CURRENT THERAPEUTICS

Intra-Articular Injection Of Steroid+

G K W Lee,* MBBS, MRCP(UK), MHKCP
C S Lau, MBChB, MRCP(UK), MD, FHKAM(Medicine)

Department of Medicine Queen Mary Hospital

Summary
Intra-articular steroid injection is a useful technique to acquire for doctors in the field of rheumatology and orthopaedic surgery as well as family medicine. When cautions are taken to avoid sepsis, intra-articular injections of steroid can yield gratifying results in the management in well selected cases of different arthritis. The techniques for common lower and upper limb joint injections are described. (HK Pract 1997; 19:482-488)

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Introduction
When administered with care, intra-articular steroid injections can bring about remarkable relief to patients' articular disease. During the process, usually aspiration of the distended joint can lead to an immediate relief, so is the concomitant administration of local anaesthetics. It is particularly useful when, for example, a patient with rheumatoid arthritis (RA) develops a monoarticular flare. In this situation, intraarticular steroid injection may help to facilitate physical therapy and avoid

the need to augment systemic treatment. However, care should be exercised to avoid the abuse of intraarticular steroid injections. For example, it will be unwise to repeatedly inject the same joint many times when actually the more appropriate action should be a change in the systemic therapy or surgery. This is also true for a polyarticular flare of RA, when the systemic treatment should be adjusted instead of multiple joint injections. Caution should be taken to avoid injecting a suspected septic joint. If there is any uncertainty, the joint

should always be aspirated first and joint fluid sent for routine microscopy, smear and microbiological study before steroid administration. Conversely, it will be wise to defer the injection when there is sepsis nearby. latrogenic joint sepsis, though uncommon, is not unheard of, and actually may lead to a lethal outcome. The common indications and the do's and don'ts of intra-articular steroid injections have been highlighted in an earlier article. 1 In this issue, we will describe the technique for steroid a d m i n i s t r a t i o n for commonly injected joints.
Hospital,

Editor's Note : This is the second in a series of three articles on local steroid injection for rheumatic disorders. * Address for correspondence: Dr Gavin KW Lee. Medical Officer, Department of Medicine. The University of Hong Kong, Queen Mary Pokfulam Road, Hong Kong.

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CURRENT THERAPEUTICS

Injection of the lower limb joints

The knee joint The knee has the largest space and is the easiest joint to puncture. The usual indications for intraarticular injection of the knee are RA, osteoarthritis (OA), gouty arthritis and reactive arthritis and other related seronegative arthritis. The knee joint can be approached from the lateral or medial aspect. The patient is usually asked to lie supine on the couch. The operator can place one hand either to displace the patella laterally/medially or press onto the supra-patellar area to open up the patellofemoral space (Figure 1). Using a 21 gauge needle, a puncture is made at the junction of the upper and middle one third of the lateral border of the patellofemoral space. A gentle negative pressure in the syringe should be applied when advancing the needle. Usually a 'give way' can be felt when the joint is entered and joint fluid can be aspirated. Occasionally, fluid will come and then stop. This may be because a piece of synovium or fibrin in the fluid has blocked the needle. A little of the fluid should be re-injected ' and a further attempt is made to aspirate. Aspiration of the knee joint does not only provide relief to the patient's symptoms but is also a good test of accurate entry to the joint before injection of steroid. Care m u s t , h o w e v e r , be taken when changing the syringe so that the needle is not pulled out of the joint. T h e n u s u a l l y 40 to 80 mg of m e t h y l p r e d n i s o l o n e acetate or equivalent can be given. After the knee injection, the patient is usually

asked to avoid excessive walking for 24 hours.

joint. However, there should not be any resistance during injection. The steroid dosage is 40 mg methylprednisolone acetate or its equivalent. I

The ankle joint When the ankle joint is actively involved by RA, gouty arthritis or seronegative arthritis (OA seldom affects the ankle joint), it can be considered for injection by applying the same principles as mentioned above. Before injecting the ankle joint or talocrural joint (which is a hinge joint between the tibia and fibula, and the trochlea of the talus), the patient should be rested supine with the leg-foot angle at 90. A 23 gauge needle is employed and the point of entry is on the medial aspect of the ankle between the medial malleolus and tibialis anterior tendon and at the space between the tibia and the talus (Figure 2). The needle should be directed posteriorly and not pointing to the heel. It may not be possible to aspirate fluid from this joint to test the accurate entry into the Small joints of the feet The small joints of the feet are usually injected because of gouty attack. For injection of the metat a r s o p h a l a n g e a l j o i n t s and toe interphalangeal joints, the joint line should be felt and the needle is introduced obliquely from the side, and aiming to have the needle tip to lie under the extensor tendon that covers the dorsum of the joint. Gentle traction on the toe may help. A 25 gauge n e e d l e s h o u l d be employed. As the capacity of these joints is limited, therefore, it would only accept about 0.5 ml maximum of the solution which usually is 20 mg methylprednisolone acetate (40 mg/ml solution), and it is unlikely to be able to aspirate any joint fluid out during the procedure.

Figure 1: Injection of knee joint - this can be approached either medially or laterally

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It should be emphasised that precaution to avoid infection is particularly important during the injection of small joints of the feet.

The hip joint This is a deep seated joint which is difficult to enter and joint aspiration and injection should not be attempted in the out-patient setting. Moreover, for very symptomatic osteoarthritic or rheumatoid hip joint steroid injection is not the choice of treatment. Systemic treatment with analgesic and anti-rheumatic medication should be used, and referral to the orthopaedic surgeon should also be considered.

the posterior route is easier than the anterior approach. Additionally, patients tend to be more apprehensive about the anterior approach and it is, even with experience, more liable to be painful. When approaching the shoulder posteriorly, the patient

is asked to sit up. By using a 21 gauge syringe, the site of puncture is at the point 1 cm below the junction of the acromion and scapular, with the needle perpendicular to all planes (Figure 3). For the anterior approach, the needle, which usually is 21 gauge

Figure 2: Injection of ankle joint

Injection of upper Joints

The shoulder joint

limb

When a patient presents with a painful shoulder, there are several possible sites being the origin of the pain, namely, acromioclavicular joint, glenohumeral joint and subacromial bursa. Therefore, the clinical diagnosis should be made before deciding on joint injection. They include various forms of arthritis, bursitis and other forms of soft tissue rheumatism. Referred pain should also be thought of. Here, we will focus on steroid intra-articular injection and treatment of other nonarticular conditions will be discussed in the next issue. Mostly the shoulder joint is injected for rheumatoid or osteoarthritic condition. There are two approaches in injecting the glenohumeral joint, and

Figure 3: Injection of gleno-humeral joint: posterior approach

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size, should enter medially to the head of the humerus and slightly inferolateral to the coracoid process, and should be directed posteriorly and slightly laterally (Figure 4). The needle should be able to enter the joint cavity. This anterior approach may be rendered more difficult with a well-developed deltoid muscle. After entering and aspirating the joint, 40 mg of methylprednisolone acetate can then be given.

communicating with each other. It is commonly affected by RA which is the most frequent indication for the injection of the wrist. A 23-25 gauge needle is used, and the injection is given perpendicular to the skin at the site distal to the radius and just ulnar to the anatomical snuff box (Figure 6). Methylprednisolone acetate 20 to 40 mg can be given into the joint.

When trying to inject the first carpometacarpal joint which is commonly affected by osteoarthritis, the joint l i n e s h o u l d be felt and injection given by a 25 gauge needle at an angle (Figure 7). It may be helpful to ask the patient to flex the thumb across the palm and feel for the base of the first metacarpal bone. During the injection, application of

Figure 4: Injection of gleno-humeral joint: anterior approach The elbow joint Again, RA or OA are the commonest indications for intraarticular injections of the elbow joint. However, occasionally steroid is given for crystal arthropathy. Intra-articular injection to the elbow can be accomplished by two different approaches - the lateral and posterior approach (Figure 5). Usually the patient's elbow is flexed at 90 and the injection can be given via a 23 gauge needle. When using the lateral approach, the head of the radius is felt at the radiohumeral part of the joint while supinating and pronating the forearm. After identifying the joint line, the injection (40 mg of methylprednisolone acetate) is given tangentially into the joint under the joint capsule. Fluid may be obtained. Posteriorly, the elbow can be injected at the level just above the olecranon process and at the depression felt at the midline of the back of the elbow.

Figure 5: Injection of elbow joint

The wrist and the hand The wrist is a complex joint that has most of the intercarpal spaces
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Figure 6: Injection of wrist joint

Figure 7: Injection of first carpometacarpal joint

traction to the thumb with another hand may also be useful. It probably would only accommodate about 10 to 20 mg of the methylprednisolone acetate. The technique in injecting the metacarpophalangeal and proximal and distal interphalangeal joints are quite similar. All are small joints, and

therefore, only a small volume of the injected s o l u t i o n (0.3-0.5 ml of methylprednisolone acetate 40 mg/ml) should be given using a fine bore (gauge 25) needle. The finger may be held in a 45 flexed position d u r i n g injection to the metacarpophalangeal and the proximal interphalangeal joints. The joint line should be identified. The needle is

directed tangentially to the joint just underneath the extensor expansion, not aiming to the centre of the j o i n t (Figures 8 and 9). It s h o u l d be noted that the nail bed is very close to the distal inter-phalangeal joint and a misplaced injection can damage the nail bed leading to nail deformity and changes. Distal interphalangeal joint injection is best avoided.
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Figure 8: Injection of metacarpophalangeal joint

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Figure 9: Injection of proximal interphalangeal joint

Conclusion
In conclusion, intra-articular steroid injections should be given only when the diagnosis is certain and for which the injection is warranted. When in doubt, always aspirate the joint before infiltrating it with steroid. Intra-articular steroid injection is a useful treatment technique to acquire for doctors in the field of rheumatology and orthopaedic surgery as well as family medicine. In carefully selected cases with adequate precaution to prevent infection, the

intra-articular injection can give a very gratifying result.

Reference
1. Ho CTK, Lau CS. Intralesional steroid injection general considerations HK Pract 1997;19:425-429.

Allied Conditions 9th edition. Philadelphia, Lea and Febiger, 1979. 2. H o l l a n d e r JL. The l o c a l e f f e c t s of compound F (Hydrocortisonc) injected into joints. Bull Rheum Dis. 1951;2:3. 3. Hollander JL, Jesser RA, Brown FM Jr. Intrasynovial corticosteroid therapy: A decade of use. Bull Rheum Dis. 1961,11:

239.
4. Hollander JL. Arthrocentesis Technique and Intrasynovial Therapy. In: A r t h r i t i s and allied conditions 11th edition. Eds: McCarty. 5. Duncan S. Owen, Jr. Diagnostic tests and procedures in R h e u m a t i c diseases. In: Textbook of Rheumatology 5th edition. Eds: Kelley, Harris, Ruddy, Sledge.

Suggested further reading

1. H o l l a n d e r JL. A r t h r o c e n t e s i s and intrasynovial therapy. In: A r t h r i t i s and

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