UCSD Musculoskeletal Radiology

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Procedures

Intraarticular steroid injections

Intraarticular steroid injection is a commonly used treatment for the temporary relief of joint pain. Steroids decrease the inflammatory reaction that is associated with osteoarthritis, and rheumatoid arthritis, and can relieve pain for many months. Different preparations of steroids have different duration of action, depending on their solubility/crystal structure. The insoluble preparations have a longer duration of action, and are therefore preferable. Aristospan (Triamcinolone HEXACETONIDE) is the most insoluble and the preferred preparation for intraarticular injection. This may have a duration of action of 6 months. When not available, Aristocort (Triamcinolone ACETONIDE) is the next best. Duration of action of 3 months. Depo-medrol (Methylprednisolone acetate) is the most soluble and least beneficial and should only be used as a last resort when the former are not available (I WOULD NOT RECOMMEND USING THIS. IF THE OTHERS PREPS ARE NOT AVAILABLE, I WOULD DEFER THE PROCEDURE UNTIL THE PROPER DRUG IS AVAILABLE - Gary Firestein, Chief of Rheumatology). Duration of action of 5 weeks. Dosage depends on the joint and the preparation and is laid out in the table below. The duration of efficacy is only a rough guide.

Putting the steroid into the joint is only part of the procedure. It is also useful to confirm if the pain is relieved by the injection. The most accurate way of doing this is to inject local anesthetic at the same time. The patient is then asked to keep a diary of their pain, which will guide the referring physician as to the appropriateness of the injected joint as the source of pain. If the patient has much pain immediately before the injection, then a short acting local anesthetic such as lidocaine 1% should be sufficient for them to note if the pain has gone. If the pain only occurs a few times a day then a long acting local anesthetic such as bupivicaine 0.25% or marcaine 0.5% will also be required to assess for relief of pain. It is advisable to inform the patients that the steroid will not start to work for 2-3 days, and they should expect the pain to recur after the local wears off.

The third part of the test is to inject iodinated contrast to observe the immediate distribution of the steroid and local anesthetic. The purpose of this is to know which joints are being treated. For instance if a surgeon is contemplating fusing the ankle for intractable pain, he/she may be relying on the effectiveness of the injection to tell him/her which joint is producing the pain. Just because you inject the ankle it does not mean this is the only joint anaesthetized. The anesthetic/steroid may pass through normal or abnormal communications to other joints, bursa or tendon sheaths and this all needs to be documented.

The main purpose of the procedure is to get the allotted dose of steroid into the joint. I would not therefore mix the steroid with the contrast and local anesthetic in case the joint becomes full and only a fraction of the injection has been made. Rather, having confirmed you are in the joint with a small amount of contrast (240 or 300mg/ml), I would next inject all the steroid, and then follow this with more local and contrast until the joint either feels full or the patient complains of the dull ache that accompanies a full joint. Five mls of local anesthetic is sufficient for any joint, and if the joint does not hold 5 mls then just fill the joint and record the quantity.

Lastly, I have found that instructing the patients to keep a simple daily diary of their pain for at least the week after the injection or until they see their referring physician next to be a useful adjunct. A simple daily recording of pain vs. previously expected pain, for the same physical workload is useful.


( WE OFTEN USE HIGHER DOSES OF ARISTOSPAN....20-40 MG IN KNEE OR HIP, 10-20 MG IN ANKLE, ELBOW, 10 MG WRIST.Gary Firestein)

This has been discussed with Don Resnick and Gary Firestein.

Tudor H Hughes MD

 


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Joint Approach Technique Aristospan Aristocort Depo-medrol
Hip Anterolateral Fluoro 20mg 40mg 80mg
Knee Subpatella Fluoro 20mg 40mg 80mg
Ankle Anterior Fluoro 10mg 20mg 40mg
Post Subtalar Lateral Fluoro 5mg 10mg 20mg
SIJ Posterior Fluoro/CT 10mg 20mg 40mg
Shoulder Anterior Fluoro 20mg 40mg 80mg
Elbow Lateral Fluoro 10mg 20mg 40mg
Wrist Post Fluoro 5mg 10mg 20mg
Sub deltoid bursa Anterior US 10mg 20mg 40mg
Tendon sheaths US 5mg 10mg 20mg
http://www.ashp.org/shortage/celestone.html
 
Intra-articular injections for disorders such as rheumatoid arthritis and bursitis Very large joint (hip) = 12 mL
Large joint (knee) = 1 mL
Medium joint (elbow)= 0.51 mL
Small joint (hand) = 0.250.5 mL
Bursae = 0.251 mL
Dexamethasone sodium phosphate
Large joint = 24 mg
Small joint = 0.81 mg
Bursae = 23 mg

Methylprednisolone acetate (e.g., Depo-Medrol [Pharmacia])*
Large joints = 2080 mg
Medium joints = 1040 mg
Small joints = 410 mg

 

 

http://bnf.vhn.net/bnf/documents/bnf.1962.html
 
Kenalog Intra-articular/Intramuscular (Squibb) This symbol has been placed against those preparations that are available only on medical or dental prescription.
Injection (aqueous suspension), triamcinolone acetonide 40 mg/mL. Net price 1-mL vial = 1.70


 

Dose: by intra-articular or intrasynovial injection (for details consult product literature), 540 mg according to size; total max. 80 mg (for doses below 5 mg use Adcortyl Intra-articular/Intradermal); where appropriate may be repeated when relapse occurs; CHILD under 6 years not recommended