Can we proceed with intra‑articular triamcinolone injection of the right thumb metacarpophalangeal and interphalangeal joints in a 40‑year‑old male after reviewing his laboratory results?

Can We Proceed with Intra-Articular Triamcinolone Injection of the Right Thumb MCP and IP Joints?

Yes, you can proceed with intra-articular triamcinolone injection of the right thumb metacarpophalangeal and interphalangeal joints in this 40-year-old male, provided you have confirmed an appropriate diagnosis, ruled out contraindications (particularly infection), obtained informed consent, and reviewed his laboratory results to exclude diabetes or other relevant contraindications. 1

Pre-Procedure Requirements

Diagnostic Confirmation and Contraindication Screening

• An appropriate diagnosis must be established before proceeding – intra-articular steroids should not be administered unless contraindications have been ruled out. 1

• Rule out active infection – this is the most critical contraindication. Do not inject if there is any suspicion of septic arthritis or local infection. 1, 2

• Review the laboratory results specifically for:

  • Glucose levels if diabetic or pre-diabetic (see below)
  • Signs of infection (elevated WBC, inflammatory markers if obtained)
  • Coagulation parameters if on anticoagulation (though not an absolute contraindication unless bleeding risk is high) 1

Indication Assessment for Thumb Joints

• For hand osteoarthritis: Intra-articular glucocorticoid injections should not generally be used, but may be considered in patients with painful interphalangeal joints. 1

• For rheumatoid arthritis: Intra-articular injections are appropriate for residual active joints as part of therapy adjustment. 1

• The aim must be to improve patient-centered outcomes such as pain relief, not simply to improve function in joints without pain. 1

Informed Consent Process

• The patient must be fully informed of the nature of the procedure, the injectable (triamcinolone), potential benefits, and risks; informed consent should be obtained and documented according to local habits. 1

• Essential information to deliver includes:

  • Nature of the procedure
  • Potential benefits (pain relief, reduced inflammation)
  • Side effects (injection-site soreness affects approximately 13% of patients, transient pain relief typically lasting days to weeks) 3, 4
  • Post-injection care instructions 1

Special Considerations Based on Laboratory Review

Diabetes Management

• If the patient is diabetic, especially with suboptimal control, inform him about the risk of transient increased glycemia following intra-articular glucocorticoid injection. 1, 4

• Advise monitoring glucose levels particularly from the first to third day post-injection – blood glucose levels increase during days 1-3 post-injection. 1, 4

Anticoagulation Status

• Intra-articular therapy is not a contraindication in people with clotting/bleeding disorders or taking antithrombotic medications, unless bleeding risk is high. 1

Procedural Execution

Optimal Setting Requirements

• Professional, clean, quiet, private, well-lit room 1

• Patient positioned appropriately, ideally on a couch/examination table that can lie flat 1

• Equipment for aseptic procedures must be available 1

• Resuscitation equipment should be close by (vasovagal reactions occur in 2.6% of cases) 1, 5

Injection Technique

• Strict aseptic technique must always be undertaken to prevent septic arthritis (current risk estimated at 0.035%, or 3 per 7,900 procedures). 1, 2

• For thumb MCP and IP joints, the initial dose is 2.5 mg to 5 mg for smaller joints. 6

• Consider offering local anesthetic, explaining pros and cons – this can reduce discomfort during the procedure. 1

• Accuracy depends on joint size and clinician expertise – for small joints like thumb MCP and IP, ultrasound guidance may improve accuracy if available, though it is not mandatory. 1

Post-Injection Instructions

Activity Modification

• Advise the patient to avoid overuse of injected joints for 24 hours following injection; however, immobilization is discouraged. 1, 4

Expected Outcomes and Follow-Up

• Counsel the patient that benefit is expected for approximately 6 weeks but not beyond – corticosteroid injections provide relatively short-lived benefit. 3, 4

• Evidence supports efficacy at 1 and 4 weeks, but not at 12 and 24 weeks. 4

• The decision to reinject should consider benefits from previous injections and other individualized factors (treatment options, compound used, systemic treatment, comorbidities). 1, 4

• Limit injections to the same joint – it is recommended that corticosteroid injections into the same joint be limited to no more than 1 injection every 6 weeks and no more than 3 to 4 in 1 year to minimize risk of cartilage damage. 2

Common Pitfalls to Avoid

• Do not proceed without confirming diagnosis – injecting without appropriate diagnosis increases risk of adverse outcomes and treatment failure. 1

• Do not inject if infection is suspected – this is the most serious contraindication and can lead to iatrogenic septic arthritis. 1, 2

• Do not inject into surrounding tissues – ensure accurate intra-articular placement to avoid tissue atrophy. 6

• Do not forget to counsel diabetic patients about glucose monitoring – failure to do so may result in uncontrolled hyperglycemia. 1, 4