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Rheumatology Advance Access published online on July 25, 2008
Rheumatology, doi:10.1093/rheumatology/ken295
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© The Author 2008. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Frequency of successful intra-articular puncture of finger joints: influence of puncture position and physician experience

W. Pichler1, W. Grechenig1, S. Grechenig1, F. Anderhuber2, H. Clement1 and A. M. Weinberg3

1Department of Traumatology, 2Department of Anatomy and 3Department of Paediatric Surgery, Medical University of Graz, Graz, Austria.

Correspondence to: W. Pichler, Department of Traumatology, Medical University of Graz (MUG), Auenbruggerplatz 7a, A - 8036 Graz, Austria. E-mail: wolfgang.pichler{at}klinikum-graz.at


   Abstract
Top
 Abstract
Introduction
 Materials and methods
 Results
 Discussion
 References
 
Objective. Physicians and specialists routinely perform IA punctures and injections on patients with joint injuries, chronic arthritis and arthrosis to release joint effusion or to inject drugs. The purpose of this study was to investigate the frequencies of intra- and peri-articular cannula positioning during this procedure.

Methods. A total of 300 cadaveric finger joints were injected with a methyl blue-containing solution and subsequently dissected to distinguish intra- from peri-articular injections. To assess the influence of puncture position on successful injection, half of the joints were injected dorsally and the other half dorso-radially. To assess the importance of practical experience for a positive outcome, half of the injections were performed by an inexperienced resident and half by a skilled specialist.

Results. The overall frequency of occurrence of peri-articular injections was much higher than expected (overall: 23%, specialist: 15%, resident: 32%) The failure rate was significantly higher than the average with the joints of the little finger and the DIP joints of each phalanx.

Conclusions. Even skilled specialists cannot guarantee to insert the cannula into the joint in every case. Unintended peri-articular drug injection moreover may affect the surrounding ligaments or tendons, leading to serious complications. Correct positioning of the needle in the joint may be facilitated by fluoroscopy in doubtful cases.

KEY WORDS: Intra-articular injection, Joint puncture, Finger joint


   Introduction
Top
 Abstract
 Introduction
Materials and methods
 Results
 Discussion
 References
 
Physicians and specialists routinely perform IA punctures and injections on patients with joint injuries, chronic arthritis and arthrosis to release joint effusion or to inject drugs. Corticosteroids, hyaluronic acid, radioactive or other miscellaneous agents for instance are frequently injected into joints to alleviate pain caused by rheumatic diseases or arthrosis [1–8]. Serious complications following unintentional peri-articular injection of corticosteroid are well documented in the literature [9–18]. The literature, in contrast, contains only a limited number of reports regarding the frequency of occurrence of peri-articular injections in finger joints [19–22]. The objectives of this study were (i) to estimate the overall frequency of occurrence of peri-articular injections in clinical practice, (ii) to investigate the degree to which experience contributes to successful joint injection and (iii) to compare the utility of the different puncture positions recommended in the literature.


   Materials and methods
Top
 Abstract
 Introduction
 Materials and methods
Results
 Discussion
 References
 
Fifty hands (25 left, 25 right) from fifty cadaver specimens with a mean age of 72.5 yrs (59–98) and preserved using the method of Thiel were used for the study. This special embalming technique, which was developed over a 30-yr period, provides a close-to-life model through the preservation of the original tissue colour, consistency and degree of transparency [23]. Extremities with arthrosis, evidence of trauma or other pathological changes were excluded from the study. Pathological skeletal changes were detected by means of X-rays. Finger joints with clinical functional deficits were also rejected. An inexperienced resident (first year of training) and a skilled specialist (surgeon) were chosen to perform the injections. Each punctured a total of 150 joints (50 DIP, 50 PIP and 50 CMC thumb joints). The cannula (14G, 23Ch) was connected to a 5 ml syringe, and then filled with methyl blue. Following palpation, 0.2 ml of methyl blue was injected into each joint. According to the current literature, punctures are to be carried out by positioning the cannula almost perpendicular to the joint along the axis of the finger (Fig. 1) [1]. Half of the punctures were performed dorsally, and half dorso-radially. After the completion of all 300 injections, arthrotomy was performed for each joint and the location of the injected methyl blue recorded in each case (Fig. 2). All results were entered into a computerized database and analysed using Microsoft Excel® (Redmond, WA, USA). Ethical approval for this study was obtained from the local ethics committee of the Medical University of Graz.


Figure 1
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  		FIG. 1. Dorsal injection of methylene blue into the PIP joint of the indices.

 

Figure 2
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  		FIG. 2. Arthrotomy to determine the location of the injected methylene blue.

 

   Results
Top
 Abstract
 Introduction
 Materials and methods
 Results
Discussion
 References
 
A total of 300 finger joints were punctured and injected with methyl blue. An inexperienced resident and a skilled specialist each injected half of these joints. The frequencies of unintended peri-articular injection were: overall: 23% (70/300), specialist: 15% (22/150); resident: 32% (48/150). The frequency of peri-articular injection was higher for radial compared with dorso-radial punctures for both the resident and the specialist [overall: dorsal 17% (25/150), dorso-radial 30% (45/150); specialist: dorsal 7% (5/75), dorso-radial 23% (17/75); resident: dorsal 27% (20/75), dorso-radial 37% (28/75)]. The rate of failure of IA injection was highest with DIP joints [overall: 29% (29/100), specialist: 16% (8/50), resident: 42% (21/50)], and lowest with PIP joints (overall: 18% (18/100), specialist: 12% (6/50), resident: 24% (12/50). An intermediate failure rate was observed with CMC thumb joints [overall: 23% (23/100), specialist: 16% (8/50), resident: 30% (15/50)].


   Discussion
Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
References
 
Although injection of drugs into finger joints is carried out less frequently than into other joints, this procedure can provide effective pain relief for sufferers of chronic degenerative and rheumatic diseases. The literature contains several reports of a distinct improvement in these disorders following IA injection of different drugs into finger joints (hyaluronic acid or corticosteroid injections for the treatment of rhizarthrosis, etanercept, glucocorticosteroids or radioactive agents for the treatment of RA of digital joints and dextrose for the alleviation of pain in osteoarthritic finger joints) [2–8].

On the other hand, reports of complications following unintended peri-articular injection of corticosteroids are common in the literature. Gerster and Fallet [9] for instance present four cases of peri-articular calcification related to corticosteroid injections into the small joints of the hands. Peri-articular calcifications are known to be caused by triamcinolone hexacetonide and by prednisone, in particular [10–12]. Gottlieb and Riskin [13] report a bowstring deformity of a finger after local corticosteroid treatment of psoriatic digital flexor tendonitis. Goldman et al [14] describe a local hypopigmentation after digital IA injection of corticosteroid. Ford and DeBender [15] present 15 cases of ruptured tendons that occurred after injection of a depository corticosteroid into or around the tendons. Several studies have investigated the effects of local corticosteroid treatment on tendons in rats. McWhorter et al [16] showed that rat Achilles tendon is neither biomechanically nor histologically deleteriously affected by hydrocortisone acetate. Oxlund [17] reports an increase in strength and stiffness of tendons, but a decrease in the strength of the bone attachments of the ligaments following local corticosteroid treatment. In a follow-on investigation the author demonstrated thinning of the tissue and collagen loss [18].

Literature reports concerning the rate of unintended peri-articular injections are rare. Jones et al [22] injected various different joints of 109 patients with a mixture of methylprednisolone and a radiographic contrast medium in order to determine the frequency of successful IA drug delivery by radiography. In the published study, a total of only five finger joints were injected (thumb carpometacarpal: three times, finger metacarpophalangeal and distal interphalangeal: twice). None of these injections were IA. One was extra-articular and four were uncertain [22].

The aim of the present study was to provide solid insight into the frequency of occurrence of peri-articular finger joint injections during daily clinical practice. The approach taken was the injection of a dye into a large number of cadaveric finger joints (300). The overall frequency of peri-articular injection was found to be surprisingly high: injection was unsuccessful in 23% of the injected finger joints. Half of the injections were done by a skilled specialist and half by an inexperienced resident to reflect the fact that, in daily practice, these injections are performed by persons with variable experience and training. Unsurprisingly, the success rate of the experienced physician was clearly higher than that of the novice (15 and 32% peri-articular injections, respectively). The injections for the study were moreover performed from two different orientations with respect to the joint, i.e. either dorsally or dorso-laterally [1]. The markedly higher failure rate observed with dorso-lateral compared with dorsal injections (30 and 17%, respectively), indicates the importance of needle positioning for successful IA injection. The directing of the oblique opening of the needle tip towards the cartilage surface is therefore to be recommended in order to avoid cartilage trauma and to increase the frequency of correctly placed IA injections.

In conclusion, the main message provided by the results of this study is that IA injection is a challenging procedure since even a highly experienced physician cannot guarantee success and that correct injection should be assessed in some manner. An ability to aspirate SF is a sure sign that the needle is intra-articularly positioned. If aspiration of SF is impossible, physiological salt solution may be injected in the joint and subsequently aspirated to assure an IA positioning of the cannula. Local swelling, painlessness and smooth injection do not necessarily indicate correct IA needle placement [24]. In cases of doubt, injections guided by fluoroscopy are to be recommended as a means of preventing unintended peri-articular injection and subsequent complications. Fluoroscopy, however, results in radiation exposure to the hands of the patient and of the physician, especially when multiple joints need to be injected. Ultrasound provides a non-radiation alternative to radioscopy but must be learnt by the physician and can sometimes be demanding to perform in a helpful manner.

Formula


   Acknowledgments
 
Disclosure statement: The authors have declared no conflicts of interest.


   References
Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 

  1. Kesson M, Atkins E, Davies I. Musculoskeletal injection skills. (2003) 1st edition. Oxford: Elsevier. 86–91.
  2. Fuchs S, Mönikes R, Wohlmeiner A, Heyse T. Intra-articular hyaluronic acid compared with corticoid injections for the treatment of rhizarthrosis. Osteoarthritis Cartilage (2006) 14:82–8.[CrossRef][Web of Science][Medline]
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  5. Tebib JG, Manil LM, Mödder G, et al. Better results with rhenium-186 radiosynoviorthesis than with cortivazol in rheumatoid arthritis (RA): a two-year follow-up randomized controlled multicentre study. Clin Exp Rheumatol (2004) 22:609–16.[Web of Science][Medline]
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Submitted 24 January 2008; revised version accepted 26 June 2008.
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