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Interphalangeal Joints Injection

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Other Names

Illustration of the interphalangeal joints of the hand marked in green
  • Interphalangeal Joints Injection of the hand
  • DIPJ injection
  • PIPJ injection
  • Proximal Interphalangeal Joint Injection
  • Distal Interphalangeal Joint Injection

Background

Key Points

  • Needle: 25- to 30- gauge
  • Transducer: High frequency, linear
  • Small joints, can be difficult to access with significant arthritic changes
  • Dorsal approach with flexion can provide better access to joint

Anatomy of the Interphalangeal Joints

  • Represent the two distal hinges of the fingers.
  • DIP joint connects distal phalanx to middle phalanx
  • PIP joint connects middle phalanx to proximal phalanx
  • Stabilized by the collateral ligaments, dorsal extensor and volar flexor ligament complex

Palpation Guidance vs Ultrasound Guidance

  • Success rate without ultrasound varies from 15-32% in one study[1]
  • Raza et al: Ultrasound guidance increases accuracy of needle placement (59% vs 96%) and aspiration (0% vs 63%)[2]

Indications


Contraindications

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

Procedure

Needle and probe position for long axis, out of plane approach[3]
Ultrasound view of long axis, out of plane approach. Needle tip is marked by arrow[3]
Needle and probe position for long axis, in plane approach[3]
Ultrasound view of long axis in plane. Joint is marked by arrow[3]

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 in long axis using a high frequency, linear transducer
  • Place over the IPJ in long axis
  • Can also evaluate in short axis

Technique: Long Axis, Out of Plane

  • Patient position
    • Supine or seated
    • Palm down with dorsal finger exposed
    • Towel or rolled object in hand for the patient to grip
  • Transducer position
    • Long axis to joint
  • Needle Approach/ Orientation
    • Out of plane
  • Target
    • Interphalangeal Joint Capsule
  • Pearls and Pitfalls
    • Color doppler can be used to avoid the digital nerves and arteries

Technique: Long Axis, In Plane

  • Patient position
    • Supine or seated
    • Palm down with dorsal finger exposed
    • Towel or rolled object in hand for the patient to grip
  • Transducer position
    • Long axis to joint
  • Needle Approach/ Orientation
    • In plane
  • Target
    • Interphalangeal Joint Capsule
  • Pearls and Pitfalls
  • Color doppler can be used to avoid the digital nerves and arteries

Aftercare

  • No significant restrictions
  • Can augment with ice, NSAIDS
  • Consider placement in a Thumb Spica Splint

Complications

  • Skin: Subcutaneus fat atrophy, skin atrophy, skin depigmentation
  • Painful local reaction
  • Infection
  • Hyperglycmia
  • Tendon, nerve or blood vessel injury

See Also


References

  1. Pichler W, Grechenig W, Grechenig S, et al. Frequency of successful intra-articular puncture of finger joints: influence of puncture position and physician experience. Rheumatology. 2008;47: 1503–1505.
  2. Raza K, Lee CY, Pilling D, et al. Ultrasound guidance allows accurate needle placement and aspiration from small joints in patients with early inflammatory arthritis. Rheumatology. (Oxford) 2003;42:976–979.
  3. 3.0 3.1 3.2 3.3 Malanga, Gerard, and Kenneth Mautner. Atlas of ultrasound-guided musculoskeletal injections. McGraw-Hill, 2014.
Created by:
John Kiel on 1 February 2024 16:23:59
Authors:
Last edited:
6 February 2024 17:02:38
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