Tehnica infiltratii

Injection or infiltration around knee and hip joint

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Intra-articular injection

Capsular pattern lesion

Indication

§ Traumatic arthritis

§ Osteoarthritis

§ RA

§ Seronegative arthritis

§ Gout





supine, support posterior knee with small pillow, palpate patellar and

condyle, tilt patellar with compression toward postero-laterally,

40mg triamcinolone with 3 cm needle, insert needle horizontally

at upper 1/3 of patellar or just proxmal to apex of condyle, 1.5cm~2cm

advance, aspiration then injection

sitting and hanging leg from the edge of table(90° knee flexion), , ,

palpate infra-patellar tendon, joint line, femoral condyle,

40mg triamcinolone with 5 cm needle, insert needle toward center of

knee joint at lateral or medial to infra-patellar tendon in level of joint space.

advance about 3~5 cm, confirm bone touch the inject.

1. Lateral approach

2. Anterior approach




retinaculum





1. Lateral approachsupine, support posterior knee with small pillow, palpate patellar and



























2. Anterior approach

sitting and hanging leg from the edge of table(90° knee flexion), , ,

palpate infra-patellar tendon, joint line, femoral condyle,

40mg triamcinolone with 5 cm needle, insert needle toward center of

knee joint at lateral or medial to infra-patellar tendon in level of joint space.

advance about 3~5 cm, confirm bone touch the inject.




prepatellar bursitis




prepatellar bursitis

Symptom

swelling or pain on prepatellar area

Functional examination

palpable swelling, limited knee flexion

Technique

supine, compress proximal portion to localize swelling,

needle insert at distal site of swelling,

aspiration, 20 mg triamcinolone injection(infiltration)

Symptom

swelling or pain on prepatellar area


palpable swelling, limited knee flexion(+/-)

Technique

supine, compress proximal portion to localize swelling,

needle insert at distal site of swelling,

aspiration, 10~20 mg triamcinolone injection(infiltration)




med. coll. ligament sprain




med. coll. ligament sprain

Symptom

swelling and pain on medial side of knee

Functional examination Valgus stress test(+), pain with p-ext. rotation,

capsular pattern limitation on next day

Technique

only 1st. 24 hour

supine, palpate tender point, with fine needle(23G)

10~20 mg triamcinolone + 2% lidocaine 2ml infiltration




lat. coll. ligament sprain




lat. coll. ligament sprain

Symptom

swelling and pain on lateral side of knee

Functional examination Varus stress test(+), pain with p-int. rotation,

Technique

only 1st. 24 hour

supine, palpate tender point, with fine needle(23G)

10~20 mg triamcinolone + 2% lidocaine 2ml infiltration




Coronary ligament sprain




Coronary ligament sprain

Symptom

swelling and pain on medial side of knee

Functional examination pain with p-ext. rotation,

tenderness on medial coronary ligament

capsular pattern limitation on next day

Technique

spine, with knee flex to 120˚, external rotate tibia,

palpate tender point,

infiltration triamcinolone 10 mg with thin(26G) needle




pes anserinus bursitis




pes anserinus bursitis

Symptom

swelling and pain on

medial, inferior area of knee

Functional examination pain with r-knee flexion and int. rotation,

tenderness on medial, inferior of knee

Technique

spine, with knee 30˚ flexion, palpate tender point, mark tender area,

23G needle insert at margin of tender area toward center

slight more advance after sharp pain(bursal wall puncture)

infiltration triamcinolone 20 mg




Baker’s cyst




Baker’s cyst

Symptom no symptom, fullness on popliteal area,

rarely tingling sense on lower leg


palpable mass,

occ. pain with p-flexion, pain with limitation with p-extension

Technique

palpate, localize mass, puncture at the center of mass

with 18G(21G) needle, aspiration,

triamcinolone 40mg injection(?)




Quadriceps tendinitis





Symptom * diffuse pain of knee joint or anterior thigh

* painful limitation of knee motion


* full ROM, tenderness (+) on patellar pole, pain with R-knee ext.

* LROM-flexion, tenderness (+++) on patellar pole, weak knee ext.

limping gait with extended knee





Technique

* patient posture : supine, knee extension.

* dosage : 10mg(1ml) triamcinolone acetonide

* syringe : 23G

* technique : push the lower pole of patellar backward and upward,

palpate and mark painful insertion of tendon, needle insert

1.5~2cm above the lesion, infiltrate.




infra-patellar tendinitis





Symptom * diffuse pain on infra-patellar area or upper tibia

d/dx Osgoods-schulatter’s dz.


* swelling on infra-patellar area(+/-)

* full ROM, tenderness (+) on lower patellar or inf-rapatellar tendon

* R-knee ext. test(+/-)





Technique


* dosage : 10mg(1ml) triamcinolone acetonide

* syringe : 23G

* technique : push the upper pole of patellar backward and

downward, palpate and mark ainful insertion of tendon, needle

insert 1.5~2cm below the lesion, infiltrate.




infrapatellar bursitis w tendinitis





Symptom * diffuse pain on upper tibia or infra-patellar area

Functional examination * swelling on infra-patellar area(+/-)

* full ROM, tenderness (+) on infra-patellar tendon or tibial tuberosity

d/dx Osgoods-schulatter’s dz.

* R-knee ext. test(+/-)





Technique


* dosage : 10~20mg(1~2ml) triamcinolone acetonide

* syringe : 23G

* technique : palpate infra-patellar tendon and tibial tuberosity

insert needle 45’ inclined line toward postero-medially at lateral side

of tendon and just proxmial to tibial tuberosity.




hip joint effusion : OA




hip joint effusion : OASymptom

pain on around hip(gluteal), inguinal area or

medial thigh and knee


capsular pattern limitation :

limitation internal rotation> flexion, abduction, extension,

no limitation adduction, external rotation. patric sign(+/-)

Technique

side lying on other side, support leg to relieve iliotibial band,

7 cm needle insert vertically at 1~2cm proximal to the middle of

upper tip of greater trochanter, bone touch,

40 mg triamcinolone injection




Iliopsoas bursitis




Iliopsoas bursitis

§ Located between hip joint and iliopsoas muscle

§ 5~7 cm in length, 2~4 cm in width, the largest bursa in human body

§ 15% communicate with hip joint

§ D/dx with solid neoplasm, inguinal hernia, undecended testes,

lymphadenopathy

Symptom

pain on inguinal area and ant. thigh, walking or cross leg

Functional examination most painful on groin with flexion with adduction of hip,

painful with lateral rotation with soft endfeel. pain with flexion

at the end range and extension.




Iliopsoas bursitisTechnique

supine position with relaxed hip,

3 land mark, ASIS, GT, femoral artery,

draw 5cm length perpendicular line from

mid-inguinal point(palpable arterial pulse),

mark insertion point at 2cm lateral to previous point,

0.5% procaine(lidocaine) 50ml with 7cm needle, needle inserted

at the marked point toward 45 degree medial and upward,

other hand monitor femoral artery, as soon as the patient

experience pain, the needle is pushed slightly farther, then

withdrawn and infiltration.

repeat injection 1 week later, for lasting effect, add triamcinolone




Gluteal bursitis




Gluteal bursitisSymptom

pain on gluteal or trochanteric area, spreading lateral or posterior

thigh and down to calf and outer malleolar

pain related to walking especially upstair, not related to sitting

pain with lying pain side or crossing leg


pain with passive external rotation, abduction, and resistive

external rotation and abduction , patric sign(+/-)

* bursa at the insertion of piriformis : pain with full passive internal

rotation and resistive external rotation

* bursa between gluteus maximus and gluteus medius : pain with

passive abduction, passive flexion, and resistive abduction.




Gluteal bursitisTechnique

Technique 1

in case highly localized bursitis,

prone, 05% procaine 50(10)ml with 7cm needle,

needle insert horizontally at the tender point

until it reach ilium, dynamic infiltration.

Technique 2 :

bursitis at the upper or inner edge of trochanter,

prone with affected leg hanging down over the edge of table

with hip and knee flexion,

05% procaine 50(5~10)ml with 7cm needle, needle insert downward

at the tender point until it hit the bone, slightly withdraw and infiltrate.




Gluteal bursitisTechnique

Technique 1

in case highly localized bursitis,

prone, 05% procaine 50ml with 7cm needle,

needle insert horizontally at the tender point

until it reach ilium, 0.5~1cm withdraw, dynamic infiltration.

Technique 2 :

bursitis at the upper or inner edge of trochanter,

prone with affected leg hanging down over the edge of table

with hip and knee flexion,

05% procaine 50ml with 7cm needle, needle insert downward

at the tender point until it hit the bone, slightly withdraw and infiltrate.




ITB : normal transition

flexion extensionPDF created with pdfFactory trial version www.pdffactory.com



Trochanteric bursitis, tendinitis,

ext. rotation int. rotationPDF created with pdfFactory trial version www.pdffactory.com



Trochanteric bursitis, tendinitis,

Symptom

pain on trochanter and spread down to the

lateral aspect knee with walking or running

most painful with upstair

pain with lateral decubitus on affected side


p-external rotation is painful, sometimes limited with soft end-feel.

no pain in r-external rotation with hip and knee extension.

pain with passive abduction, tenderness on greater trochanter.

Technique

0.5% procaine 5~10ml, needle insert at tender point, with bone touch,

slightly withdraw, infiltration, no lasting effect, add triamcinolone 20mg




Ischial bursitis




Ischial tendinitis or bursitis

Symptom pain at gluteal with sitting,

occationally, posterior thigh pain

d/dx. with discogenic pain

Functional examination tenderness on ischial tuberosity

Technique

needle insert at tender point, after sharp pain and bone touch,

infiltration.

20mg triamcinolone or 0.5% procaine 5~10ml with 3cm needle ,

no lasting effect, add triamcinolone 20mg




conclusion

DEFINITE DIAGNOSIS

WELL LOCALIZATION

PROPER DRUG

ACCURATE INJECTION

Thank you !

GOOD EFFECT? NO GOOD EFFECT?




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Tehnica infiltratii