Joint aspiration or injection in adults: Complications
- W Neal Roberts, Jr, MD
W Neal Roberts, Jr, MD
- Chief of Rheumatology
- University of Lousiville
- Howard W Hauptman, MD
Howard W Hauptman, MD
- Chief of Rheumatology
- Greater Baltimore Medical Center
- Section Editor
- Daniel E Furst, MD
Daniel E Furst, MD
- Section Editor — Treatment Issues in Rheumatology
- Clinical professor, University of Washington, Seattle
- Clinical professor, University of Florence, Florence, Italy
- Professor of Rheumatology, University of California in Los Angeles (Emeritus)
- Director of Research, Pacific Arthritis Associates
A needle is inserted into a joint for two main indications: aspiration of fluid (arthrocentesis) for diagnosis or for relief of pressure, or injection of medications. In practical terms, almost all injections into joints consist of a glucocorticoid, a local anesthetic, or combinations of the two. Adverse outcomes from glucocorticoid injection are uncommon, but several are serious. These include iatrogenic infection and three serious types of atrophy (ie, tendon rupture, nerve damage, and inhibition of chondrocytes leading to glucocorticoid arthropathy) (table 1). The last of these is more of a theoretical than actual risk of glucocorticoid injection.
The complications of joint aspiration or injection in adults are discussed here. The technique and indications for joint aspiration and intraarticular and periarticular injections of glucocorticoids and intraarticular hyaluronate derivatives, as well as the choice and frequency of agents for injection, are discussed separately. (See "Joint aspiration or injection in adults: Technique and indications" and "Intraarticular and soft tissue injections: What agent(s) to inject and how frequently?".)
Tendon rupture is most commonly encountered when undiluted glucocorticoid is injected near the rotator cuff or near the insertion of the long head of the biceps tendon. This complication may be more common with the posterior approach, which can be directed upward in the direction of the subdeltoid bursae and rotator cuff, than with the anterior approach, which is only intraarticular (figure 1). Tendon rupture can usually be avoided by sticking to one size of needle and syringe so as to be able to recognize the higher resistance that comes with injecting into a tendon.
Nerve atrophy or necrosis occurs when glucocorticoids enter the nerve sheath directly, an event which usually occurs only with carpal tunnel injections that come quite close to the median nerve. These injections should be performed by a subspecialist with specific training (eg, a hand surgeon or a rheumatologist). One would think that injection of the nerve would be quite painful and would, therefore, be uncommon. However, once the perineurium is pierced, the pain may be moderate and may be accompanied by a burning sensation. In the worst case, permanent nerve injury with a claw hand deformity ensues.
Other minor atrophies can also occur. These include skin atrophy, hypopigmentation, and dystrophic calcification around joint capsules. Hypopigmentation around the injection site is the most troublesome, especially on the wrist and hand of deeply pigmented individuals in whom it takes years to resolve (picture 1). Thus, such patients should be specifically advised about this complication. It may be possible to reduce the incidence of hypopigmentation by switching syringes and by flushing the needle with a small volume of lidocaine before withdrawing it.
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