Intra-Articular Injection of the Wrist Joint

Indications and Clinical Considerations

The wrist joint is susceptible to developing arthritis from a variety of conditions that all have the ability to damage the joint cartilage. Osteoarthritis of the joint is the most common form of arthritis that results in wrist joint pain. However, rheumatoid arthritis, posttraumatic arthritis, and psoriatic arthritis also are common causes of wrist pain secondary to arthritis. Less common causes of arthritis-induced wrist pain include the collagen vascular diseases, infection, and Lyme disease. 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 wrist joint, although wrist pain secondary to collagen vascular disease responds exceedingly well to the intra-articular injection technique described later.

The majority of patients with wrist pain secondary to osteoarthritis and posttraumatic arthritis pain complain of pain that is localized around the wrist and hand ( Fig. 76.1 ). Activity makes the pain worse; rest and heat provide some relief. The pain is constant and is characterized as aching. The pain may interfere with sleep. Some patients report a grating or “popping” sensation with use of the joint, and crepitus may be present on physical examination.

In addition to the previously mentioned pain, patients with arthritis of the wrist joint often experience a gradual decrease in functional ability with decreasing wrist range of motion, making simple everyday tasks, such as using a computer keyboard, holding a coffee cup, or turning a doorknob, quite difficult. With continued disuse, muscle wasting may occur, and an adhesive capsulitis with subsequent ankylosis may develop ( Fig. 76.2 ).

Plain radiographs are indicated for all patients with wrist 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. Ultrasound and Doppler imaging may help identify wrist disease responsible for the patient’s pain ( Figs. 76.3 and 76.4 ). Magnetic resonance imaging and/or ultrasound imaging of the wrist is indicated if joint instability is suspected.

Clinically Relevant Anatomy

The wrist joint is a biaxial, ellipsoid-type joint that serves as the articulation between the distal end of the radius and the articular disk above and the scaphoid, lunate, and triquetral bones below ( Figs. 76.5 and 76.6 ). The joint’s primary role is to optimize hand function by allowing flexion and extension as well as abduction, adduction, and circumduction. The joint is lined with synovium, and the resultant synovial space allows intra-articular injection, although the septa within the synovial space may limit the flow of injectate. The entire joint is covered by a dense capsule attached above to the distal ends of the radius and ulna and below to the proximal row of metacarpal bones. The anterior and posterior joint is strengthened by the anterior and posterior ligaments, with the medial and lateral ligaments strengthening the medial and lateral joint, respectively. The wrist joint also may become inflamed as a result of direct trauma or overuse of the joint.

The wrist joint is innervated primarily by the deep branch of the ulnar nerve, as well as by the anterior and posterior interosseous nerves. Anteriorly, the wrist is bounded by the flexor tendons and the median and ulnar nerves; posteriorly, the wrist is bounded by the extensor tendons; and laterally, the radial artery can be found. The dorsal branch of the ulnar nerve runs medial to the joint, and frequently this nerve is damaged when the distal ulna is fractured.