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INTRA-ARTICULAR AND ALLIED INJECTIONS
Third EditionSureshwar Pandey
MBBS (Hons) MS (Gen) FICS FIAMS MS (Ortho) FACFAC FACS FNAMS
Professor Emeritus, University of Ranchi
Founder and Founder Director, GNH Handicapped Children Hospital and
RJS Artificial Limb Centre
Founder and Consultant, Ram Janam Sulakshana
Institute of Orthopaedics and Research
Ranchi, Jharkhand, India
Founder and Emeritus President and Ex-Secretary General, Indian Foot and Ankle Society
[Affiliated to International Federation of Foot and Ankle Societies (IFFAS)]
Founder and Emeritus Editor, The Journal of Foot and Ankle Societies Surgery
Visiting Professor, Universities of Tokyo, Osaka, Teikyo, Adelaide, Flinders,
Ujung Pandang, Singapore
Ex-Chairman ASIA-CIP (IFFAS)
Founder and Chairman, Ram Janam Sulakshana Pandey Cancer Hospital
& Research and Rehabilitation Centre, Ranchi
Hon President, Asia-Pacific Society for Foot and Ankle Surgery
Anil Kumar Pandey MBBS CORM PhD Orth MAMS
Director and Consultant
Ram Janam Sulakshana Institute of Orthopaedics and Research (RJSIOR)
Associate Director and Consultant
GNH Handicapped Children Hospital and RJS Artificial Limb Centre
Executive Director and Consultant
Ram Janam Sulakshana Pandey Cancer Hospital and Research and Rehabilitation Centre
Ranchi, Jharkhand, India
Consultant, Kiran Centre for Education and Rehabilitation
Varanasi, Uttar Pradesh, India
Consultant, RAHA, Chhattisgarh, India
Reconstructive Surgeon, Rotary International Project, Government of Nigeria
Foreword
Padma Bhushan Dr B Mukhopadhaya
New Delhi | London | Panama
The Health Sciences Publisher
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Intra-articular and Allied Injections
First Edition: 1982First Japanese Edition: 1987Second Edition: 2005American Edition: 2007Third Edition: 2017
ISBN 978-93-5270-130-8
Printed at
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Dedicated toThe fond memory of my beloved parents
Sulakshana Pandey
and
Ramjanam Pandey
who were, are, and will be
always with me to love, teach and guide
who taught me to persue my
dreams—because nothing is impossible
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* This painting has been commissioned by Pfizer Ltd (India) based on an old painting belonging to the Late
Maharaja of Mysore, Krishnaraja Wodeyar II (South India).
“DHANVANTARI”*
The Hindu God of Medicine
the original exponent of Indian medicine. Dhanvantari has many myths and legends
Legends make him reappear as “Divodasa”, the prince of Banaras (Kasiraja), in the
is “the first G
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Intra-articular and Allied Injectionsviii
Dhanvantari also appears to have been an actual historical person, although his pre-
cise identity is hard to be ascertained. He taught surgery and other divisions of Ayurve-
da (Indian System of Medicine) at the instance of Susruta, to a group of sages among
Dhanvantari is regarded as the patron-God of all branches of medicine. While
to Dhanvantari.
Dhanvantari-Nighantu is considered the most ancient of the medical glossaries that
medicinal substances; their names, synonyms, and brief description of properties being
extensively relied upon, despite several more comprehensive glossaries that have been
be considered more as indicative.
(By courtesy Pfizer Limited)
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“kiFk ¼fpfdRld ds fy;s½u rks LokFkZ ds fy;sugha fdlh lalkfjd oLrq ;k ykHk dh iwfrZ ds fy;s]vfirq loZnk ihfMr ekuork ds dY;k.k ds fy;seSa vius jksxh dh fpfdRlk d:a vkSj bl dk;Z esa lcls vkxs jgwa
‘pjd’
Oath (for a Medical Practitioner)“Not for the self,
Charak Oath
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accepted method of treatment for a variety of painful conditions, although its exact
No monograph detailing the proper procedure of these injections is available. The
this method of treatment for their patients.
Padma Bhushan Dr B MukhopadhayaMBBS (Hons) FRCS (Eng) MCh Orth (L Pool) FAMS
Professor Emeritus, Patna University
Hunterian Professor, Department of Orthopaedics
Royal College of Surgeons, England
Vice-President, Medical Council of India
Chairman,
Artificial Limb Manufacturing Corporation of India
Foreword
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Intra-
articular and Allied Injections
and American editions. This proved to be a useful guide for the interns, registrars,
practitioners rheumatologist, acupuncture practitioners and orthopaedic surgeons.
In this third edition, besides updating the manuscript, here and there, small sections
have been added on acupressure and yoga and the role of platelet-rich plasma (PRP)
advices and guide to improve the monograph further.
Sureshwar PandeyAnil Kumar Pandey
Preface
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observations over the subjects—the patients. We are obliged to them for providing
To upgrade the Second E
Campbell’s Operative Orthopaedics,
12th Edition by S Terry Canale and James H Beaty (E
Orthopaedic Management in Cerebral Palsy, 2nd Edition by Helen M Horstmann and
Eugene E Bleet, Mac Keith P
Unless the users, the young orthopaedic and general surgeons, rheumatologists and
Arranging the manuscript and putting them in proper order and further printing it
out are really great annoying jobs. These all have been very gladly and patiently done
by my dear granddaughter Dr Pallavi. I (SP) cannot return her debt.
Shruti, and Satyam and my great grand child Atharva Pranjal Kanha have been real source
for me.
Mr Ankit Vij (Group President) of M/s Jaypee Brothers Medical Publishers (P) Ltd, and all
persons involved in producing such a nice monograph. We are really thankful to one
and all of Jaypee—The Health Sciences Publisher.
Acknowledgements
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1. Principles of Intra-articular and Allied Injections 1
Mode of Action of Glucocorticoids 2
Immune Responses 2
Anti-inflammatory Properties 2
Potency 5
2. How Frequently to Inject Corticosteroid? 6
Why should Intra-articular Corticosteroid not be Given
7
Whether Intra-articular Corticosteroid should be Given
7
3. How to Inject? 9
Word of Caution 9
Localisation of the Site of the Injection 9
4. Indications of Corticosteroid Injection 11
12
Relative Indications of Corticosteroid Injections 13
Tendons (Mostly Around the Tendon Cautiously, and
very Rarely into the Tendons) 13
Ligaments 13
Fibrofatty Nodules 14
Peripheral Nerves 14
14
Skin Conditions 14
Ophthalmic Condition 14
Gynaecological Conditions 15
Reflex Sympathetic Dystrophy Syndrome 15
Trial Indications 15
5. Contraindications for Local Corticosteroid Therapy 16
General Infections 16
Contents
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Intra-articular and Allied Injectionsxviii
6. Intra-articular Hyaluronic Acid and Platelet-rich Plasma Injection 17
Viscosupplementation 18
Role of Hyaluronic Acid in Osteoarthritis 19
Corticosteroids vs Hyaluronic Acid 19
Platelet-rich Plasma Injection 20
7. Methodology 22
Preparation 22
22
Position of the Patient 22
Soap Water Cleaning of the Part 23
Certain Considerations in Relation to
Intra-articular and Allied Injections 23
Sites for Injection 25
8. Shoulder Joint 27
Anterior Approach 27
Posterior Approach 27
28
Anterolateral Approach 30
9. Elbow Joint 32
Lateral Approach 32
Posterior Approach 32
33
Olecranon Bursitis 34
35
10. Wrist Joint 36
Approaches for Wrist Joint 36
37
Injection Approaches for Metacarpophalangeal Joints
and Interphalangeal Joints 40
Trigger Thumb/Finger 40
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Contents xix
11. Hip Joint 42
Anterior Approach 42
Lateral Approach 42
12. Knee Joint 45
Mode of Injection 45
Infrapatellar Approach 46
Suprapatellar Approach 47
Posterior Approach 48
Method of Injecting into the Anserinus Bursa 49
(Apophysitis of Tibial Tuberosity) 49
49
13. Ankle Joint and Foot 51
Indications 51
Approaches 51
51
Painful Heel Syndrome 53
Plantar Fasciitis 56
Symptomatic Accessory Navicular 58
Subtalar Joint 58
14. Spine, Peripheral Nerves, Sacroiliac Joint 59
59
Herpetic Neuritis 60
Lumbar Disc Disease 60
Epidural Steroid Injections 61
Complications of Epidural Injections 65
Selective Nerve Root Injection 65
Method of Nerve Root Injection 66
Vertebroplasty and Kyphoplasty 66
Injection into and Around the Peripheral Nerves 66
67
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Intra-articular and Allied Injectionsxx
Popliteal Nerve 67
Nerve of Thigh 67
Coccydodynia (Painful Coccyx) 67
69
Old Pelvic Fracture 69
Recurrent Fibrositis 69
Rheumatoid Spondylitis 70
SacroIliac Joint 70
15. Facial Region 71
Oral Cavity 71
16. Joints Around the Clavicle 73
Method 73
17. Occipital Region 75
Trigeminal Neuralgia 76
18. Complications of Intra-articular Injections 78
Complications due to Lack of Aseptic Procedure 78
Management of Infection 79
Complications due to Error on the Part of Clinicians 80
Corticosteroids can Produce General Complications 80
Complications due to the Drug 81
Rebound Phenomenon 81
Delayed Manifestations of Infections 81
19. Role of Botulinum Toxin Type A Injection in Spastics and Other Indications 82
Botulinum Toxin Type A 82
Mode of Working of Botulinum Toxin Type A
(BT—A—BOTOX) 83
20. Acupuncture 85
Complications of Acupuncture 86
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Contents xxi
Acupuncture in Arthritis 86
Acupuncture in Painful Shoulder Syndromes 87
Acupressure 87
Moxibustion 88
21. Reiki and Yoga 89
Reiki 89
Yoga 90
Appendix 97
Bibliography 101
Index 105
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Elbow is a composite joint having ulnohumeral, radiohumeral and radioulnar components. These have continuous and communicating synovial reflections. Therefore, if the drug is injected into one component, it easily spreads into other compartments, unless there is intra-articular adhesions.
LATERAL APPROACHLateral approach is through radiohumeral compartment. The patient lies supine. The arm is kept in slight internal rotation at shoulder. The elbow is flexed 30 to 40 degree from zero extension, with forearm is midprone position. A transverse slit can be felt at the posterolateral aspect just below the lateral epicondylar region. Further confirmation can be done by rotating the forearm in which radial head is felt rotating just beneath the slit. The needle is pushed into the slit having a direction anteriorly with about 20 degree upward inclination (Figure 9.1).
POSTERIOR APPROACHThe patient lies on the side with the affected limb above. Elbow is flexed about 45 degree with forearm in midprone position. The olecranon tip stands prominent. On either side of the olecranon process a vertical slit can be felt. At a convenient point along the slit, a needle can be pushed on either side of the olecranon, having a direction downwards and towards mid-line (Figure 9.2).
C H A P T E R 9Elbow Joint
Chapter Outline
� Lateral approach
� Posterior approach
� Lateral epicondylitis (extra-articular tennis
elbow)
� Olecranon bursitis
� Medial epicondylitis (golfer’s elbow,
pitcher’s elbow, little league elbow
syndrome)
‘Remain cool to reach your goal safe and fast.’
—PP Wangchuk
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Elbow Joint 33
Fig. 9.2: Elbow joint—posterior approach
LATERAL EPICONDYLITIS (EXTRA-ARTICULAR TENNIS ELBOW)Lateral epicondylitis (tennis elbow) has been recogonized for over 100 years. It is an enthesopathy of the common extensors origin in the lateral epicondylar region, however, its pathogenesis is not clear. It has been also recognized as an overuse syndrome (repetitive stress disorder) due to repetitive tension overloading of the wrist extensor origin at the lateral epicondylar region. First clinical description of lateral epicondylitis was given by Runge in 1873. More than 40 different types of treatment have been used alone or in combinations, e.g. anti-inflammatory drugs, steroids, physiotherapy techniques, cast immobilisation, orthosis, surgery and less conventional methods such
Fig. 9.1: Elbow joint—lateral approach
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Intra-articular and Allied Injections34
as radiotherapy, acupuncture and vitamins (Labelle et al. 1992). Recently, extracorporeal shock-wave therapy (ESWT) has been used in tennis elbow. The mobile lithotriper (2000 shock waves at 2.5 bars of air pressure with a frequency of 8–10 Hz—a total of three sittings at an interval of 2 weeks, each lasting for three to four minutes is an effective way of treating tennis elbow and plantar fascitis but it requires, further trials for authentication. However, it is much costly as compared to corticosteroids injection (100 times) and also less effective. By and large injection of corticosteroids alongwith hyaluronidase and local anaesthetic is more effective treatment of tennis elbow. In the elbow region, it is the commonest indication. Infiltration in such cases is done in and around the origin of common extensors from anteroinferior aspect of lateral epicondylar region. The patient lies supine. The elbow is kept in 45 degrees flexion in midprone position. The anteroinferior part of lateral epicondylar region is easily felt. Palpate over the bony region and its adjoining area for locating the maximum tenderness. The most tendor point is directly injected pushing the needle almost up to subperiosteal region. The adjoining areas should also be infiltrated (Figure 9.3). It is better to manipulate at the elbow in the same sitting. Hold the hand of the patient in your right hand in the handshake position. Support the elbow from behind by your left hand. While gently rotating the forearm and flexing/extending at elbow, give a sudden jerky extension to the elbow. You may hear a mild click. Quite often it gives good relief, probably by viture of breaking the fibrotic adhesions.
OLECRANON BURSITISOlecranon bursitis (Figure 9.4) is the inflammation of the bursa overlying the olecranon process caused by repetitive or even acute trauma. It presents as a more or less
Fig. 9.3: Elbow joint—approach of extra-articular tennis elbow
Fig. 9.4: Olecranon bursitis on left elbow
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Elbow Joint 35
round tense, fluctuant (may not be demonstrable), tender swelling. It should be aspirated from the nondependent side (to avoid leakage after withdrawing the needle). Usually no local anaesthetic is required. The aspiration needle is advanced while maintaining negative pressure in the syringe. When the fluid starts flowing in the syringe, the needle is no longer advanced further. If the fluid is clear, the needle should be left in situ and other syringe containing the steroid is changed to inject it slowly after the aspirate stopped flowing. It may prevent recurrence. The fluid should be sent for examination and culture, especially if the fluid is not clear.
MEDIAL EPICONDYLITIS (GOLFER’S ELBOW, PITCHER’S ELBOW, LITTLE LEAGUE ELBOW SYNDROME)It is an overuse syndrome, common in young persons and is caused by chronic tension stress injuries, repetitive tension overloading of the flexor-pronator muscles at or near its origin from the medial epicondyle. When the problem does not improve with non-invasive methods (as noted in lateral epicondylitis) local infiltration of the corticosteroid cocktail should be done in the flexor-pronator muscles origin complex just at and near the medial epicondyle.
MethodPatient lies supine with shoulder abducted (by 90°), elbow flexed by 40° and forearm supinated. The medial epicondyle is palpated and maximum tender point is spotted and marked by skin pencil or nail edge. After preparing the skin antiseptically, the needle is pushed from just below the medial epicondylar tip in the upward and anterior direction. Just before reaching the bone, the medicine is pushed infiltrating the zone.
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