CONTRAINDICATIONS
- Cellulitis or broken skin over the needle entry site
would increase the risk for infection. - Anticoagulation or a coagulopathy is a relative con-
traindication and should be individualized. - Intra-articular fractures are a contraindication to a
corticosteroid injection. - Septic effusion of a bursa or a periarticular structure.
- Lack of response to prior injections.
- More than three prior injections in the last year to a
weight bearing joint. - Inaccessible joints, e.g., hip, spine, and sacroiliac
joint. - Joint prostheses.
GENERAL PRINCIPLES (White, 2002;
Paluska, 2002)
- Consent:As there are inherent risks and complica-
tions associated with corticosteroid injections,
informed consent should be obtained, witnessed, and
documented. - Equipment:Most injections are performed using an
alcohol, chlorhexidene or povidone-iodine wipe;
some authors recommend a sterile scrub before inject-
ing into a large joint. Gloves are another area of con-
troversy; as a rule I teach that sterile gloves are used
for a joint and nonsterile gloves for soft tissue struc-
tures. Some advocate sterile gloves for all injections,
while some authors prefer using the one sterile glove
technique. In this technique the physician wears the
sterile glove on the noninjecting hand to insure proper
positioning after the local prep. Other equipment
include the following:- Povidone-iodine wipes or alcohol wipes
- Sterile or nonsterile gloves
- Sterile drapes: optional
- 21 to 27 gauge 1.5-in. needles for injection
- 18 to 20 gauge needles for aspirations
- 1- to 10-cc syringes for injections
- 3- to 50-cc syringes for aspirations
- Ethyl chloride surface coolant
- 1% lidocaine
- 0.5% bupivicaine
- 2 ×2 gauze sponges
- Band-Aids
- Access to equipment to treat severe allergic reac-
tions: oxygen; epinephrine 1:1000; benadryl 25-
to 50-mg intramural(IM); advanced cardiac life
support(ACLS) equipment.
- Anesthesia:The three main uses of anesthesia include
diminishing pain, aiding in diagnosis, and providing a
volume for corticosteroid injections. Although there are
many local anesthetics, the two most commonly used
are amide compounds, lidocaine, and bupivicaine.- Lidocaine (xylocaine) is available commercially as
a 0.5 to 2% concentration. The most commonly
utilized is 1%; 2% may be used in small areas
where a small volume is required. Time from injec-
tion to onset of effect is 1–2 min, with duration of
action of approximately 1–2 h. The upper limit of
dosing is 10 mL for 2% and 20 mL for 1%; above
these levels side effects can be expected. - Bupivicaine (marcaine) is available commercially
in 0.25–0.5% concentrations. Time from injection
to onset of effect is 5 to 30 min, with duration of
action of approximately 8 h. The upper limit of
dosing is 30 mL for 0.5% and 60 mL for 0.25%;
above these levels side effects can be expected. - Side effects to include anaphylaxis can occur;
resuscitation equipment should be available. - An alternative to a local anesthestic injection is
topical ethyl chloride. When utilized, however,
spray lightly to avoid cold injury and secondary
skin changes.
- Corticosteroids:Corticosteroids are commonly uti-
lized in musculoskeletal medicine. The corticosteroid
treats the local inflammatory response, and not the
clinical problem. Steroids have both mineralocorti-
coid and glucocorticoid effects. The mineralocorti-
coid effects modify salt and water balance, while the
glucocorticoid effect suppresses the inflammatory
response. The ideal choice is to use a medication that
maximizes the anti-inflammatory effect. Steroids also
differ in their solubilities, potencies, and duration of
action (see Table 71-3). The duration of the effect is
thought to vary inversely with the drug’s solubility.
Shorter acting agents tend to have a lower incidence
of postinjection flare. In general, higher solubility
agents (e.g., celestone, dexamethasone, and methyl-
prednisilone) tend to better for soft tissues, while
lower solubility agents (e.g., triamcinolone hexace-
tonide) tend to favor joint injections. Selected dosing
is found in Table 71-4. - Technique
- Patient: The patient should be in a comfortable
position, preferably sitting or lying down. The
most important aspect of the patient’s position,
however, is that the physician injecting is comfort-
able and can easily identify anatomic landmarks
and administer the injection. - Be prepared: Have all your equipment ready so
that you can move quickly. Have your combination
of steroid and anesthetic already drawn up and
ready to go. Remember to use separate needles for
drawing up different agents.
428 SECTION 5 • PRINCIPLES OF REHABILITATION