Joint injection pharmacology and procedure

Written by Dr Deepak Jadon, 5th year Specialist Trainee in Rheumatology and General Medicine

Indications for joint injection

The introduction of corticosteroids and local anaesthetic can be particularly effective for the treatment of symptoms
from the joint and para-articular structures. It allows the clinician to focus the anti-inflammatory effect of
corticosteroids to one site, thus minimising systemic adverse effects.

Injections can be done directly into a synovial space or surrounding soft tissue structure. In broad terms, a
corticosteroid injection is indicated for an inflamed:

• synovial joint
• bursa
• enthesis
• tendon sheath
• ligament
• ganglion
• inflammatory cyst
• nerve sheath

Absolute contraindications for injection:

1. Joint/ bursal sepsis

2. Cellulitis of overlying skin
3. Overlying skin disease, such as a psoriatic plaque
4. Acute fracture
5. Systemic sepsis or pyrexia of unknown origin
6. Sickle cell disease
7. Previous allergic reaction

Relative contraindications:

1. Thrombocytopaenia
2. Warfarin use with a significantly elevated INR
• An INR of <3 is preferable for medium/ large joints
• A higher INR may be tolerated for small joints, such as PIPJs or trigger finger, where significant external
pressure can be applied to achieve haemostasis
• Try to use the smallest feasible needle
4. Bleeding disorders
5. Markedly elevated blood glucose due to diabetes
Potential complications of injections

1. Post-injection flare of inflammatory symptoms for 48 hours. This may be due to crystallisation of the
corticosteroid resulting in a crystal synovitis or alternatively the initial short-acting local anaesthetic
effect has worn off. The flare may be managed with a short course of NSAIDs.
2. Septic arthritis, risk is approximately 1:10,000 to 1:15,000
3. Subcutaneous fat atrophy due to tracking of corticosteroid along the needle track. This often recedes
with time.
4. Tissue depigmentation
5. Tissue telangiectasia or flushing
6. Bruising
7. Anaphylaxis or vasovagal reaction
8. Tendon atrophy/ rupture
9. Aseptic necrosis of the joint surface due to infarction of the subchondral bone (hips and knees in RA
patients)
10. Cartilage damage
11. Hypertension
12. Elevated blood sugars, particularly to be wary in diabetics
13. Heart failure
14. Insomnia

The risk of the above complications, especially tissue atrophy, cartilage damage and AVN, may be minimised by not
injecting any one joint more than four times a year, trying to keep at least 3-4 months in between injections.

PHARMACOLOGY

Corticosteroids

There are no large randomised double-blind prospective controlled trials comparing different corticosteroid
preparations for both efficacy and toxicity.

Three corticosteroid agents are used in common practice.

1. Hydrocortisone acetate
• A typical dose is 25 mg
• Short acting
• Weak anti-inflammatory effect
• May be used for superficial injections, such as trigger finger, de Quervain’s tenosynovitis
and small joints of the hands/ feet, as it carries a lower risk of soft tissue atrophy and depigmentation

2. Methylprednisolone acetate
• A typical dose is 20 mg for small joints (of the hands/ feet), 40 mg for medium joints (wrists, elbows,
greater trochanteric bursa) and 80 mg for larger joints (knees, ankles, shoulders)
• Long acting
• Strong anti-inflammatory effect
• May also be used for superficial injections, such as trigger finger, de Quervain’s tenosynovitis and
small joints of the hands/ feet, as it carries a lower risk of soft tissue atrophy and depigmentation

3. Triamcinolone acetonide
• A typical dose is 40 mg
• Very long acting due to its limited solubility
• Particularly strong anti-inflammatory effect
• Only use in medium/ large joints due to the higher risk of tissue atrophy and depigmenation associated with this agent
Local anaesthetic

Local anaesthetics have four key functions for joint injections. Firstly, they provide some immediate relief after
injection, allowing time for the corticosteroid to take affect (approximately 48 hours). Secondly, they act as a carrier
to allow wide dispersion of the corticosteroid in the joint/ soft tissue. Their dilutional effect may reduce the risk of
tissue atrophy. Lastly, they may reduce the impact of a post-injection flare.

There is a risk of flocculation when the corticosteroid is mixed with lidocaine, due to the presence of parabens
in the lidocaine solution. Such floculation may reduce the efficacy of injection and linger in the joint to cause an
inflammatory reaction. Premixed vials are now available which reduce this risk.

Two local anaesthetic agents are used in common practice.

1. Lidocaine
• Usually 1% concentration
• Short-acting agent
• Provides quick relief
• The volume used will vary according to the size of the joint and status of the patient.
The following are possible, but not definitive, amounts that may be used:
o Small joint 0.5-1.0 mL
o Medium joint 1-2 mL
o Large joint 3-5 mL

2. Bupivacaine (Marcaine)
• Long-acting agent
• Mainly used for occipital nerve blocks and trigger point injections

It is standard practice to advise the patient to rest the joint for 48 hours. Although some clinicians still recommend
splinting of the joint, this can be impractical in real life. The reason for joint immobilisation is to limit the vascularity
associated with use and reduce drainage via the lymphatic system. Thus, the corticosteroid remains in situ for longer
to provide anti-inflammatory effect and minimises systemic transmission.

INJECTION PROCEDURE

Aseptic technique is not needed as research and experience suggests that non-touch technique is sufficient. The
choice to wear gloves is individual, and is unlikely to alter outcome as long as the needle or site of injection is not
touched once cleaned. A clinician may wish to wear gloves for one’s own protection.

A possible routine may include:

• Obtain verbal consent after an explanation of the procedure, indications and adverse effects
• Mark the site of injection with a cross-hair produced with a fingernail or needle bezel
• Wash hands
• Use a syringe appropriate to the volume to be instilled. A 5 mL syringe will suffice for most injections.
Using a similar sized syringe each time may allow the operator to recognise the resistance when
injecting, thus allowing differentiation between subcutaneous, intra-articular or tendinous injections.
Some micro- crystalline suspensions are difficult to inject through very fine needles, irrespective of
correct/ incorrect positioning of the needle
• Draw up the corticosteroid and local anaesthetic using a green needle. Change the needle for the
purpose of injection
o 21 gauge green needle for large joints (shoulder, knees)
o 23 gauge blue needle for medium joints (wrists, elbows, ankles, GTB)
o 25 gauge orange needle for small joints (PIPJ, MCPJ, trigger finger, tendon sheaths)
o Diabetic needle for small joints (PIPJ, MCPJ, trigger finger, tendon sheaths)

• Clean the skin with an alcohol steret or 2% chlorhexidine solution

• Administer surface analgesia using a cryogesic or local anaesthetic spray
• Insert the fresh needle-syringe into the target site. Do not guide the needle with your finger.
• Aspirate back to:
o ensure that frank blood is not aspirated, indicating venous/ arterial puncture
o ensure one is in the joint when synovial fluid is aspirated
o drain an effusion if present
o Often it is not possible to aspirate fluid from small joints
• Inject the corticosteroid-anaesthetic preparation
o Too little resistance to injection suggests an incorrect subcutaneous injection
o Medium resistance suggests correct injection into a high pressure joint space
o Too much resistance implies the wrong space, perhaps into bone, cartilage or tendon

• Withdraw the needle and apply pressure to achieve haemostasis

• Dispose of sharp instruments
• Apply a plaster
• Provide aftercare advice and rest the joint for 48 hours