What to do about a scheduled intra-articular (IA) injection for the right thumb in a patient experiencing sharp electrical pain when applying pressure with their thumbs?

Management of Right Thumb Pain with Intra-articular Injection

For a patient with sharp electrical pain in the right thumb upon pressure application, an intra-articular glucocorticoid injection is conditionally recommended as it may provide pain relief and functional improvement, especially if the pain is related to inflammatory arthritis of the interphalangeal joints.

Assessment of Thumb Pain

Before proceeding with the scheduled injection, consider:

• Location of pain: Determine if pain is in the thumb base (carpometacarpal joint) or interphalangeal joints
• Character of pain: "Sharp electrical" suggests potential neurological component or acute inflammation
• Provocative factors: Pain with pressure application indicates mechanical stress component
• Presence of swelling, erythema, or limited range of motion

Treatment Algorithm

Step 1: Determine Appropriate Injection Approach

• For interphalangeal joint pain:

  • Intra-articular glucocorticoid injection may be considered 1
  • Evidence supports effectiveness for pain during joint movement and joint swelling in interphalangeal OA 1

• For thumb base (carpometacarpal) pain:

  • Current evidence does not strongly support glucocorticoid injections 1
  • Consider alternative treatments as first-line approach

Step 2: Injection Technique Considerations

• Use ultrasound guidance if available, especially for precise joint targeting 2
• Triamcinolone hexacetonide is strongly recommended over triamcinolone acetonide for better and longer clinical response 1
• Consider fluoroscopic control to ensure accurate intra-articular placement 3

Step 3: Alternative or Adjunctive Treatments

If glucocorticoid injection is not appropriate or patient prefers alternatives:

• Non-pharmacological options:

  • Splints for thumb base OA are recommended (evidence level 67/100) 1
  • Physical therapy with range of motion and strengthening exercises 1
  • Education on joint protection techniques 1

• Pharmacological alternatives:

  • Topical NSAIDs as first-line treatment for localized pain 1
  • Oral NSAIDs for short-term use if no contraindications 1
  • Consider hyaluronic acid injection which may provide longer-lasting relief than corticosteroids 2, 4

Important Considerations and Caveats

• Potential complications: Pain, infection, nerve dysfunction, and skin changes 1

• Timing considerations: If surgery is being considered in the future, avoid injections within 3 months prior as they may increase infection risk 1

• Efficacy duration: Effects of intra-articular glucocorticoid injections are often temporary 1, 4

• Structural concerns: For patients with significant structural abnormalities, consider surgical consultation if conservative treatments fail 1

• Follow-up plan: Re-evaluate at 4-6 weeks post-injection to assess response 1

Conclusion for This Patient

Given the description of sharp electrical pain with pressure, an intra-articular glucocorticoid injection may provide relief if the pain is inflammatory in nature. However, the response may be better for interphalangeal joint involvement than for thumb base (carpometacarpal) OA. Consider ultrasound guidance for the injection to ensure accurate placement, and discuss expectations regarding the potentially temporary nature of relief.