FIGURE 6.29 Anterior aspect of right elbow. (From Tank PW, Gest TR. Lippincott Williams & Wilkins Atlas of Anatomy. Philadelphia, PA: Lippincott Williams & Wilkins, 2009.)

PATIENT POSITION

Supine on the examination table with the head of the bed elevated 30 degrees.
The affected elbow is slightly flexed.
The wrist is in a neutral to slightly pronated position.
The elbow is supported with the placement of chucks pads or towels.
Rotate the patient’s head away from the side that is being injected. This minimizes anxiety and pain perception.

LANDMARKS

1. With the patient supine on the examination table, the clinician stands lateral to the affected forearm.

2. Identify the lateral epicondyle.

3. The point of maximal tenderness is usually located about 4 cm distal and anterior to the lateral epicondyle.

4. Identify and mark the point of maximal tenderness.

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 elbow.

ANESTHESIA

Local anesthesia of the skin using topical vapocoolant spray.

EQUIPMENT

3-mL syringe
25-gauge, 1-in. needle
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 needle tip directed posteriorly.

4. Using the no-touch technique, introduce the needle at the insertion site (Fig. 6.30).

5. Slowly advance the needle until the needle tip is at the anticipated injection site at the radial nerve.

6. If any pain, paresthesias, or numbness is encountered, withdraw the needle slightly.

7. When the needle is placed along the radial nerve, slowly deposit the steroid solution as a bolus around that structure.

8. If increased resistance is encountered, advance or withdraw the needle slightly before attempting further injection.

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

10. Apply a sterile adhesive bandage.

11. Instruct the patient to move his or her wrist and elbow through their full range of motion.

12. Reexamine the proximal forearm in 5 min to confirm pain relief and the development of numbness in the distribution of the radial nerve from the local anesthetic.