Skin preparation is generally recommended prior to surgical
procedures to reduce the numbers of skin bacteria – although there appears to be little published information on infection rates when no skin cleaning has been carried out prior to joint injection. T ere have been rare recorded incidents of infection resulting from contaminated topical antiseptics. All skin cleansers should be used strictly in accordance with the manufacturer’s instructions. Consideration should be given to single-use skin preparations labelled as sterile. Once the skin has been prepared, use a ‘no touch’ technique when injecting unless full sterility is observed.
Soft tissue atrophy Soſt tissue atrophy and local depigmentation are uncommon complications of steroid injection. Although these are predominantly cosmetic eff ects, at some sites such as the heel pad, atrophy can be clinically signifi cant and may persist for years. Atrophy may be due to the persistence of steroid crystals in the tissues and seems less likely to occur with more soluble preparations, e.g. hydrocortisone and methylprednisolone. T ese are therefore preferred for soſt -tissue, small-joint and superfi cial injections. Should concerning soſt -tissue atrophy occur, referring the patient for a course of local injections of saline may be helpful.
Tendon rupture T e risk of tendon rupture attributed to steroid injection, for example at the shoulder, is somewhat controversial. However, it has been demonstrated in animal studies that intra-tendinous injections of steroid can result in collagen necrosis and weakening of the tendon, potentially lasting for several weeks. T erefore if injecting in peri-tendinous regions where there is a risk of suboptimal needle placement, avoid injecting if resistance is encountered and consider the use of image guidance if available. Generally avoid injecting regions where concern regarding the risk of tendon rupture is high, for example at the Achilles tendon.
Nerve damage Ensure you are familiar with the anatomy of the injection site to avoid inadvertently injecting a nearby nerve. In neuropathies (e.g. carpal tunnel syndrome) the aff ected nerve may be swollen and therefore anatomical landmarks may be less reliable. Before injecting, ask the patient to report symptoms of nerve activation when the needle is inserted. Withdraw and reposition the needle
AUTUMN 2014
if this occurs. Avoid local anaesthetic at such sites if this may prevent the patient reporting symptoms of nerve irritation. Consider image-guided injections.
Menstrual disturbances Eff ects on the hypothalamic-pituitary axis are thought to be responsible for the menstrual irregularities or vaginal bleeding seen in some women aſt er steroid injections. It is important to warn of this eff ect, which may persist for several weeks, to avoid unnecessary alarm or investigations. Facial fl ushing may also occur follow a steroid injection. T is is
not an allergic reaction and does not preclude future injections. T is side-eff ect generally aff ects women and can be dramatic and distressing, particularly if not forewarned.
Glycaemic control Small increases in glycaemia lasting a few days may be seen aſt er steroid injections in diabetic patients. T e increase is generally not clinically signifi cant but again it is sensible to warn patients.
Allergic reactions Although allergic reactions are rare, full resuscitation equipment must be readily accessible and staff available and trained to use it in all locations where injections are performed. According to the Resuscitation Council UK website, cardiopulmonary arrest resulting from injected medication predominantly occurs up to 20 minutes post injection. It would seem sensible therefore for patients to remain on site for this time.
PCRS guidelines
Comprehensive guidelines on joint and soft tissue injections can be found in the Resources section of the Primary Care Rheumatology Society website: www.
pcrsociety.org
n Dr Lucy Douglas is a GP with special interest (GPwSI) in musculoskeletal medicine and rheumatology
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