Corticosteroid injection for de Quervain's tenosynovitis

Back ground 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 injections for the treatment of hand and wrist disorders in general practice

General practitioners are frequently consulted by their patients for hand and wrist disorders, such as carpal tunnel syndrome, trigger finger or de Quervain’s tenosynovitis. These disorders are important causes for disability, health-care consumption and absence from work. Local corticosteroid injection is one of the treatment options that can be used for managing these conditions. The aim of this thesis is to contribute to the body of evidence concerning effectiveness and safety of corticosteroid injections for carpal tunnel syndrome, trigger finger and de Quervain’s tenosynovitis, in particular when applied in general practice. Chapter 2 of the thesis presents the results of a systematic review assessing effectiveness of local corticosteroid injections for the treatment of trigger finger in adults and chapter 3 presents the results of a systematic review assessing effectiveness of local corticosteroid injections for the treatment of de Quervain’s tenosynovitis. Both systematic reviews were written according to the conventions of the Cochrane Collaboration and published in the Cochrane Library. Chapters 4, 5, 6 describe the results of a randomized controlled trial in general practice, investigating the effectiveness of injections with triamcinolonacetonide versus placebo injection (NaCl) for respectively carpal tunnel syndrome, trigger finger and de Quervain’s tenosynovitis. The results indicate that patients presenting to general practitioners with carpal tunnel syndrome, trigger finger and de Quervain’s tenosynovitis can effectively be treated with local corticosteroid injections. Chapter 7 focuses on the measurement properties reliability, responsiveness and interpretability of the Dutch version of the Boston Carpal Tunnel Questionnaire. We translated the BCTQ into Dutch for use as an outcome assessment tool in the randomised controlled study described in chapter 4. In Chapter 8 the findings of the previous chapters are interpreted and implications for daily practice and future research are discussed. Finally a summary in English and Dutch are given.

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

<p>Abstract</p> <p>Background</p> <p>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.</p> <p>Methods</p> <p>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).</p> <p>Results</p> <p>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.</p> <p>Conclusion</p> <p>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.</p> <p>Trial registration</p> <p>Current Controlled Trials ISRCTN53171398</p