Impact of Corticosteroid Injection Site on the Treatment Success Rate of Trigger Finger: A Prospective Study Comparing Ultrasound-Guided True Intra-Sheath and True Extra-Sheath Injections

Accuracy and Safety of Non-Image Guided Trigger Finger Injections: A Cadaveric Study

BACKGROUND

Stenosing flexor tenosynovitis is commonly treated by injection of corticosteroids into the flexor tendon sheath. However, there is no consensus in the literature regarding the optimal technique, specifically when not utilizing ultrasound guidance. Here, we present a cadaver study in which 3 common techniques of flexor sheath injection were compared with regard to their accuracy and safety profiles.

METHODS

Fifteen fresh-frozen cadaver hands (60 digits) were evenly divided into 3 groups (20 digits per group). Digits in each group were injected with methylene blue dye using 1 of the 3 techniques (palmar-to-bone, palmar supra-tendinous, and mid-axial). The fingers were then dissected and were inspected for location of dye, as well as injury to tendon or digital nerves.

RESULTS

The mid-axial technique demonstrated the greatest accuracy with the highest rate of all intra-sheath injection, 15 of 20 digits (75%), while the palmar-to-bone technique produced the most combined intra- and extra-sheath injections, 13 of 20 digits, (65%) and the palmar supra-tendinous technique resulted in the most all extra-sheath injections, 9 of 20 digits (45%). The difference in rates of all intra-sheath injection was significant (P = .01). The mid-axial technique also produced the fewest intra-tendinous injections 0 of 20, although this result did not reach statistical significance (P = .15).

CONCLUSIONS

Compared to other common non-image guided flexor tendon sheath injection techniques, the mid-axial injection technique was found to be the most accurate in producing all intra-sheath injection and least likely to result in intra-tendinous injection.

Responsiveness of PROMIS Instruments for Trigger Digit After Corticosteroid Injection or A1 Pulley Release

PURPOSE

The purpose of the study was to determine if the patient-reported outcomes measurement information system (PROMIS) is sufficiently sensitive to detect improvement after 2 common treatments of trigger finger: corticosteroid injection or A1 pulley release.

METHODS

This retrospective cohort study included 72 patients in the injection group and 51 in the A1 pulley release group. PROMIS physical function (PF), pain interference (PI), and upper extremity (UE) scores were collected at baseline and 6 weeks after injection for the injection group and at baseline, and 1 week, 6 weeks, and 3 months after surgery for A1 pulley release patients. Descriptive statistics and paired t tests were used to compare PROMIS scores within each cohort. Standardized response means (SRMs) were calculated for each PROMIS domain to gauge instrument responsiveness.

RESULTS

Average age was 62 years, 65% were female patients, and 86% were White for the steroid injection cohort, compared to 60 years, 71%, and 88%, respectively, for the A1 pulley release cohort. For the steroid injection group, mean PROMIS PI scores (-4.0 points; SRM = -0.6) and PROMIS UE scores (+3.3 points; SRM = 0.5) improved significantly at 6 weeks after injection compared to baseline. Meanwhile, A1 pulley release patients improved significantly in mean PI scores (-3.7 points; SRM = -0.5) and in UE scores (+4.9 points; SRM = 0.7) at 3 months after surgery compared to baseline.

CONCLUSIONS

Clinical improvements after trigger digit treatments are reflected in improved PROMIS PI and UE scores that reach previously accepted minimum clinically important difference values for hand patients. PROMIS PI and UE also are more responsive than PROMIS PF in capturing improvement for trigger digit treatments.

CLINICAL RELEVANCE

As health care payers continue to emphasize patient-reported outcomes to determine treatment value and set reimbursement rates, this study helps establish that clinical improvement after trigger digit treatments are reflected in PROMIS PI and UE domains by reaching previously established minimum clinically important difference values for hand patients.

EULAR points to consider for the use of imaging to guide interventional procedures in patients with rheumatic and musculoskeletal diseases (RMDs)

OBJECTIVES

To develop evidence-based Points to Consider (PtC) for the use of imaging modalities to guide interventional procedures in patients with rheumatic and musculoskeletal diseases (RMDs).

METHODS

European Alliance of Associations for Rheumatology (EULAR) standardised operating procedures were followed. A systematic literature review was conducted to retrieve data on the role of imaging modalities including ultrasound (US), fluoroscopy, MRI, CT and fusion imaging to guide interventional procedures. Based on evidence and expert opinion, the task force (25 participants consisting of physicians, healthcare professionals and patients from 11 countries) developed PtC, with consensus obtained through voting. The final level of agreement was provided anonymously.

RESULTS

A total of three overarching principles and six specific PtC were formulated. The task force recommends preference of imaging over palpation to guide targeted interventional procedures at peripheral joints, periarticular musculoskeletal structures, nerves and the spine. While US is the favoured imaging technique for peripheral joints and nerves, the choice of the imaging method for the spine and sacroiliac joints has to be individualised according to the target, procedure, expertise, availability and radiation exposure. All imaging guided interventions should be performed by a trained specialist using appropriate operational procedures, settings and assistance by technical personnel.

CONCLUSION

These are the first EULAR PtC to provide guidance on the role of imaging to guide interventional procedures in patients with RMDs.

Value of imaging to guide interventional procedures in rheumatic and musculoskeletal diseases: a systematic literature review informing EULAR points to consider

OBJECTIVES

To summarise current data on the value of imaging to guide interventional procedures in patients with rheumatic and musculoskeletal disease (RMDs) informing an European Alliance of Associations for Rheumatology taskforce.

METHODS

A systematic literature review was conducted to retrieve prospective and retrospective studies published in English and comparing different (imaging) techniques, different settings and procedural protocols to guide interventions in patients with RMDs. MEDLINE, EMBASE, the Cochrane Library and Epistemonikos databases were searched through October 2021. Risk of bias (RoB) was assessed using the Cochrane RoB tool for randomised trials V.2 (ROB2), the RoB tool for Non-Randomised Studies of Interventions and the appraisal tool for cross-sectional studies.

RESULTS

Sixty-six studies were included (most with moderate/high RoB); 49 were randomised controlled trials, three prospective cohort studies and 14 retrospective studies. Fifty-one studies compared either one imaging technique with another imaging technique, or with palpation-guided interventions. Ultrasound (US) was most frequently studied (49/51), followed by fluoroscopy (10/51). Higher accuracy was found for US or fluoroscopy compared with palpation-guided interventions. Studies comparing different imaging techniques (12/51) did not endorse one specific method. Different settings/equipment for imaging-guided procedures (eg, automatic vs manual syringes) were investigated in three studies, reporting heterogeneous results. Fifteen studies compared different imaging-guided procedures (eg, intra-articular vs periarticular injections).

CONCLUSION

Higher accuracy of needle positioning at joints and periarticular structures was seen in most studies when using imaging (especially US) guidance as compared with palpation-guided interventions with the limitation of heterogeneity of data and considerable RoB.

Comparison of Different Dosages and Volumes of Triamcinolone in the Treatment of Stenosing Tenosynovitis: A Prospective, Blinded, Randomized Trial

Background

Stenosing tenosynovitis is a condition due to a size mismatch between the flexor tendons and the first annular pulley. Corticosteroid injection is the mainstay treatment. The purpose of this study is to compare different dosages and volumes of triamcinolone in the treatment of primary stenosing tenosynovitis.

Methods

Patients with primary Quinnell grades 1 or 2 stenosing tenosynovitis were recruited in this prospective, blinded, randomized trial. Patients were randomized into 1 of 2 groups. Group A received 0.25 mL of triamcinolone 40 mg/mL, mixed with 0.25 mL of 1% lidocaine with epinephrine (10 mg of triamcinolone, 0.5 mL in total volume). Group B received 0.5 mL of triamcinolone 40 mg/mL, mixed with 0.5 mL of 1% lidocaine with epinephrine (20 mg of triamcinolone, 1 mL in total volume). Patients were assessed by a blinded hand therapist at 2 and 4 weeks, and by a blinded hand surgeon at 6 weeks. The primary outcome was complete symptom resolution at 6 weeks. Both per-protocol and intention-to-treat analyses were performed.

Results

One hundred ninety-one patients were recruited from 2009 to 2018. Eighty-two and 77 patients had complete data in group A and B, respectively. There was no difference in success rates in complete symptom resolution at 6 weeks between group A (59.8%) and group B (62.3%). The mean visual analogue pain scores on injection were 4.31 ± 2.11 for group A and 4.30 ± 2.09 for group B.

Conclusions

Triamcinolone 10 mg was as effective as 20 mg in the resolution of symptoms of Quinnell grade 1 or 2 stenosing tenosynovitis at 6 weeks.

Time to Improvement After Corticosteroid Injection for Trigger Finger

Purpose

Trigger finger is a commonly occurring hand condition that presents with symptoms of pain, clicking, locking, and catching of the finger. A common non-operative management option is corticosteroid injection. The purpose of this study was to evaluate the short-term patient response to corticosteroid injections for trigger finger. 

Methods

The patients of six fellowship-trained orthopedic hand surgeons who underwent a corticosteroid injection for trigger finger between June 2019 and October 2019 were invited to participate in this study. Patients were contacted by phone at one week, two weeks, and three weeks after the injection to complete a questionnaire regarding their pain and triggering symptoms. Medical records were also reviewed to collect basic demographic data.

Results

A total of 452 patients were included in the study. At the final follow-up, 82.4% of patients reported complete pain relief, 16.3% had partial relief, and 1.2% had no relief from their pain. For their triggering symptoms, 65.9% reported complete triggering relief, 30.4% had partial relief, and 3.5% had no triggering relief. It took an average of 6.6 days following injection for patients to experience complete pain relief, and an average of 8.1 days for patients to experience complete triggering relief.

Conclusions

This analysis found that most patients experience relief of pain and triggering at three weeks following corticosteroid injection. The majority of patients experienced some pain relief within the first week following corticosteroid injection, while improvement in triggering appeared to lag behind pain relief.

Trigger Finger? Just Shoot!

Trigger finger is a common condition usually curable by a safe, simple corticosteroid injection. Trigger finger results from a stenotic A1 pulley that has lost its gliding surface producing friction and nodular change in the tendon. This results in pain and tenderness to palpation of the A1 pulley, progressing to catching and then locking. Splinting for 6 to 9 weeks produces gradual improvement in most patients as does a quick steroid injection with the latter resulting in resolution of pain in days and resolution of catching or locking in a few weeks. Percutaneous or open release should be reserved for injection failures particularly those at high risk for continued injection failure including diabetics and those with multiple trigger fingers. We present a step-by-step method for injection with illustrations to encourage primary care providers to offer this easily performed procedure to their patients.

Ultrasound Features of Trigger Finger: Review of the Literature

Trigger finger is a common pathologic condition of the digital pulleys and flexor tendons in the hand. The key clinical finding is a transient blockage of the digit when it is flexed with subsequent painful snapping when it is extended. Imaging is a helpful guide for establishing the severity of the disease, identifying the underlying cause, and deciding the appropriate management. This narrative review aims to recall the anatomic and pathologic bases and describe the ultrasound features of trigger finger, also including common ultrasound findings and complications after therapy. Ultrasound enables an accurate static and dynamic evaluation of trigger finger as well as a comparison with the adjacent normal digits and thus should be considered the radiologic modality of first choice for its diagnosis.

A Critical Appraisal of Adult Trigger Finger: Pathophysiology, Treatment, and Future Outlook

Trigger finger (TF) is a common referral to a hand surgeon, with people with diabetess being the most at-risk population. Abnormal thickening, scarring, and inflammation occur at the A1 pulley and flexor tendon, and histological changes correlate well with the clinical severity of TF. Corticosteroid injections decrease the thickness of the A1 pulley and are considered a first-line treatment. However, corticosteroids are only moderately effective, especially for people with diabetes. Patients may elect for surgery if nonoperative treatments prove ineffective; some may choose immediate surgical release instead. To release the A1 pulley, patients have the option of an open or percutaneous approach. The open approach has a greater risk of infection and scar tissue formation in the short run but an overall superior long-term outcome compared with the percutaneous approach.

METHODS

We critically reviewed the efficacy and cost-effectiveness of the treatment methods for TF through a comprehensive search of the PubMed Database from 2003 to 2019.

RESULTS

To reduce costs, while still delivering the best possible care, it is critical to consider the likelihood of success for each treatment method in each subpopulation. Furthermore, some patients may need to return to work promptly, which ultimately may influence their desired treatment method.

CONCLUSIONS

Currently, there is no universal treatment algorithm for TF. From a purely financial standpoint, women without diabetes presenting with a single triggering thumb should attempt 2 corticosteroid trials before percutaneous release. It is the most cost-effective for all other subpopulations to elect for immediate percutaneous release.

Epidermal Inclusion Cyst following Percutaneous Trigger Finger Release

Epidermal inclusion cyst is a benign lesion that commonly occurs due to inclusion of epidermal cells into the dermal or deeper layers in a trauma event. Percutaneous release is a minimally invasive technique, and good surgical outcomes can be achieved. However, the percutaneous procedure is a puncture injury, and the epidermal inclusion cyst is reasonable to become a possible complication. In this article, we presented a case of trigger finger in left middle finger. The patient underwent percutaneous release as the treatment and a second percutaneous release 5 months later due to recurrence of the symptoms. An epidermal inclusion cyst was noted 5 months thereafter, and it was treated with excision. With this case, we need to be more aware of this possibility if a mass lesion without infection signs occurs in the released area and recommend sonography if there is a mass lesion a few months after the procedure.

Efficacy of Corticosteroid Injection for Treatment of Trigger Finger: A Meta-Analysis of Randomized Controlled Trials

Purpose: To determine the efficacy and safety of corticosteroid injection for trigger finger by performing a meta-analysis of all relevant studies. Methods: PubMed, EMBASE, and Cochrane Library databases were searched for randomized controlled trials (RCTs) comparing corticosteroid injection with other treatments for trigger finger. Pooled summary estimates for outcomes, including success rate, relapse rate, visual analogue score (VAS) and complications, were calculated as standardized mean difference (SMD) or relative risk (RR) either on a fixed- or random-effect model via Stata 12.0 software. Results: Ten literatures involving 806 patients (387 in corticosteroid injection group and 419 in control group) were included. Pooled analysis showed there were no differences in the success rate, VAS and complications between patients undergoing corticosteroid injection and others. However, the relapse rate was significantly higher in patients treated with corticosteroid injection than that of other treatments (RR = 19.53, 95% CI = 6.23-61.19). Subgroup analysis indicated the efficacy of corticosteroid injection was superior to other non-surgical treatments (success rate: RR = 1.54, 95% CI = 1.01-2.35), but inferior to surgery (success rate: RR = 0.55, 95% CI = 0.48-0.63; relapse rate: RR = 21.15, 95% CI = 6.06-73.85; VAS: SMD = 3.49, 95% CI = 2.84-4.14). Conclusions: Corticosteroid injection may be an effective strategy for management of trigger finger, although surgery may be needed for some patients due to recurrence.

Open Surgery Versus Ultrasound-Guided Corticosteroid Injection for Trigger Finger: A Randomized Controlled Trial With 1-Year Follow-up

PURPOSE

Trigger finger is a common condition with a lifetime prevalence of 2%. Corticosteroid injection is a treatment often considered as a first-line intervention with reported cure rates between 60% and 90% in observational cohorts. Nevertheless, open surgery remains the most effective treatment with reported cure rates near 100%. Head-to-head trials on these treatments are limited. We investigated the efficacy of open surgery compared with ultrasound-guided corticosteroid injections.

METHODS

The study was performed as a single-center, randomized, controlled trial with a 1-year follow-up. A total of 165 patients received either open surgery (n = 81) or ultrasound-guided corticosteroid injection (n = 84). Follow-up was conducted at 3 and 12 months. If the finger had normal movement or normal movement with discomfort at latest follow-up, the outcome was considered a success. Secondary outcomes were postprocedural pain and complications.

RESULTS

The groups were similar at baseline except for lower alcohol consumption in the open surgery group. At 3 months, 86% and 99% were successfully treated after corticosteroid injection and open surgery, respectively. At 12 months, 49% and 99% were considered successfully treated after corticosteroid injection and open surgery, respectively. The pain score at latest follow-up was significantly higher in the corticosteroid injection group. Complications after open surgery were more severe and included 3 superficial infections and 1 iatrogenic nerve lesion. After corticosteroid injection 11 patients experienced a steroid flare and 2 had fat necrosis at the site of injection.

CONCLUSIONS

Open surgery is superior to ultrasound-guided corticosteroid injections. Complications after open surgery are more severe; this must be taken into account when advising patients with regard to treatment.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.