Norwich March 2004
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Transcript of Norwich March 2004
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JOINTS & SOFT TISSUE
INJECTIONS OF THE UPPERLIMB
V Rajaratnam [email protected]
Royal Orthopaedic Hospital &
University Hospital Birmingham
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Why?
Very useful modality and immensely
appreciated by patientsMinimal systemic effect
Maximal Local effects
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PREPARATIONS
soluble - little role in infiltration(e.g., hydrocortisone)
depot - crystalline, bulky, andrelatively impervious to degradingenzymes (methylprednisoloneacetate, triamcinolone acetonide,
triamcinolone hexacetonide)
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Potencies
methylprednisolone acetate has a shorterduration of action (is relatively more soluble) thantriamcinolone hexacetonide.cost of triamcinolone hexacetonide, however, is3-4 times that of methylprednisoloneMethylprednisolone reserved for superficialstructures such as subcutaneous bursae andflexor tendon sheaths, and when there is concernabout tendon rupture, e.g., rotator cuff tendinitis
and retrocalcaneal (Achilles) bursa injections.Triamcinolone hexacetonide - more effective inreducing stubborn synovitis in a rheumatoid knee,wrist, elbow, or shoulder .
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ADVERSE EFFECTS
Post-injection flare
5% of articular infiltrations and a muchlarger proportion of soft tissueinfiltrations .
Rx - single dose of a nonsteroidal anti-
inflammatory drug or with the use of cold packs
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ADVERSE EFFECTS -cont.
Skin atrophy,hypopigmentation,fat pad atrophy, andtendon rupture
All above generally due to poor technique .
Infection rareVasovagalAnaphylaxis rare Rx - epinephrine
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General side effects
Diabetics - transienthyperglycemia,Arterial hypertension,Chronic adrenal suppression,Iatrogenic Cushing's syndrome,Menstrual irregularities,Osteoporosis,Avascular necrosis of bone femoral head, Kienbochs etc
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Technique
Effective sterilization - 70-92%ethyl alcohol or povidone-iodinesolution (Betadine)local anesthetic, e.g., lidocaine 1%or 2%, can be used concomitantlyResting an injected joint for 24-48hours following infiltration helps toconfine the corticosteroid to theinjected site and enhances local
action
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Guidelines for dosage/volume of infiltration
Knee 40-80 mg 3-10mlGlenohumeral joint 40-80 mg 3-10 mlSubacromial bursa 20-40 mg 3-5mlAcromioclavicular joint 10 mg 1-2 mlOlecranon bursa 20 mg 2 ml
Trochanteric bursa 20-40 mg 2-5mlTrigger finger 10 mg 1 ml
Region Dosage (methylprednisolone acetate or triamcinoloneRegion Dosage (methylprednisolone acetate or triamcinoloneacetonide)acetonide)Volume (corticosteroid + lidocaine)Volume (corticosteroid + lidocaine)
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Indications
Chronic tenosynovitisTrigger finger De Quervain`s tenosynovitisGangliaTennis elbowOlecranon bursitisCubital Tunnel SyndromeOA Hand jointsRotator cuff tendinitisSubacromial impingementFrozen shoulder AC joint disease
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Continued
Trochanteric bursitisOA hipAnserine bursitisInfrapatellar bursitisOA kneeAchilles bursaPlantar fasciitisMetatarsalgiaOA Foot and Ankle
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De Quervain`s tenosynovitis
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video
http://dequervans.wmv/http://dequervans.wmv/ -
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OA Hands
http://f/VIAO%20D%20drive/My%20Documents/My%20Videos/cmc5.WMVhttp://f/VIAO%20D%20drive/My%20Documents/My%20Videos/cmc5.WMV -
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CMC OA
CMC Injection video
http://cmc2inj.wmv/http://cmc2inj.wmv/ -
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Wrist OA
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Carpal Tunnel Syndrome
http://f/VIAO%20D%20drive/My%20Documents/My%20Videos/ctinjection.WMVhttp://f/VIAO%20D%20drive/My%20Documents/My%20Videos/ctinjection.WMV -
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Cubital Tunnel Syndrome
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Tennis Elbow
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Differential Diagnosis
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Paraesthesia
CTS video 2Cubital tunnel video
Thoracic outlet syndromeCervical Disc degenerative disease
http://ctinj.wmv/http://ctinj_0001.wmv/http://cubitalinj_0001.wmv/http://cubitalinj_0001.wmv/http://ctinj_0001.wmv/http://ctinj.wmv/ -
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Traumatic Synovitis PIP J
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ECU Tendinitis
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Trigger Digits
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Trigger finger TRIGGERDIGITS
http://f/VIAO%20D%20drive/My%20Documents/My%20Videos/trigger.WMVhttp://f/VIAO%20D%20drive/My%20Documents/My%20Videos/trigger.WMVhttp://f/VIAO%20D%20drive/My%20Documents/My%20Videos/trigger.WMVhttp://f/VIAO%20D%20drive/My%20Documents/My%20Videos/trigger.WMVhttp://f/VIAO%20D%20drive/My%20Documents/My%20Videos/trigger.WMVhttp://f/VIAO%20D%20drive/My%20Documents/My%20Videos/trigger.WMVhttp://f/VIAO%20D%20drive/My%20Documents/My%20Videos/trigger.WMVhttp://f/VIAO%20D%20drive/My%20Documents/My%20Videos/trigger.WMVhttp://f/VIAO%20D%20drive/My%20Documents/My%20Videos/trigger.WMVhttp://f/VIAO%20D%20drive/My%20Documents/My%20Videos/trigger.WMVhttp://f/VIAO%20D%20drive/My%20Documents/My%20Videos/trigger.WMVhttp://f/VIAO%20D%20drive/My%20Documents/My%20Videos/trigger.WMVhttp://f/VIAO%20D%20drive/My%20Documents/My%20Videos/trigger.WMVhttp://f/VIAO%20D%20drive/My%20Documents/My%20Videos/trigger.WMVhttp://f/VIAO%20D%20drive/My%20Documents/My%20Videos/trigger.WMVhttp://f/VIAO%20D%20drive/My%20Documents/My%20Videos/trigger.WMV -
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Digits
Trigger Digits videoOA PIP and DIP video
Synovitis RA, gout
http://triggerrelease_0001.wmv/http://pipjinj.wmv/http://pipjinj.wmv/http://triggerrelease_0001.wmv/ -
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Ganglion
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Ganglion
AspirateSurgery
Digital BlockDigital Tourniquet
http://aspiration%20ganglion.wmv/http://ganglion.wmv/http://digitalblock.wmv/http://digitaltx.wmv/http://digitaltx.wmv/http://digitalblock.wmv/http://ganglion.wmv/http://aspiration%20ganglion.wmv/ -
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Thank You
www.handsurgerymanual.com
user name : guestpassword: hands
j@ d k
http://www.handsurgerymanual.com/http://www.handsurgerymanual.com/