A 75-year-old woman presented with progressing pain, cyanosis, and hypaesthesia in her left hand after an intra-articular injection with diazepam into the wrist for osteoarthritis-related pain. Due to an iatrogenic intra-arterial injection, malperfusion of the ulnar digits developed. Angiography revealed blockage of perfusion of the 4th and 5th digits. Despite intra-arterial lysis, heparinisation, and vasodilatation, perfusion could not be reinstalled. Necrosis of the distal phalanges of the 4th and 5th digits developed, which had to be treated with amputation. The pathomechanism of tissue damage and the treatment options after intra-arterial injections are reviewed and discussed.
A 75-year-old woman (nonsmoker with history of hypertension and depression) had repeatedly been administered an intra-articular injection with diazepam for left-sided chronic wrist pain due to osteoarthritis by a primary physician and chiropractor. After the last injection, she immediately developed progressing, cyanosis and hypaesthesia pain in her hand (Figure
Clinical findings after admission of the patient, 3 days after the injection.
Digital angiography showing complete blockage of perfusion to the 4th and 5th digits.
Demarcated necrosis of the 4th and 5th fingers after 5 weeks.
Intraoperative view of the amputated 5th finger showing a thrombosed digital artery (circle) with the visible thrombus at the dissected end (arrow).
Amputated fingers after suture removal 2 weeks postoperatively.
The patient denied to name the primary physician because she “has always been treated so well.”
Distal gangrene of extremities after intra-arterial injections has been described in the literature before, most commonly in i.v. drug abusers or after arterial catheterization [
To our best knowledge, this is the first report of a case of iatrogenic, intra-arterial injection resulting from a failed “therapeutic” intra-articular injection of diazepam by a medical professional for osteoarthritis-related pain. While the oral application of diazepam as an adjunct medication for rheumatoid arthritis has been described [
The pathomechanism of peripheral gangrene after intraarterial injections is yet poorly understood. Many theories have been put forward including inflammation of the endothelium [
Consequently, numerous treatment options addressing the proposed mechanisms have been suggested. Most authors agree on consequent analgesia, early mobilization of the extremity, and administration of i.v. heparin, although understandably in most reports there is no control group to this approach, proving that heparin is really responsible for at least partial resolution of underperfusion. Elevation may be harmful when perfusion pressure is low but edema leading to compression of small vessels is also harmful. The optimal position may be the one that gives most pain relief, whether it is slightly lowering or elevating the hand. Thrombolysis (streptokinase [
Vasodilatation using different substances (prostaglandins [
A sympatholytic and therefore also vasodilating effect is achieved by stellate ganglion blocks or axillary plexus anesthesia [
Dextrans [
Like in most medical fields the existence of so many treatment options suggests that none shows reliable and satisfying results for this difficult condition. The resultant tissue necrosis can only be handled by excision and amputation. In necrotic fingers without any signs of inflammation, we suggest to wait for at least 4 weeks before definitive amputation to allow for clear demarcation, thus preventing unnecessary secondary intervention after insufficient resection or exaggerated resections of healthy tissue.
This case report should remind us of the fact that injections around the wrist carry the risk of intra-arterial injections with possibly catastrophic results. Based on the frequency of reports in the literature, this condition is not as rare as one might think. Yet, there is still no clear understanding of the mechanisms leading to peripheral gangrene and consequently there is no reliable treatment available.
Intra-articular diazepam injections for osteoarthritis-related pain is an absurd concept in our view and although “it is only” an injection that can lead to severe complications.
None of the above-mentioned authors have any financial or personal interest in the products or medications mentioned in this paper.