Atlas of Primary Care Procedures, 1st Edition

Musculoskeletal Procedures

59

Greater Trochanteric Bursa Injection

Greater trochanteric bursitis is a common condition that often produces hip, lateral thigh, or referred knee pain. The patient often complains of nighttime pain when lying in bed on the affected side. Characteristic local tenderness can be elicited by palpation from over the greater trochanter of the femur when the patient lies on the examination table with the affected side up.

Greater trochanteric bursitis occurs predominantly in middle-aged to elderly individuals, with women affected more often than men. Onset tends to be gradual, and symptoms tend to last for months. Individuals with longer-lasting symptoms may fail to localize their pain, often describing diffuse pain over the entire thigh with walking.

Two major bursae overlying the greater trochanter have clinical significance, although it is believed that at least three distinct bursae exist at this site. The superficial bursa rests between the lateral aspects of the trochanter and the skin and subcutaneous tissue. The deep bursa lies above the tendinous insertion of the gluteus maximus muscle and extends behind the trochanter. Either of these bursa may become inflamed and can produce swelling or pain in the area. Swelling and erythema is more apparent when the superficial bursa is inflamed, and pain is produced with marked abduction of the hip. Pain from the deep bursa may be produced by passive internal rotation when the hip is adducted or by passive external rotation when the hip is abducted.

The differential diagnosis includes osteoarthritis of the hip, iliotibial band syndrome, or adductor tendonitis (and bursitis) of the hip. The localized, lateral tenderness of greater trochanteric bursitis helps to differentiate the condition. The discomfort of hip arthritis generally is felt in the groin, with pain produced by internal and external rotation of the hip.

One presentation for trochanteric bursitis is the “snapping hip” syndrome. Excessive tightening of the iliotibial band over the trochanter can produce friction, bursitis, and popping as it snaps over the bony prominence during flexion and extension of the hip. Steroid injections reduce local inflammation and may soften and stretch the iliotibial band. This syndrome also appears to improve with exercises that stretch the iliotibial band.

P.480

INDICATIONS

  • Symptomatic individuals with characteristic localized tenderness over the trochanter

RELATIVE CONTRAINDICATIONS

  • Bleeding diathesis
  • Uncooperative patient
  • Bacteremia or cellulitis of the proximal, lateral thigh

P.481

 

PROCEDURE

The two major bursa are illustrated.

 

(1) Anatomy of the lateral hip.

Position the patient on the examination table with the unaffected hip down and the affected hip up. Drapes can be used to keep the surrounding body areas covered.

 

(2) Position the patient on the examination table with the unaffected hip down and the affected hip up.

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Palpate over the greater trochanter to reveal the characteristic localized tenderness.

 

(3) Palpate over the greater trochanter to reveal the characteristic localized tenderness.

After skin preparation, insert a 1¼- or 1½-inch needle to the hub. The needle tip should reach the greater trochanter. If the needle is too short, it may be “lengthened” by pressing it into the skin.

 

(4) Insert a long needle to the hub until the tip reaches the greater trochanter.

P.483

 

A 10-mL syringe with 1 mL of steroid (e.g., 6 mg of Celestone, 40 mg of triamcinolone) and 6 to 9 mL of 1% lidocaine is used. Injecting a larger volume of fluid appears to be beneficial in the treatment of greater trochanteric bursitis. Inject a small amount just over the initial contact point with trochanter (Figure 5A). Redirect the needle around the initial site, and administer additional solution in a wide or fan-shaped pattern. Redirect the needle posteriorly, making sure that the needle tip “walks'' off the end of the bone, to deliver solution to the portion of the bursa posterior to the trochanter (Figure 5B).

 

(5) Inject a small amount of steroid and 1% lidocaine just over the initial contact point with the trochanter, redirect the needle around the initial site, and administer additional solution in a wide or fan-shaped pattern.

P.484

 

CODING INFORMATION

CPT® Code

Description

2002 Average 50th Percentile Fee

20610*

Injection of major joint or bursa (hip)

$110

CPT® is a trademark of the American Medical Association.

INSTRUMENT AND MATERIALS ORDERING

Consult the ordering information that appears in Chapter 65. It is easier to perform this procedure and reach the posterior portion of the bursa with a 22-gauge, 3½-inch (spinal) needle. These special needles can be ordered through local surgical supply houses. A suggested tray for performing soft tissue aspirations and injections is listed in Appendix D. Skin preparation recommendations appear in Appendix H.

BIBLIOGRAPHY

Adkins SB, Figler RA. Hip pain in athletes. Am Fam Physician 2000;61: 2109–18.

Anderson LG. Aspirating and injecting the acutely painful joint. Emerg Med 1991;23:77–94.

Biundo JJ. Regional rheumatic pain syndromes. In: Klippel JH, Weyand CM, Wortmann RL, eds. Primer on the rheumatic diseases, 11th ed. Atlanta: Arthritis Foundation, 1997:136–148.

Blackburn WD. Approach to the patient with a musculoskeletal disorder. Caddo, OK: Professional Communications, 1997.

Brown JS. Minor surgery: a text and atlas, 3rd ed. London: Chapman & Hall, 1997:12.

Hollander JL. Arthrocentesis and intrasynovial therapy. In: McCarty DJ, ed. Arthritis, 9th ed. London: Henry Kimpton Publishers, 1979:402–414.

Owen DS, Irby R. Intra-articular and soft-tissue aspiration and injection. Clin Rheum Pract 1986;Mar-May:52–63.

Pando JA, Klippel JH. Arthrocentesis and corticosteroid injection: an illustrated guide to technique. Consultant 1996;36:2137–2148.

Pronchik D, Heller MB. Local injection therapy: rapid, effective treatment of tendonitis/bursitis syndromes. Consultant 1997;37:1377–1389.

Schapira D, Nahir M, Scharf Y. Trochanteric bursitis: a common clinical problem. Arch Phys Med Rehab 1986;67:815–817.

Scopp JM, Moorman CT. The assessment of athletic hip injury. Clin Sports Med 2001;20:647–659.

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