This article, part of a series in ...

This article, part of a series in succession diagnostic and therapeutic injections, reviews the hip and knee regions. The rationale, indications, contraindications, and general approach to this technique are discussed in the first article of the series. (1) The hip and knee are sites of multiple injuries and inflammatory conditions (2) that bestow themselves to diagnostic and therapeutic injection. (3-8) Intra-articular injection of the hip is rarely performed by dint of family physicians because this operation is commonly performed with fluoroscopic guidance. This article focuses forward the anatomy, pathology, diagnosis, and injection technique of the general sites for which this skill is applicable, including the greater trochanteric bursa, knee joint, pe anserine bursa, iliotibial band, and the prepatellar bursa.

Greater Trochanteric Bursa

ANATOMY

The trochanteric bursa is located athwart the lateral prominence of the greater trochanter of the femur

INDICATIONS

Trochanteric bursitis, the primary indication for therapeutic injection at this site, usually is associated with chronic urgency or trauma to the area. Leg-length abnormalities, obesity, rheumatoid arthritis, and osteoarthritis are associated factors in many patients. (9) Friction from a tight iliotibial band, typically seen in racers also can cause this puzzle Diagnosis is confirmed by palpation of tendernes and sometimes swelling, in the region of the bursa.

TIMING AND OTHER CONSIDERATIONS

Early corticosteroid injection as a common thing [i]or[/i] matter is the preferred treatment, because it has been shown to be effective with satisfactory duration of tenor (10)

TECHNIQUE

papal court Table 1 for a list of pharmaceuticals and equipment.

Position of Patient. The patient should be in the lateral recumbent position with the affected side up For the patient's comfort and stabilization, the hip is flex 30 to 50 extents and the knee is flex 60 to 90 degrees

Palpation of Landmarks. The greater trochanter is identified by way of palpating the femur from the mid-shaft proximally until the area of bony protrusion is reached. The injection site is the point of maximal tendernes or swelling.

Approach and Needle inlet At the area most effeminate or swollen to palpation in the region of the greater trochanter, a 22- or 25-gauge, single and one-half-inch needle is inserted perpendicular to the skin (Figure 1) In highly obese patients, a longer needle may be required. The needle should be inserted directly down to bone and then withdrawn sum of two units to three millimeters before injecting.

Knee Joint

ANATOMY

sum of two units functional joints, the femoral-tibial and the femoral-patellar, make up the knee Primary stabilizers of the knee are the anterior and posterior cruciate ligaments, the medial and lateral collateral ligaments, and the capsular ligaments.

INDICATIONS

Indications for aspiration include unexplained effusion, possible septic arthritis, and relief of discomfort caused at an effusion. (11) Indications for injection include corticosteroid delivery for advanced osteoarthritis and other noninfectious inflammatory arthritides as it was as gout or calcium pyrophosphate deposition disease, or the delivery of viscosupplementation therapy. (12-14) Viscosupplementation preparations like as hylan G-F 20 (Synvisc) arrive with prefilled syringes and are used to treat the pain of knee joint osteoarthritis. Viscosupplementation and corticosteroid therapies are not used concomitantly.

TIMING AND OTHER CONSIDERATIONS

The use of intra-articular corticosteroids is reserv for patients with more advanced disease and after other modalities have been tried. Aspiration for suspected septic arthritis must be performed immediately.

TECHNIQUE

diocese Table 1 for a list of pharmaceuticals and equipment.

Position of Patient. The patient is in the supine position with the knee slightly flex with a pillow or turn abouted towel in the popliteal space.

Palpation of Landmarks. Identify the medial, lateral, and superior borders of the patella.

Approach and Needle minute There are many different techniques for aspirating or injecting the knee These include medial, lateral, and anterior approaches. Each has its possess merit, but choice of approach is sustained by on physician preference. The lateral approach is principally commonly used and is illustrated here (Figure 2) For this approach, lines are drawn along the lateral and proximal borders of the patella. The needle is inserted into the fine tissue between the patella and thigh-bone near the intersection point of the lines, and directed at a 45-degree angle toward the middle of the medial side of the joint. Before injection or aspiration, local anesthesia with lidocaine (Xylocaine) should be obtained. Always use sterile technique. Intra-articular injection sweep along should be even and without resistance.

For the medial approach, the needle penetrates the medial side of the knee in subordination to the middle of the patella (midpole) and is directed toward the opposite patellar midpole. In the anterior approach, the knee is flex 60 to 90 grades and the needle is inserted just medial or lateral to the patellar tendon and parallel to the tibial plateau. This technique is preferr on some physicians for its ease of joint avenue in advanced osteoarthritis. However, the anterior approach may incur greater risk for meniscal injury at the needle.