FIGURE 6.12 Right AC joint. (From Tank PW, Gest TR. Lippincott Williams & Wilkins Atlas of Anatomy. Philadelphia, PA: Lippincott Williams & Wilkins, 2009.)

PATIENT POSITION

Sitting or lying supine on the examination table.
The patient’s hands are folded in his or her lap with fingers interlaced.
This allows consistency of positioning of the shoulder so that the landmarks do not change from the time that they are identified and marked until the time of injection.
Rotate the patient’s head away from the side that is being injected. This minimizes anxiety and pain perception.

LANDMARKS

1. With the patient seated or lying supine on the examination table, the clinician stands lateral and anterior to the affected shoulder.

2. Identify the AC joint. Palpate the clavicle in a medial-to-lateral direction. At the lateral aspect of the clavicle, there is a small depression that will be tender in the above conditions.

3. The injection point is located directly over the AC joint. At that site, press firmly with the retracted tip of a ballpoint pen. This indention represents the entry point for the needle.

4. Once the landmarks are identified, the patient should not move the chest or shoulder.

ANESTHESIA

Local anesthesia of the skin using topical vapocoolant spray.

EQUIPMENT

3-mL syringe
25-gauge, 5/8-in. needle
0.5 mL of 1% lidocaine without epinephrine
0.5 mL of the steroid solution (20 mg of triamcinolone acetonide)
One alcohol prep pad
Two povidone–iodine prep pads
Sterile gauze pads
Sterile adhesive bandage

TECHNIQUE

1. Prep the insertion site with alcohol followed by the povidone–iodine pads.

2. Achieve good local anesthesia by using topical vapocoolant spray.

3. Position the needle and syringe perpendicular to the skin with the needle tip directed caudad.

4. Using the no-touch technique, introduce the needle at the insertion site (Fig. 6.13).

5. Advance the needle into the AC joint. If the needle does not “drop” into the AC joint, then “walk” the needle in the area until it does so.

6. Inject the steroid solution as a bolus into the AC joint. The injected solution should flow smoothly into the space. If increased resistance is encountered, advance or withdraw the needle slightly before attempting further injection. If the needle will not drop into the joint, then perform a periarticular injection.

7. Following injection of the corticosteroid solution, withdraw the needle.

8. Apply a sterile adhesive bandage.

9. Instruct the patient to move his or her shoulder through its full range of motion. This movement distributes the steroid solution throughout the AC joint.

10. Reexamine the shoulder in 5 min to confirm pain relief.