Upper Limb Injections

Published on 18/03/2015 by admin

Filed under Rheumatology

Last modified 18/03/2015

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Section 3 Upper Limb Injections

Examination of the upper limb 98

Glenohumeral joint 106

Acute or chronic capsulitis – ‘frozen shoulder’ 106

Acromioclavicular joint 108

Acute or chronic capsulitis 108

Sternoclavicular joint 110

Acute or chronic capsulitis 110

Subacromial bursa 112

Chronic bursitis 112

Subscabularis bursa and tendon 114

Acute or chronic tendinopathy or bursitis 114

Biceps – long head 116

Chronic tendinopathy 116

Infraspinatus tendon 118

Chronic tendinopathy 118

Supraspinatus tendon 120

Chronic tendinopathy 120

Suprascapular nerve 122

In acute or chronic capsulitis of the glenohumeral joint 122

Elbow joint 124

Acute or chronic capsulitis 124

Biceps bursa and tendon insertion 126

Chronic tendinopathy or bursitis 126

Olecranon bursa 128

Acute or chronic bursitis 128

Common extensor tendon 130

Chronic tendinopathy – ‘tennis elbow’ 130

Common flexor tendon 132

Chronic tendinitis – ‘golfer’s elbow’ 132

Inferior radioulnar joint and triangular meniscus 134

Chronic capsulitis or acute tear of the meniscus 134

Wrist joint 136

Acute capsulitis 136

Thumb and finger joints 138

Acute or chronic capsulitis 138

Flexor tendon nodule 140

Trigger finger or trigger thumb 140

Thumb tendons 142

de Quervain’s tenosynovitis 142

Carpal tunnel 144

Median nerve compression under flexor retinaculum 144

Temporomandibular joint 146

Acute or chronic capsulitis 146

Summary of suggested upper limb dosages 148

Examination of the upper limb

The capsular pattern is a set pattern of loss of motion for each joint. It indicates that there is some degree of joint capsulitis caused by degeneration, inflammation or trauma. There may be a hard end feel in advanced capsulitis

Shoulder tests
Active flexion above head	Resisted abduction
Passive flexion with overpressure	Resisted lateral rotation
Active abduction to ear for painful arc	Resisted medial rotation
Passive lateral rotation	Resisted elbow flexion
Passive abduction	Resisted elbow extension
Passive medial rotation	Resisted adduction
Impingement/lag/stability/proprioception tests
Shoulder capsular pattern: most loss of lateral rotation, less of abduction, least of medial rotation
Elbow tests
Passive flexion	Resisted flexion
Passive extension	Resisted extension
Passive pronation	Resisted pronation
Passive supination	Resisted supination
	Resisted wrist flexion
	Resisted wrist extension
Elbow capsular pattern: more loss of flexion than extension
Wrist tests
Passive pronation	Resisted extension
Passive supination	Resisted flexion
Passive extension	Resisted radial deviation
Passive flexion	Resisted ulnar deviation
Passive radial deviation
Passive ulnar deviation
Wrist capsular pattern: equal loss of flexion and extension
Finger tests
Passive thumb extension	Passive finger extension
Resisted thumb abduction	Passive finger flexion
Resisted thumb adduction	Resisted finger abduction
Resisted thumb extension	Resisted finger adduction
Resisted thumb flexion
Finger capsular patterns: Loss of:
Thumb: extension & abduction
Metacarpophalangeal joints: extension and radial deviation
Interphalangeal joints: flexion
Distal phalangeal joints: extension

Shoulder Examination

1 Active flexion above head

2 Passive flexion with overpressure

3 Active abduction to ear for painful arc

4 Passive lateral rotation

5 Passive abduction

All photographs © Stephanie Saunders 2012.

6 Passive medial rotation

7 Resisted abduction

8 Resisted lateral rotation

9 Resisted medial rotation

10 Resisted elbow flexion

11 Resisted elbow extension

All photographs © Stephanie Saunders 2012.

12 Resisted adduction

Elbow Examination

1 Passive flexion

2 Passive extension

3 Passive pronation

4 Passive supination

5 Resisted flexion

All photographs © Stephanie Saunders 2012.

6 Resisted extension

7 Resisted pronation

8 Resisted supination

9 Resisted wrist flexion

All photographs © Stephanie Saunders 2012.

10 Resisted wrist extension

Wrist and Hand Examination

1 Passive pronation

2 Passive supination

3 Passive extension

4 Passive flexion

5 Passive ulnar deviation

All photographs © Stephanie Saunders 2012.

6 Passive radial deviation

7 Resisted extension

8 Resisted flexion

9 Resisted radial deviation

10 Resisted ulnar deviation

11 Passive thumb extension

All photographs © Stephanie Saunders 2012.

12 Resisted thumb abduction

13 Resisted thumb adduction

14 Resisted thumb extension

15 Resisted thumb flexion

16 Resisted finger abduction

All photographs © Stephanie Saunders 2012.

17 Resisted finger adduction

Glenohumeral joint

Acute or chronic capsulitis – ‘frozen shoulder’

Causes and findings

• Trauma, osteoarthritis or rheumatoid arthritis, idiopathic or secondary to neurological disease, diabetes, stroke, etc

• Pain in deltoid area, possibly radiating down to hand in severe cases, aggravated by arm movements and lying on shoulder

• Painful and limited: capsular pattern – most loss of lateral rotation with hard endfeel

Equipment

Anatomy

The shoulder joint is surrounded by a large capsule and the easiest and least painful approach is posteriorly, where there are no major blood vessels or nerves. An imaginary oblique line running anteriorly from the posterior angle of the acromion to the coracoid process passes through the shoulder joint. The needle follows this line, passing through deltoid, infraspinatus and posterior capsule. The end point should be the sticky feel of cartilage on the head of the humerus or the glenoid.

Technique

• Patient sits with arms folded, thus opening up the posterior joint space

• Identify posterior angle of acromion with thumb, and coracoid process with index finger

• Insert needle directly below angle and pass anteriorly obliquely towards coracoid process until needle gently touches intra-articular cartilage

• Inject solution as a bolus

Comments

The less the radiation of pain and the earlier the joint is treated, the more dramatic is the relief of symptoms. If there is resistance to the injection, the needle has probably been inserted too laterally and must be repositioned more medially. Occasionally there is slight resistance when the needle passes through the capsule. Usually one injection suffices in the early stages of the condition, but if necessary more can safely be given at increasing intervals of a week, 10 days, 2 weeks, etc.; it is sometimes necessary in advanced capsulitis to give four to six injections over about 2 months. Advise the patient that a repeat dose might be needed if the symptoms are severe and gradually return as the effect of the drug wears off.

Alternative approaches

Rarely the posterior approach is not effective, so an anterior approach is used. In this case, the arm is held in slight lateral rotation and the needle inserted on the anterior surface between the coracoid process and the lesser tuberosity of the humerus, and aimed posteromedially towards the spine of the scapula. The same dose and volume is used. The disadvantages to this approach are that the patient can see the needle advancing, the flexor skin surfaces are more sensitive and there are more neurovascular structures lying on the anterior aspect of the shoulder.

Adcortyl (10 mg/ml) can be used for this injection, especially in large shoulders where more volume is required; the dose would then be 4 ml of Adcortyl with 4 ml of 1% local anaesthetic. Smaller patients may require only 30 mg of corticosteroid.

Aftercare

Patient maintains mobility with pendular and stretching exercises within the pain-free range, progressing to stronger stretching when pain is reduced. Strong passive stretching of the capsule can be given when the pain has abated. A strengthening and stabilizing programme is often required, together with postural correction.

Acromioclavicular joint

Acute or chronic capsulitis

Causes and findings

• Trauma or occasionally prolonged overuse in a degenerative shoulder

• Pain at point of shoulder: a bump of bone or swelling may be seen

• Painful: all full passive movements, especially full passive horizontal adduction

occasionally painful arc on active elevation

Equipment

Anatomy

The acromioclavicular joint line runs in the sagittal plane about a thumb’s width medial to the lateral edge of the acromion. The joint plane runs obliquely medially from superior to inferior and usually contains a small meniscus. Often a small step can be palpated where the acromion abuts against the clavicle, or a small V-shaped gap felt at the anterior joint margin. Passively gliding the acromion downwards on the clavicle may help in finding the joint line.

Technique

• Patient sits supported with arm hanging by side to slightly separate the joint surfaces

• Identify lateral edge of acromion. Move medially about a thumb’s width and mark mid-point of joint line

• Insert needle angling medially about 30° from the vertical and pass through capsule

• Inject solution as a bolus

Comments

Occasionally the joint is difficult to enter; it is normally a narrow space and degenerative changes make it more so. Traction on the arm can open up the joint space and peppering of the capsule with the solution will anaesthetize it while feeling for the joint space with the needle. This will avoid giving unnecessary pain.

Alternative approach

The joint can also be injected anteriorly and horizontally at the V-shaped gap if the superior approach is difficult. The unstable or repeatedly subluxing joint can be helped by sclerosing injections or possibly surgery.

Aftercare

The patient should rest the shoulder for a week then begin gentle mobilizing exercises. Acutely inflamed joints are helped by the application of ice, taping across the joint to stabilize it and by oral pain killers.

Sternoclavicular joint

Acute or chronic capsulitis

Causes and findings

• Trauma, overuse in the degenerate shoulder or occasionally rheumatoid arthritis

• Pain over sternoclavicular joint

• Painful: retraction and protraction of the shoulder

full elevation of the arm

clicking or subluxation after trauma

Equipment

Anatomy

The sternoclavicular joint contains a small meniscus that can sometimes be damaged and then give painful symptoms. The joint line runs obliquely laterally from superior to inferior and can be identified by palpating the joint medial to the end of the clavicle while the patient protracts and retracts the shoulder.

Technique

• Patient sits supported with arm in slight lateral rotation

• Identify mid-point of joint line

• Insert needle perpendicularly through joint capsule

• Inject solution as a bolus

Comments

Although not a common lesion, this usually responds well to one infiltration.

Aftercare

Rest for a week followed by mobilization and a progressive postural and exercise regimen. Taping the joint helps stabilize it in the acute stage after trauma.

Related

Injection Techniques in Musculoskeletal Medicine A Practical Man