Intra-synovial corticosteroid injections in juvenile chronic arthritis--a review

Locally injected intra-synovial corticosteroids are an important and effective part of treatment for juvenile chronic arthritis (JCA). They work rapidly, effectively and safely. They are most useful for limited joint, tendon sheath or bursal involvement in pauciarticular JCA or the few most active joints in polyarticular or systemic JCA while awaiting the onset of action of disease modifying anti-rheumatic drugs. This article includes a brief history of intra-synovial steroid use, the mechanisms of action in decreasing inflammation and contraindications, as well as local and systemic complications. Important contraindications include infection, prostheses, arthroscopy, surgical procedures, damaged joints and hypersensitivity. The commonest complication is subcutaneous atrophy while serious complications include infection and damage to the joint and surrounding structures. Proper technique, use of imaging and adequate analgesia or anaesthesia, post injection rest and subsequent mobilisation are important. The efficacy and duration of action of the various steroids available are discussed. Long-acting microcrystalline steroids such as triamcinolone hexacetonide are useful for prolonged remission. Repeated injections can be safe and effective. Failure may be due to incorrect technique, insufficient or short-acting steroid, poor general disease control or intra-synovial septa.