1003
Short report letters
van Schoonhoven J, Fernandez DL, Bowers WH, Herbert TJ. Salvage of failed resection arthroplasties of the distal radioulnar joint using a new ulnar head prosthesis. J Hand Surg Am. 2000, 25: 438–46.
A. Kaempfen1,2 and G. Smith1 1Department
for Plastic Surgery, Great Ormond Street Hospital for Children, London, UK 2Clinic for Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital and University Children’s Hospital Basel, Basel, Switzerland Corresponding author: [email protected]
© The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav doi: 10.1177/1753193414559494 available online at http://jhs.sagepub.com
Accuracy of clinical assessment in intra-articular positioning for injections of the hand and wrist Dear Sir,
Figure 1. Final situation after wrapping.
APL: abductor pollicis longus; BR: brachioradialis; PQ: pronator quadratus; RA: radial artery; SBRN: superficial branch of radial nerve.
Acknowledgements Ms Julia Ruston.
Conflict of interests None declared.
Informed consent The patient and his mother have been informed and have signed the informed consent form for publishing in Journal of Hand Surgery.
References Burke CS, Gupta A, Buecker P. Distal ulna giant cell tumor resection with reconstruction using distal ulna prosthesis and brachioradialis wrap soft tissue stabilization. Hand. 2009, 4: 410–4. Gupta A. CHAPTER 32 - Brachioradialis Wrap: A New Method of Stabilizing the Distal Radioulnar Joint. Principles and Practice of Wrist Surgery. Philadelphia, WB Saunders, 2010: 359–61.
Intra-articular injections are routinely performed for therapeutic effect in painful joints of the hand and wrist in a wide range of clinical settings, commonly without image guidance. The difficulty in accurate intra-articular needle placement when using clinical assessment alone, even for the larger joints of the body, has long been appreciated (Smith et al., 2011). In a meta-analysis of comparative studies, ultrasound-guided injections to the wrist resulted in greater reductions in pain and a greater likelihood of achieving a clinically significant improvement in symptoms, compared with clinical assessment alone, at 1 to 6 weeks follow-up (Dubreuil et al., 2013). The complication rate (skin hypopigmentation, fat atrophy and crystal deposition) doubles with peri-articular injection (Lopes et al., 2008). Accurate placement of the needle in the joint contributes in achieving the desired therapeutic benefit and reduces the incidence of complications. Fluoroscopic guidance is frequently used by hand surgeons performing joint injections. The aim of the study was to determine the accuracy of clinical assessment alone in achieving intra-articular positioning for a wide range of hand and wrist joint injections and compare this with the accuracy achieved using fluoroscopic guidance. Data was collected prospectively over 12 months. All injections were undertaken in the operating theatre under aseptic technique in conscious patients and were performed by two Consultant Hand Surgeons, three senior Registrars and one Core Surgical
Downloaded from jhs.sagepub.com at UNIV OF FLORIDA Smathers Libraries on November 16, 2015
1004
The Journal of Hand Surgery (Eur) 40(9)
Trainee. The injection technique was standardized. The needle was placed into the position clinically assessed to be intra-articular using anatomical landmarks. The needle was advanced until there was a perceived puncture of the joint space. The accuracy of needle placement was then assessed with fluoroscopy using orthogonal views. If an intra-articular position had not been achieved using clinical assessment alone then fluoroscopy was used to achieve this. The joint was then injected with a prepared mixture of local anaesthetic and corticosteroid. Our standardized technique for each joint is described in detail in Appendix 1 (available online). The data were collected and entered onto Excel (Microsoft, Seattle, WA, USA) and analysed. Fischer’s exact test was used in the statistical analysis. A total of 50 joint injections were performed in 37 patients (26 women and 11 men) with a mean age of 59 years. The aetiology was primary osteoarthritis (40 injections), post-traumatic osteoarthritis (four) and post-traumatic pain (six). The mean patient follow-up time was 6.5 months (range 2 to 11). Four joints had further injections (two thumb carpometacarpal (CMC) joints, two interphalangeal joints); seven joints underwent operative management (four trapeziectomies, one fusion of the little finger CMC joint and two distal interphalangeal joint fusions). One case of hypopigmentation of the skin occurred as a delayed complication on routine review of all patients in the outpatient clinic at 6 weeks post-injection. The distribution and accuracy of the intraarticular injections is shown in Table 1. The overall accuracy using clinical assessment alone was 48%. When intra-articular positioning using clinical assessment failed, subsequent positioning using fluoroscopy was always successful. Accurate localization using clinical assessment alone was significantly lower than that achieved when using fluoroscopy (p
Short report letters
van Schoonhoven J, Fernandez DL, Bowers WH, Herbert TJ. Salvage of failed resection arthroplasties of the distal radioulnar joint using a new ulnar head prosthesis. J Hand Surg Am. 2000, 25: 438–46.
A. Kaempfen1,2 and G. Smith1 1Department
for Plastic Surgery, Great Ormond Street Hospital for Children, London, UK 2Clinic for Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital and University Children’s Hospital Basel, Basel, Switzerland Corresponding author: [email protected]
© The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav doi: 10.1177/1753193414559494 available online at http://jhs.sagepub.com
Accuracy of clinical assessment in intra-articular positioning for injections of the hand and wrist Dear Sir,
Figure 1. Final situation after wrapping.
APL: abductor pollicis longus; BR: brachioradialis; PQ: pronator quadratus; RA: radial artery; SBRN: superficial branch of radial nerve.
Acknowledgements Ms Julia Ruston.
Conflict of interests None declared.
Informed consent The patient and his mother have been informed and have signed the informed consent form for publishing in Journal of Hand Surgery.
References Burke CS, Gupta A, Buecker P. Distal ulna giant cell tumor resection with reconstruction using distal ulna prosthesis and brachioradialis wrap soft tissue stabilization. Hand. 2009, 4: 410–4. Gupta A. CHAPTER 32 - Brachioradialis Wrap: A New Method of Stabilizing the Distal Radioulnar Joint. Principles and Practice of Wrist Surgery. Philadelphia, WB Saunders, 2010: 359–61.
Intra-articular injections are routinely performed for therapeutic effect in painful joints of the hand and wrist in a wide range of clinical settings, commonly without image guidance. The difficulty in accurate intra-articular needle placement when using clinical assessment alone, even for the larger joints of the body, has long been appreciated (Smith et al., 2011). In a meta-analysis of comparative studies, ultrasound-guided injections to the wrist resulted in greater reductions in pain and a greater likelihood of achieving a clinically significant improvement in symptoms, compared with clinical assessment alone, at 1 to 6 weeks follow-up (Dubreuil et al., 2013). The complication rate (skin hypopigmentation, fat atrophy and crystal deposition) doubles with peri-articular injection (Lopes et al., 2008). Accurate placement of the needle in the joint contributes in achieving the desired therapeutic benefit and reduces the incidence of complications. Fluoroscopic guidance is frequently used by hand surgeons performing joint injections. The aim of the study was to determine the accuracy of clinical assessment alone in achieving intra-articular positioning for a wide range of hand and wrist joint injections and compare this with the accuracy achieved using fluoroscopic guidance. Data was collected prospectively over 12 months. All injections were undertaken in the operating theatre under aseptic technique in conscious patients and were performed by two Consultant Hand Surgeons, three senior Registrars and one Core Surgical
Downloaded from jhs.sagepub.com at UNIV OF FLORIDA Smathers Libraries on November 16, 2015
1004
The Journal of Hand Surgery (Eur) 40(9)
Trainee. The injection technique was standardized. The needle was placed into the position clinically assessed to be intra-articular using anatomical landmarks. The needle was advanced until there was a perceived puncture of the joint space. The accuracy of needle placement was then assessed with fluoroscopy using orthogonal views. If an intra-articular position had not been achieved using clinical assessment alone then fluoroscopy was used to achieve this. The joint was then injected with a prepared mixture of local anaesthetic and corticosteroid. Our standardized technique for each joint is described in detail in Appendix 1 (available online). The data were collected and entered onto Excel (Microsoft, Seattle, WA, USA) and analysed. Fischer’s exact test was used in the statistical analysis. A total of 50 joint injections were performed in 37 patients (26 women and 11 men) with a mean age of 59 years. The aetiology was primary osteoarthritis (40 injections), post-traumatic osteoarthritis (four) and post-traumatic pain (six). The mean patient follow-up time was 6.5 months (range 2 to 11). Four joints had further injections (two thumb carpometacarpal (CMC) joints, two interphalangeal joints); seven joints underwent operative management (four trapeziectomies, one fusion of the little finger CMC joint and two distal interphalangeal joint fusions). One case of hypopigmentation of the skin occurred as a delayed complication on routine review of all patients in the outpatient clinic at 6 weeks post-injection. The distribution and accuracy of the intraarticular injections is shown in Table 1. The overall accuracy using clinical assessment alone was 48%. When intra-articular positioning using clinical assessment failed, subsequent positioning using fluoroscopy was always successful. Accurate localization using clinical assessment alone was significantly lower than that achieved when using fluoroscopy (p
