Musculoskeletal Injection Procedures April 16, 2011 3:30-5:00pm

This is the property of Andrew Cooperman, M.D. and should not be copied or otherwise used without express written permission of the author. 1

Musculoskeletal Injection Musculoskeletal Injection ProceduresProcedures

Andrew E. Cooperman, MDAndrew E. Cooperman, MD

Center for Diagnostic ImagingCenter for Diagnostic Imaging

Musculoskeletal Injection Musculoskeletal Injection ProceduresProcedures

ArthrographyArthrography–– MR, CT, Conventional (Radiographic)MR, CT, Conventional (Radiographic)

TherapeuticTherapeuticC ti t idC ti t id–– CorticosteroidsCorticosteroids

Kenalog (Triamcinolone)Kenalog (Triamcinolone)

DepoDepo--Medrol (Methylprednisolone)Medrol (Methylprednisolone)

–– Local AnestheticsLocal AnestheticsMarcaine (Bupivacaine)Marcaine (Bupivacaine)

Xylocaine (Lidocaine)Xylocaine (Lidocaine)

Musculoskeletal Injection Musculoskeletal Injection ProceduresProcedures

Benefits of Fluoroscopic GuidanceBenefits of Fluoroscopic Guidance–– Faster and more accurate placement of Faster and more accurate placement of

needle into desired targetneedle into desired target

–– Ability to confirm location of needle tip usingAbility to confirm location of needle tip usingAbility to confirm location of needle tip using Ability to confirm location of needle tip using IodineIodine--based contrast materialbased contrast material

Omnipaque 240 (Iohexol)Omnipaque 240 (Iohexol)

IntraIntra--Articular Steroid InjectionsArticular Steroid Injections

Commonly used since the 1950sCommonly used since the 1950s

Effective for painful flareEffective for painful flare--ups of DJD and ups of DJD and RARA

Di i i h d t i ti t id idDi i i h d t i ti t id idDiminished systemic corticosteroid sideDiminished systemic corticosteroid side--effectseffects

Relatively low morbidityRelatively low morbidity

Musculoskeletal Injection Procedures April 16, 2011 3:30-5:00pm

This is the property of Andrew Cooperman, M.D. and should not be copied or otherwise used without express written permission of the author. 2

Procedure FlowProcedure Flow

Informed consentInformed consent

Sterile Prepping and DrapingSterile Prepping and Draping–– Betadine scrub and alcohol rinseBetadine scrub and alcohol rinse

Local (skin) anesthesiaLocal (skin) anesthesia

Needle placement under fluoroscopic Needle placement under fluoroscopic guidanceguidance

Procedure FlowProcedure Flow

Confirmation of desired needle placementConfirmation of desired needle placement–– Loss of resistance upon injection of local Loss of resistance upon injection of local

anestheticanesthetic

–– Injection of contrast materialInjection of contrast materialInjection of contrast materialInjection of contrast material

Save image of needle placement and Save image of needle placement and contrast patterncontrast pattern

Inject therapeutic agentsInject therapeutic agents

Procedure FlowProcedure Flow

Remove needleRemove needle

Exercise (mildly) if necessaryExercise (mildly) if necessary

PostPost--procedural interviewprocedural interview–– Degree of initial pain reliefDegree of initial pain relief

–– Assess for signs of complicationAssess for signs of complication

DischargeDischarge

Musculoskeletal Injection Procedures April 16, 2011 3:30-5:00pm

This is the property of Andrew Cooperman, M.D. and should not be copied or otherwise used without express written permission of the author. 3

Procedural RisksProcedural Risks

BleedingBleeding

InfectionInfection

Contrast allergyContrast allergy

Medication RisksMedication Risks

Local anestheticLocal anesthetic–– AllergyAllergy

–– Avoid intravascular injectionAvoid intravascular injection

C ti t idC ti t idCorticosteroidCorticosteroid–– Osteonecrosis (AVN)Osteonecrosis (AVN)

–– Exacerbation of DiabetesExacerbation of Diabetes

–– Others (Glaucoma, ulcer, headache, Others (Glaucoma, ulcer, headache, insomnia, flushing)insomnia, flushing)

Upper ExtremityUpper Extremity

ShoulderShoulder–– Glenohumeral, Subacromial, AC JointGlenohumeral, Subacromial, AC Joint

ElbowElbowI tI t A ti lA ti l–– IntraIntra--ArticularArticular

WristWrist–– Radiocarpal, Midcarpal, DRUJRadiocarpal, Midcarpal, DRUJ

Sternoclavicular JointSternoclavicular Joint

Musculoskeletal Injection Procedures April 16, 2011 3:30-5:00pm

This is the property of Andrew Cooperman, M.D. and should not be copied or otherwise used without express written permission of the author. 4

Musculoskeletal Injection Procedures April 16, 2011 3:30-5:00pm

This is the property of Andrew Cooperman, M.D. and should not be copied or otherwise used without express written permission of the author. 5

Lower ExtremityLower Extremity

HipHip–– IntraIntra--Articular, Trochanteric Bursa, Ilioposas, Articular, Trochanteric Bursa, Ilioposas,

Hamstrings OriginHamstrings Origin

KneeKneeKneeKnee

Ankle / FootAnkle / Foot–– Tibiotalar, Subtalar, etc.Tibiotalar, Subtalar, etc.

–– Diagnostic and TherapeuticDiagnostic and Therapeutic

Musculoskeletal Injection Procedures April 16, 2011 3:30-5:00pm

This is the property of Andrew Cooperman, M.D. and should not be copied or otherwise used without express written permission of the author. 6

Musculoskeletal Injection Procedures April 16, 2011 3:30-5:00pm

This is the property of Andrew Cooperman, M.D. and should not be copied or otherwise used without express written permission of the author. 7

When in doubt…When in doubt…

Radiology Consult LineRadiology Consult Line–– 888888--541541--SCAN (7226)SCAN (7226)

CDI Musculoskeletal TeamCDI Musculoskeletal TeamH lli F itt MDH lli F itt MD–– Hollis Fritts, MDHollis Fritts, MD

–– Cooper Gundry, MDCooper Gundry, MD

–– Andrew Cooperman, MDAndrew Cooperman, MD

–– Kevin Snyder, MDKevin Snyder, MD