Você está na página 1de 44

Injection or infiltration

around knee and hip joint

www.painOK.com

PDF created with pdfFactory trial version www.pdffactory.com

Intra-articular injection
Indication
Capsular pattern lesion
Traumatic arthritis
Osteoarthritis
RA
Seronegative arthritis
Gout
PDF created with pdfFactory trial version www.pdffactory.com

Intra-articular injection
1. Lateral approach
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

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.
PDF created with pdfFactory trial version www.pdffactory.com

retinaculum

PDF created with pdfFactory trial version www.pdffactory.com

Intra-articular injection
1. Lateral approach
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,
advance, aspiration then injection

PDF created with pdfFactory trial version www.pdffactory.com

1.5cm~2cm

Intra-articular injection
1. Lateral approach
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,
advance, aspiration then injection

PDF created with pdfFactory trial version www.pdffactory.com

1.5cm~2cm

Intra-articular injection
1. Lateral approach
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,
advance, aspiration then injection

PDF created with pdfFactory trial version www.pdffactory.com

1.5cm~2cm

Intra-articular injection
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.

PDF created with pdfFactory trial version www.pdffactory.com

prepatellar bursitis

PDF created with pdfFactory trial version www.pdffactory.com

prepatellar bursitis
Symptom
swelling or pain on prepatellar area

Functional examination
palpable swelling, limited knee flexion(+/-)
flexion

Technique
supine, compress proximal portion to localize swelling,
needle insert at distal site of swelling,
aspiration, 10~20
20 mg triamcinolone
mg triamcinolone
injection(infiltration
injection(infiltration
)
)

PDF created with pdfFactory trial version www.pdffactory.com

med. coll. ligament sprain

PDF created with pdfFactory trial version www.pdffactory.com

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
PDF created with pdfFactory trial version www.pdffactory.com

lat. coll. ligament sprain

PDF created with pdfFactory trial version www.pdffactory.com

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
PDF created with pdfFactory trial version www.pdffactory.com

Coronary ligament sprain

PDF created with pdfFactory trial version www.pdffactory.com

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
PDF created with pdfFactory trial version www.pdffactory.com

pes anserinus bursitis

PDF created with pdfFactory trial version www.pdffactory.com

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
PDF created with pdfFactory trial version www.pdffactory.com

Bakers cyst

PDF created with pdfFactory trial version www.pdffactory.com

Bakers cyst
Symptom
no symptom, fullness on popliteal area,
rarely tingling sense on lower leg

Functional examination
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(?)
PDF created with pdfFactory trial version www.pdffactory.com

Quadriceps tendinitis

PDF created with pdfFactory trial version www.pdffactory.com

Quadriceps tendinitis

Symptom
* diffuse pain of knee joint or anterior thigh
* painful limitation of knee motion

Functional examination
* 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

PDF created with pdfFactory trial version www.pdffactory.com

Quadriceps tendinitis

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.

PDF created with pdfFactory trial version www.pdffactory.com

infra-patellar tendinitis

PDF created with pdfFactory trial version www.pdffactory.com

infra-patellar tendinitis

Symptom
* diffuse pain on infra-patellar area or upper tibia
d/dx Osgoods-schulatters dz.

Functional examination
* swelling on infra-patellar area(+/-)
* full ROM, tenderness (+) on lower patellar or inf-rapatellar tendon
* R-knee ext. test(+/-)
PDF created with pdfFactory trial version www.pdffactory.com

infra-patellar tendinitis

Technique
* patient posture : supine, knee extension.
* 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.
PDF created with pdfFactory trial version www.pdffactory.com

infrapatellar bursitis w tendinitis

PDF created with pdfFactory trial version www.pdffactory.com

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

PDF created with pdfFactory trial version www.pdffactory.com

infrapatellar bursitis w tendinitis

Technique
* patient posture : supine, knee extension.
* 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.
PDF created with pdfFactory trial version www.pdffactory.com

hip joint effusion : OA

PDF created with pdfFactory trial version www.pdffactory.com

hip joint effusion : OA


Symptom
pain on around hip(gluteal), inguinal area or
medial thigh and knee

Functional examination
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
PDF created with pdfFactory trial version www.pdffactory.com

Iliopsoas bursitis

PDF created with pdfFactory trial version www.pdffactory.com

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.
PDF created with pdfFactory trial version www.pdffactory.com

Iliopsoas bursitis
Technique
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
PDF created with pdfFactory trial version www.pdffactory.com

Gluteal bursitis

PDF created with pdfFactory trial version www.pdffactory.com

Gluteal bursitis
Symptom
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

Functional examination
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.
PDF created with pdfFactory trial version www.pdffactory.com

Gluteal bursitis
Technique
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.
PDF created with pdfFactory trial version www.pdffactory.com

Gluteal bursitis
Technique
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.
PDF created with pdfFactory trial version www.pdffactory.com

ITB : normal transition

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

extension

Trochanteric bursitis, tendinitis,

ext. rotation
PDF created with pdfFactory trial version www.pdffactory.com

int. rotation

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

Functional examination
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
PDF created with pdfFactory trial version www.pdffactory.com

Ischial bursitis

PDF created with pdfFactory trial version www.pdffactory.com

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
PDF created with pdfFactory trial version www.pdffactory.com

conclusion
DEFINITE
WELL

LOCALIZATION

PROPER
ACCURATE
GOOD

EFFECT?

DIAGNOSIS

DRUG
INJECTION
NO GOOD

Thank you !
PDF created with pdfFactory trial version www.pdffactory.com

EFFECT?

Você também pode gostar