Trigger Thumb Is Acting Up Again After Steroid Shot 5 Months Ago
Hand (North Y). 2013 Dec; 8(4): 439–444.
Corticosteroid injection therapy for trigger finger or thumb: a retrospective review of 577 digits
Cornelius Schubert
Segmentation of Hand Surgery, Department of Orthopaedic Surgery, The Johns Hopkins Academy, 601 N. Caroline Street, Baltimore, Physician 21287 USA
Helen G. Hui-Chou
Division of Hand Surgery, Section of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, Baltimore, Doctor 21287 USA
Alfred P. See
Sectionalisation of Hand Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, 601 Northward. Caroline Street, Baltimore, Dr. 21287 The states
Eastward. Gene Deune
Sectionalization of Hand Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, Baltimore, MD 21287 Us
c/o Elaine P. Henze, BJ, ELS, Medical Editor and Director, Editorial Services, Department of Orthopaedic Surgery, The Johns Hopkins University/Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., #A665, Baltimore, MD 21224-2780 USA
Abstruse
Background
Stenosing flexor tenosynovitis of the digital flexor tendon (trigger digit) is a common condition encountered by manus surgeons. Our purpose was to determine the efficacy of corticosteroid injections and review the demographic profile of patients with trigger digits.
Methods
We reviewed the records of 362 patients (577 trigger digits) treated with steroid injections (8 mg of triamcinolone acetonide in one % lidocaine) from 1998 through 2011. Follow-upward (intervention to last visit) averaged 66.4 months. We assessed patient demographics (e.g., gender, historic period, diabetes mellitus, hand dominance, trigger digit distribution) and determined recurrence rate and injection duration of efficacy. If one injection failed, boosted injections or surgical A1 pulley release were offered. Results were analyzed with Student'due south t test or Fisher's exact test (significance, p < 0.05).
Results
Women (258, 71.iii %) were affected significantly (p < 0.001) more frequently than men (104, 28.seven %) and at a significantly (p < 0.001) younger age (average, 58.3 versus 62.i years, respectively). Eighty patients (22.1 %) were diabetic. We observed no correlation betwixt trigger digit and hand potency. The two most usually affected digits were the right long finger (17.8 %) and right thumb (17.7 %). For 721 injections, the recurrence rate was xx.3 %; in that location were no major complications. For recurrences, the injection efficacy averaged 315 days. Surgery was required for 117 patients.
Conclusions
Injection therapy is safe and highly constructive (79.vii %). Women were affected by trigger digits more than oft than men and at a younger age. Surgical release provides a definitive therapeutic choice if corticosteroid injection fails.
Keywords: Corticosteroid injection, Efficacy, Open up trigger finger release, Recurrence, Stenosing tendovaginitis, Stenosing tenosynovitis, Trigger digits, Trigger finger
Introduction
Stenosing tenosynovitis, also known equally trigger finger or trigger digit (TD), is a very common condition that a mitt surgeon encounters and treats. Patients commonly present with clicking or locking of a digit about commonly acquired past a size mismatch between the first annular pulley (A1) and the corresponding flexor tendon sheath, which consequently leads to a secondary entrapment of the tendon itself [10, 20]. The French medico Alphonse Notta outset described trigger fingers in 1850 [24], resulting in the term "Notta'due south node" being assigned to the swollen nodule within the flexor tendon in symptomatic patients [viii]. Amidst nondiabetic patients more than than xxx years sometime, the lifetime prevalence of TD has been estimated to be 2.2 %, with middle-anile women nigh ordinarily affected [30].
Histologic analyses of the A1 pulley of trigger patients accept shown fibrocartilaginous metaplasia and degenerative changes [10, 15, 20, 26, 32], which are believed to be adaptations to shear loads. Although TD is called tenosynovitis, histologic evaluations show minimal inflammatory changes inside the synovial sheath [10, fifteen, 20]. The hypertrophy of the A1 pulley, which may triple in thickness secondary to fibrocartilaginous metaplasia, creates a size discrepancy between the tendon and its sheath [26, 30, 32]. Constriction of the flexor tendon and increased shear load may pb to a "pinching" of the tendon, causing a nodule to form, further aggravating the trigger symptoms [19, 21, 26] and restricting flexor tendon circuit, resulting in the inability to extend or flex the digit smoothly. Symptoms range from painless clicking to locking and triggering, with pain felt at the palm over the A1 pulley and distally at the PIP joint or the IP joint (thumb).
Although TDs are normally idiopathic, some authors contend about a possible correlation between excessive apply of the mitt and triggering of the finger [13, 35]. TD likely occurs more ofttimes in patients with diabetes mellitus, rheumatoid arthritis, carpal tunnel syndrome, Dupuytren's disease, hypothyroidism, mucopolysaccharide storage disorders, amyloidosis, and congestive middle failure [5, 7].
Nonoperative therapy includes remainder, nonsteroidal anti-inflammatory medications, splinting, and corticosteroid injections. Some investigators have indicated that splinting may be a reasonable approach simply for balmy triggering [thirty]. The injection of long-acting corticosteroid into the flexor tendon sheath is a major treatment option for TD. Advantages include ease of administration, low complication rate, low morbidity, function setting applicability, and depression price [4, 19, 23, 26]. The verbal mode of action of corticosteroids is non withal exactly understood. Information technology is believed that the anti-inflammatory effect might reduce the swelling of the A1 caster, despite a lack of evidence of inflammatory responses in histologic studies [10, 15, 20, 26].
Surgical treatment includes percutaneous or open A1 pulley release. Surgical release is considered an effective and definitive treatment choice, but in comparing with steroid injection, it is associated with longer recovery time, higher costs [4, 36, 37], and rates of complications (due east.thou., nerve injury, flexor tendon bowstringing, tendon scarring) ranging from xi to 43 % [34, 36, 37].
The purpose of this study was to determine the efficacy of corticosteroid injections, in particular recurrence rates, and to review the demographic contour of patients with trigger digits.
Materials and Methods
This retrospective written report was approved by our institutional review board.
Patients and Definitions
We reviewed our patient database for those whose hands were treated between November 1998 and September 2011 and identified the ones with TDs treated with corticosteroid injection every bit commencement-line therapy by the senior writer at a major American urban bookish medical center. Of the 545 identified patients with TD in this time period, 183 were excluded. Exclusion criteria were as follows: (1) patients less than 18 years old who did not have congenital TDs (north = 1), (ii) presence of built TDs (n = 26), (iii) previous surgical release for triggering (northward = 1), and (4) previous injection therapy by other physicians and patients who wished to proceed with surgical release of the A1 caster without an initial corticosteroid injection (n = 155).
Therefore, 362 patients with 577 trigger digits formed our study group (Tableone). The average follow-up fourth dimension was 66.four months (range, 2–152 months). The follow-up time was defined as a fourth dimension period betwixt the date of each intervention (single injections, surgery) and their last visit.
Tabular array 1
Demographics by gender
| Characteristics | Male person | Female person | Total |
|---|---|---|---|
| No. (%) of patients | 104 (28.7) | 258 (71.3) | 362 (100) |
| Average (range) age (years) | 62.1 (34–91) | 58.3a (22–96) | 59.5 (22–96) |
| No. (%) of trigger digits | 166 (28.8) | 411 (71.2) | 577 (100) |
| Average (range) number of simultaneous trigger digits affecting 1 paw | one.14b (1–3) | 1.17b (one–4) | 1.sixteen (1–4) |
Patient demographics (gender, age, hand dominance, distribution of TDs, and presence of diabetes mellitus) were recorded. The diagnosis was made based on history and physical exam with varying presentations of TDs, tenderness over the A1 caster and along the flexor tendon, and a palpable Notta's nodule. Corticosteroid injections were offered to those patients who had (1) observed locking that was corrected with active motility (Quinnell grade ii), (2) locking with passive move (Quinnell grade 3), or (iii) uncorrectable locking (Quinnell grade 4). Those who had uneven finger motion (Quinnell grade 1) on examination were as well offered an injection if they had a strong disarming history of locking (Quinnell grades two–iv). Patients who did not have a history of triggering/locking or observed abnormality (normal finger motility, Quinnell grade 0) were non offered the injection. TD recurrence was defined as return of preinjection symptoms requiring additional injections or surgery. We defined the duration of efficacy as the time interval between the previous injection and the patient'south return office visit for reinjection or evaluation for surgery due to recurrence of symptoms.
Corticosteroid Injection Regimen
The injections were administered in a make clean fashion. The skin was cleansed with alcohol over the A1 pulley region, and the injection was given via a 30-gauge, 0.5-in. hypodermic needle (Becton Dickinson & Co., Franklin Lakes, NJ) filled with 0.2 mL (8 mg) of triamcinolone acetonide (Kenalog-40, Bristol-Myers Squibb Co., Princeton, NJ) mixed with 0.6 mL of 1 % lidocaine hydrochloride (Hospira, Inc., Lake Forest, IL) (total volume, 0.8 mL). The needle was inserted through the palmar skin at a slight oblique bending at the A1 caster region. The needle was advanced into the supratendinous infinite. The patient was asked to flex and extend the finger. If the needle and the syringe were still, then we gave the injection. This avoided accidental intratendinous injection, which tin can event in a tendon rupture secondary to collagen necrosis [xxx]. Nosotros used a 30-gauge needle primarily to decrease the discomfort from the pain. If the corticosteroid was in solution immediately before the injection, we did non encounter whatsoever problems with any precipitate lodging inside the needle lumen. Afterward the injection, the patient was instructed to resume activity as tolerated. No further concrete therapy or splinting was recommended. We instructed the patients to telephone call the office for a follow-up if the triggers recurred after the injection. We informed the patients that it may have up to one calendar month for the beneficial results to be noticed, although some patients saw beneficial results in a few days. If the symptoms did non ameliorate or got worse after an initial improvement, we considered a repeat injection as early every bit 1 month from the initial injection. Up to iii injections were offered for recurrent symptoms. A fourth injection was provided but on explicit patient asking and merely if in that location were medical contraindications to having surgery and patients knew that recurrence was likely. The patients were not required to have all 3 injections earlier proceeding with surgical decompression. We recommended surgical release if the patient did not obtain sufficient relief from the first, 2d, or third injection and had interference with hand function secondary to the trigger and wished to keep with the surgery.
Statistical Assay
Statistical analyses were generated using Microsoft Excel (Microsoft Corp., Redmond, WA) or QuickCalcs (GraphPad Software, Inc., La Jolla, CA). The significance of differences amid various sets of information was calculated with a one-tailed Student'due south t examination bold equal variance or a 2-tailed Fisher'southward exact examination. A probability of error less than 5 % (p < 0.05) was considered significant, and a value of less than one % (p < 0.01) was significant. To brandish the variance, the standard deviation or standard error of the mean was calculated.
Results
Patient Demographics
At that place were 258 (71.3 %) women and 104 (28.seven %) men (p < 0.01). Of the 577 TDs, women had 411 (71.2 %) and men had 166 (28.8 %). The female/male ratios in patient demographics (ii.5:one) and TDs (2.five:one) were identical. In contrast, inside the same time period, there were 2,641 (55.vii %) female person and 2,100 (44.iii %) male patients who presented with upper extremity diagnoses for evaluation in our mitt dispensary.
The mean presentation age was 59.5 years (range, 22–96 years). Women were significantly (p < 0.01) younger than men [58.iii years (range, 22–96 years) versus 62.1 years (range, 34–91 years), respectively]. Eighty patients (22.1 %) were diabetic.
Virtually all (290, 91.5 %) patients were right-handed, 23 (7.2 %) were left-handed, and 4 (ane.3 %) were ambidextrous. The hand authority of 45 (14 %) was unknown. Of the 577 TDs, 332 (57.5 %) were in the right hand (Fig.1).
Distribution of trigger fingers in male and female person patients (total number of digits, 577). Values are illustrated as pct of digits and number of digits (in parentheses)
Finger Distribution
The right long finger (103, 17.8 %) and the right thumb (102, 17.7 %) were the almost afflicted (Fig.1). Nearly patients presented with only one affected digit per hand (425 digits, 73.7 %). On boilerplate, there were 1.sixteen fingers (range, 1 to 4 fingers) affected simultaneously: men, 1.14 (range, one to 3 fingers); women, 1.17 (range, ane to iv fingers). This difference was not significant. No patient presented with simultaneous ipsilateral involvement of all five digits.
Corticosteroid Injections
Later on the 577 initial injections, 196 TDs (34.0 %) recurred. Of those 196 recurrences, 117 TDs were treated with a second injection, and 79 TDs were treated surgically. In the 117 digits treated with a second injection, 56 TDs (47.9 %) recurred, 23 of which were treated with a third injection, and 33 of which were treated surgically. After the tertiary injection, half-dozen TDs (26.ane % of the 23) recurred, four of which underwent a fourth injection, and 2 of which were treated surgically. After the fourth injection, three TDs (75 %) recurred and were treated surgically. No patient received a 5th injection. In total, 721 injections were administered, and 117 TDs were treated surgically. The number of injections in the same finger averaged one.25 injections/finger (range, ane to 4 injections/finger) for our entire written report grouping.
Recurrence after the showtime, second, tertiary, and fourth injections was 34.0, 47.9, 26.i, and 75.0 %, respectively, the cumulative recurrence was 20.iii %. In other words, of all 577 TDs, merely 117 TDs (xx.iii %) failed injection therapy consisting of up to four injections/TD. These patients required surgical release of the A1 pulley. In that location was i injection done subsequently a surgical release (see below). In cases of recurrence, duration of efficacy for the commencement, second, and tertiary injections averaged 320 days (range, 15 days to 68 months), 300 days (range, 29 days to 43 months), and 286 days (range, fifty days to 34 months), respectively (Fig.2). Although the efficacy of the 3rd injection was reduced by ten.half-dozen % in comparison to that of the outset injection, the divergence was not significant. The duration of efficacy for any steroid injection averaged 315 days (range, 15 days to 68 months) in those patients with recurrence. There were 117 open up releases performed. On average, those patients who had surgery received one.4 injections/finger (range, one to four injections/finger) before surgery.
Elapsing of steroid injection efficacy. Values are displayed as average days of efficacy and range of efficacy, in parenthesis. d days, 1000 months, yrs years, ns non significant
No major complications or wound-healing problems occurred after corticosteroid injections. One patient reported a transient marked superlative of claret glucose levels (mid 300s mg/dL) subsequently simultaneous injections to three affected fingers. We have not express the number of injections in diabetics primarily because they normally take presented with only one or two symptomatic fingers. Three has been the maximal number of fingers that take been injected in a diabetic patient. Nosotros inform all diabetic patients of the risks of transient glucose elevation.
Discussion
Since the first description of corticosteroid injection therapy in TDs in 1953 [14], multiple studies have analyzed its efficacy. Most had fewer than 120 patients [two, 3, 16, xviii, 21, 23, 26, 29, 33]. The largest retrospective report we establish contained only 235 patients (338 digits) [22]. Therefore, our report of 362 patients, with 577 TDs and 721 corticosteroid injections, is one of the largest retrospective analyses to engagement.
Investigators disagree with regard to the correlation between hand use and the evolution of triggering symptoms. Based on a TD prevalence of fourteen % among 665 workers in a meat-packing plant, Gorsche et al. [13] claimed that intense paw tool use increased the gamble of developing TD. Yet, Trezies et al. [35] establish that nigh TDs developed for reasons other than occupation. Our finding that 91.5 % of patients were right-handed, whereas only 57.5 % of all TDs occurred on the right hand, may propose a lack of direct correlation between paw use and triggering.
There was significant (p < 0.01) female authorisation among patients with TD (71.iii %) and symptoms started significantly (p < 0.01) earlier in women (three.eight years younger than men at symptom onset). These data are consequent with those of multiple other studies [ii, 10, 11, 17, 22, 25]. Nevertheless, little is known nearly the reasons for the increased incidence and earlier onset of TD in women; farther investigations are needed.
In our report, 80 (22.1 %) patients were diabetic, which supports the association between TD and diabetes mellitus ("diabetic manus syndrome") reported in the literature, with percentages of seven to 22 % [5, 22, 23]. Patients with diabetes remain a treatment challenge because of the increased risks of side effects of steroid injection and surgery, such as elevated blood glucose levels and wound-healing issues.
In our report, the efficacy of the total injection therapy regimen was 79.7 %. Merely 20.3 % of patients required an open surgical release. Symptoms resolved with ane injection in 66 % of TDs; 34 % required additional intervention. Both values are within the ranges reported in the literature [two, 12, 19, 31], underlining the strong efficacy of this therapy. However, the retrospective nature of our study may accept led to an incomplete follow-up, which may accept additionally influenced the value of the recurrence rate. Nosotros institute that if there was a recurrence, the efficacy of the kickoff injection averaged 315 days. The loftier standard error of the mean for efficacy of the third injection may be explained by the fact that a fourth injection was administered to only 3 patients (iv fingers) and that surgery after the third injection was performed in only two patients (two fingers), resulting in a full of only six recurrences later on the third injection. This duration value should therefore exist considered a potential tendency, suggesting similar long-lasting effects for a third steroid injection. These results seem to point that even though some patients may require surgery, it could be delayed for 2.5 to three years with the assistance of multiple corticosteroid injections.
Nosotros did not observe a drastic diminishing effectiveness of multiple steroid injections as has been described in the literature [i, 22, 27, 29]; we noted only a minor and nonsignificant reduction in the duration of efficacy. Two studies reported the maximum duration as 6 weeks [29] and 12 months [27]. Our maximum duration was more than v.v times longer (68 months). Reasons for the other studies' short duration could include shorter follow-up time (3 months [29] and 12 months [27], respectively) and differing injection modalities (a dose of but five mg of triamcinolone acetonide, injected by three different hand surgeons around the sheath [29] and 1 mL of triamcinolone acetonide of unknown concentration injected by 21 different full general practitioners effectually the sheath [27]). In our series, the dose of 8 mg was injected into the tendon sheath merely by the senior author, a board-certified hand surgeon. The exact injection site is believed to be irrelevant for the treatment response [33]. Nonetheless, we conclude that the outcome seems to exist improved not only by the dosage but probable also by the verbal injection site and by beingness performed by an experienced paw surgeon.
Another potential reason for our extended duration of efficacy might be our definition of recurrence. In our study, we set the date of recurrence every bit the date of the office visit for a repeat injection or for scheduling surgery. Although the symptoms of recurrence may have existed before the part visit, selecting this date eliminated the uncertainty of how long before the visit the symptoms recurred. What may be a few weeks to the patient may really have been a few months or a few days. Although this definition and method practice lengthen the duration of "efficacy," nosotros were unable to discover another solution to this dilemma because some of the patients could no longer be contacted or, if they could, had difficulty recalling exactly when their recurrence was (in some cases, ten years previously). This gene is ane of the weaknesses of a retrospective study.
Because corticosteroids may additionally impair wound-healing capabilities, injections should exist avoided immediately before surgery for patients with diabetes [nine, 28]. The manufacturer's production information [vi] indicates that post-obit a unmarried intramuscular dose of lx to 100 mg of triamcinolone, adrenal suppression occurs inside 24 to 48 h and gradually returns to normal, usually past 30 to 40 days; this timing correlated closely with the drug'southward duration of therapeutic action. In our practice, should the patient not have improved symptoms or had worsening symptoms, we recommended waiting at least 1 month subsequently the most recent corticosteroid injection to perform surgery. This delay was probable sufficient to decrease whatsoever adverse wound-healing properties secondary to the injected 8 mg of kenalog.
In conclusion, our information confirm that TDs touch on women more frequently than men and at a younger age. There seems to exist no singled-out correlation between the manus dominance and the appearance of TDs. Handling with a corticosteroid injection therapy regimen appears to be safe and highly effective (symptom resolution in 79.7 %). Fifty-fifty patients with symptomatic recurrence benefited from corticosteroid injection, with an average injection efficiency duration of 315 days.
Conflict of Interest
The authors declare that they have no conflict of interest.
Human Rights/Consent Statement
All procedures followed were in accordance with the upstanding standards of the responsible commission on homo experimentation (institutional and national) and with the Helsinki Annunciation of 1975, equally revised in 2008 [5]. Informed consent was obtained from all patients for being included in the study.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3840755/
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