Wrist joint osteoarthritis

Ultrasound guided wrist joint steroid injection

What is wrist osteoarthritis?

Wrist osteoarthritis (OA) refers to the wear and tear changes within the wrist joint. It can be a disabling, chronic condition that causes joint pain, swelling and stiffness - making even routine tasks challenging. Osteoarthritis occurrence increases with age - often without an apparent cause. Sometimes, a previous injury history (like a wrist fracture) exists.

Relevant wrist anatomy

The wrist complex comprises 10 bones which articulate into numerous small joints and provide different movements at the level of the wrist. The main wrist joint is formed by the articulation between the two long forearm bones (the radius and ulna) and the small bones in the wrist, collectively known as the carpal bones. The main wrist joint, referred to as “the radiocarpal joint”, is the largest in the wrist.

The small carpal bones are divided into a proximal row (Scaphoid, Lunate, Triquetrum &

Pisiform), and a distal row (Trapezium, Trapezoid, Capitate & Hamate). The articulation between the two is referred to as (the mid-carpal joint).

The wrist complex is enclosed within a thin but strong layer of tissue (the joint capsule) and contains a special type of lubricating fluid (synovial fluid). In addition, the joint bone surfaces are covered by a special tissue (the articular cartilage) that ensures smooth and frictionless movements of the joints. This protective surface can wear and thin with time, leading to osteoarthritis. Often, there is a degree of associated joint inflammation (Synovitis). This can result in joint pain and swelling and is linked with more rapid degeneration.

What are the risk factors for wrist joint arthritis?

Radiocarpal joint osteoarthritis may be caused by the following:

Age. There is an increased incidence of wrist arthritis as we age. This is due to the daily demands on the joint.
Injury. Previous injury to the hand or wrist can alter its mechanics, making the wrist more susceptible to arthritis. These include:
- Bony injuries. Fractures that involve the radius articular surface, scaphoid or lunate can increase the risk of wrist osteoarthritis incidence later.
- Ligamentous wrist injuries also increase the risk of radiocarpal osteoarthritis. Scapholunate ligament injury is one of the main contributors to wrist joint instability. This ligament connects and stabilises two important bones within the proximal carpal row, the scaphoid and lunate. The ligamentous structures here may become disrupted during injury leading to instability and abnormal wrist mechanics, and can predispose to radiocarpal joint osteoarthritis.
Family history. There might be an increased incidence of wrist arthritis if a family member suffers from the same condition.

How can you tell if you have wrist arthritis?

Wrist osteoarthritis (OA) is a progressive degenerative condition that develops slowly. The most common clinical features include:

A dull, slowly progressive wrist joint pain. Episodes of inflammation (synovitis) can exacerbate symptoms and cause intense pain, particularly in wrist movement. The pain can worsen after activities that put extra stress on the wrist joint (like push-ups).
Joint stiffness, particularly in the morning or after periods of inactivity.
Joint swelling. This can be due to swelling of the soft tissue due to inflammation (synovitis), but sometimes it can be due to the formation of bone spurs as part of the osteoarthritis process. The latter is referred to as osteophytes.

What other conditions can resemble wrist osteoarthritis (OA)?

The following conditions can be mistaken for wrist osteoarthritis:

Carpal Tunnel Syndrome vs wrist osteoarthritis

Wrist Osteoarthritis usually results in pain, swelling and stiffness around the wrist. Carpal tunnel syndrome (CTS) is a different condition resulting from pressure on the median nerve within the wrist as the nerve passes through a certain space (the carpal tunnel). It is characterised by wrist pain and numbness, but the symptoms are often felt in the hand. The symptoms can also include weakness and pins and needles sensation in the hand, particularly in the thumb, index, and middle fingers. The symptoms usually worsen at night and can interfere with sleep.

How is wrist osteoarthritis diagnosed?

The diagnosis of wrist joint osteoarthritis starts with a clinical assessment performed by a hand & wrist specialist.

If you are suspected of having wrist osteoarthritis, you may be referred for a wrist X-ray. An X-ray is the first imaging modality and has proven excellent at diagnosing bone disorders, including osteoarthritis. It will assess for any narrowing or loss of the joint space because of the osteoarthritis, as well as assess the severity of the changes.

You may be referred for certain blood tests if there is concern about an underlying inflammatory condition, for example, rheumatoid arthritis.

Although X-rays are very sensitive in diagnosing osteoarthritis and other bony changes like erosions, they cannot detect wrist joint soft tissue inflammation (synovitis).

Dedicated Musculoskeletal Ultrasound with Doppler is very sensitive for assessing synovitis. This is particularly important in inflammatory arthritis (like rheumatoid arthritis). Synovitis can indicate a suboptimal response to treatment, necessitating a change in the approach. Ultrasound is also very useful in guiding injections in the hand & wrist, ensuring safety and accuracy.

A wrist X-ray showing complete loss of the wrist joint space secondary to severe wrist osteoarthritis.

What are the treatment options for wrist osteoarthritis?

The treatment usually starts with a dedicated physiotherapy program. This comprises of flexibility and strengthening exercises to ensure joint health is preserved. Soft tissue techniques like massage and taping can also be useful. Wearing a wrist brace and activity modification is often helpful.

What injection treatment options are available for wrist arthritis?

There are currently two injection options to treat osteoarthritis of the wrist.

Ultrasound-guided steroid injection

Corticosteroids provide an effective and safe method to manage wrist arthritis. A combination of corticosteroid injection and numbing medicine (local anaesthesia) is administered under ultrasound guidance to relieve pain and aid wrist rehabilitation. Current evidence shows that corticosteroids can provide significant pain reduction lasting an average of 3 months, but the effect is longer sometimes.

Ultrasound Guided Hyaluronic Acid Injection

Hyaluronic acids are synthetic materials replicating the natural fluid found within our joints. They help in joint lubrication and reduce joint pain and inflammation.

Frequently asked questions about wrist steroid/cortisone injections.

What is a cortisone injection?

Cortisone is a potent anti-inflammatory medicine routinely used to manage inflammatory conditions (like bursitis, arthritis, and tendinosis). A cortisone injection will reduce the inflammation in the injected area (like the thumb base or the carpal tunnel) and allow you to manage the condition, usually by undergoing a physiotherapy program. To learn more, please see our FAQs.

Should hand & wrist injections be done under ultrasound guidance?

Yes. This is our routine practice, as plenty of evidence supports ultrasound guidance when performing joint injections. Doing hand and thumb injections under ultrasound/imaging guidance allows for direct visualisation of the needle to ensure accurate placement into the area of pain/inflammation (like a bursa, an arthritic joint, or an inflamed tendon sheath). Ultrasound guidance results in more accurate, less painful, and faster procedures, with better outcomes than these injections without guidance. Ultrasound guidance avoids sensitive structures (like nerves and vessels) during the procedure.

How long will the effect of a cortisone injection last?

Current evidence suggests that cortisone can improve pain and function for up to 3 months, but in some cases, it can last longer. Pain relief duration depends on the condition's diagnosis and severity. The steroid injection will provide a window of opportunity to undergo effective rehabilitation and attempt to address the underlying cause to enhance the pain relief achieved from the injection.

How soon will a steroid injection start to work?

A steroid injection usually takes a few days (1-3) before you notice the effect, although sometimes the pain relief can start on the same day. The injected area will often feel sore for the first few days. This is referred to as (steroid flare) and can be seen after a steroid injection.

Do steroid injections just hide/mask the pain?

Steroid injections do not just mask or hide the pain, but they act by reducing the inflammation in the targeted area, thus providing a strong and local anti-inflammatory effect to help control the symptoms and allow the patient to manage the condition, usually by undergoing effective rehabilitation.

How many steroid injections can I have?

If possible, we advise reducing the number of cortisone injections by combining any injection therapy with an effective physiotherapy programme to address the underlying cause. Repeated steroid injection into the same area should be avoided if the previous injection was less than 3-4 months ago.