection: 1cc Depo Medrol, 3cc Lidocaine, 3cc
Marcaine
Greater Trochanteric Injection
Joint Injection Reimbursement
BCBS
MEDICARE
MEDICAID
CPT 20610-modifier $144.00
for left/right
$54.02
$42.17
Depomedrol 1cc
$5.51/unit (cc)
$3.35/unit
$2.79/unit
Liocaine/Marcaine
$0.00
$0.00
$0.00
E/M: Place -25 modifier when doing injection/ Variability based on products used
Don’t Forget to Add Visit
Level (Est.)
BCBS
Medicare
Medicaid
99213
$75.00
$56.16
$53.51
99214
$112.00
$98.13
$88.32
99213 + Inj
$224.51
$113.53
$ 98.47
99214 + Inj
$261.51
$155.50
$133.28
Cost of Supplies
• Ethyl Chloride pinpoint spray
– $32.69 per 3.5 oz. bottle (last a while)
• Depo Medrol (40mg/ml)
– $42.00 per 10ml vial
Don’t Forget About Topicals
• Safe, effective
• May or may not be covered by insurance
• Various anti-inflammatory combinations:
– Ketoprofen 18% (anti-inflammatory), Baclofen 2% (anti-spastic)
Cyclobenzaprine 2% (muscle relaxer), & Lidocaine 6% (anesthetic)
– Ketoprofen 10%, Indomethacin 5% (anti-inflammatory),
Triamcinolone 2% (corticosteroid), Lidocaine 5%
Viscosupplementation
• Injection of hyaluronic acid preparation for the
knee
• Given in the same manner as steroid injection
• Several types, most are series of three injections
given a week apart
• There is a one time injection available now
• Expensive, low reimbursement, pain relief is not
immediate
Helpful References
• Injection Techniques in Orthopedics and
Sports Medicine
• Essentials of Musculoskeletal Care
• www.orthogate.org
• Free Patient Education:
– www.aaos.org and www.orthogate.org
Thank You!