Joint
Injections
Workshop.
RNZCGP Conference 2011
Dr Francesco Lentini
FRNZCGP
CARPAL TUNNEL SYNDROME
ANATOMY
The carpal tunnel is formed by the carpal
bones dorsally, and the transverse carpal
ligament (Flexor Retinaculum), ventrally. The
contents of the tunnel include the Median
Nerve and flexor tendons of the hand. The
median nerve sensory and motor
distribution includes the palmar aspect of
the thumb and the index and middle
fingers, and it allows opposition of the tip of
the thumb with the tips of the fingers.
Carpal Tunnel syndrome
-Diagnosis


Diagnosis of carpal tunnel syndrome is clinical.
Electro-diagnostic studies (nerve conduction
and electromyography) may assist in
confirming the diagnosis. Weakness of thumb
abduction is a specific and reliable sign.
Tinel’s test: Percuss lightly over the Flexor
Retinaculum with a tendon hammer between
the Palmaris Longus and the Flexor Carpi
Radialis > tingling sensation in Median nerve
distribution.
Phelan’s test: Hold wrist in flexion for up to 1
min > Pain and paraesthesia
Carpal Tunnel Syndrome
Indications for injection
 The
major indication for carpal tunnel
injection is the syndrome of median nerve
compression, which may result from
osteoarthritis, rheumatoid arthritis,
diabetes mellitus, hypothyroidism,
repetitive use injury or other traumatic
injuries to the area.
Carpal Tunnel Syndrome
Indications
 The
use of local corticosteroid injection for
CTS has been shown to provide greater
clinical improvement in symptoms one
month after injection, compared with
placebo. Injection of the CT is considered
a later modality after appropriate
nonsurgical therapeutic interventions
have been undertaken. These include the
use of NSAIDs, splinting, and avoidance of
precipitating activities.
Carpal Tunnel Syndrome
Injection Landmarks
 Essential
landmarks to palpate before
performing this injection include the
proximal wrist crease and the Palmaris
Longus Tendon when present. The
Palmaris Longus Tendon is best identified
by having the patient pinch all the
fingertips together while the wrist is in a
neutral position.
Carpal Tunnel Syndrome
Materials + Pharmaceuticals
 Syringe:
5 Ml
 Needle: 25 gauge, 1.5 inch
 Anaesthetic: 2-3 Mls of 1% Lidocaine
 Cortico-steroid: 1 Ml Methylprednisolone,
40 Mg in 1 Ml
Carpal Tunnel Syndrome
Approach and needle entry
 The
injection is performed at a site just
ulnar to the Palmaris Longus Tendon and
at the proximal wrist crease. The needle is
inserted at a 30-degree angle and
directed toward the ring finger. If the
needle meets obstruction or if the patient
experiences paraesthesia, the needle
should be withdrawn and re-directed in a
more ulnar fashion.
Carpal Tunnel Syndrome
Injection Site
1st Carpo-Metacarpal Joint
Anatomy
 The
movements of the thumb are
dictated by the saddle-shaped articular
surface of the base of the first
metacarpal, which articulates with the
trapezium.
1st CMC Joint
Indications and diagnosis

Pain associated with arthritis or overuse is the
most common indication for injection of this
joint. Diagnosis is determined by limitation of
motion and palpation of crepitus and
tenderness over the joint. Diagnosis may be
confirmed by radiographs. Injection is usually
performed after other more conservative
therapies, including use of NSAIDs and a brief
period of immobilization, have been tried. As
with any arthritic joint, relief after injection
may only be temporary, and surgical
intervention may need to be considered.
1st CMC Joint
Approach and needle entry


Palpate the joint space between the
Trapezium and the First Metacarpal.
The needle enters just proximal to the first
metacarpal on the extensor surface. Care
must be taken to avoid the Radial Artery and
the Extensor Pollicis tendons. To avoid the
radial artery, the needle should enter toward
the dorsal (ulnar) side of the Extensor Pollicis
Brevis tendon. The needle should fall into the
joint space. Traction can be applied to the
thumb to further open the joint space.
1st CMC Joint
Materials + Pharmaceuticals
 Syringe:
3 Mls
 Needle: 25 Gauge, 1 inch
 Anesthetic: 0.5 Ml of 1% Lidocaine
 Cortico-Steroid: 0.5 Ml of
Methylprednisolone 40 Mg/1 Ml
1st CMC Joint
de Quervain’s Disease
Anatomy
 This
disorder, a stenosing tenosynovitis,
involves the Abductor Pollicis Longus and
Extensor Pollicis Brevis tendons.
de Quervain’s Disease
Indications and Diagnosis
 Usually
occurs with repetitive use of the
thumb. Thickening is noted, and
tenderness is elicited just distal to the
radial styloid process over the site of the
involved tendon sheath. The Finkelstein
test is performed by having the patient
make a fist with the thumb inside while
simultaneously ulnar deviating the hand.
Pain over the affected area is elicited in
dQD
de Quervain’s Disease
 Immobilization
and the use of NSAIDs
should be tried before injection therapy is
performed.
De Quervain Disease
Injection Approach
 With
the thumb abducted and extended,
palpate the course of the tendons distal
to the radial styloid process. The needle is
placed into the first extensor
compartment, directed proximally toward
the radial styloid process and sliding in
parallel to the abductor and extensor
tendons. Do not inject directly into a
tendon.
de Quervain’s Disease
Materials + Pharmaceuticals
 Syringe:
5 Ml
 Needle: 25 gauge, 1.5 inch
 Anaesthetic: 2 Mls of 1% Lidocaine
 Cortico-steroid: 1 Ml Methylprednisolone,
40 Mg in 1 Ml
de Quervains Disease
Knee Joint
Anatomy
 Two
functional joints, the femoral-tibial
and the femoral-patellar, make up the
knee. Primary stabilizers of the knee are
the anterior and posterior cruciate
ligaments, the medial and lateral
collateral ligaments, and the capsular
ligaments.
Knee Joint
Indications for Aspiration
 Unexplained
effusion, possible septic
arthritis and relief of discomfort caused by
an effusion.
Knee Joint
Indications for injection
 The
use of intra-articular corticosteroids is
reserved for patients with more advanced
disease (osteoarthritis and other noninfectious inflammatory arthritides such as
gout) and after other modalities have
been tried.
Knee Joint
Position and Landmarks
 Position
of Patient: The patient is in the
supine position with the knee slightly
flexed with a pillow or rolled towel in the
popliteal space.
 Palpation of Landmarks: Identify the
medial, lateral, and superior borders of
the patella.
Knee Joint
Techniques
 There
are many different techniques for
aspirating or injecting the knee. These
include medial, lateral, and anterior
approaches. Each has its own merit, but
choice of approach is dependent on
physician preference
Knee Joint
Materials + Pharmaceuticals
 Syringe:
50 Mls for Aspiration; 10 Mls for
Injection
 Needles: 18, 20 or 22 gauge. 1.5 inch
 Anaesthetics: 5 Mls 1% Lidocaine.
 Cortico-steroid: 2-3 Mls of
Methylprednisolone 40 Mg/1 Ml.
Knee Joint
Approach and needle entry
 The
lateral approach is most commonly
used. For this approach, lines are drawn
along the lateral and proximal borders of
the patella. The needle is inserted into the
soft tissue between the patella and femur
near the intersection point of the lines,
and directed at a 45-degree angle
toward the middle of the medial side of
the joint.
Knee Joint
Approach and needle entry
Knee Joint
Approach and needle entry
 For
the medial approach, the needle
enters the medial side of the knee under
the middle of the patella (midpole) and is
directed toward the opposite patellar
midpole.
Knee Joint
Approach and needle entry
 In
the anterior approach, the knee is
flexed 60 to 90 degrees, and the needle is
inserted just medial or lateral to the
patellar tendon and parallel to the tibial
plateau. This technique is preferred by
some physicians for its ease of joint entry
in advanced osteoarthritis. However, the
anterior approach may incur greater risk
for meniscal injury by the needle.
Joint injections
Follow up care

Following injection, the joint or injected region
may be put through passive range of motion. The
patient should remain in the office for 30 minutes
after the injection to monitor for any adverse
reactions. Avoid strenuous activity involving the
injected region for several days. Patients should be
cautioned that they may experience worsening
symptoms during the first 24 to 48 hours related to
a possible steroid flare, which can be treated with
ice and NSAIDs. Instruct against the application of
heat. A F/u appointment should be scheduled
within three weeks.
THANK YOU
ANY QUESTIONS?