Acromioclavicular Joint Injection

Consent Form

• Joint Injection Consent Form

Equipment List

Nitrile Exam Gloves (1 pair)

Kenolog (Triamcinolone Acetonide) 40mg/ml (1 vial)

1% lidocaine (without epinephrine) (1 vial with minimum 2 ml remaining)

5 ml syringe (1)

18 gauge 1.5 inch needle (1)

25 gauge 1.5 inch needle (1)

Iodine swabs (2), or 3 ml ChloraPrep swab (1)

Sterile 4x4 gauze (2)

Alcohol Swabs (4)

Band-Aid (1)

Procedure Note

ACROMIOCLAVICULAR INJECTION Risks and benefits were discussed, including treatment failure (no relief from this injection), new pain, swelling, and infection. Specifically, the patient was counseled that in the first 72 hours it is common to have rebound worsening of pain symptoms, before improvement is noted. Patient verbalized understanding and wished to go forward with procedure. Verbal timeout performed, pausing to verify patient and procedure. Patient remained in a seated position, superior approach without ultrasound guidance. Posterior acromion palpated. The skin was prepped. 40 mg of triamcinolone acetonide (1 ml of 40mg/ml) was drawn into a syringe with 2 ml of 1% lidocaine without epinephrine. A 25 gauge 1.5" needle was used to inject all 3 ml into the acromioclavicular space. The patient tolerated the procedure well. No bleeding noted.