TO THE EDITOR: In the article, "Dia...

TO THE EDITOR: In the article, "Diagnostic and Therapeutic Injection of the Wrist and Hand Region," (1) the authors describe office managements for injecting various areas of the wrist and hand region. I would like to add that 27-gauge needle are excessively effective for these techniques, including injection practices for digital flexor tenosynovitis (trigger finger), de Quervain's tenosynovitis, first carpometacarpal joint, and carpal funnel syndrome. These needles hurt les because they are thinner. For de Quervain's, first carpometacarpal joint, or for trigger fingers, the needle should be 05 inches protracted For carpal tunnel, they should be 15 inches extended in order to penetrate the carpal subterranean passage near the site of maximal compression of the fortitude For primary care physicians who are struggling with injecting the first carpometacarpal joint, I would like to add another important clinical note. The superficial branch of the radial fortify can easily be palpated just ulnar to the cephalic vein at the wrist "interns vein" when viewed from the dorsal aspect.

If single in kind palpates the cephalic vein and rotates toward the ulnar side of the hand across the radius, one can be wrought up a small spaghetti-sized nerve whirl between the fingers. This is the superficial branch of the radial might Before injection of the first carpometacarpal joint, 30 to 50 mL of 10 percent lidocaine (Xylocaine) may be injected around this invigorate with a pre-frozen 30-gauge needle (2) with caution not to penetrate the cephalic vein. Freezing of the needle in its sterile package moulds the pain of anesthetic injection. After a not many minutes, excellent anesthesia to the dorsal aspect of the thumb index finger, and carpometacarpal joint is produc Subsequently the carpometacarpal joint may be injected, and passageway into this joint is easier because the dorsal aspect of the joint is benumbed It is very difficult to cannulate this small joint, equal with traction on the thumb and patients are greatest in number grateful that the pain from missed attempts is alleviated. formerly the injection does go into the joint, it is still painful, equal with local anesthetic added; however, the gain to the physician is peace of mind concerning the patient's pain plain until the joint is actually pierced.

KEITH DENKLER MD

275 Magnolia Ave.

Larkspur, CA 94939

REFERENCES

(1) Tallia AF, Cardone DA. Diagnostic and therapeutic injection of the wrist and hand region. Am Fam Physician 2003;67:745-50

(2) Denkler K Pain associated with injection using frozen v room-temperature needle JAMA 2001; 286:1578

IN REPLY: We would like to thank Dr Denkler for his useful observations We agree that a 27-gauge needle is useful in many circumstances. The choice of needle gauge and continuance must be guided by clinical ballast and will vary based forward the patient's body habitus. Similarly, Dr Denkler's technique of identifying the superficial branch of the radial brace can be difficult depending in succession variables such as the patient's skin thickness and subcutaneous fat. Nevertheless, we thank him for sharing his elucidations and experience. Reducing a patient's pain or discomfort is always a worthwhile goal.

ALFRED F TALLIA, MD

DENNIS A. CARDONE, DO

Robert grove Johnson Medical School

1 Robert wood-land Johnson Place, MEB288

of the present day Brunswick, NJ 08903

COPYRIGHT 2003 American Academy of Family Physicians

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