Orthopedics Book

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First Metatarsophalangeal Joint Injection

Aka: First Metatarsophalangeal Joint Injection, Great Toe MTP Injection, First MTP Aspiration
  1. See Also
    1. Joint Injection
    2. Injectable Corticosteroid
  2. Indications
    1. Turf Toe (First MTP Sprain)
    2. Hallux Rigidus
    3. Severe Arthritis of first MTP joint
      1. Gouty Arthritis
      2. Osteoarthritis
      3. Rheumatoid Arthritis
  3. Contraindications
    1. Septic Arthritis (rule-out before steroid injection)
  4. Preparation
    1. Needle
      1. Gauge: 25 to 27
      2. Length: 1.0 to 1.5 inches
    2. Syringe: 3 to 5 ml
    3. Corticosteroid options
      1. Betamethasone (Celestone) 0.25 ml of 6 mg/ml
      2. Methylprednisolone (Sol-umedrol): 0.25 ml of 40 mg/ml
    4. Anesthetic
      1. Lidocaine 1%: 1 ml or
      2. Bupivacaine 0.25% or 0.5%: 1 ml
  5. Technique
    1. Images
      1. OrthoFootInjectMTP.jpg
    2. Patient position
      1. Supine position with knee flexed over towel roll
      2. Foot in neutral position against exam table
      3. Slightly plantar flex great toe
    3. Landmarks
      1. Mark dorsum of first metatarsophalangeal joint (MTP)
    4. Consider ethyl chloride spray prior to needle insertion
    5. Sterilize local skin with betadine or hibiclens
    6. Insert needle into skin at MTP on dorsal surface
      1. Angle needle 60 degrees distally
      2. Insert needle into joint (relatively shallow depth)
      3. Aspirate before injection
    7. Aspiration pointers
      1. Apply negative pressure on syringe
      2. Back and forth motion for 5 seconds
      3. Release negative pressure before exiting skin
        1. Avoids blood in sample (obscures crystal exam)
      4. Spray quickly onto slide and apply cover slip
      5. Send for polarized crystal exam at CLIA approved lab
  6. Follow-up Instructions
    1. No stress to foot for 2 weeks after injection
    2. Examine again in 3 weeks post-injection
  7. References
    1. Tallia (2003) Am Fam Physician 68(7):1356-62 [PubMed]

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