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Am Fam Physician. 1998;58(9):2147-2148

Experience with intra-articular corticosteroid injections in children with arthritis is limited, primarily because of concern about infection and the potential for cartilage damage. However, reports in the literature seem to attest to its safety in children. Padeh and Passwell evaluated the efficacy of intra-articular corticosteroid injections in 71 children treated at a pediatric rheumatology clinic from 1992 through 1996.

The 47 girls and 24 boys in the study were six months to 18 years of age (mean age: 9.4 years). Sixty-one of the children fulfilled the American College of Rheumatology criteria for the diagnosis of juvenile rheumatoid arthritis. Six children had reactive arthritis, two had juvenile psoriatic arthritis, one had Crohn's disease and one had mixed connective tissue disease.

Most of the patients had not responded to six to eight weeks of therapy with an oral non-steroidal anti-inflammatory agent, most commonly naproxen. They had objective signs of inflammatory arthritis, including joint swelling, effusion, warmth or decreased range of motion. Four patients had pauciarticular disease that either had not been treated or was misdiagnosed, and three children had developed joint deformities such as flexion contractures or leg-length discrepancies by the time they were referred.

Intra-articular injections were performed under local anesthesia with 2 percent lidocaine; sedation was used in children younger than six years and in children who had more than four joints injected at a time. Triamcinolone hexacetonide was administered in a dose of 10 to 40 mg, depending on the size of the joint. Patients were asked to limit themselves to non–weight-bearing activities for 24 hours after injection of the lower limbs and were seen one week later for a follow-up visit. A “good” response was defined as complete resolution of symptoms within one week and lasting for at least six months. A failed response was classified as a relapse of active synovitis within six months of the injection.

A total of 300 joint injections were performed, including injections in 124 knees, 71 ankles, 46 wrists, 12 tendon sheaths, 10 shoulders, seven elbows and 30 metacarpophalangeal and proximal interphalangeal joints.

Full remission that lasted more than six months occurred with 246 (82.0 percent) of the 300 injections. In 43 children (60.6 percent), it became possible to discontinue all oral medications, including nonsteroidal anti-inflammatory agents, sulfasalazine (four patients) and corticosteroids (three patients). Correction of joint contractions occurred in 42 children (55 joints), and Baker's cysts resolved completely in 11 patients. Inflammation recurred within six months in 54 (18.0 percent) instances.

There were no joint infections or other late effects such as joint instability, osteonecrosis or soft tissue atrophy during a follow-up that ranged from five to 48 months (average follow-up: 30 months). Two children had a postinjection flare-up that was apparent 24 hours after the injection but resolved within three to five days. Twenty children who had more than one injection of the same joint underwent radiographic evaluation, and no calcifications in or around the joints were visualized.

The authors conclude that intra-articular corticosteroid injections are safe and effective in children with inflammatory arthritis. The authors note that advantages of intra-articular corticosteroid injections include a rapid response, a low incidence of side effects and avoidance of long-term systemic therapy.

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Copyright © 1998 by the American Academy of Family Physicians.

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