Subacromial Injections

Indications: Subacromial impingement, rotator cuff tendonitis, subacromial bursitis

Materials and where to find them:

All supplies can be found in Clean Utility Room (Code 888). For locked drawers/cabinet, use key located in drawer labelled “pens scissors tape” (located above drawer D).

Supply Quantity Where to find
10cc syringe 1 Bins
18g needle (pink) 1 Bins
25g needle (blue) 1 Bins
Chlorhexidine 1-2 Bins
Ethyl chloride spray 1 use key with white dot to open cabinet C
Triamcinolone 10mg/ml 1 vial use key with yellow dot to open drawer with yellow dot
Bupivacaine 0.5% w/o epi 1 vial use key with yellow dot to open drawer with yellow dot
Gauze 1-2 In patient room
Band aid 1 Bins

Knee Injection steps:

  1. Obtain patient consent
  2. Meds: With the 10cc syringe and the 18g needle, draw up 4cc of triamcinolone and 4cc of bupivacaine, gently mix the contents (note, some providers will inject the anesthetic and steroid separately in order to confirm site of injection).
  3. Remove 18g needle (and dispose in sharps container)
  4. Patient Positioning: Sitting, arms resting in lap, shoulder/neck relaxed
  5. Identify landmarks, including clavicle, acromion, and the spine of the scapula
  6. Identify injection site: For posterior approach, find the posterior corner of the acromion. Identify and mark target just medial to the posterior corner, about 1 cm inferior.
  7. Cleanse the injection site with chlorhexidine
  8. Attach the 25g needle to your medication syringe
  9. Spray the injection site with ethyl chloride spray for 5 seconds, then insert the needle, aiming anteriorly, slightly medially, and superiorly (parallel to angle of acromion). Aspirate as you advance.
  10. When needle is hubbed or near hubbed, slowly inject the 8cc of bupivacaine/triamcinolone. There should not be much resistance.
  11. Remove needle when done, disposing into sharps
  12. Hold pressure with gauze if needed for hemostasis
  13. Apply bandaid

Do the following in Epic:

  • Under med/orders, enter arthrocentesis, major joint (code 20610)
  • If problem focused visit + procedure:
    • Enter normal encounter level (ie “E3)
    • Under modifiers, type “25”
  • If just a procedure visit:
    • Bill as procedure for visit type