Ulnar Wrist Injection for Arthritis
For ulnar-sided wrist arthritis, use intra-articular triamcinolone hexacetonide at 20 mg as the preferred corticosteroid agent, as it provides superior and more durable clinical responses compared to triamcinolone acetonide. 1, 2
Preferred Corticosteroid Agent
Triamcinolone hexacetonide is strongly recommended over triamcinolone acetonide based on moderate-quality evidence from randomized trials and large observational studies demonstrating more complete and longer duration of clinical response without increased adverse effects 1, 2
If triamcinolone hexacetonide is unavailable (it has been commercially unavailable in the US for several years), use triamcinolone acetonide as an alternative, though expect shorter duration of benefit 2
Dosing Recommendations
For wrist joints, 20 mg of triamcinolone hexacetonide is appropriate, though a randomized controlled trial found that both 20 mg and 40 mg doses showed equivalent effectiveness in rheumatoid arthritis wrist injections with no statistical difference between them 3
For triamcinolone acetonide specifically, 10 mg appears sufficient for wrist arthritis, as a prospective randomized study found no significant difference in pain relief, power doppler improvement, or functional outcomes between 10 mg and 20 mg doses 4
Expected Clinical Response
Intra-articular glucocorticoid injections should result in clinical improvement lasting at least 4 months 1
A shorter duration of clinical response implies the need for escalation of systemic therapy rather than repeated injections 1
Pain relief is typically rapid, with significant improvement demonstrated at 4 weeks and maintained through 12 weeks in rheumatoid arthritis patients 4, 5
Injection Frequency and Limitations
Limit injections to no more than one every 6 weeks and no more than 3-4 injections per year in the same joint to minimize risk of cartilage damage and progressive joint destruction 6
Injections that provide at least 4 months of benefit may be repeated as needed 1
When multiple joints require injection or when joints have been injected multiple times, escalation to systemic therapy is preferred over continued local injections 1
Clinical Indications for Prioritizing Injection
Strongly consider intra-articular injection when:
- Arthritis is preventing ambulation or interfering with important daily activities 1
- More prompt disease control is needed 1
- Patient has active monoarthritis or oligoarthritis in the context of polyarticular disease 1
Role as Adjunct Therapy
Intra-articular glucocorticoids are conditionally recommended as adjunct therapy regardless of concurrent systemic treatment (no DMARD, non-biologic DMARD, or biologic DMARD) 1
For patients with low disease activity, intra-articular injection is preferable to systemic bridging glucocorticoid therapy 1
Important Safety Considerations
Always rule out infection prior to injection and use strict aseptic technique to avoid iatrogenic septic arthritis 6
Avoid injection within 3 months of planned joint replacement surgery due to theoretical infection risk 7
Triamcinolone hexacetonide can cause local tissue necrosis when injected outside a synovial cavity, so it should only be used by experienced clinicians 6
Long-term concerns include potential effects on cartilage, bone health, and joint structure, though clinical significance remains debated as cartilage changes have not been associated with worsening pain or function 7, 2
Prophylactic Use
- In the specific context of distal radius fractures, prophylactic betamethasone injection in the dorsoulnar wrist before reduction decreases severity of ulnar-sided wrist pain and improves grip strength and functional scores, though the effect on complete pain resolution may not persist beyond 3 months 8