Injection—Shoulder

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SAMPLE EXCERPT
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PRE-PROCEDURE
INDICATIONS

Diagnostic Indications

  • To perform a therapeutic trial to differentiate between various causes of a condition
  • To differentiate an intra-articular from an extra-articular cause of pain symptoms

Therapeutic Indications

  • To inject lidocaine for noninfectious inflammatory arthritis or bursitis to reduce pain and/or inflammation

Indications for Corticosteroid Use

  • Inflammation due to chronic osteoarthritis
  • Persistent pain despite medical therapy
CONTRAINDICATIONS
  • Cellulitis or broken skin over the intended entry site for injection or aspiration
  • Anticoagulant therapy that is not well controlled
  • Severe primary coagulopathy
  • Infected effusion of a bursa or a periarticular structure (for injection)
  • Lack of response to two or three previous injections (relative)
  • Suspected bacteremia
  • Unstable joints (for steroid injection)
  • Joint prostheses
  • Pregnancy (relative)
EQUIPMENT
  • Gloves (sterile or nonsterile)
  • Sterile drapes (optional)
  • Povidone-iodine wipes or alcohol wipes
  • Needle and syringe
    • Shoulder joint space: 1½-inch, 20-gauge needle
    • Acromioclavicular joint: 1- to 1½-inch, 22-gauge needle
    • Subacromial bursa: 1- to 1½-inch, 22-gauge needle
    • Rotator cuff (supraspinatus tendinitis): 1½-inch, 18- to 20-gauge needle
    • Short head of the biceps: 1½-inch, 22-gauge needle
    • Long head of the biceps (bicipital tendinitis): 1½-inch, 22-gauge needle
  • ½-inch, 30-gauge needle, if skin anesthesia is to be given (usually not needed)
  • Single-dose vials of 1% lidocaine
  • Adhesive bandage dressing
  • Corticosteroid preparation
    • Shoulder joint space: 5 to 7 mL 1% lidocaine and 20 to 40 mg methylprednisolone acetate or equivalent
    • Acromioclavicular joint: 5 to 7 mL 1% lidocaine and 30 to 40 mg methylprednisolone acetate or equivalent
    • Subacromial bursa: 5 to 7 mL 1% lidocaine and 30 to 40 mg methylprednisolone acetate or equivalent
    • Rotator cuff (supraspinatus tendinitis): 5 mL 1% lidocaine and 20 to 40 mg methylprednisolone acetate or equivalent
    • Short head of the biceps: 5 to 10 mL 1% lidocaine and 10 to 20 mg methylprednisolone acetate or equivalent
    • Long head of the biceps (bicipital tendinitis): 5 to 10 mL 1% lidocaine and 10 to 20 mg methylprednisolone acetate or equivalent
ANATOMY
  • Humerus
    • The supraspinatus, infraspinatus, and teres minor muscles insert at the greater tubercle.
    • The long head of the biceps (biceps brachii) rests in the bicipital groove of the humerus.
  • Clavicle
    • The clavicle articulates medially with the sternum at the sternoclavicular joint. The lateral articulation is found within the acromion of the scapula.
  • Scapula
    • The scapula articulates with the shoulder via the glenoid fossa and the acromion.
    • The acromion of the scapula arises as the lateral projection of the scapular spine. At its distal end, it curves medially to meet the clavicle.

PROCEDURE
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  • Links to medical evidence and related procedures

POST-PROCEDURE
CARE
  • Place a dressing at the injection site for 8 to 12 hours.
  • Advise the patient that it is essential that the affected area be rested.
  • Physical therapy, NSAIDs, and hot or cold compresses all may be indicated.
  • Advise the patient to report immediately if he or she develops fever, chills, or any sign of infection.
  • Reexamine the patient if discomfort caused by the injection does not resolve within 72 hours, to rule out a septic joint.
  • Advise the patient that normal bathing is allowed.
  • Consider prescribing an NSAID.
COMPLICATIONS
  • Injection into a vein or artery
  • Introduction of infection into a joint space
  • Trauma to articular cartilage
  • Injury to nearby nerves
  • Subcutaneous fatty atrophy
  • Adverse drug reaction (adverse effects)
  • Injection of steroid into a septic joint
  • Osteoporosis and cartilage damage
  • Tendon rupture
  • Inappropriate diagnosis
  • Reactions to lidocaine
  • Steroid flare
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