FIGURE 8.38 Right anterior ankle. (Adapted from Tank PW, Gest TR. Lippincott Williams & Wilkins Atlas of Anatomy. Philadelphia, PA: Lippincott Williams & Wilkins, 2009.)
PATIENT POSITION
- Supine on the examination table.
- The knee on the affected side is placed in 90 degrees of flexion.
- The ankle is slightly plantar flexed so that the plantar surface is in full contact with the chucks pad covering the exam table.
- Rotate the patient’s head away from the side that is being injected. This minimizes anxiety and pain perception.
LANDMARKS
1. With the patient lying supine on the examination table, the clinician stands medial to the affected ankle.
2. Locate the junction between the fibula, distal tibia, and talus over the anterolateral aspect of the ankle.
3. Identify the anterior tibialis tendon.
4. Mark a point over the ankle joint line that is 1 cm medial to the anterior tibialis tendon. There is normally a depression in that area.
5. At that site, press firmly on the skin with the retracted tip of a ballpoint pen. This indention represents the entry point for the needle.
6. After the landmarks are identified, the patient should not move the ankle.
ANESTHESIA
- Local anesthesia of the skin using topical vapocoolant spray.
EQUIPMENT
- 20-mL syringe—for optional aspiration
- 3-mL syringe—for injection
- 20-gauge, 1 in. needle—for optional aspiration
- 25-gauge, 1½ in. needle—if not aspirating fluid
- 1 mL of 1% lidocaine without epinephrine
- 1 mL of the steroid solution (40 mg of triamcinolone acetonide)
- One alcohol prep pad
- Two povidone–iodine prep pads
- Sterile gauze pads
- Sterile adhesive bandage
- Nonsterile, clean chucks pad
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 tip of the needle directed toward the center of the ankle.
4. Using the no-touch technique, introduce the needle at the insertion site (Fig. 8.39).
5. Advance the needle into the ankle joint. This places the needle tip between the distal tibia and fibula in the ankle joint.
6. If aspirating, withdraw the fluid using a 20-gauge, 1½ in. needle with the 20-mL syringe.
7. If only injecting corticosteroid solution, use a 25-gauge, 1½ in. needle with the 3-mL syringe.
8. If injection following aspiration is elected, remove the large syringe from the 20-gauge needle and then attach the 3-mL syringe filled with the steroid solution.
9. Inject the steroid solution as a bolus into the ankle 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.
10. Following injection of the corticosteroid solution, withdraw the needle.
11. Apply a sterile adhesive bandage.
12. Instruct the patient to move his or her ankle through its full range of motion. This movement distributes the steroid solution throughout the ankle joint.
13. Reexamine the ankle in 5 min to confirm pain relief.
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