Injection of the first carpometacarpal joint

May 27, 2008

Hand function may be hampered by osteoarthritis inthe first carpometacarpal joint. When a patient experiences pain thatis not relieved by conservative therapies, a corticosteroid injectionis indicated. Examination findings may include tenderness tocompression and limited range of motion. Radiographic changesinclude joint-space narrowing and periarticular bony sclerosis. Thejoint space may be palpated at the palmar side of the tendons orwithin the snuffbox at its most distal end. If insertion of the needle isdifficult, traction should be applied to the thumb. Careful positioningis vital to avoid injection of the more proximal portion of the anatomicsnuffbox because it contains the radial artery and superficial radialnerve. (J Musculoskel Med. 2008;25:295-296)

Hand function may be hampered by osteoarthritis in the first carpometacarpal joint. When a patient experiences pain that is not relieved by conservative therapies, a corticosteroid injection is indicated. Examination findings may include tenderness to compression and limited range of motion. Radiographic changes include joint-space narrowing and periarticular bony sclerosis. The joint space may be palpated at the palmar side of the tendons or within the snuffbox at its most distal end. If insertion of the needle is difficult, traction should be applied to the thumb. Careful positioning is vital to avoid injection of the more proximal portion of the anatomic snuffbox because it contains the radial artery and superficial radial nerve. (J Musculoskel Med. 2008;25:295-296)

The base of the thumb (first carpometacarpal [CMC] joint) is a common site of osteoarthritis (OA), which may adversely affect hand function. Proper CMC joint function is critical for the fine, dexterous hand movements that are required for activities of daily living because it allows for the "opposition" movement of the thumb.

A corticosteroid injection is indicated when a patient experiences pain at the CMC joint that is not relieved by conservative therapies. These may include analgesics and analgesic creams, NSAIDs, and temporary immobilization with a thumb splint.

Examination findings may include tenderness to compression of the CMC joint, limited range of motion, crepitation, a bony prominence resulting from osteophyte formation, and radial subluxation of the base of the first metacarpal. Radiographic changes of CMC joint OA include joint-space narrowing and periarticular bony sclerosis.

This article is the eighth in a 12-part series on the most frequently injected joints and bursae. Here we discuss injection of the first CMC joint.

Suggested supplies

• 3-mL syringe with 27-gauge ?⁄?- to 1-inch needle; 0.5 to 1 mL of 1% lidocaine for anesthetic.
• 3-mL syringe with 25-gauge 1-inch needle; 5 to 10 mg of prednisone equivalents (we prefer 5 to 10 mg of a nonfluorinated corticosteroid, such as methylprednisolone) admixed with 0.5 mL of 1% lidocaine.
• Alcohol wipes, povidone-iodine, or chlorhexidine for sterilization.
• Local anesthesic: ethyl chloride topical spray (optional).
• Needle cap or ballpoint pen to mark the site of insertion.
• Nonsterile or sterile gloves.
• Gauze pads and bandage.

 

Surface anatomy

The groove of the first CMC joint space is palpated between the trapezium and the first metacarpal at the distal palmar border of the anatomic snuffbox, which is bounded by the extensor pollicis brevis (EPB) and abductor pollicis longus (APL) and is identified by actively extending the thumb. The joint space may be palpated at the palmar side of the tendons when the hand is in a supine position or within the snuffbox at its most distal end with the thumb slightly flexed into the palm.

Patient position

The thumb is opposed against the fifth digit. The joint line is palpable on either side of the EPB and APL tendons.

Procedure

After sterilization and application of local anesthetic, the 25-gauge needle enters the CMC joint at the base of the first metacarpal on whichever side of the APL and EPB tendons it is more easily palpated (Figure). If insertion of the needle is difficult, apply traction to the thumb; once the needle falls into the joint space, infiltrate with anesthetic and corticosteroid.

 

Figure –

To inject the first carpometacarpal joint, insert the needle at the base of the first metacarpal on whichever side of the abductor pollicis longus and extensor pollicis brevis tendons palpation is easier.

 

Pearls

• Careful positioning is vital to avoid injection of the more proximal portion of the anatomic snuffbox because it contains the radial artery and superficial radial nerve. To accomplish this, insert the needle on the palmar border of the anatomic snuffbox or, when injecting within the snuffbox, as close as possible to the bony edge of the first metacarpal.

 

Therapeutic agents mentioned in this article:
Methylprednisolone
Prednisone


References:

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