Joint Injection

1. See Also
   1. Intra-articular Corticosteroid
   2. Elbow Injection
   3. Ankle Injection
   4. Hand Injection
   5. Hip Injection
   6. Knee Injection
   7. Shoulder Injection
   8. Spray and Stretch
   9. Trigger Point Injection
2. Indications: Articular conditions
   1. Rheumatoid Arthritis
   2. Seronegative Spondyloarthropathy
      1. Ankylosing Spondylitis
      2. Inflammatory Bowel Disease arthritis
      3. Psoriasis
      4. Reiter's Syndrome
   3. Crystal-induced arthritis
      1. Gout
      2. Pseudogout
   4. Osteoarthritis
3. Indications: Nonarticular conditions
   1. Fibrositis (Localized, systemic)
   2. Bursitis
      1. Subacromial bursitis
      2. Trochanteric Bursitis
      3. Anserine bursitis
      4. Prepatellar Bursitis
   3. Periarthritis
      1. Adhesive Capsulitis
   4. Tenosynovitis or Tendonitis
      1. Dequervain's Tenosynovitis
      2. Trigger Finger
      3. Bicipital Tendonitis
      4. Tennis Elbow (Lateral Epicondylitis)
      5. Golfer's Elbow
      6. Plantar Fasciitis
   5. Neuritis
      1. Carpal Tunnel Syndrome
      2. Tarsal Tunnel syndrome
      3. Costochondritis
      4. Tietze's Syndrome
4. Contraindications: Intra-articular Injection
   1. Overlying Cellulitis
   2. Severe coagulopathy
   3. Anticoagulant therapy (relative contraindication)
   4. Septic effusion
   5. More than 3 injections per year in weight bearing joint
   6. Lack of response after 2-4 injections
   7. Bacteremia
   8. Unstable joints
   9. Inaccessible joints
   10. Joint prosthesis
   11. Osteochondral Fracture
   12. Overlying soft tissue infection or dermatitis
5. Precautions
   1. Do not inject directly into tendons
      1. Injection into tendon sheath is appropriate
      2. Tendon weakens with direct injection (rupture risk)
      3. Do not inject high risk tendons
         1. Avoid Achilles tendon injection
         2. Avoid Patella tendon injection
   2. Aspirate before injection to confirm no vessel
   3. Avoid needle trauma to cartilage on Joint Injection
   4. Limit Corticosteroid Injections to >4 week intervals
      1. Intra-articular Injections are typically limited to 3 month intervals
   5. Limit Corticosteroid to one large joint per visit
   6. Exercise caution with nearby nerves
      1. Withdraw needle if patient reports Paresthesias
      2. Example: Ulnar Nerve lies close to medial epicondyle
6. Complications
   1. Postinjection flare (2-5%)
      1. Relieved with ice to the area for 15 minutes/hour
      2. Resolves within 24 to 48 hours
      3. More common with longer acting Corticosteroids
   2. Steroid arthropathy (0.8%)
   3. Tendon rupture (<1%)
   4. Facial Flushing (<1%)
   5. Skin atrophy or depigmentation (<1%)
   6. Iatrogenic Infectious Arthritis (<.07%)
   7. Transient paresis of injected extremity (Rare)
   8. Hypersensitivity Reaction (rare)
   9. Asymptomatic pericapsular calcification (43%)
   10. Acceleration of cartilage attrition (unknown)
   11. Hyperglycemia in Diabetes Mellitus patients
       1. Single Intra-articular Injections do not typically affect blood sugars
       2. Soft tissue and peritendinous injections increase blood sugars for 5-21 days
       3. Wang (2006) J Hand Surg 31(6):979-81
       4. Younes (2007) Joint Bone Spine 74(5): 472-6
   12. Reference
       1. Gray (1983) Clin Orthop Relat Res, (177): 253-63
7. Preparations: Based on duration and potency
   1. See Injectable Corticosteroid for dosing
   2. Short-Acting and Low Potency
      1. Cortisone
      2. Hydrocortisone
   3. Intermediate-Acting and Intermediate Potency
      1. Prednisone
      2. Prednisolone tebutate (Hydeltra)
      3. Triamcinolone (Aristocort, Aristospan, Kenalog)
      4. Methylprednisolone acetate (Depo-Medrol)
   4. Long-Acting and High Potency
      1. Dexamethasone sodium phosphate (Decadron)
      2. Betamethasone (Celestone Soluspan)
8. Preparations
   1. Preferred agents for large Joint Injections (longer duration but local skin reaction risk)
      1. Triamcinolone hexacetonide (Aristospan)
      2. Triamcinolone acetonide (Kenalog)
   2. Preferred agents for small joints and soft tissue
      1. Methylprednisolone acetate (Depo-medrol)
9. Needles
   1. Joint Injection
      1. Needle Gauges 22-27 with length of 1.5 inches (author prefers 27 gauge)
   2. Joint Aspiration
      1. Needle Gauges 18-20 with length of 1.5 inches
   3. Special Circumstances: Spinal needle
      1. Obesity interferes with joint or bursa access
      2. Trochanteric Bursitis
10. References
    1. Cardone (2002) Am Fam Physician 66(2):283-90
    2. Genovese (1998) Postgrad Med 103:125-34
    3. Pfenninger (1991) Am Fam Physician 44(4): 1196-202
    4. Scott (1996) Sports Med 22:406-16
    5. Stephens (2008) Am Fam Physician 78(8): 971-6