Local glucocorticoid injections in soft tissues and joints

Extract

• The skin is carefully cleaned with spirit-containing cleanser, and good aseptic principles are followed. The site of the injection is determined and marked before cleansing (video Marking the site for puncture1).
• If an ultrasound device is available, it is used, as necessary, to check the existence and location of fluid.
  • A hip joint injection requires ultrasound guidance.
• Soft tissues, the glenohumeral joint, the subacromial bursa and the trochanteric bursa are treated with an injection containing a glucocorticoid and a local anaesthetic in the proportion of 1:1 to 1:2, or a glucocorticoid and 0.9% NaCl in the proportion of 1:1. An observed local effect of the anaesthetic soon after the injection also serves as a diagnostic test in the treatment of disorders in the glenohumeral region and in bursitides.
• Other joints (provided that fluid can be obtained through aspiration) and small joints can be treated with glucocorticoid only or with a combination of glucocorticoid and an anaesthetic.
• Intra-articular injections should be reserved for inflamed joints: swelling or hydrops and pain (see Clinical diagnosis of joint inflammation in the adult1).
• Triamcinolone
  • In the knee joint 20–40 mg
  • In other large joints (elbow, wrist) 20 mg if there is obvious inflammation or if fluid can be aspirated
  • Triamcinolone, when extravasated outside the joint cavity, carries a higher risk of side effects (tendon rupture, skin atrophy, cartilage damage) than methylprednisolone.
• Methylprednisolone 12–80 mg depending on the size of joint/injection area
  • In smaller joints and soft tissues. Because of the risk of skin atrophy (picture 1), intracutaneous or subcutaneous injection should be avoided.
  • In the finger tendon sheaths
• The needle should be as thin (see table Recommended needle size for injections into soft tissues and joins1) and the pressure applied as light as possible (do not inject against a counter pressure) so as not to damage the joint cartilage or tendons.
• Aspiration of the joint before a glucocorticoid is injected enhances the therapeutic effect at least in rheumatoid arthritis.
• In acute arthritis, injection to the same large joint more frequently than once a month during the first 3 months or more than 4 injections per year is not recommended. Smaller joints and soft tissues may be injected more frequently, but not into the skin!.
  • If the need for injections is consistently high, assess the potential for enhancing the effectiveness of the basic rheumatic treatment and, in the case of severely damaged joints, the need for a consultation with a specialist in rheuma-orthopedics.
• In osteoarthritis, the same joint should not be injected more frequently than at 3-month intervals, and injections should only be given if other treatments are insufficient.
• Systemic adverse effects are possible.
  • Repeated injections can cause adrenocortical insufficiency, i.e. adrenal suppression.
  • The control of diabetes can be negatively affected for a few weeks. This effect is smaller with a long-acting preparation (less is transferred into the circulation due to its large crystal structure).
• Glucocorticoid injections, especially when used repeatedly, can impair the structure and metabolism of articular cartilage and predispose to tendon degeneration. Tendon ruptures are relatively rare.
• Partial immobilization of the joint for 24 hours and avoiding vigorous exercise for a week after the injection improves the result of the treatment, at least as far as the large joints are concerned.
  • In weight-bearing joints, the immobilization should be as complete as possible for 24 hours. Without immobilization, the drug is absorbed too quickly from the joint to the blood circulation and its effect is decreased.

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Arthritis, Bursitis, Elbow Joint, Finger Joint, Glucocorticoids, Injections, Injections, Intra-Articular, Internal medicine, Knee Joint, Metacarpophalangeal Joint, Metatarsophalangeal Joint, Methylprednisolone, Physical medicine, Popliteal Cyst, Rheumatology, Shoulder Joint, Steroids, Tarsal Joints, Temporomandibular Joint, Toe Joint, Triamcinolone, Wrist Joint, corticosteroid injections, injection needle, proximal interphalangeal joint, soft tissue injection, steroid-anethetic injection, steroid-injections, subacromial bursitis, tendon sheath, trochanteric bursitis