Articular injections Guide Clinical Guidelines Consultation Help Medicines Training Virtual Library Shop Consultation Help - Techniques

for A. P. - Guide articular infiltration Articular injections Guide Authors: Map Advanced Search Arthrocentesis, intra-articular injection therapy in soft tissue Maestro Javier Saavedra. Family physician. C.S. Noia. A Coruña (Spain) Enrique N ieto Pol family physician. C.S. C. Arenal. Santiago. A Coruña (Spain) Carlos Eir e Eiras. Family physician. C.S. Bueu. Pontevedra (Spain) Castano Ana Carou. Fami ly physician. Transfusion Centre. Porto (Portugal) Juan José Díaz Garel. Rheumat ologist. C. Hospital of Santiago de Compostela. A Coruña (Spain Updated on 27/03/2007. Contents: Injections in ... Overview and objectives. Justification General Information Directions Directions intraarticular infiltration periarticular infiltration Instrumental Drug Contra indications General rules How many injections side effects we do? Bibliography Shoulder Elbow Hand Knee Foot More Cortisone Injection of Soft Tissues and Joints (MedicineNet) Corticosteroid Inje ctions of Joints and Soft Tissues - (eMedicine) http://www.fisterra.com/material/tecnicas/infiltracio/indice.asp (1 of 8) 20/03/ 2008 8:11:10 pm Articular injections Guide Overview and objectives. Justification arthrocentesis is a relatively straightfo rward procedure with few side effects is joint puncture and removal of joint flu id for diagnostic or therapeutic. The local administration or intra-articular so ft tissues of drugs, chemicals or radioisotopes is one of the therapeutic modali ties of rheumatic diseases, which generally produces a relief of symptoms, with few side effects, and is in many cases the treatment of choice, primarily in sof t tissue inflammation. The main objectives of the workshop are, first, acquire t he ability to diagnose periarticular inflammatory conditions or to articulate th at is a subsidiary of local treatment and, secondly, promoting the acquisition o f technical skills for the primary care physician to perform this therapy. There are several reasons for conducting infiltration into the primary care field, am ong which we would highlight:

The technique is simple, requiring a learning that is acquired quickly and only require training, practice and caution the clinician. It requires few resources, feasible in any office or health center. Greater accessibility for patients abo ut specialized care. Very favorable clinical results and short term. Very rare c omplications. Aval years of experience on the part of primary care physicians. P rofessional motivation: learning and problem-solving. Epicondylitis Epitrocleítis http://www.fisterra.com/material/tecnicas/infiltracio/indice.asp (2 of 8) 20/03/ 2008 8:11:10 pm Articular injections Guide General information on a steroid injection. Monofocal or oligofocal inflammatory joint or soft tissue. 2. Polifocal inflammatory disease, but more severely mono focal or oligofocal. 3. Failure of drug treatment and / or rehabilitation. 4. Wh en other treatments are contraindicated. 5. Need quick functional recovery. Bursitis Indications for intra-articular infiltration with glucocorticoids Rheumatoid arthritis (adult and juvenile) microcrystals deposit arthropathies (g out and pseudogout) Lupus erythematosus and other connective acute traumatic art hritis Arthritis / Osteoarthritis Inflammatory Joint Diseases from another sourc e (inflammatory bowel disease, ankylosing spondylitis with peripheral involvemen t, psoriatic arthritis, disease Reiter, etc. N. Morton http://www.fisterra.com/material/tecnicas/infiltracio/indice.asp (3 of 8) 20/03/ 2008 8:11:10 pm Articular injections Guide Heel spur Indications for periarticular infiltration with glucocorticoids SHOULDER

Subacromial bursitis bicipital tendinitis supraspinatus tendinitis adhesive caps ulitis suprascapular neuropathy olecranon bursitis Epicondylitis Epitrocleitis c ubital tunnel syndrome Ganglion De Quervain's Tenosynovitis Carpal Tunnel Syndro me Trigger finger Meralgia paresthetica trochanteric bursitis anserina bursitis ischial bursitis Bursitis Bursitis prepatellar iliopectineal Achilles Tendinitis Achilles Bursitis Calcaneal Bursitis Neurinoma of Morton tarsal tunnel syndrome calcaneal spur plantar fasciitis

ELBOW

Wrist and hand

HIP

KNEE

PELVIS

PIE

http://www.fisterra.com/material/tecnicas/infiltracio/indice.asp (4 of 8) 20/03/ 2008 8:11:10 pm Articular injections Guide To follow a therapeutic regimen. 2. 3. 4. Local measures rest on NSAIDs / analge sics (5-7 days) Assess local infiltration Contraindications for an infiltration with glucocorticoids. Lack of accurate dia gnosis. 2. Coagulation disorders 3. Presence of infection intraarticular or peri articular tissues, or in case of bacteremia. 4. Injections repeated previous ine ffective. 5. Adverse drug reaction in previous infiltration. 6. Chronic polyarth ritis, including rheumatoid arthritis, multiple actively inflamed joints. Genera l rules for infiltration with glucocorticoids 1. Carried out by trained personne l. 2. Anatomical knowledge of the joint structures and soft tissue infiltrate. 3 . Choose the path more comfortable and safer, if necessary marking the entry poi nt. 4. Always have all materials ready before starting the technique. 5. Always follow a strict hygiene. 6. Choosing the proper needle home joint or soft tissue . 7. Insert the needle gently, not violently, without making untimely or multidi rectional movements without necessity. 8. No unexpected overcome resistance to t he introduction of the needle. 9. If in the joint cavity, aspirate before all th e synovial fluid that may exist. 10. Before injecting the drug, with suction ens ure that you are not in the vascular access. 11. If infiltrates within proximity of nervous tissue, ask the patient if you notice numbness or lancinating pains

to avoid injury. 12. Managing the volume does not exceed that supports each join t. 13. After infiltration, carefully remove the needle and a protective dressing to the puncture site. 14. Tell the rest of the joint for 24-48 hours after infi ltration. Apparatus necessary for carrying out infiltration Always use sterile d isposable single use only. It states: http://www.fisterra.com/material/tecnicas/infiltracio/indice.asp (5 of 8) 20/03/ 2008 8:11:10 pm Articular injections Guide 1. 2. 3. 4. 5. 6. Disposable needles, various models by location and pathology. Disposable syringe s. Sterile gauze. Sterile surgical drapes. Sterile gloves. Antiseptics. Drugs used in the infiltration 1. Corticosteroids: The use of steroids via intra articular or soft tissue requires delayed or deposit formulations in the form of esters in crystalline suspension, giving them a lower solubility and greater pe rsistence and duration of local effect, necessary to achieve clinical efficacy . There are several synthetic analogues, with similar efficacy but different pote ncy such as betamethasone acetate and betamethasone sodium phosphate (Celestone cronodose) parametasona acetate (cortidene depot) and triamcinolone acetonide (T rigon depot), probably the latter is the best result has contributed, probably b ecause of its low solubility and the effect lasts longer local. Some authors rec ommend as mixed formulations of Celestone cronodose (poorly soluble steroids - d elayed-action corticoid-soluble fast). 2. Local anesthetics: They can be used si ngly or in combination with corticosteroids when infiltrated soft tissues. It is also possible that mixtures of both in intraarticular infiltrations decrease th e frequency of arthritis steroids microcrystals, since its concentration decreas es. Examples of local anesthetics used are: mepivacaine, lidocaine, xylocaine. A dverse effects of infiltration with glucocorticoids 1. Joint infection: is the m ost serious complication. Infiltration occurs in approximately 1:10,000. 2. Post injection arthritis (arthritis steroids microcrystals). It occurs in 1-3% of cas es and is characterized by acute arthritis within 48 hours after infiltration. 3 . Tendon ruptures: not to do intratendinosas infiltration. 4.€Corticosteroid art hropathy: the repeated infiltration of a single joint may produce a like arthrop athy neuropathic arthropathy. 5. Vasovagal syncope, by intense pain during the p rocedure or in those predisposed or apprehensive. http://www.fisterra.com/material/tecnicas/infiltracio/indice.asp (6 of 8) 20/03/ 2008 8:11:10 pm Articular injections Guide 6. Hematoma in the area infiltrated. 7. The adverse effects of its dissemination to the systemic circulation. How many injections can be performed with the same disease? The patterns of use, relatively arbitrary, they recommend: 1. Infiltra tion Spacing between 7 days and 1 month. 2. Do not inject the same joint more th an four times a year, or more than two consecutive if they are ineffective. 3. D o not inject more than 3 joints in one sitting. 4. Keep infiltrated the joint at rest 24-48 hours. 5. Do not use in accompanying which could aggravate condition s (eg diabetes). References 1. Arribas JM. Minor surgery and procedures in famil y medicine. Madrid: Jarpio Publishers, 2000. 2. St John A, Graber J. Articular i njection techniques. Barcelona: Termis, 1989. 3. Mazzucheli R, Quiros J, Zarco P . Emergencies in the Locomotive (II): Pain in soft tissue. Medicine 2001, 8 (35) : 1832-1839. 4. Palomino B, Peña A. Effectiveness of corticosteroid and anesthet ic infiltration in epicondylitis. Rheuma 2000; 4: 44-47. 5. Fernandez A, Povedan o J, Campos S, García A. Clinical efficacy of steroid injections. Rev Esp Reumat ol 1998, 25: 361-370. [Full Text] 6. Benito S, Lopez JA. Arthrocentesis and inje ction techniques of local. In: Eliseo Pascual, Vicente Rodríguez, Jordi Carbonel l, Juan J: Gomez-United. Treaty of Rheumatology. Vol II. Madrid: Aran, 1998: p.2

447-2453. 7. Vidal J, Turner J. Intraarticular therapy. In: Gabriel Herrero-Beau mont, Emilio Martín, José Luis Riestra, Jesus Tornero. Manual of rheumatic disea ses. Madrid: Doyma, 1992: p.21-127. 8. S. Duncan Owen, Jr. Aspiration and inject ion Of joints and soft tissues. In: William N. Kelley, M.D., Edward D. Harris, J r, MD, Shaun Ruddy, MD, Clement B. Sledge, MD Textbook of rheumatology. Vol II. 4th ed. Philadelphia: W. B. Saunders Company, 1993: 545-561. 9. Frank H. Netter, M.D. Bones and joints of the shoulder and arm. In: Russell T, Woodburne MA, Edm und S, Crelin PhD, Frederick S, Kaplan MD. Musculoskeletal System Volume VIII. N ew Barcelona: Salvat, 1990: p.30-34. 10. JJ Rodriguez, Tristan M, Escribano E. G irdle: anatomic remember. History and physical examination. In: Juan Jose Rodrig uez, Valverde Lis. Manual trauma in primary care. Spain: http://www.fisterra.com/material/tecnicas/infiltracio/indice.asp (7 of 8) 20/03/ 2008 8:11:10 pm Articular injections Guide 11. 12. 13. 14. Smithkline Beecham, 1996: p.125-131. Rotes Querol J. Exploration of the musculos keletal system. In: Eliseo Pascual, Vicente Rodríguez, Jordi Carbonell, Juan J. Gómez-United. Treaty of Rheumatology Vol I. Madrid: Aran, 1998: p.177-208. Grana dos J, Soler R. Local and regional syndromes of the upper extremities. In: Elise o Pascual, Vicente Rodríguez, Jordi Carbonell, Juan J. Gomez-United. Rheumatolog y Vol II Treaty. Madrid: Aran, 1998: p.1783-1789. Seamus ED. The Shoulder. In: J ohn H. Klippel, Paul. A. Dieppe. Rheumatology. London: Mosby, 1994. MacKenney E. Manual basic exploration of the hand. Madrid. Jarpio, 2001. Up © 2008 fisterra.com My Details Notice Contact-Suggestions FAQ's Terms of Use Privacy Policy Legal

http://www.fisterra.com/material/tecnicas/infiltracio/indice.asp (8 of 8) 20/03/ 2008 8:11:10 pm