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Orthopedic Surgery Ultimate > Orthopedic Injections > Flashcards

Orthopedic Injections Flashcards

1
Q

INDICATIONS FOR INJECTIONS

9

A
  1. Osteoarthritis
  2. Rheumatoid arthritis
  3. Gouty arthritis
  4. Synovitis
  5. Bursitis
  6. Tendonitis
  7. Muscle trigger points
  8. Carpal tunnel syndrome
  9. Wound anesthesia
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2
Q

LOCAL INFILTRATION

  1. Injecting into the subcutaneous tissue of open wounds: does what?
  2. What do you do before injecting the wound?
  3. What does epi do?
  4. Doses for lidocaine and lidocaine with epi?
A
  1. Injecting into the subcutaneous tissue of open wounds
    - Provides good anesthesia
    - Little discomfort while injecting
  2. Before injecting, clean and sterilize the wound
  3. Epinephrine decreases blood loss
  4. Avoid toxic doses of lidocaine
    - 4mg/kg for plain lidocaine
    - 7 mg/kg for lidocaine with epinephrine
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3
Q
  1. Field blocks are what?
  2. Why wouldnt you use locl anethesia for this?
  3. Skin prep with what?
  4. Procedure? 2
A
  1. Good for superficial lesions such as skin abscesses
  2. Local anesthesia not effective and painful, may spread infection
  3. Skin preparation with betadine or alcohol
  4. -Inject slowly
    while advancing
    needle
    -Only need to go
    thru skin twice
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4
Q

DIGITAL BLOCKS

  1. Each digit supplied by how many nerves?
  2. Use what kind of needle?
  3. Procedure?
  4. Big toe… may need to make third pass on what?
  5. Do not use if there is what?
  6. Be cautious using what?
A
  1. 4 nerves,
    - 2 dorsal
    - 2 palmar/plantar
  2. small needle, 25 – 27 gauge
  3. Start dorsally, go down each side of proximal phalanx
    Inject as you go, change angle
  4. dorsal aspect
  5. vascular compromise
  6. epinephrine
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5
Q

Trigger Point Infections
1. Inflamed tendon/bursa by bony prominence: Use what and when?

  1. Skin prep with what?
  2. Slow injection into point of what?
  3. Advance needle to bone and then withdraw ______?
  4. Tennis elbow – lateral epicondylitis
    - Pain with what?
  5. Greater trochanteric bursitis
    - Pain with what?
  6. Ischial tuberosity bursitis – Weaver’s bottom
    - Pain with what?
A
    • Combination of lidocaine and steroid
    • When conservative treatment fails and for Dx
  2. betadine swab x3 or chloraprep x1 (let dry)
  3. maximum tenderness
  4. 2 mm
  5. resisted wrist dorsiflexion
  6. stretching of lateral side of hip
  7. resisted knee flexion
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6
Q

Describe the injection for LATERAL EPICONDYLITIS, and GREATER TROCHANTERIC BURSITIS.
4

A
  1. Find point of maximum tenderness,
  2. advance needle until it hits bone,
  3. withdraw needle 2 mm’s
  4. Patient should confirm that you are in the sore spot
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7
Q 
ISHCIAL 
TUBEROSITY 
BURSITIS
Injection
1. What will make the tuberosity more prominent for the maximum tenderness?
2. Key structure to miss?
A
  1. Feel for point of maximum tenderness, hip flexion makes tuberosity more prominent
  2. Key structure to miss is the sciatic nerve

Be sure injection site is sterilized

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8
Q

AFTERCARE

2

A
  1. Rest, ice, anti-inflammatories
  2. Resume conservative treatment including stretching

May be overkill

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9
Q

JOINT INJECTIONS
Intra-articular injections with steroids are useful, safe, and cost-effective treatments
1. Most joint injections for symptoms of what?

  1. Shoulder… also for what? 2
  2. Which steroids to use?
  3. Also put needles in joints to aspirate for what?
A
  1. arthritis
    • rotator cuff tendinitis and
    • subacromial bursitis
  3. Methylpredisone is usually first line. depends if you want short or long acting.
  4. Synovial fluid analysis for arthritis or infection
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10
Q

WHY INJECT JOINTS?

  1. Can be what?
  2. Inflammation? 3
  3. Corticosteroid injection helps with what? 3
A
  1. Can be joint or soft tissue
  2. Inflammation
    - degenerative joint disease,
    - bursitis,
    - tendinitis
  3. Corticosteroid injection helps
    - decrease inflammatory reaction
    - includes limiting capillary dilatation
    - vascular permeability
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11
Q

RISKS OF JOINT INJECTIONS

11

A
  1. Infections in healthy patients – 1 in 17k to 77K
  2. Soft tissue infection - 1 in 10K
  3. Acceleration of a septic joint
  4. SubQ atrophy and skin depigmentation in
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12
Q

CONTRAINDICATIONS for joint injections

15

A
  1. Adjacent osteomyelitis
  2. Evidence of bacteremia or febrile illness
  3. Hemarthrosis
  4. Impending (scheduled within days) joint replacement surgery
  5. Infectious arthritis
  6. Joint prosthesis
  7. Osteochondral fracture
  8. Periarticular cellulitis / severe dermatitis/ soft tissue infection
  9. Poorly controlled diabetes mellitus
  10. Uncontrolled bleeding disorder or coagulopathy
  11. Clotting disorder and anticoagulation(correct before injecting)
    - Probably okay if INR
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13
Q

INJECT WITH CAUTION

7

A
  1. Charcot joint (neuropathic sensory loss)
  2. Tumour
  3. Neurogenic disease
  4. Active infections (eg, tuberculosis)
  5. Hypothyroidism
  6. Bleeding dyscrasias
  7. Diabetics (likely to raise BG for several days)
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14
Q

EQUIPMENT

for injections 10

A
  1. Sterile gloves and drapes
  2. 5 Gauze pads (4x4)
  3. Skin prep solution
  4. Lidocaine 1%
  5. Steroid of choice
  6. Syringes….5ml, 20 ml, 30 ml, 60 ml
  7. Needles….18 or 20 G and 25 or 27 G
    - Morbidly obese patients may require a 21 G spinal needle for arthrocentesis
  8. Hemostat
  9. Specimen tubes
  10. Bandage
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15
Q

INFORMED CONSENT: Tell them about?

  1. Risks? 4
  2. Benefits? 2
  3. Realistic expectations? 3
A
  1. Risks:
    - infection,
    - bleeding,
    - allergic reaction,
    - pain
  2. Benefits:
    - simple office procedure
    - May provide relief for patients too frail for definitive treatment
  3. Realistic expectations
    - May not help or only for a few months
    - May have increased pain for a day or two after the injection
    - May take several days to take effect
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16
Q

ANESTHESIA
Often warranted:
1. After skin prep, draping, and identification of the needle insertion site, use ______________ to inject how much of local anesthetic into subcutaneous tissue?

  1. Deep injections that might enter the joint space are not recommended
    why?
A
  1. 25-27 gauge needle, 2-5ml

2. Might enter joint space and alter synovial fluid analysis results

17
Q

STEROIDS FOR INJECTIONS

  1. Short-acting? 2
  2. Long acting? 5
  3. Combination preparations? 1
A
  1. Short-acting preparations (soluble)
    - Hydrocortisone
    - Prednisilone
  2. Long-acting Preparations (depot steroids)
    - Kenalog,
    - Aristospan,
    - Depo-Medrol (methylprednisolone),
    - Decadron
    - Triamcinolone acetonide: 40 mg/large, 30 mg/medium, 10 mg /small
  3. Combination Preparations (Soluble and Depot)
    - Celestone Soluspan
18
Q

Half life of intra-articular injections – can give months of relief:

  1. Depo Medrol-how long?
  2. Kenalog?
  3. Aristospan?
A
  1. 6 days
  2. 22 days
  3. 33 days
19
Q

INJECTION TECHNIQUE

13

A
  1. Swab top of vials with alcohol before drawing into syringe
  2. Change needles after drawing up solution in the syringe
  3. Visualize the anatomy
  4. Mark the area for the injection – marker or retracted ball point pen
  5. Need sterile gloves only if you need to feel the site after prep
  6. Prep area with Betadine swabs or chlorhexadine or alcohol
  7. Choose needle and syringe based on joint involved
  8. Advance needle slowly until you feel a pop – through capsule
  9. Once needle is felt to be in the joint, aspirate before injecting
  10. Grasp needle with hemostat while you twist off syringe and swap syringes
  11. Put aspirated fluid in collection tube
  12. If you meet resistance while injecting, probably not in the joint
  13. Amount of resistance felt depends on diameter of the needle
20
Q

ASPIRATION TECHNIQUE

5

A
  1. Use same route as for injection
  2. Larger needle so fluid can be withdrawn (effusion and hemarthrosis)
  3. Large syringe to withdraw fluid
  4. Anesthetize track down to the joint
  5. Same skin prep as for injections
21
Q

KNEE INJECTIONS

  1. Best approach to a knee injection is what?
  2. Options? 3
  3. Plain radiographs recommended for what?
  4. The knee injection site can be selected according to the what and marked with the tip of a retracted ball point pen before sterile prep?
  5. Drug doses? 2
A
  1. the path of least obstruction and maximal access to the synovial cavity….
  2. which could be
    - superolateral**8
    - superomedial or
    - anteromedial/anterolateral
  3. assessment of the bony anatomy of the individual knee joint
  4. patient’s bony anatomy
    • 5 ml 1% Lidocaine and
    • 20-80 mg methylprednisolone
22
Q
  1. Where is the most common place to injection the knee?

2. What if you go anteriorly?

A
  1. Lateral side at level of superior pole of the patella

2. Anterior medial approach…can inject into fat pad rather than joint

23
Q

What position should the patient be in?

A

Position slightly flexed knee with a towel in the popliteal space on exam table

24
Q

Superolateral approach
Describe this procedure?
6

A
  1. Clinician’s thumb is used to gently rock then stabilize the patella
  2. Palpate the superior lateral aspect of the patella and insert the needle 1 cm superior and lateral to the this point
  3. Apply gentle pressure on the contralateral side of the knee to encourage the fluid to pool in the area of aspiration.
  4. Direct the needle under the patella at a 45 degree angle to the midpoint area
  5. Aspirate all fluid prior to injection
  6. There should be no resistance!
25
Q

SHOULDER INJECTIONS

3

A
  1. Intra-articular: arthritis rotator cuff tear frozen shoulder
  2. Subacromial: rotator cuff tendinitis bursitis
  3. AC joint: inflammation/arthritis
26
Q
  1. What is the most common route for shoulder injection?
  2. Where?
  3. Can feel joint move in the slender
    Angle towards what?
A
  1. Posterior: Most common route – patient sitting
  2. 2cm below base of acromion, 2 cm medial to edge of humerus
  3. tip of coracoid process
27
Q
  1. What position is the pt in for anterior shoulder injection?
  2. Where should you inject?
  3. Can usually feel what?
A
  1. Not used as much – patient supine
  2. Fingertip below clavicle and lateral to tip of coracoid process. Inject into upper half of the joint, avoid brachial plexus
  3. Can usually feel the joint move
28
Q

AC JOINT INJECTION

  1. Patient in what position?
    - why?
  2. Palpate the joint, inject from above, angle how?
A
  1. Patient sitting with hands behind back
    - Makes joint more prominent and easier to palpate
  2. medially
29
Q

JOINT INJECTION AFTER CARE

4

A
  1. Passive ROM after injection
  2. Explain that immediate effect is due to local anesthetic, steroid may take several days and they may have a flare up of pain before seeing benefit from steroid
  3. OK to use ice/OTC anti-inflammatories – do not use hot pad
  4. Call if signs of infection/allergic reactions

Orthopedic Surgery Ultimate (88 decks)

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