Intra-Articular Injection of the Interphalangeal Joints

Indications and Clinical Considerations

The interphalangeal joint is susceptible to developing arthritis from a variety of conditions that all have the ability to damage joint cartilage. Osteoarthritis of the joint is the most common form of arthritis that results in interphalangeal joint pain. However, rheumatoid arthritis, posttraumatic arthritis, and psoriatic arthritis also are common causes of interphalangeal pain secondary to arthritis ( Figs. 92.1 and 92.2 ). Less common causes of arthritis-induced interphalangeal joint pain include collagen vascular diseases, infection, crystal deposition disease, and Lyme disease ( Fig. 92.3 ). Acute infectious arthritis usually is accompanied by significant systemic symptoms, including fever and malaise, and should easily be recognized by the astute clinician and treated appropriately with culture and antibiotics rather than injection therapy. The collagen vascular diseases generally manifest as a polyarthropathy rather than a monoarthropathy limited to the interphalangeal joint, although interphalangeal pain secondary to collagen vascular disease responds exceedingly well to the intra-articular injection technique described later.

The majority of patients with interphalangeal joint pain secondary to osteoarthritis and posttraumatic arthritis pain report pain localized to the region of the interphalangeal joints. Activities, especially those with gripping and pinching motions, will exacerbate the pain; rest and heat provide some relief. The pain is constant and is characterized as aching and may interfere with sleep. Some patients note a grating or “popping” sensation with use of the joint; crepitus may be present on physical examination. Swelling of the joints commonly occurs, with enlargement of the distal interphalangeal joints (called Heberden nodes ) and enlargement of the proximal interphalangeal joints (called Bouchard nodes ) ( Figs. 92.4 and 92.5 ).

In addition to the previously mentioned pain, patients with arthritis of the interphalangeal joint often experience a gradual decrease in functional ability with decreasing grip strength, making everyday tasks, such as turning a doorknob or opening a jar, quite difficult. With continued disuse, muscle wasting may occur, and an adhesive capsulitis with subsequent ankylosis may develop.

Plain radiographs are indicated for all patients with interphalangeal pain. On the basis of the patient’s clinical presentation, additional testing may be indicated, including complete blood cell count, sedimentation rate, and antinuclear antibody testing. Magnetic resonance imaging and/or ultrasound imaging of the interphalangeal joints is indicated if joint instability is suspected ( Fig. 92.6 ).

Clinically Relevant Anatomy

The interphalangeal joints are synovial hinge-shaped joints that serve as the articulation between the phalanges ( Fig. 92.7 ). Their primary role is to optimize the gripping function of the hand. The joint allows flexion and extension. It is lined with synovium, and the resultant synovial space allows intra-articular injection. The joint is covered by a capsule that surrounds the entire joint and is susceptible to trauma if the joint is subluxed. Volar and collateral ligaments help strengthen the joints; the palmar ligaments are particularly strong.