Posted on 21 November 2010. Tags: 20550, CPT code, depo-medrol, ICD-10 code, ICD-9 code, Kenalog, steroid, technique, tendon sheath, trigger finger, trigger thumb, volar flexor tendinitis
By Chris Faubel, MD –
aka “trigger thumb injection”, “trigger digit injection”
Indications
- Trigger Finger
- ICD-9 code:
- 727.03 “trigger finger” (acquired)
- ICD-10 code:
- M65.3 “trigger finger“ nodular tendinous disease
CPT code: 20550 “Injection(s); single tendon sheath, or ligament, aponeurosis”
Materials Needed
- Pen – clicking type
- Gloves – non-sterile
- Alcohol swabs (or povidone-iodine)
- Band-aid
- Tuberculin needle/syringe (27-gauge, o.5″ needle with 1-ml syringe)
- Injectate
- 0.3-0.4-ml of 40mg/ml Depo-Medrol or Kenalog
- 0.3-0.4-ml of 1% lidocaine
Technique / Procedure Steps
- Always start with informed consent from the patient, and then a time-out to verify correct patient and injection site.
- Mark the injection site with the pen tip in order to leave an impression in the skin.
- Clean the skin thoroughly with as many alcohol swabs as needed (usually only 1-2 are needed).
- Patient position: Perform lying supine or seated with the hand supinated.
- With the tuberculin needle/syringe, enter the skin a few millimeters either distally or proximally to the nodule (triggering site) at about a 30-degree angle.
- Aspirate to make sure you’re not in any vessel.
- After negative aspiration, inject the full contents of the syringe, unless lots of resistance is met (means intratendinous needle tip position). Withdraw very slightly, or reposition completely, and try again.
- Withdraw the needle after syringe if fully empty, and apply band-aid.
Tips
- Finding the injection site
- Palpate the volar flexor tendon sheath and tendon in the distal palm, feeling for a nodule.
- Finger/extend the triggering digit to find the triggering site and nodule.
- Numbing the skin
- Find out all about “Taking the Sting Out” (of injections) by going here.
- Since I use a tiny tuberculin needle, most patients have no problem with the injection and don’t need any extra lidocaine skin wheal, although some freezing spray may help.
- After the injection
- Have the patient move their involved digit (flex/extend) while you throw away supplies.
- Then, re-palpate the nodule so they can see the immediate results of the lidocaine.
- Explain to the patient that the lidocaine will wear off in an hour or so, and that they will be back to their normal pain until the steroids start kicking in (anywhere from 1-7 days).
- May also ask the patient to not do much repetitive activity with that digit for 12-24 hours.
Related Content:
Posted in Procedures, Trigger Finger, Upper Extremity
Posted on 06 November 2010. Tags: aspiration, bursa, bursitis, celestone soluspan, corticosteroid, ethyl chloride, injection, olecranon, procedure, steroid, technique
aka “Elbow bursa aspiration/injection”
This patient does NOT have olecranon bursitis. Image shown only as an example of needle placement.
Indications
- Olecranon Bursitis
- ICD-9 code:
- 726.33 “olecranon bursitis”
- ICD-10 code:
- M70.21 “olecranon bursitis, right elbow”
- M70.22 “olecranon bursitis, left elbow”
CPT code: 20610 “Arthrocentesis, aspiration and/or injection; major joint or bursa”
Materials Needed
- Gloves (non-sterile)
- Alcohol swabs (or betadine)
- Band-aid
- Numbing
- Ethyl chloride “numbing” spray
- 27-gauge 0.5″ tuberculin needle with syringe – for the skin wheal (if needed)
- Fill with 1-ml of 1% lidocaine
- Aspiration
- 20 or 18-gauge 1.5 inch needle with 3-ml syringe [for aspirating] — get a larger syringe if aspirating larger volumes
- Injecting
- Same needle as above, with new 3-ml syringe
- 0.5-ml of 6mg/ml Celestone Soluspan
- 0.5–ml of 1% lidocaine
Note: If the patient has a fever, and/or the skin over the bursa is erythematous, warm, and swollen, it is NOT recommended to inject any steroids.
Technique / Procedure Steps
- Always start with informed consent from the patient, and then a time-out to verify correct patient and injection site.
- Patient position: Perform with patient lying supine with the involved elbow flexed and held to chest; though many other positions can be used.
- Mark the injection site with a pen tip to leave an impression mark.
- Clean the skin thoroughly with as many alcohol swabs as needed (usually only 1-2 are needed). Or clean with betadine and allow to dry completely.
- Spray ethyl chloride or other “numbing” spray over the injection site.
- With the tuberculin needle/syringe, enter nearly parallel to the skin over the injection site and create a skin wheal with 0.5ml 0f 1% lidocaine. Then advance the 0.5″ needle in the direction the injection needle with take, and anesthetize the bursa.
- If aspirating, use an 18 or 20-gauge needle and enter perpendicular to skin, into the bursa. Aspirate as much fluid as possible. If only injecting, you can use a 25-gauge needle.
- After aspirating, keep that needle in the bursa, and switch to the corticosteroid/lidocaine syringe. Note: Only a small amount of a more water-soluble corticosteroid is used because of the theoretical risk of causing subcutaneous fat atrophy.
- Inject the full contents of the syringe. Should flow easily.
- Withdraw the needle after syringe if fully empty, and apply band-aid.
Tips
- Finding the injection site
- The bursa should be rather obvious. Enter at the fullest point.
- Numbing the skin
- Find out all about “Taking the Sting Out” (of injections) by going here.
- As noted above, use ethyl chloride (or other freezing spray), as well as a skin wheal to reduce the pain of this injection.
- After the injection
- Have the patient flex and extend their elbow while you throw away supplies.
- Explain to the patient that the lidocaine will wear off in an hour or so, and that they may be back to their normal pain until the steroids start kicking in (anywhere from 1-7 days) — though just aspirating the fluid will help with the pain right away.
- May also ask the patient to not kneel or apply any direct pressure on the patella for 12-24 hours.
Related Content:
Posted in Olecranon Bursa, Procedures, Upper Extremity
Posted on 03 November 2010. Tags: code, corticosteroid, CPT, depo-medrol, DIP, distal interphalangeal joint, ethyl chloride, finger, ICD-10, ICD-9, injection, Kenalog, osteoarthritis, procedure, Rheumatoid arthritis, steroid
By Chris Faubel, MD –
aka. “DIP injection”
Just need to get the needle under the joint capsule.
Indications
- Osteoarthritis (painful) of the distal interphalangeal (DIP) joint
- Rheumatoid arthritis of the distal interphalangeal (DIP) joint
- **see all ICD-9 and ICD-10 codes at end of post
CPT code: 20600 “Arthrocentesis, aspiration and/or injection; small joint or bursa (eg, fingers, toes)”
Continue Reading
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Posted in Distal Interphalangeal, Procedures, Upper Extremity
Posted on 03 November 2010. Tags: depo-medrol, ethyl chloride, injection, Kenalog, osteoarthritis, painful, PIP, procedure, proximal interphalangeal joint, Rheumatoid arthritis, steroid, technique, tuberculin
By Chris Faubel, MD –
Just need to be beneath the joint capsule. Don't try to get into the middle of the joint.
aka. “PIP injection”
Indications
- Osteoarthritis (painful) of the proximal interphalangeal (PIP) joint
- Rheumatoid arthritis of the proximal interphalangeal (PIP) joint
- **see all ICD-9 and ICD-10 codes at end of post
CPT code: 20600 “Arthrocentesis, aspiration and/or injection; small joint or bursa (eg, fingers, toes)”
Continue Reading
Related Content:
Posted in Procedures, Proximal Interphalangeal, Upper Extremity
Posted on 30 October 2010. Tags: 1st CMC, Allen's test, CPT code, first carpometacarpal joint, ICD-10 code, ICD-9 code, injection, procedure, steps, steroid
By Chris Faubel, MD –
Steroid injection of 1st CMC joint. Needle at about a 45-degree angle. Distract the thumb to open the joint space.
Indications
- First carpometacarpal (CMC) joint painful osteoarthritis
- ICD-9 codes:
- 715.14 “osteoarthrosis, localized, primary, hand”
- 719.44 “pain in joint, hand”
- ICD-10 codes:
- M18.0 “primary arthrosis of first carpometacarpal joint, bilateral“
- M18.1 “primary arthrosis of first carpometacarpal joint, unilateral“
- M25.54 “pain in a joint, hand”
CPT code: 20600 “Arthrocentesis, aspiration and/or injection; small joint or bursa (eg, fingers, toes)”
Continue Reading
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Posted in 1st Carpometacarpal Joint, Procedures, Upper Extremity
Posted on 30 October 2010. Tags: abductor pollicis longus, celestone, CPT code, de quervain's, extensor pollicis brevis, Finkelstein's test, ICD-10 code, ICD-9 code, Kenalog, procedure, radial styloid, stenosing tenosynovitis, steps, tendovaginitis
By Chris Faubel, MD –
Put needle between the abductor pollicis longus and extensory pollicis brevis tendon
Indications
- de Quervain’s tenosynovitis
- ICD-9 code: 727.04 “radial styloid tenosynovitis”
- ICD-10 code: M65.4 “radial styloid tenosynovitis [de Quervain]“
CPT code: 20550 “injection(s); single tendon sheath, or ligament, aponeurosis”
Materials Needed
Related Content:
Posted in De Quervain's, Procedures, Upper Extremity
Posted on 30 October 2010. Tags: celestone, code, depo-medrol, golfer's elbow, ICD-10, ICD-9, medial epicondyle, medial epicondylitis, pain, post-injection flare, procedure, skin wheal, steps, steroid, tuberculin
By Chris Faubel, MD –
Point of maximal tenderness just distal to the medial epicondyle
Indications
- Medial Epicondylitis / “Golfer’s Elbow”
- ICD-9 code: 726.31 “medial epicondylitis”
- ICD-10 codes:
- M77.01 “medial epicondylitis, right elbow”
- M77.02 “medial epicondylitis, left elbow”
CPT code: 20551
Materials Needed
Related Content:
Posted in Medial Epicondyle, Procedures, Upper Extremity
Posted on 30 October 2010. Tags: Cozen's test, ICD-10, ICD-9, Lateral epicondyle, lateral epicondylitis, pain, post-injection flare, procedure, steps, steroid, Tennis elbow, tuberculin syringe
By Chris Faubel, MD –
Point of maximal tenderness 1-3cm distal to lateral epicondyle
Indications
- Lateral Epicondylitis / “Tennis Elbow”
- ICD-9 code: 726.32 “lateral epicondylitis”
- ICD-10 codes:
- M77.11 “lateral epicondylitis, right elbow”
- M77.12 “lateral epicondylitis, left elbow”
CPT code: 20551
Materials Needed
Related Content:
Posted in Lateral Epicondyle, Procedures, Upper Extremity
Posted on 30 October 2010. Tags: biceps, biceps tendon injection, bicipital, bicipital tendinitis, injection, procedure, sheath, skin wheal, steps, steroid, tendon, tenosynovitis
Biceps Tendon Sheath Injection
By Chris Faubel, MD –
Indications
- Bicipital tenosynovitis
- ICD-9 code: 726.12 “bicipital tenosynovitis”
- ICD-10 code: M75.2 “bicipital tendinitis”
CPT code: 20550
Materials Needed
Related Content:
Posted in Bicipital Tendon Sheath, Procedures, Upper Extremity
Posted on 29 October 2010. Tags: Allen's test, carpal tunnel injection, carpal tunnel syndrome, procedure, steps, steroid, wrist splints
By Chris Faubel, MD –
Carpal Tunnel Injection
Indications
- Carpal Tunnel Syndrome
- ICD-9 code: 354.0 “carpal tunnel syndrome”
- ICD-10 code: G56.0 “carpal tunnel syndrome”
CPT code: 20526
Materials Needed
Related Content:
Posted in Carpal Tunnel, Procedures, Upper Extremity
