General Principles of Corticosteroid Injections
Is it safe to give this patient an injection?
Active infection
Joint replacement
Upcoming surgery
The number one absolute contraindication to corticosteroid injections is an active infection involving the injection site. This could be suspected septic arthritis, overlying cellulitis, nearby wounds or sores, or a systemic infection that could seed to the injection site.
Another absolute contraindication is a known allergy to the medication – whether it be the corticosteroid or the anesthetic.
Relative contraindications require more individualized decision making.
Injection into a prosthetic joint is generally considered a strong relative contraindication. The prosthetic joint provides a surface on which bacteria can form biofilms, increasing the potential for infection. A prosthetic joint infection can be catastrophic, often requiring multiple surgeries, implant removal, long term IV antibiotics, and significant disability.
In patients with poorly controlled diabetes, blood glucose levels may rise to dangerous levels. Blood glucose begins to rise within 6 to 24 hours, peaks between 24 and 72 hours, and gradually returns to baseline between 3 and 7 days after the injection. Insulin usually increases 50 to 100 mg per dL above baseline, However, some patients experience larger spikes of more than 200 above baseline. The effect may be worse in insulin-dependent diabetes, poorly controlled diabetes, and with larger doses of corticosteroid.
Patients on anticoagulation therapy are at an increased risk of bleeding and hemarthrosis. However, evidence suggests that the risk is very low and therapy is not typically interrupted for the injections reviewed in this course.
Corticosteroids may impede healing and regeneration of tendon tissue, resulting in weakened tendons and an increased risk of rupture. Injections are avoided around tendons that are suspected to be weakened or torn.
If surgery involving the site in question is anticipated, the injection should be avoided. Most orthopedic surgeons will not proceed with a joint replacement if the joint has been injected within the past 3 months.
As discussed earlier, injecting a joint that has recently been injected should be avoided.
Key Takeaways
Do not inject if there is an active infection
Avoid injections into prosthetic joints
Avoid injections if surgical treatment is likely
