Performing an Ultrasound Guided Trapeziometacarpal Joint Injection
Introduction
The carpometacarpal joint (CMC) is also known as the trapeziometacarpal joint. The joint is comprised of the proximal portion of the first metacarpal and the distal portion of the trapezius bone. Arthritis of this joint can be seen in up to 3% of men and 5% of women (3). Standard radiographs can aid in diagnosis by showing joint space narrowing, osteophyte formation, and subchondral sclerosis. Ultrasound images can also show joint space narrowing and osteophyte formation (3).
Patients with CMC arthritis will typically complain of pain that localizes to the base of their thumb (1). They also may describe difficulty with pinching and gripping activities like opening up a jar (1). Due to the small size of the joint, studies have found palpation guided injections can carry an accuracy rate as low as 58% (2). As a result, this study will review the procedure in using ultrasound to inject the CMC joint.
Procedure
There are multiple approaches described in the literature when performing an ultrasound guided CMC joint injection. Providers should be aware of the superficial radial nerve and radial artery, which can be in close proximity to the CMC joint (8). Most of the CMC joint injections are performed using a walk down approach. The walk down approach involves angling the needle at a 45 degree angle to the probe and then progressively increasing the angle until the target is reached (10).
One approach has the patient in a chair or supine position with their hand placed flat on a table and their palm facing upwards (1). A linear 12-5mHz ultrasound will be used and placed in long axis of the trapeziometacarpal joint (1). Then, a 25g one to two inch needle can be used to infiltrate the joint using an out of plane approach (1).
Figure 1 shows the joint space and ultrasound positioning (1)
A similar technique was described in a paper from the Archives of Physical Medicine and Rehabilitation that shows the needle being guided in a different plane. This study has the hand placed similarly with the volar surface of the hand facing upwards (2). The ultrasound was placed parallel to the trapeziometacarpal joint (2). Then, a needle was guided in a thirty to forty five degree angle towards the CMC joint in an out of plane approach (2).
Figure 2 shows an out of plane approach of the CMC joint (2)
For those providers who prefer an in-plane approach, the patient can be placed in a similar position with the palm facing upwards (3). The probe is placed over the thenar eminence with the trapeziometacarpal joint visible in long axis (3). The needle is then injected in a 45 degree angle towards the trapeziometacapral joint with the needle visualized the entire time (3). The authors of this paper believe that the CMC joint is more narrow on the dorsal aspect of the hand and opens up more along the volar side (3).
Figure 3 shows the ultrasound position for the in-plane injection (3)
Figure 4 shows the ultrasound image for the in-plane approach (3)
Another approach would be to place the hand in neutral position with the thumb superior (8). The injection is then performed in an out plane approach with a walk down approach in a dorsal to palmar direction (8). The authors prefer the dorsal to palmar approach compared to the palmar to dorsal approach due to increase hand sensitivity of the thenar eminence (8).
Figure 5 shows the hand in neutral position and an out of plane injection (8)
The final ultrasound guided technique is to have the patient place their hand flat on a table (9). The ultrasound probe is centered around the CMC joint and then a needle can be injected in an out of plane approach (9).
Figure 6 shows the hand placed downwards for the injection
Providers can inject corticosteroids, hyaluronic acid, or platelet rich plasma into the trapeziometacarpal joint. There is varying levels of evidence regarding hyaluronic acid into the CMC joint (4).
Conclusion
The trapeziometacarpal joint can be affected by osteoarthritis and lead to pain that localizes to the base of the thumb. Due to osteophyte formation, it can be difficult to inject this joint by palpation. As a result, ultrasound guidance can aid in a successful intra-articular injection.
By Gregory Rubin, DO
rubinsportsmed.com
– More Hand Pain on Sports Med Review: https://www.sportsmedreview.com/by-joint/hand/
– More on Wiki Sports Medicine: https://wikism.org/Hand_Pain_Main
References
1) Di Sante, Luca, et al. “Ultrasound-Guided Procedure for the Treatment of Trapeziometacarpal Osteoarthritis.” Clinical Rheumatology, vol. 30, no. 9, Sept. 2011, pp. 1195–200. PubMed, https://doi.org/10.1007/s10067-011-1730-5
2) Umphrey, Gregory L., et al. “Ultrasound-Guided Intra-Articular Injection of the Trapeziometacarpal Joint: Description of Technique.” Archives of Physical Medicine and Rehabilitation, vol. 89, no. 1, Jan. 2008, pp. 153–56. PubMed, https://doi.org/10.1016/j.apmr.2007.07.048
3) Hamoudi, Ceyran, et al. “Accuracy of Wireless Hand-Held Guided Ultrasound Injections in the Trapeziometacarpal Joint: A Cadaveric Study.” Cureus, vol. 15, no. 9, Sept. 2023, p. e45779. PubMed, https://doi.org/10.7759/cureus.45779
4) Frizziero, Antonio, et al. “Six-Months Pain Relief and Functional Recovery after Intra-Articular Injections with Hyaluronic Acid (Mw 500-730 KDa) in Trapeziometacarpal Osteoarthritis.” Muscles, Ligaments and Tendons Journal, vol. 4, no. 2, Apr. 2014, pp. 256–61
5) Erpelding, Jason M., et al. “The ‘Thumbs-up’ Sign and Trapeziometacarpal Joint Injection: A Useful Clinical Indicator.” Hand (New York, N.Y.), vol. 10, no. 2, June 2015, pp. 362–65. PubMed, https://doi.org/10.1007/s11552-014-9683-1
6) Derian, Armen, et al. “Accuracy of Ultrasound-Guided versus Palpation-Based Carpometacarpal Joint Injections: A Randomized Pilot Study in Cadavers.” Ultrasound (Leeds, England), vol. 26, no. 4, Nov. 2018, pp. 245–50. PubMed, https://doi.org/10.1177/1742271X18789711
7) To, Philip, et al. “The Accuracy of Common Hand Injections With and Without Ultrasound: An Anatomical Study.” Hand (New York, N.Y.), vol. 12, no. 6, Nov. 2017, pp. 591–96. PubMed, https://doi.org/10.1177/1558944717692086
8) Colio, Sean W., et al. “Ultrasound-Guided Interventional Procedures of the Wrist and Hand: Anatomy, Indications, and Techniques.” Physical Medicine and Rehabilitation Clinics of North America, vol. 27, no. 3, Aug. 2016, pp. 589–605. PubMed, https://doi.org/10.1016/j.pmr.2016.04.003
9) Atlas of Pain Management Injection Techniques: 5th Edition | Steven D. Waldman | ISBN: 9780323828260.” Elsevier Asia Bookstore, https://www.asia.elsevierhealth.com/atlas-of-pain-management-injection-techniques-9780323828260.html. Accessed 22 Oct. 2023
10) Chin, Ki Jinn, et al. “Needle Visualization in Ultrasound-Guided Regional Anesthesia: Challenges and Solutions.” Regional Anesthesia and Pain Medicine, vol. 33, no. 6, 2008, pp. 532–44. PubMed, https://doi.org/10.1016/j.rapm.2008.06.002
