Peggers’ Super Summary of Articular Injections & Aspirations
Principles:
STERILITY

No touch aseptic technique

Sterile gloves

70% alcohol wipe
FREQUENCY

4 weekly intervals

No more than 3 times a year

If no benefit review the diagnosis
STEROID CHOICE

Hydrocortisone acetate 25mg/ml (hydrocortistab)

Methylprednisolone acetate 40mg/ml (Depo-Medrone)

Triamcinolone hexacetonide 20mg/ml (Aristispan)

Triamcinolone acetonide 40mg/ml (Kenalog)
NB tennis elbow can painful therefore the use of a stronger steroid to use
less volume is advisable
NB only Both hydrocortisone and Triamcinolone are licenced to mix with
LA
CI TO STEROID USE

Prosthetic joint

Patient awaiting joint replacement < 6 months

Infected joint

Overriding skin infection
Relative CI

Diabetes

Hypertension

Hyperthyroidism

Osteoporosis

Pregnancy certainly in first 16 weeks!
LA

Lignocaine 1%

Bupivicaine (Marcaine) 0.25% or 0.5% longer lasting
POST INJECTION ADVICE

Pain may increase between days 1-3

Relative rest over days 1-3

Avoid carrying heavy objects or aggrevating activities for 1-3
days
Medical Legal Issues:
PAIN POST INJETION & COMPLICATIONS

48HR TO 72 HRS OF PAIN take paracetamol

Lipodytrophy and dimpling due to s/c injection of steroid

Loss of skin pigmentation

Tendon rupture

OA (though evidence suggests that 4 annula injections for 2
years did not increase joint space narrowing)
INFORMED CONSENT

Diagnosis of condition and natural time course

Effect of injection with benefits and risks
SPECIFIC INDICATION

Specific injection for a specific condition
FULL RECORDS

History, subjective findings, examination findings, diagnosis
and past management
TECHNIQUE

Aseptic washing hands and sterility
Shoulder:
ACJ
Diagnosis

Direct pain

Scalf test or abduction painful
Anatomy

Lateral end of clavicle, mark the end of clavicle and start of
acromium

Osteophyte in OA may obscure joint
Approach

Anterior or vertically though pushing too far will cause injection
into joint capsule
Apparatus

2ml syringe and orange needle

Max volume 0.5ml triamcinolone no LA
Bicipital Tendinopathy
Diagnosis

Local tenderness

Yergasons resisted supination test
Anatomy

Found between the greater and lesser tubercle of the shoulder
Approach

Inject at level of groove, if there is resistance this is due to
injection into the tendon, pull back to inject into the sheath
Apparatus

2ml syringe orange needle

1ml of triamcinolone (Kenalog) + 1ml 1% lignociane
Subacromial space
Diagnosis

Painful arc

Hawkin’s Kennedy sign positive
Anatomy

Space between humeral head and acromium
Approach

Palpate most lateral part of acromium

Mark 1.5cm below and aim horizontally and slightly posteriorly
Apparatus

2ml syringe blue or green needle

1ml of kenalog

1ml of lignocaine
Glenohumeral Joint
Diagnosis

Frozen shoulder limited ER

None of the following ACJ, rotator cuff tears, impingement,
biceps tendinopathy
Anatomy

Line of injection is between posterior tip of acromion and
coracoid process anteriorly
Approach

2.5cm inferior to acromion and medial to humeral head
posteriorly
Apparatus

Green needle 2ml syringe

1ml of lignocaine and triamcinolone
Hand and Wrist:
OA 1st CMCj
Diagnosis

Aching in region and pain on passiv backward movement of
thumb

OA changes on x ray
Anatomy

Joint between metacarpal and trapezium
Approach

Directly for joint draw it on

Between the extensor tendon of the thumb
Apparatus

2ml syringe and orange needle

0.5ml of triamcinolone not space for lignocaine
Carpal tunnel:
Diagnosis

Wasting of thenar muscles tingling

Phalens or tinel’s test positive
Anatomy

Median nerve lies radial side of Palmaris longus
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Peggers’ Super Summary of Articular Injections & Aspirations
Approach


Apparatus


o
Superficial anaesthetic aim at distal wrist crease aiming distally
Enter ulnar side of PL and once feeling pop in the carpal tunnel
2ml syringe and blue needle
1ml of triamcinolone
De Quervain’s:
Diagnosis

Tendon pain

Exacerbated by Finklesteins test
Anatomy

Tendinopathy of abductor pollicis longus and extensor pollicis
brevis
Approach

Insert needle pointing proximally DISTAL to site of maximum
pain along line of tendon/sheath
Apparatus

2ml syringe and orange needle

1ml of each lignocaine and methyprednisolone
Trigger finger:
Diagnosis

Tender nodule in the palm

Which locks having to painfully extend the finger with help
Anatomy

A1 pulley is where the nodule gets stuck
Approach

The A1 pulley is the same distance of the P1 skin creases into
the palm from the volar MCPJ skin crease
Apparatus

2ml syringe and orange needle

1ml of lignocaine and methyprednisolone into this region
OA or RA relief
Aim for the space underneath the patella bone
Knee flexed with a pillow underneath
Lateral approach under the superior pole of the patella
Tilting the opposite pole with increase the gap
Aim the needle horizontally
Aseptic apparatus
20ml syringe and white need if aspirating or grey venflom
Local anaesthetic can be infiltrated initially
If injecting can use either
o
2ml of triamcinolone
o
Viscosupplementation i.e. hyaluronic acid
preparation 3 courses 1 week apart
Aspiration of Joints
NB Always use green/white needle or grey venflom
Wrist
Anatomy

Listers tubercle is the boundary between the extensor
compartments 2/3 of the wrist
Approach

Distal to Lister’s tubercle
Ankle
Anatomy

The n/v structures lie between Tibialis anterior and EHL at the
ankle joint.
Approach

Medial to Tibialis anterior tendon in sulcus of ankle joint
Elbow
Anatomy

The safe zone over the radial head changes depending on the
rotation of the forearm

The radial nerve crosses the radius 3.8cm distal to the joint
margin in pronation (2.2cm in supination)
Approach

In full pronation with hand flat on the table the ‘safe zone’ is 90 0
vertically with a 450 angled zone either side
The Elbow:
Tennis elbow/lateral
Diagnosis

Lateral elbow pain in racket sports or house activities

Painful resisted wrist extension
Anatomy

Common extensor origin for brachioradialis, extensor carpi
radialis, extensor carpi ulnaris, digitorum muscles
Approach

Fan technique into all the tender areas of the lateral elbow
Apparatus

2ml syringe blue needle

1ml of methyprednisolone NB anaesthetic may mask all the
tender areas
Golfers Elbow/medial
Diagnosis

Medial elbow pain

Resisted flexion of the wrist exacerbates pain
Anatomy

Close proximity to the ulnar nerve (ask patient to tell you if any
little finger tingling
Approach

Place patients hand behind their back and pinpoint tender region
and use a fanning technique
Apparatus

As above
Knee Joint:
Diagnosis

Diagnosis or therapeutic reasons

Diagnosis
o
Traumatic effusion to relieve swelling and pain
o
Gout or pseudogout
o
Septic arthritis

Therapeutic
Anatomy

Approach




Apparatus




Shoulder
Anatomy

The shoulder joint can be approached either anteriorly or
posteriorly

Inferiorly and posteriorly is the quadrangle space where the
axillary nerve and circumflex humeral artery exits
Approach

2.5cm down from the acromion and 2.5 medial to the humerus
posteriorly
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