Yes. Steroid injections are an effective first-line therapy for flexor tenosynovitis of the hand, with a number needed to treat [NNT] of 2.3 for injection of steroids and lidocaine (strength of recommendation [SOR]: B, based on 1 prospective RCT and low- quality studies). Injection into the tendon sheath may not be critical to a successful outcome (SOR: B, based on 1 prospective uncontrolled trial)

Bosworth, Michele

Graham, Jeffrey B.

Hulkower, Stephen D.

White, Elizabeth L.

University of Missouri: MOspace

	 vol	56,	No	12	/	December	2007	 1045www.jfponline.comCliniCal INquIrIes From the Family Physicians Inquiries NetworkAre steroid injections  effective for tenosynovitis  of the hand?z Evidence summaryFlexor tenosynovitis and de Quervain’s tenosynovitis are the 2 most common types of tenosynovitis of the hand. While the term “tenosynovitis” implies an inflammatory condition, pathoana-tomically it is better described as a fric-tion overuse injury, resulting in fibrosis   Yes.	steroid	injections	are	an	effective	first-line	therapy	for	flexor	tenosynovitis	of	the	hand,	with	a	number	needed	to	treat	[NNT]	of	2.3	for	injection	of	steroids	and	lidocaine	(strength	of	recommendation	[sor]:	B,	based	on	1	prospective	rcT	and	2	low-quality	studies).	Injection	into	the	tendon	sheath	may	not	be	critical	to	a	successful	outcome	(sor:	B,	based	on		1	prospective	uncontrolled	trial).	 For	de	quervain’s	tenosynovitis,	steroid	injections	without	splinting	are	more	effective	than	injection	plus	splinting	or	splinting	alone.	The	cure	rates	are	83%	(steroid	alone),	61%	(steroid	plus	splinting),	and	14%	(splinting	alone)	(sor:	B,	based	on	a	systematic	review	of	descriptive	noncontrolled	studies).	Injecting	into	the	tendon	compartments	was	more	effective	than	injecting	into	the	surrounding	soft	tissues	(sor:	B,	based	on	1	prospective	controlled	trial).Steroids are helpful, especially  for a quick return to functionI	often	see	flexor	and	de	quervain’s	tenosynovitis	in	my	practice,	particularly	among	patients	whose	occupations	require	repetitive	hand	use.	Acute	treatment	for	these	conditions	typically	consists	of	immobilization	with	buddy	taping	or	finger/thumb	spica	splinting.	For	those	who	do	not	improve	in	4	weeks,	or	require	a	quick	return	to	function,	I’ve	found	that	corticosteroid	injection	using	a	25-	to	30-gauge	needle	can	be	very	effective.		 De	quervain’s	tenosynovitis	must	be	injected	into	the	sheath	between	the	abductor	longus	and	extensor	pollicis	brevis;	flexor	tenosynovitis	is	injected	in	the	nodule.	I	typically	have	excellent	results,	with	patients	returning	to	function	within	72	hours.	Depigmentation	and	atrophy	can	occur	with	injections,	especially	in	small-statured	or	dark-pigmented	patients.	surgical	release	is	rarely	required	for	either	condition.	 Infectious	tenosynovitis	must	be	recognized	early;	it	is	typically	due	to	lacerations	or	puncture	wounds.	In	these	cases,	I	immediately	refer	to	orthopedic	surgery	for	further	treatment	and	evaluation. Robert Gauer, MDFort	bragg,	NcEvidence-based answerClinical commentary“Trigger finger” due to tenosynovitisJeffrey B. Graham, MD,  Stephen D. Hulkower, MD, and Michele Bosworth, MDMAHEC Family Medicine  Residency Program,  Asheville, NCElizabeth l. White, MliSCarolinas Medical Center,  Charlotte, NCfast trackThe exact  location of  a steroid injection for flexor  tenosynovitis  of the hand does not appear  to be important fast track1046 vol	56,	No	12	/	December	2007		ThE Journal of family PraCTiCECliniCal INquIrIesof the surrounding tissue and subsequent narrowing of the synovium.1 Flexor tenosynovitis:  Steroid injections provided relief A prospective, double-blinded RCT2 published by an orthopedic group in 1995 compared 24 patients with pri-mary flexor tenosynovitis. Patients were injected with either 1 cc of betametha-sone (Celestone 6 mg) and 3 cc of 1% lidocaine, or 4 cc of 1% lidocaine alone. A successful outcome was defined as ab-sence of triggering and pain, both sub-jectively and on examination. Follow-up examination was completed for all patients at 3 weeks and 4 months after injection.The treatment group had success outcomes for 10 of 14 patients (71%) at 3 weeks and 9 of 14 patients (64%) at 4 months, compared with 2 of 10 (20%) at both 3 weeks and 4 months in the control group (NNT=2.3; P<.05 at 4 months). No significant side effects were noted. It is unclear how the study blinded the white, thick consistency of betameth-asone compared with the clear nature of lidocaine alone.injection site may not matter. In an-other prospective, uncontrolled trial, 107 patients with flexor tenosynovitis were injected with 1 cc of betamethasone, 0.5 cc of 1% lidocaine, and 0.5 cc of radio opaque dye.3 Some patients got their in-jections in the tendon sheath at the A1 pulley site, others got their injections in the subcutaneous tissue surrounding the pulley, and a third group got injections in both sites. Patients graded their relief subjectively as either good (total allevia-tion of symptoms), fair (lasting improve-ment), or poor (only transient improve-ment or none at all). Those who received an intrasheath injection reported good results 47% of the time at 2 weeks follow-up, compared with 70% and 50% for patients in the subcutaneous and mixed groups, respec-tively. There was no statistically significant difference between the groups, suggesting that the exact location of injection may not be important. de Quervain’s tenosynovitis:  Steroids better than splintingA pooled quantitative literature search concerning the treatment of de Quer-vain’s tenosynovitis compared 7 studies (a total of 459 wrists) with identical diag-nostic and success criteria.4 Average fol-low-up was 9.6 months (range, 1 week to 7 years). There were no control groups in the studies, and none of the studies were randomized. Of the 226 cases treated with steroid injection alone, 83% were cured, though 30 of these needed a sec-ond injection. Sixty-one percent of those treated with injection and splint were cured, while 14% treated with splint alone reported cure. Steroids outperform splinting and nSaiDs. A retrospective study not includ-ed in the above review compared steroid injection with splinting and nonsteroi-dal anti-inflammatory drugs (NSAIDs).5 Researchers stratified subjects into mini-mal, mild, or moderate-to-severe, based on their severity of disease and limitation on their activities of daily living. Mean follow-up was 2.3 years. Of those cases treated with splinting and NSAIDs, 15 of 17 in the minimal group had resolution of symptoms, but only 4 of 20 in the mild group and 2 of 8 in the moderate-to-severe group had symptoms resolve. The injection group obtained better results, with 100% of cases in the minimal and mild groups re-solving and 76% of those in the more se-vere group resolving completely, with an additional 7% reporting improvement. injection site appears to matter with de Quervain’s tenosynovitis. In 1 small, controlled, prospective, double-blinded study, the authors attempted to correlate clinical relief of de Quervain’s tenosyno-vitis with accuracy of injection into the first dorsal compartment.6 The research-ers enrolled 19 patients. The same hand surgeon injected 3 cc of 1% lidocaine, 1 cc betamethasone, and 1 cc Omnip-For de Quervain’s tenosynovitis,  steroid injection into the tendon  compartments was more effective than injection into the surrounding soft tissue  fast trackwww.jfponline.com 	 vol	56,	No	12	/	December	2007	 1047aque 300 dye into the abductor pollicis longus sheath and then attempted, with ulnar deviation of the needle, to fill the extensor pollicis brevis sheath. Patients were followed-up at 1 month and 3 months postinjection. Success—defined as a negative Finkel-stein’s test, absence of pain, and normal activities of daily living—was noted in 11 of 19 patients at 3 months. In a ra-diographic check, 4 of 5 of the patients with dye in both compartments were asymptomatic, while the 3 who had no dye in either compartment remained symptomatic. This suggests that the lo-cation of injection may be important in de Quervain’s tenosynovitis. Recommendations from othersThe Brigham and Women’s Hospital guidelines for treatment of de Quervain’s tenosynovitis state that corticosteroid in-jections “may be very helpful,” and that they should be considered if symptoms persist beyond 6 weeks of conservative treatment.7 DeLee and Drez’s Orthope-dic Sports Medicine text recommends corticosteroid injection for de Quervain’s tenosynovitis after 2 weeks of conserva-tive treatment have failed.8 UpToDate recommends steroid in-jection for de Quervain’s tenosynovi-tis if pain persists for more than 2 to 6 weeks despite splinting, icing, and NSAID therapy.9 For flexor tenosynovi-tis, UpToDate recommends local injec-tion when symptoms persist for 4 to 6 weeks despite splinting.10   nreferences 	 1.	 	Zingas	c,	Failla	Jm,	van	Holsbeeck	m.	Injection	ac-curacy	and	clinical	relief	of	de	quervain’s	tendinitis.	J Hand Surgery (Am)	1998;	23:89–96.	 2.	 	murphy	D,	Failla	Jm,	Koniuch	mP.	steroid	versus	placebo	 injection	 for	 trigger	 finger.	 J Hand Surg (Am)	1995;	20:628–631.		 3.	 	Taras	Js,	raphael	Js,	Pan	WT,	et	al.	corticosteroid	injections	for	trigger	digits:	is	intrasheath	injection	necessary?	J Hand Surg (Am)	1998;	23:717–22.		 4.	 	richie	cA	3rd,	briner	WW	Jr.	corticosteroid	injec-tion	 for	 treatment	 of	 de	quervain’s	 tenosynovitis:	a	 pooled	 quantitative	 literature	 evaluation.	 J Am Board Fam Prac	2003;	16:102–106.	 5.	 	lane	lb,	boretz	rs,	stuchin	sA.	Treatment	of	de	quervain’s	disease:	 role	of	conservative	manage-ment.	J Hand Surgery (Br)	2001;	26:258–260.		 6.	 	Zingas	c,	Failla	Jm,	van	Holsbeeck	m.	Injection	ac-curacy	and	clinical	relief	of	de	quervain’s	tendinitis.	J Hand Surgery (Am)	1998;	23:89–96.	 7.	 	brigham	and	Women’s	Hospital.	Upper Extremity Musculoskeletal Disorders: A Guide to Prevention, Diagnosis and Treatment. boston,	mass:	brigham	and	Women’s	Hospital;	2003:9.		 8.	 	Delee	J,	Drez	D,	miller	m.	DeLee and Drez’s Ortho-paedic Sports Medicine: Principles And Practice.	2nd	ed.	Philadelphia,	Pa:	saunders;	2003.	 9.	 	Anderson	bc,	sheon	rP.	de	quervain’s	tenosyno-vitis.	upToDate	[online	database].	updated	may	7,	2004.	Waltham,	mass:	upToDate;	2004.		10.	 	Anderson	bc.	Trigger	finger	 (flexor	tenosynovitis).	upToDate	 [online	 database].	 updated	 December	26,	2000.	Waltham,	mass:	upToDate;	2000.Next month in Clinical Inquiriesn 	What are the most effective non-drug therapies  for irritable bowel syndrome?n 	Is low-dose aspirin therapy effective in reducing pre-eclampsia  and associated maternal-fetal complications?n 	What is the best approach to  malaria prophylaxis during pregnancy?Steroid injection alone had a better cure rate for  de Quervain’s  tenosynovitis (83%) than  steroids plus splinting (61%)Steroid injections for tenosynovitis

Are steroid injections effective for tenosynovitis of the hand?

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