[Trigger finger: to operate or to inject?] / Trigger finger: opereren of injecteren?

Trigger finger is a common hand disorder in which swelling of the affected flexor-tendon results in triggering, locking or pain at the A1-pulley and impaired function of the finger. In this clinical lesson we describe 4 cases of patients with this condition, illustrating the clinical picture of trigger finger and how decisions regarding treatment are made. In typical cases the diagnosis is straight forward, but if the clinical presentation is less clear (e.g. in case if there is only pain at the A1-pully or a locked finger) making the diagnosis can be challenging. Conservative (doing nothing, orthosis, injection) and operative treatment options are discussed. Guiding principles are formulated which may help in choosing the most appropriate treatment for individual patients.

Randomised controlled trial of local corticosteroid injections for carpal tunnel syndrome in general practice.

BACKGROUND: Carpal tunnel syndrome is caused by entrapment of the median nerve and results in pain, tingling and numbness in the wrist and hand. It is a common condition in general practice. Effectiveness of treatment by intracarpal corticosteroid injection has never been investigated in general practice. The objective of this study was to determine if corticosteroid injections for carpal tunnel syndrome provided by general practitioners are effective. METHODS: In this study 69 participants with a clinical diagnosis of carpal tunnel syndrome were recruited from 20 general practices. Short-term outcomes were assessed in a randomised, placebo-controlled trial. Long-term results were assessed in a prospective cohort-study of steroid responders. Participants were randomised to intracarpal injections of 1 ml triamcinolonacetonide 10 mg/ml (TCA) or 1 ml NaCl (placebo). Non-responders to NaCl were treated with additional TCA injections. Main outcomes were immediate treatment success, mean score of the Symptom Severity Scale (SSS) and Functional Status Scale (FSS) of the Boston carpal tunnel questionnaire, subjective improvement and proportion of participants with recurrences during follow-up. Duration of follow-up was twelve months. RESULTS: The TCA-group (36 participants) had better outcomes than the NaCl-group (33 participants) during short-term assessment for outcome measures treatment response, mean improvement of SSS-score (the mean difference in change score was 0.637 {95% CI: 0.320, 0.960; p < 0.001}) and FSS-score (the mean difference in change score was 0.588 {95% CI: 0.232, 0.944; p = 0.002}) and perceived improvement (p = 0.01). The number to treat to achieve satisfactory partial treatment response or complete resolution of symptoms and signs was 3 (95% CI:1.83, 9.72).49% of TCA-responders (17/35) had recurrences during follow-up. In the group of TCA-responders without recurrences (51%, 18/35) outcomes for SSS-score and FSS-score deteriorated during the follow-up period of 12 months (resp. p = 0.008 and p = 0.012). CONCLUSIONS: Corticosteroid injections for CTS provided by general practitioners are effective regarding short-term outcomes when compared to placebo injections. The short-term beneficial treatment effects of steroid injections deteriorated during the follow-up period of twelve months and half of the cohort of steroid-responders had recurrences. TRIAL REGISTRATION: Current Controlled Trials ISRCTN53171398.

Randomised controlled trial of local corticosteroid injections for de Quervain's tenosynovitis in general practice.

BACKGROUND: De Quervain's tenosynovitis is a stenosing tenosynovitis of the first dorsal compartment of the wrist and leads to wrist pain and to impaired function of the wrist and hand. It can be treated by splinting, local corticosteroid injection and operation. In this study effectiveness of local corticosteroid injections for de Quervain's tenosynovitis provided by general practitioners was assessed. METHODS: Participants with de Quervain's tenosynovitis were recruited by general practitioners. Short-term outcomes (one week after injections) were assessed in a randomised, placebo-controlled trial. Long-term effectiveness was evaluated in an open prospective cohort-study of steroid responders during a follow-up period of 12 months. Participants were randomised to one or two local injections of 1 ml of triamcinolonacetonide (TCA) or 1 ml of NaCl 0.9% (placebo). Non-responders to NaCl were treated with additional TCA injections. Main outcomes were immediate treatment response, severity of pain, improvement as perceived by participant and functional disability using sub items hand and finger function of the Dutch Arthritis Impact Measurement Scale (Dutch AIMS-2-HFF). RESULTS: 11 general practitioners included 21 wrists in 21 patients. The TCA-group had better results for short-term outcomes treatment response (78% vs. 25%; p = 0.015), perceived improvement (78% vs. 33%; p = 0.047) and severity of pain (4.27 vs. 1.33; p = 0.031) but not for the Dutch-AIMS-HFF (2.71 vs. 1.92; p = 0.112). Absolute risk reduction for the main outcome short-term treatment response was 0.55 (95% CI: 0.34, 0.76) with a number needed to treat of 2 (95% CI: 1, 3). In the cohort of steroid responders (n = 12) the beneficial effects of steroid injections were sustained during the follow-up of 12 months regarding severity of pain (p = 0.67) and scores of Dutch AIMS-2-HFF (p = 0.36), but not for patient perceived improvement (p = 0.02). No adverse events were observed during the 12 months of follow-up. CONCLUSION: One or two local injections of 1 ml triamcinolonacetonide 10 mg/ml provided by general practitioners leads to improvement in the short term in participants with de Quervain's tenosynovitis when compared to placebo. The short-term beneficial effects of steroid injections for symptoms were maintained during the follow-up after 12 months. TRIAL REGISTRATION: Current Controlled Trials ISRCTN53171398.

Corticosteroid injection for de Quervain's tenosynovitis.

BACKGROUND: De Quervain's tenosynovitis is a disorder characterised by pain on the radial (thumb) side of the wrist and functional disability of the hand. It can be treated by corticosteroid injection, splinting and surgery. OBJECTIVES: To summarise evidence on the efficacy and safety of corticosteroid injections for de Quervain's tenosynovitis. SEARCH STRATEGY: We searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, Issue 2), MEDLINE (1966 to April 2009), EMBASE (1956 to April 2009), CINAHL (1982 to April 2009), AMED (1985 to April 2009), DARE, Dissertation Abstracts and PEDro (physiotherapy evidence database). SELECTION CRITERIA: Randomised and controlled clinical trials evaluating the efficacy and safety of corticosteroid injections for de Quervain's tenosynovitis. DATA COLLECTION AND ANALYSIS: After screening abstracts of studies identified by the search we obtained full text articles of studies which fulfilled the selection criteria. We extracted data using a predefined electronic form. We assessed the methodological quality of included trials by using the checklist developed by Jadad and the Delphi list. We extracted data on the primary outcome measures: treatment success; severity of pain or tenderness at the radial styloid; functional impairment of the wrist or hand; and outcome of Finkelstein's test, and the secondary outcome measures: proportion of patients with side effects; type of side effects and patient satisfaction with injection treatment. MAIN RESULTS: We found one controlled clinical trial of 18 participants (all pregnant or lactating women) that compared one steroid injection with methylprednisolone and bupivacaine to splinting with a thumb spica. All patients in the steroid injection group (9/9) achieved complete relief of pain whereas none of the patients in the thumb spica group (0/9) had complete relief of pain, one to six days after intervention (number needed to treat to benefit (NNTB) = 1, 95% confidence interval (CI) 0.8 to 1.2). No side effects or local complications of steroid injection were noted. AUTHORS' CONCLUSIONS: The efficacy of corticosteroid injections for de Quervain's tenosynovitis has been studied in only one small controlled clinical trial, which found steroid injections to be superior to thumb spica splinting. However, the applicability of our findings to daily clinical practice is limited, as they are based on only one trial with a small number of included participants, the methodological quality was poor and only pregnant and lactating women participated in the study. No adverse effects were observed.

Corticosteroid injection for trigger finger in adults.

BACKGROUND: Trigger finger is a disease of the tendons of the hand leading to triggering (locking) of affected fingers, dysfunction and pain. Available treatments include local injection with corticosteroids, surgery, or splinting. OBJECTIVES: To summarize the evidence on the efficacy and safety of corticosteroid injections for trigger finger in adults using the following endpoints: treatment success, frequency of triggering or locking, functional status of the affected fingers, and severity of pain of the fingers. SEARCH STRATEGY: The databases CENTRAL, DARE, MEDLINE (1966 to November 2007), EMBASE (1956 to November 2007), CINAHL (1982 to November 2007), AMED (1985 to November 2007) and PEDro (a physiotherapy evidence database) were searched. SELECTION CRITERIA: We selected randomized and controlled clinical trials evaluating efficacy and safety of corticosteroid injections for trigger finger in adults. DATA COLLECTION AND ANALYSIS: The databases were searched for titles of eligible studies. After screening abstracts of these studies, full text articles of studies which fulfilled the selection criteria were obtained. Data were extracted using a predefined electronic form. The methodological quality of included trials was assessed by using items from the checklist developed by Jadad and the Delphi list. We planned to extract data regarding information on the primary outcome measures: treatment success, frequency of triggering or locking, and functional impairment of fingers, severity of the trigger finger; and the secondary outcome measures: proportion of patients with side effects, types of side effects, and patient satisfaction with injection. MAIN RESULTS: Two randomized controlled studies were found that involved 63 participants: 34 were allocated to corticosteroids and lidocaine, and 29 were allocated to lidocaine alone. Corticosteroid injection with lidocaine was more effective than lidocaine alone on treatment success at four weeks (relative risk 3.15, 95% CI 1.34 to 7.40). The number needed to treat to benefit was 3. No adverse events or side effects were reported. AUTHORS' CONCLUSIONS: The effectiveness of local corticosteroid injections was studied in only two small randomized controlled trials of poor methodological quality. Both studies showed better short-term effects of corticosteroid injection combined with lidocaine compared to lidocaine alone on the treatment success outcome. In one study the effects of corticosteroid injections lasted up to four months. No adverse effects were observed. The available evidence for the effectiveness of intra-tendon sheath corticosteroid injection for trigger finger can be graded as a silver level evidence for superiority of corticosteroid injections combined with lidocaine over injections with lidocaine alone.