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Distal Radial Ulnar Joint Injection

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Other Names

The components of the distal radioulnar joint[1]
Ultrasound of a normal distal radioulnar joint. Lister’s tubercle (LT) is located on the left side (radial), whereas the ulnar head (UH) is on the right side (ulnar). From left to right, one can see the third extensor compartment (3, extensor pollicis longus), fourth extensor compartment (4, extensor digitorum and extensor indicis proprius), and extensor digiti minimi (EDM, fifth extensor compartment). The DRUJ space lies between the extensor digiti minimi and the ulnar head (asterisk).[2]
  • Distal Radial Ulnar Joint Injection
  • DRUJ Injection

Background

Key Points

  • Use a 25 to 27 gauge, 1 to 1.5 inch needle
  • High frequency linear transducer
  • Don't confuse the distal radioulnar joint with the radiocarpal joint or TFCC
  • Optimal approach is short axis in plane with an ulnar-to-radial vector

Anatomy of the Distal Radioulnar Joint

  • Synovial joint between the distal ends of the radius and ulna
  • Allows for movement in supination and pronation
  • Extensor Digiti Minimi is superficial to the DRUJ acts an important landmark

Palpation Guidance vs Ultrasound Guidance

  • Smith et al: 100% success rate with ultrasound-guided injections into the DRUJ[3]
  • To date, there are no papers comparing palpation guided and ultrasound guided techniques

Indications


Contraindications

  • Absolute
    • Anaphylaxis to injectates
    • Overlying cellulitis, skin lesion or systemic infection
  • Relative
    • Uncertainty in diagnosis
    • Can be treated with less invasive means
    • Hyperglycemia or poorly controlled diabetes
    • Lack of symptom improvement with previous injection

Procedure

Needle and probe position (A), being advanced into the DRUJ (asterisk, B) and peri-injection (C).[2]
Needle and probe position for the out-of-plane approach[1]

Equipment

  • Sterile including chloraprep, chlorhexadine, iodine
  • Gloves
  • Needle: typically 21-25 gauge, 1.5 inch
  • Syringe: 5-10 mL
  • Gauze
  • Ethyl Chloride
  • Bandage
  • Injectate
    • Local anesthetic
    • Corticosteroid
  • Sterile probe cover

Ultrasound Findings

  • Best visualized dorsally in short axis
  • Joint effusions are better seen proximal to the joint where the capsule is less restricted
  • Additional findings include:
    • Synovitis
    • Cortical irregularities
    • Cartilage degeneration

Short Axis, In Plane

  • Patient Position
    • Seated or supine
    • Arm is pronated, resting on table
    • Wrist is slightly flexed (i.e. on a rolled towel)
  • Transducer Position
    • Dorsal wrist
    • Short axis
  • Needle Approach
    • In plane
    • Ulnar to radial
  • Target
    • Distal Radioulnar Joint
  • Pearls and Pitfalls
    • A standoff/ stepoff technique can be used to optimize approach
    • Use the anistropy of the EDM tendon to help advance identification of the joint capsule
    • Do not inject too distally or you will end up in TFCC
    • Do not inject too proximally, you will end up with an extra-articular injection

Short Axis, Out of Plane

  • Patient Position
    • Seated or supine
    • Arm is pronated, resting on table
    • Wrist is slightly flexed (i.e. on a rolled towel)
  • Transducer Position
    • Dorsal wrist
    • Short axis
  • Needle Approach
    • Out of plane
    • Distal to proximal
  • Target
    • Distal Radioulnar Joint
  • Pearls and Pitfalls
    • Place the needle just ulnar to the EDM tendon
    • Avoid placing the needle through the TFCC

Aftercare

  • Apply bandage
  • No major restrictions in most cases
  • Can augment with ice, NSAIDS

Complications

  • Intravascular injection
  • Nerve injury
  • Local trauma

See Also


References

  1. 1.0 1.1 Malanga, Gerard, and Kenneth Mautner. Atlas of ultrasound-guided musculoskeletal injections. McGraw-Hill, 2014.
  2. 2.0 2.1 Smith, Jay, et al. "Sonographically guided distal radioulnar joint injection: technique and validation in a cadaveric model." Journal of Ultrasound in Medicine 30.11 (2011): 1587-1592.
  3. Smith J, Rizzo M, Sayeed YA, Finnoff JT. Sonographically guided distal radioulnar joint injection: technique and validation in a cadaveric model. J Ultrasound Med. 2011;30(11):1587–1592.
Created by:
John Kiel on 11 December 2023 03:07:44
Authors:
Last edited:
27 December 2023 22:24:54
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