7 The Wrist and Hand: Guided Injection Techniques

10.1055/b-0038-161012

7 The Wrist and Hand: Guided Injection Techniques

Abstract

This chapter outlines commonly used injection techniques at the wrist and hand. The aim is to detail the position and alignment of the probe and needle to allow accurate placement into the target tissue. In addition a brief clinical presentation is given for each condition as well as some of the anatomical considerations which should be noted. The drugs, dosages, and volumes given are those used in the author’s clinic.

7.1 Wrist Joint Injection—Radiocarpal Joint

7.1.1 Cause

Osteoarthritis.
Rheumatoid arthritis.
Overuse.

7.1.2 Presentation

Pain is located within the wrist joint.
The capsular restriction of the wrist results in an equal limitation of both passive flexion and extension.

7.1.3 Equipment

See Table 7‑1.

Table 7.1 Equipment needed for wrist joint injection—radiocarpal joint
Syringe	Needle	Corticosteroid	Local anesthetic	Transducer
5 mL	23 gauge – 1 inch	20-mg Depo-Medrone	2-mL 1% lidocaine	Small hockey stick

7.1.4 Anatomical Considerations

The radiocarpal joint is formed by the distal radius, triangular fibrocartilage, and the three bones of the proximal carpal row: the scaphoid, lunate, and triquetrum. Although the wrist joint as a whole is not continuous having various internal septa dividing it into separate compartments, a variable degree of communication can exist with the radiocarpal, intercarpal, midcarpal, and carpometacarpal joints often intercommunicating through a common synovial cavity.

This intercommunication can work to the advantage of the patient with generalized arthritic change as one injection into the midradiocarpal joint is able to perfuse throughout the wrist.

7.1.5 Procedure

The patient is seated facing the clinician with the forearm and hand resting on a table palm facing down.
The transducer is placed in the longitudinal plane over the midpoint of the dorsal aspect of the wrist joint. In this position, it should be possible to visualize the distal radius, lunate, and capitate.
The needle is inserted at approximately 45 degrees to the transducer from a distal to proximal direction. The needle should lie along and parallel to the posterior surface of the lunate.
The injection is given as a bolus into the radiocarpal joint.

7.1.6 The Injection

See Fig. 7‑1 and Fig. 7‑2.

Fig. 7.1 Wrist joint injection. The probe is placed in the longitudinal plane over the midpoint of the dorsal aspect of the wrist joint. In this position it should be possible to visualize the distal radius, lunate, and capitate. The needle is inserted at approximately 45 degrees to the probe from a distal to proximal direction. The needle should lie along and parallel to the posterior surface of the lunate. If the midcarpal joint is the aim, then the needle is aimed slightly more distally toward the midcarpal recess between the capitate and lunate.

Fig. 7.2 Longitudinal image of the dorsal aspect of the wrist demonstrating the proximal radiocarpal joint to the right of the image between the distal radius and lunate. The midcarpal joint may be seen to the center of the image between lunate and capitate. The respective joint recesses are indicated by the white arrows. The tendons of the fourth dorsal compartment (IV) may be seen overlying both joints. The yellow arrow demonstrates the line of the needle to inject the proximal radiocarpal joint. White arrows, dorsal joint recesses of the proximal and midcarpal joints; yellow arrow, direction of the needle.

7.1.7 Notes

The patient may be advised on a period of relative rest for 2 weeks during which time a splint is worn to protect the joint. Following this a programme of rehabilitation aimed at mobilizing and strengthening the wrist should be implemented.

7.2 Carpometacarpal Joint of the Thumb Injection

7.2.1 Cause

Osteoarthritis.

7.2.2 Presentation

Pain is located at the base of the thumb and thenar eminence.
The capsular restriction of the thumb is a painful passive restriction of both extension and abduction with the thumb gradually becoming fixed into an adducted position. In cases of advanced degeneration of the joint a loss of normal thenar muscle mass may also be noted.

7.2.3 Equipment

See Table 7‑2.

Table 7.2 Equipment needed for carpometacarpal joint of the thumb injection
Syringe	Needle	Corticosteroid	Local anesthetic	Transducer
2 mL	25 gauge –1 inch	10-mg Depo-Medrone	1-ml 1% lidocaine	Small hockey stick

7.2.4 Anatomical Considerations

The carpometacarpal joint of the thumb is formed by the articulation of the head of the first metacarpal and the trapezium proximally. The radial artery lies immediately proximal to the joint and should not be at risk.

7.2.5 Procedure

The patient is seated facing the clinician with the forearm and hand resting on a table with the thumb facing upward.
The thumb is flexed into the palm allowing the carpometacarpal joint to open laterally.
The transducer is placed in the longitudinal plane over the carpometacarpal in line with the thumb.
The needle is inserted at approximately 45 degrees to the transducer from a proximal to distal direction.
The injection is given as a bolus into the carpometacarpal joint.
If difficulty is experienced with correct needle placement, the clinician may passively flex and extend the metacarpal applying a gentle distraction force to the joint.

7.2.6 The Injection

See Fig. 7‑3 and Fig. 7‑4.

Fig. 7.3 Injection of the carpometacarpal joint of the thumb. The probe is placed in the longitudinal plane over the carpometacarpal in line with the thumb. The needle is inserted at approximately 45 degrees to the transducer from a proximal to distal direction. The injection is given as a bolus into the carpometacarpal joint.

Fig. 7.4 Longitudinal image of the carpometacarpal joint of the thumb. The trapezium (TR) may be seen to the right of the image and the base of the first metacarpal (MC) to the left. The base of the metacarpal normally sits in a more superior position relative to the trapezium. This facilitates injection from a proximal to distal direction outlined by the yellow arrow. Yellow arrow, direction of the needle.

7.2.7 Notes

Osteoarthritis of the carpometacarpal joint is a common presentation in older patients particularly in those who have had very manual occupations or taken part in sports involving high loading of the joint. Local injection followed by a programme of strengthening exercise can provide significant and long-term relief.

In mild to moderate cases of osteoarthritis in patients who are still very active injection of hyaluronan may provide a long-term relief of symptoms.

7.3 First Dorsal Compartment Injection—de Quervain’s Tenosynovitis

7.3.1 Cause

Overuse.

7.3.2 Presentation

Pain is located at the base of the thumb and along the radial border of the wrist.
Pain may be reproduced with resisted thumb extension and abduction.
Pain may also be reproduced with Finkelstein’s test which is performed by passively flexing the patient’s thumb while the wrist is placed into ulnar deviation.

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Tags: Diagnostic Musculoskeletal Ultrasound and Guided Injection, Medical Imaging: Sonography, Orthopaedics and Trauma Surgery, Ultrasonics

May 21, 2020 | Posted by drzezo in ORTHOPEDIC | Comments Off

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7 The Wrist and Hand: Guided Injection Techniques