CLINICAL RISK REDUCTION


JOINT AND SOFT TISSUE


Injections J


Lucy Douglas highlights new guidelines from the Primary Care Rheumatology Society


OINT and soſt tissue injections are commonly used to help ease the discomfort and loss of function associated with musculoskeletal disorders. T ey are a safe and eff ective treatment option for many patients and generally perceived


to be a low-risk intervention. However, complaints and claims against doctors performing such injections are not infrequent. T ere is little fi rm evidence on which to base best practice in


this area and as a result there is variability regarding exactly how and when such injections are used in clinical practice. But there are certain considerations which can enhance patient safety and help clinicians avoid some of the medico-legal pitfalls. T e following article is based on guidelines for joint and soſt tissue injections which have recently been developed by the Primary Care Rheumatology Society.


Before treatment As with all medical procedures, any clinician undertaking joint and soſt tissue injections must be adequately trained and have up- to-date clinical skills. Ensure all medication or other equipment is appropriate for the intended use and in date. For example, some steroid preparations vary in clinical indication yet the packaging and constituents can be similar. Ensure enough time is available to explain the procedure.


Consent for joint injection requires the same rigorous attention to detail as other interventional medical treatments. T e patient must be informed about the nature of the injection, relevant risks and benefi ts and alternative treatment options. A patient information leafl et can aid patient understanding and decision- making and also helps ensure that no important contraindications or adverse eff ects are overlooked. A suggested leafl et is available on the PCRS website. Clear documentation must be made of the above discussion


and that the patient has consented to the treatment. Signed consent is not required in the UK but may be used in addition to the above documentation. Further information regarding consent can be found on relevant MDDUS and GMC web pages. Contraindications to joint and soſt tissue injections include:


• allergy to local anaesthetic, steroid, skin cleanser or dressing • local or systemic infection • active rash/broken skin at site of injection • uncontrolled coagulopathy • fracture/unstable joint • tendon regions at risk of rupture


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• injection into a prosthetic joint or surgical metal work in situ


• imminent surgery at the site of or close to the proposed injection.


Anticoagulant therapy is not a contraindication to joint


injection but precautions apply. You should discuss the risks of continuing or stopping anticoagulation with the patient and ensure a management plan is in place should a bleeding complication occur. Several studies suggest that joint and soſt tissue injections can


be safely carried out provided the INR is within the therapeutic range. T is should therefore be checked prior to the procedure. For patients taking novel oral anticoagulants, given the shorter half-life, consideration should be given to avoiding interventional procedures during peak drug activity – for example for rivaroxaban this peak would be 2-4 hours aſt er the last dose.


Procedure and associated risks When positioning the patient, be prepared for the possibility they may faint during or aſt er the injection. Ensure that they will not get injured should this occur. When marking the skin, avoid using an ink marker directly at the site where the needle is to be inserted or a permanent tattoo may result. Potential risks associated with joint and soſt tissue injections include: • infection • soft tissue atrophy and local depigmentation • tendon rupture • nerve damage • menstrual disturbances • disturbance in glycaemic control in diabetics • allergic reaction.


Infection Infection is considered a rare complication of joint and soſt tissue injection, however the consequences can be catastrophic. T e patient should be warned in advance about the serious consequences of infection, what symptoms may occur and how to seek immediate medical attention if required. Dust covers on vials of medication are not necessarily adequate


to ensure sterility of the outside of the vial top. T erefore swabbing the vial with a sterile alcohol swab is recommended for some medications.


SUMMONS


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