Wrist Injection

Other Names

• Wrist Joint Injection
• Radioulnar Joint Injection
• Radiocarpal Joint Arthrocentesis
• Ulnocarpal Joint Aspiration
• Wrist Joint Arthrocentesis
• TFCC Injection

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Background

Articular surfaces of the wrist joint

• This page refers to injections of the wrist joint, this includes both the radiocarpal and ulnocarpal joint
  • This includes both injection and aspiration as the technique and approach are the same

Anatomy

• Radiocarpal Joint
  • Proximally bounded by the distal radius
  • Distally bounded by scaphoid, lunate and triquetrum
• Ulnocarpal Joint
  • Proximally bounded by the distal ulna
  • Distally bounded by the lunate and triquetrum
  • There is an articular disk between the and proximal carpal row

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Aspiration

Indications

• Rule out Septic Arthritis
• Diagnose Gout or other spondyloarthropathy
• Symptomatic relief
• Unexplained joint effusion or monoarthritis

Contraindications

• Absolute
  • No absolute contraindications
• Relative
  • Abnormal or altered anatomy
  • Overlying infection or bacteremia
  • Coagulation
  • Prosthetic joint
  • Uncooperative patient
  • Diagnosis can be made with less invasive method

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Injection

Indications

• Wrist Osteoarthritis
• TFCC Injury

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

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Procedure

Palpation guided radiocarpal injection

Radiocarpal joint injection in plane, short axis. The needle (arrowheads) is passed radial to extensor compartment four. EDC, extensor digitorum, compartment four; ECRB, extensor carpi radialis brevis tendon; Lun, lunate; Sca, scaphoid.

The radiocarpal joint transducer position and normal appearance under ultrasound

Equipment

• Sterile including chloraprep, chlorhexadine, iodine
• Ultrasound with sterile probe cover
• Gloves
• Needle: typically 25 gauge, 0.5-1 inch
• Syringe: 1-3 mL
• Gauze
• Ethyl Chloride
• Bandage
• Injectate
  • Local anesthetic
  • Corticosteroid

Preparation

• Position
  • The patient can lay supine or sit upright
  • Arm is in extension, palm is pronated
  • Wrist should be in mild flexion, typically resting on a towel roll

Radiocarpal Palpation Guided

• Identify the radiocarpal joint space
  • Area of injection is distal to radius between the thumb and index finger extensor tendons
• Mark site, sterile prep area
• Injection
  • Optional: local anesthetic in skin and subcutaneous tissue
  • Advance needle into joint space perpendicular to the skin
  • If bone is hit, pull back and slightly redirect distally
  • Once the needle drops into the radiocarpal space, injection/ aspiration can occur

Ulnocarpal Palpation Guided

• Dorsal approach: Identify the ulnocarpal joint space
  • Area of injection is just distal to ulnar styloid between the fourth and fifth extensor tendons
• Mark site, sterile prep area
• Injection
  • Optional: local anesthetic in skin and subcutaneous tissue
  • Advance needle into joint space perpendicular to the skin
  • If bone is hit, pull back and slightly redirect distally
  • Once the needle drops into the ulnocarpal space, injection/ aspiration can occur
• Alternative medial approach
  • Needle is inserted into the depression distal and slightly palmar to the ulnar styloid
  • Angle 10° to 15° in a cephalad direction

Ultrasound Guided Technique

• Pre-procedure ultrasound evaluation
  • Identify either the radiocarpal or ulnocarpal joint dorsally in long axis
  • For the radiocarpal joint, orient from listers tubercle on the radius
  • The proximal and distal bones should be evaluated for optimal needle approach
  • Wrist flexion can be adjusted to optimize approach
  • It is important to identify a tendon-free region for the needle to transverse
• In-Plane Approach
  • Transducer is maintained in a long axis view
  • Needle approach is typically distal-to-proximal
• Out-of-Plane Approach
  • Transducer remains in long axis
  • Follow needle into space in a step-wise approach

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Aftercare

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

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Complications

• Pain
• Infection
• Recurrence of effusion
• Damage to surrounding soft tissue structures

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See Also

• Procedures Main
• Ultrasound Main
• Wrist Pain Main

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