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Scaphotrapeziotrapezoidal Joint Injection

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Other Names

Illustration of the Scaphotrapeziotrapezoidal Joint[1]
  • Scaphotrapeziotrapezoidal Joint Injection
  • Triscaphe Joint Injection
  • STT Joint injection

Background

Key Points

  • Use a high frequency, linear transducer
  • Needle should be 25 gauge, 1-1.5 inch

Anatomy of the Scaphotrapeziotrapezoidal Joint

Palpation Guidance vs Ultrasound Guidance

  • Palpation guided injection of the STT joint have not been well described
    • Author commentary: unlikely you can predictably enter joint by palpation guidance
  • Smith et al: palmer approach with ultrasound was 100% accurate, palpation guided dorsal approach was 80%[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 palmer approach[3]
Ultrasound view with needle trajectory for palmer approach[3]
On ultrasound the needle is an echogenic dot (horizontal arrows) between the scaphoid (SCPH) and trapezium (TRZ). Also seen are the carpometacarpal joint (CMC) to the right of the STT joint (STT JT), and the flexor carpi radialis tendon (FCR). Bottom is deep; left, proximal; right, distal; and top, superficial.[4]
Demonstration of the palpation guided, dorsal approach[2]

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

  • Using the palmer approach, the palm should be up
  • Place the transducer in long axis with the thumb metacarpal
    • Slide the transducer proximally to identify the CMC joint
    • As you continue proximal translation, the STT joint comes into view
    • Center the joint space between the scaphoid and trapezium

Technique Palmer Approach: Long Axis, Out-of-plane

  • Patient position
    • Seated or supine
    • Palm up
  • Transducer position
    • Long axis to the thumb metacarpal
  • Needle Approach/ Orientation
    • Out of plane
    • Radial to ulnar
    • Use a step down technique
  • Target
    • Palmer aspect of STT joint, specifically the scaphoid-trapezium space
  • Pearls and Pitfalls
    • Anesthetic will disperse through other metacarpal joints
    • Avoid the superficial palmer branch of the radial artery

Technique Dorsal Approach: Long Axis, Out-of-plane

  • Patient position
    • Seated or supine
    • Palm down
  • Transducer position
    • Radial to the extensor pollicis longus tendon, anatomic snuffbox
    • Long axis to the thumb metacarpal
  • Needle Approach/ Orientation
    • Out of plane
    • Radial to ulnar
    • Use a step down technique
  • Target
    • Dorsal aspect of STT joint, specifically the scaphoid-trapezium space
  • Pearls and Pitfalls
    • Identify and avoid the superficial branch of the radial nerve
    • Identify and avoid the dorsal carpal arch

Technique Dorsal Approach: Palpation Guided

  • Patient position
    • Seated or supine
    • Palm down
  • Identify Landmarks
    • Palpate the STT joint just radial to the extensor pollicis longus tendon at the base of the anatomic snuff box.
    • Palpate the radial artery to determine course
    • Mobilize the thumb metacarpal-phalangeal joint to ensure that the STT joint is being palpated and not the carpometacarpal joint.
  • Needle Approach/ Orientation
    • Advance the needle perpendicular to the skin in a palmar direction until the capsule is felt to be penetrated by feeling a distinct puncture.
  • Target
    • Dorsal aspect of STT joint
  • Pearls and Pitfalls
    • Take care to avoid puncture of the radial artery

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. Anakwe, R. E., and S. D. Middleton. "Osteoarthritis at the base of the thumb." BMJ 343 (2011).
  2. 2.0 2.1 Smith J, Brault JS, Rizzo M, Sayeed YA, Finnoff JT. Accuracy of sonographically guided and palpation guided scaphotrapeziotrapezoid joint injections. J Ultrasound Med. 2011;30(11): 1509–1515.
  3. 3.0 3.1 Malanga, Gerard, and Kenneth Mautner. Atlas of ultrasound-guided musculoskeletal injections. McGraw-Hill, 2014.
  4. Smith et al.. Accuracy of sonographically guided and palpation guided scaphotrapeziotrapezoid joint injections. Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine 2011. 30:1509-15. PMID: 22039023. DOI
Created by:
John Kiel on 22 January 2024 15:28:58
Authors:
Last edited:
22 January 2024 16:38:24
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