FIGURE 6.50 Dorsal aspect of the right hand. (From Tank PW, Gest TR. Lippincott Williams & Wilkins Atlas of Anatomy. Philadelphia, PA: Lippincott Williams & Wilkins, 2009.)

PATIENT POSITION

Supine on the examination table with the head of the bed elevated 30 degrees.
The affected wrist is held in a neutral position. The wrist is pronated, and the patient is asked to make a loose fist.
The hand is supported with the placement of chucks pads or towels.
Rotate the patient’s head away from the side that is being injected. This minimizes anxiety and pain perception.

LANDMARKS

1. With the patient supine on the examination table, the clinician stands anterior to the affected hand.

2. Locate the affected MCP joint.

3. The point of entry is located directly over the MCP joint, just radial or ulnar to the extensor tendon.

4. At that site, press firmly on the skin with the retracted tip of a ballpoint pen. This indention represents the entry point for the needle.

5. After the landmarks are identified, the patient should not move the hand or fingers.

ANESTHESIA

Local anesthesia of the skin using topical vapocoolant spray.

EQUIPMENT

3-mL syringe
25-gauge, 5/8-in. needle
0.25 mL of 1% lidocaine without epinephrine
0.25 mL of the steroid solution (10 mg of triamcinolone acetonide)
One alcohol prep pad
Two povidone–iodine prep pads
Sterile gauze pads
Sterile adhesive bandage
Nonsterile, clean chucks pad

TECHNIQUE

1. Prep the insertion site with alcohol followed by the povidone–iodine pads.

2. Achieve good local anesthesia by using topical vapocoolant spray.

3. Position the needle and syringe perpendicular to the skin with the needle tip directed posteriorly toward the first MCP joint.

4. Using the no-touch technique, introduce the needle at the insertion site (Fig. 6.51).

5. Advance the needle down into the joint.

6. Inject the steroid solution as a bolus into the joint. The injected solution should flow smoothly into the space. If increased resistance is encountered, advance or withdraw the needle slightly before attempting further injection.

7. Following injection of the corticosteroid solution, withdraw the needle.

8. Apply a sterile adhesive bandage.

9. Instruct the patient to move his or her MCP joint through its full range of motion. This movement distributes the steroid solution throughout the joint.

10. Reexamine the MCP joint in 5 min to confirm pain relief.