Tendon sheath injections

Tendon sheath injections are suggested when the tissues around a tendon are painful, swollen or difficult to move. This can be caused by many conditions, but the most common is arthritis (inflammation of the joints).

A tendon is a cord of strong fibrous tissue that connects muscle to bone. It is what allows the muscle to bend and straighten a joint when it contracts. Most tendons are surrounded by a sheath or sleeve of synovial tissue. This tissue produces tiny quantities of fluid that lubricate the tendon and allow it to slide smoothly over the joint and work effectively.

In some inflammatory conditions, the synovial tissue becomes thickened and irritable, so that it produces too much fluid and causes pain. Injecting steroid medicine into the fluid within the tendon sheath can treat the inflammation, decreasing the pain and increasing the range of movement in that area.

Your doctor will suggest tendon sheath injections based on your child’s current symptoms, the underlying cause of these symptoms and recent imaging studies. Tendon sheath injections on their own are unlikely to offer a ‘cure’ but can be helpful alongside other treatments such as physiotherapy, splinting and other longer-term medicines.

You will already have received information about how to prepare your child for the procedure in your admission letter. You may need to come to GOSH before the procedure so that your child can have a pre-admission assessment to check that they are well enough. The appointment may involve taking blood samples and other tests.

Your child will need to be admitted to a bed on a ward in the hospital. The person bringing your child to the procedure should have ‘parental responsibility’ for them. Parental responsibility refers to the individual who has legal rights, responsibilities, duties, power and authority to make decisions for a child. If the person bringing your child does not have parental responsibility, we may have to cancel the procedure.

An anaesthetist will visit to talk to you about your child’s anaesthetic. The specialist performing the procedure will explain the procedure in more detail, discuss any questions you may have and ask you to sign a consent form giving permission for your child to have the procedure. If your child has any medical problems, please tell the specialists.

Many of the procedures we perform involve the use of X-rays. Legally, we are obliged to ask anyone over the age of 12 whether there is any chance they might be pregnant, and we will also ask for the first date of their last period (if started). This is to protect babies in the womb from receiving unnecessary radiation.

You and your child will then be brought to the Interventional Radiology (IR) suite within the X-ray department for the procedure to be done.

You will already have received information about how to prepare your child for the procedure in your admission letter. You may need to come to GOSH before the procedure so that your child can have a pre-admission assessment to check that they are well enough. This appointment may involve taking blood samples and other tests.

This test can be performed under local, Entonox® or general anaesthetic. Your admission letter will specify which type you need to prepare for. For local anaesthetic there is no fasting required. For Entonox® fasting is required for 1 hour before the procedure – this means no food or water. For general anaesthetic please follow the below instructions.

Your child needs to be fasted for the procedure for the general anaesthetic. If your child takes regular medication, please speak to your child’s team about when to stop these before the procedure.

As a general rule:

Food and milk:

• Breast-fed babies- can have their last feed three hours before the procedure. Breast milk is digested faster than solid food or formula.
• Bottle-fed babies and children- can have their last milk feed, food or milk drink, six hours before the procedure. They should not have any food or milk after this time.

Water:

• All babies and children can have a drink of water (but no other fluids), until one hour before the procedure.

It is equally important to keep giving your child food and drink until those times to ensure they remain well-hydrated and get adequate nutrition. This may involve waking your child in the night to give them a drink which we recommend.

Please follow these instructions carefully, otherwise your child’s procedure may be delayed or even cancelled.

Once your child is under general anaesthetic or sedated with Entonox®, the doctor will clean the area over the joint and use ultrasound to assess the tendon sheath and confirm that it looks abnormal and can be treated. The doctor will then insert a very small needle into the tendon sheath (sleeve surrounding the tendon). The doctor uses real-time ultrasound images to guide the needle into place. When it is in the correct position, they will inject a mixture of steroid medicine and local anaesthetic around the tendon. They will then remove the needle and may cover the injection site with a small plaster if required.

If your child will be having the procedure under general anaesthetic, every anaesthetic carries a risk, but this is extremely small.

Occasionally it is difficult to inject much medicine into the tendon sheath space, as the doctor needs to avoid injecting the steroid into the tendon itself. If the sheath is not very inflamed, it can be difficult to do this safely, as there is not enough space around the tendon. If this is the case, other medicines may be prescribed to treat your child’s symptoms.

The procedure may involve the use of X-rays. The levels that are used are low dose and therefore low risk. If you have any concerns regarding the use of radiation, please discuss this with the person performing your procedure beforehand.

Physiotherapy and medicines taken by mouth or intravenously (via the veins) can be used as an alternative to tendon sheath injections. The doctor will explain all the options suitable for your child before you make a decision.

Your child will return to the ward after they have recovered from the general anaesthetic if they have had one. Some children feel sick and vomit after a general anaesthetic. Your child may have a headache or sore throat or feel dizzy, but these side effects are usually short-lived and not severe. Your child can start eating and drinking as normal once they feel like it.

If your child does not need to stay in hospital for other treatment, you can return home once they have recovered from the anaesthetic or sedation. The doctor on the ward will give you advice regarding rest, physiotherapy and exercises after the procedure.

You should call the hospital (or go to A&E out of hours) if:

• The injection site looks red, swollen and feels hotter than the surrounding skin for longer than 24 hours after the procedure.
• The injection site is oozing.
• Your child is in a lot of pain and pain relief does not seem to help.
• Your child has a temperature of 38⁰C or higher.

You can call the ward by calling the GOSH switchboard and asking for the ward your child was discharged from.

Telephone: 020 7405 9200

If you are unable to get through, please call NHS111 by dialling 111.

If you have any questions, please speak to you child’s doctor or nurse or call Interventional Radiology:

Telephone: 020 7405 9200

You can also contact us through MyGOSH.