Is it safe to proceed with the scheduled intra-articular (IA) injection of the right thumb carpometacarpal (CMC) joint given the patient's symptoms and history?

Intra-Articular Injection for Right Thumb CMC Joint: Safety Assessment

It is safe to proceed with the scheduled intra-articular injection for the patient's right thumb CMC joint, but proper technique and precautions should be implemented to ensure optimal outcomes.

Patient Assessment and Considerations

• 63-year-old male with right thumb CMC joint pain
• History of traumatic fall months ago, landing on both palms
• Current symptoms include sharp electrical pain when applying pressure with thumbs
• No contraindications to injection are mentioned in the patient history

Procedure Safety and Recommendations

Pre-Procedure Preparation

• Fully inform the patient about the procedure, potential benefits, risks, and expected outcomes 1
• Set up an optimal environment:
  • Professional, clean, well-lit, private room
  • Patient positioned appropriately on examination table
  • Equipment for aseptic procedures readily available
  • Resuscitation equipment nearby 1, 2

Anesthesia Considerations

• Offer local anesthetic (lidocaine) to reduce procedural discomfort 1, 2
• If using lidocaine, be aware of maximum dosage limitations (should not exceed 4.5 mg/kg of body weight) 3
• Consider warming the local anesthetic to 37°C to reduce infiltration pain 1

Procedural Technique

• Employ strict aseptic technique including:

  • Surgical gloves
  • Skin preparation with alcohol, iodine disinfectant, or chlorhexidine
  • Change needles between drawing medication and injecting 1, 2

• Consider ultrasound guidance if available to improve accuracy 1, 2

  • Ultrasound guidance can reduce procedural pain by 43% and improve outcomes by increasing responder rates by 25.6% compared to landmark-guided injections 4
  • If ultrasound is unavailable, use appropriate anatomical landmarks for the CMC joint

• Aspirate before injecting to:

  • Confirm needle placement
  • Rule out vascular entry
  • Remove any effusion if present 1, 2

Post-Procedure Care

• Advise the patient to avoid overuse of the injected joint for 24 hours following the injection 1
• Complete immobilization is not necessary and may be counterproductive 1
• Schedule follow-up in approximately 30 days to assess treatment response 2

Important Precautions

• Be vigilant about avoiding intra-arterial injection, which can lead to severe complications including paresthesias, severe pain, motor dysfunction, and tissue damage 5
• Ensure proper needle positioning by aspirating before injecting; absence of blood in the syringe does not guarantee avoidance of intravascular injection 3
• Be aware of potential adverse joint events following corticosteroid injections, including:
  • Accelerated osteoarthritis progression
  • Subchondral insufficiency fracture
  • Osteonecrosis complications 6

Conclusion

The patient's history of trauma and current symptoms are consistent with CMC joint pathology that may benefit from an intra-articular injection. The electrical pain described by the patient likely represents irritation of local nerve structures but is not a contraindication to the procedure. With proper technique and precautions, the scheduled injection can safely proceed.