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Tips For Performing Joint Injections

procedures rehabilitation

The general procedure and anatomic approaches to joint injections are nearly identical to joint taps. Below is a cheat sheet for joint injections but this can easily be adapted for arthrocentesis as well. Arthrocentesis should also be considered prior to joint injections to help confirm needle placement, decrease soreness from capsule over-filling, and provide a diagnostic sample if needed.


Indications:
  • Treatment of osteoarthritis
  • Treatment of naturally occurring or surgically induced acute synovitis
  • Treatment of intra-articular ligamentous or tendon injury 

Contraindications:
  • Pyoderma
  • Bleeding disorders
  • Contraindications for sedation

Risks:
  • Transient soreness – usually 24-72 hours after injection
  • Iatrogenic cartilage damage
  • Infection – less than 0.1% 

Restraint:
  • Appropriate sedation helps reduce risk of iatrogenic cartilage damage
  • Use sedation protocol that provides analgesia and minimizes patient motion
    • My preference (if no contraindications): Dexdomitor 5 mcg/kg + Butorphanol 0.3 mg/kg 

Site Preparation:
  • Standard aseptic preparation
    • Clip wide area 

Equipment:
  • Sedation and monitoring supplies
  • Site preparation
    • Hair clippers
    • Sterile scrub solution and alcohol
    • Sterile gauze
  • Sterile gloves
  • Needles
    • Small dogs/cats: 25–22 g needles, 1′′ length
    • Medium to large dogs: 22–20 g needles, 1–1.5′′ length depending on site
    • Giantā€breed dogs: May require spinal needle depending on site; 2.5′′ length
  • Syringes
    • 1 syringe for initial aspiration to ensure intra-articular needle placement and collect synovial fluid for evaluation if needed
      • Small dogs/cats: 1-3 ml
      • Medium to giant breed dogs: 3-6 ml
  • Joint injection supplies
    • Syringe with joint injectate
  • Arthrocentesis supplies (if concern for infection)
    • Glass slides
    • EDTA tubes

Procedure:
  1. Sedation
  2. Clip and aseptically prep
  3. Identify anatomic landmarks
  4. Place needle as described below
  5. Perform arthrocentesis to ensure needle placement and collect sample
  6. Inject selected injectate (PRP, stem cell, corticosteroid, hydrogel, etc.)
  7. Recommend rest and pain medications as needed for transient soreness

Approaches:

Carpus

  • Radiocarpal joint
  • Patient positioning: Lateral recumbency, target joint up
  • Needle placement:
    • Cranial approach
    • Carpus slightly flexed
    • Needle perpendicular to skin
    • Just below palpable distal radius
    • Aim palmar, parallel to joint surface of radius
  • Avoid: Cephalic and accessory cephalic vein

Elbow

  • 2 different approaches – medial and lateral
  • Medial
    • Patient positioning: Lateral recumbency, target joint/limb down
    • Needle placement:
      • Distal and caudal to medial epicondyle
        • ~1cm in average sized labrador
      • Perpendicular to skin
    • Avoid: Ulnar nerve
  • Lateral
    • Patient positioning: Lateral recumbency, target joint/limb up
    • Needle placement
      • Between lateral epicondyle and olecranon
      • Aim distomedial, parallel to axis of ulna

Shoulder

  • 2 different approaches: cranial and lateral
  • Patient positioning: Lateral recumbency, target joint up
  • Cranial
    • Needle placement:
      • Just lateral to greater tubercle
  • Lateral
    • Needle placement:
      • Just distal and slightly caudal to acromion process 

Tarsus

  • 2 different approaches: cranial and caudal
  • Patient positioning: Lateral recumbency, target joint up
  • Cranial
    • Flex to open joint
    • Needle placement:
      • Just medial and cranial to the lateral malleolus
  • Caudal
    • Hyperextend to open joint
    • Needle placement:
      • Caudal to the lateral malleolus and distal tibia 

Stifle

  • 2 options for patient positioning
    • Lateral recumbency with target joint up
    • Dorsal recumbency with target joint facing clinician
  • Needle placement:
    • Flex stifle slightly
    • Medial or lateral to patellar tendon
    • Aim caudodistal
    • If dog has a steep tibial plateau angle (TPA) enter more proximally

Hip

  • Patient positioning: Lateral recumbency with target joint up
  • Needle placement:
    • Just proximal and cranial to greater trochanter
    • Needle perpendicular to skin 

References:

#practicepearls


 

About the Guide: Arielle Pechette Markley, DVM, cVMA, CVPP, CCRT, DAIPM
 

Dr. Arielle Pechette Markley is an Assistant Professor of Sports Medicine and Rehabilitation at The Ohio State University Veterinary Medical Center. She graduated from Colorado State University College of Veterinary Medicine, during which time she also became certified in veterinary acupuncture.  After graduation she worked in emergency medicine and general practice where she developed a passion for pain management and rehabilitation. Dr. Pechette Markley went on to complete her Certified Veterinary Pain Practitioner certification through IVAPM and her Certified Canine Rehabilitation Therapist certification through the Canine Rehabilitation Institute. She then started a sports medicine and rehabilitation practice in Indianapolis, Indiana. In 2018 Dr. Pechette Markley began working at The Ohio State University Veterinary Medical Center and helped to start their Sports Medicine and Rehabilitation program. In 2022 she completed a residency in canine sports medicine and rehabilitation through ACVSMR. She has completed research in the field of canine agility injuries and has received grant funding for research on agility biomechanics.  

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