Proximal phalanx injection for trigger finger: randomized controlled trial

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.

Non-steroidal anti-inflammatory drugs (NSAIDs) for trigger finger

BACKGROUND

Trigger finger is a common hand condition that occurs when movement of a finger flexor tendon through the first annular (A1) pulley is impaired by degeneration, inflammation, and swelling. This causes pain and restricted movement of the affected finger. Non-surgical treatment options include activity modification, oral and topical non-steroidal anti-inflammatory drugs (NSAIDs), splinting, and local injections with anti-inflammatory drugs.

OBJECTIVES

To review the benefits and harms of non-steroidal anti-inflammatory drugs (NSAIDs) versus placebo, glucocorticoids, or different NSAIDs administered by the same route for trigger finger.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, CNKI (China National Knowledge Infrastructure), ProQuest Dissertations and Theses, www.ClinicalTrials.gov, and the WHO trials portal until 30 September 2020. We applied no language or publication status restrictions.

SELECTION CRITERIA

We searched for randomised controlled trials (RCTs) and quasi-randomised trials of adult participants with trigger finger that compared NSAIDs administered topically, orally, or by injection versus placebo, glucocorticoid, or different NSAIDs administered by the same route.

DATA COLLECTION AND ANALYSIS

Two or more review authors independently screened the reports, extracted data, and assessed risk of bias and GRADE certainty of evidence. The seven major outcomes were resolution of trigger finger symptoms, persistent moderate or severe symptoms, recurrence of symptoms, total active range of finger motion, residual pain, patient satisfaction, and adverse events. Treatment effects were reported as risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs).

MAIN RESULTS

Two RCTs conducted in an outpatient hospital setting were included (231 adult participants, mean age 58.6 years, 60% female, 95% to 100% moderate to severe disease). Both studies compared a single injection of a non-selective NSAID (12.5 mg diclofenac or 15.0 mg ketorolac) given at lower than normal doses with a single injection of a glucocorticoid (triamcinolone 20 mg or 5 mg), with maximum follow-up duration of 12 weeks or 24 weeks. In both studies, we detected risk of attrition and performance bias. One study also had risk of selection bias. The effects of treatment were sensitive to assumptions about missing outcomes. All seven outcomes were reported in one study, and five in the other. NSAID injection may offer little to no benefit over glucocorticoid injection, based on low- to very low-certainty evidence from two trials. Evidence was downgraded for bias and imprecision. There may be little to no difference between groups in resolution of symptoms at 12 to 24 weeks (34% with NSAIDs, 41% with glucocorticoids; absolute effect 7% lower, 95% confidence interval (CI) 16% lower to 5% higher; 2 studies, 231 participants; RR 0.83, 95% CI 0.62 to 1.11; low-certainty evidence). The rate of persistent moderate to severe symptoms may be higher at 12 to 24 weeks in the NSAIDs group (28%) compared to the glucocorticoid group (14%) (absolute effect 14% higher, 95% CI 2% to 33% higher; 2 studies, 231 participants; RR 2.03, 95% CI 1.19 to 3.46; low-certainty evidence). We are uncertain whether NSAIDs result in fewer recurrences at 12 to 24 weeks (1%) compared to glucocorticoid (21%) (absolute effect 20% lower, 95% CI 21% to 13% lower; 2 studies, 231 participants; RR 0.07, 95% CI 0.01 to 0.38; very low-certainty evidence). There may be little to no difference between groups in mean total active motion at 24 weeks (235 degrees with NSAIDs, 240 degrees with glucocorticoid) (absolute effect 5% lower, 95% CI 34.54% lower to 24.54% higher; 1 study, 99 participants; MD -5.00, 95% CI -34.54 to 24.54; low-certainty evidence). There may be little to no difference between groups in residual pain at 12 to 24 weeks (20% with NSAIDs, 24% with glucocorticoid) (absolute effect 4% lower, 95% CI 11% lower to 7% higher; 2 studies, 231 participants; RR 0.84, 95% CI 0.54 to 1.31; low-certainty evidence). There may be little to no difference between groups in participant-reported treatment success at 24 weeks (64% with NSAIDs, 68% with glucocorticoid) (absolute effect 4% lower, 95% CI 18% lower to 15% higher; 1 study, 121 participants; RR 0.95, 95% CI 0.74 to 1.23; low-certainty evidence). We are uncertain whether NSAID injection has an effect on adverse events at 12 to 24 weeks (1% with NSAIDs, 1% with glucocorticoid) (absolute effect 0% difference, 95% CI 2% lower to 3% higher; 2 studies, 231 participants; RR 2.00, 95% CI 0.19 to 21.42; very low-certainty evidence).

AUTHORS' CONCLUSIONS

For adults with trigger finger, by 24 weeks' follow-up, results from two trials show that compared to glucocorticoid injection, NSAID injection offered little to no benefit in the treatment of trigger finger. Specifically, there was no difference in resolution, symptoms, recurrence, total active motion, residual pain, participant-reported treatment success, or adverse events.

Reduction in pain from corticosteroid injection for the treatment of trigger finger with subcutaneous single-injection digital block: a randomized controlled trial

PURPOSE

The pain from corticosteroid injections is not an insignificant issue for patients with trigger finger. The aim of this study was to evaluate the efficacy of subcutaneous single-injection digital block (SSIDB) for pain reduction during trigger finger corticosteroid injection.

METHODS

Ninety patients requiring corticosteroid injections for trigger finger were randomized to three groups: SSIDB with 2 ml of 1% lidocaine, SSIDB with 1 ml of 1% lidocaine and no digital block (control group). In SSIDB groups, the intrasynovial corticosteroid injections were performed after digital nerve block. In control group, ethyl chloride spray was applied prior to intrasynovial injection of the corticosteroid and 1% lidocaine mixture. The pain during lidocaine needle insertion, lidocaine infiltration, corticosteroid needle insertion and corticosteroid infiltration were determined with a visual analog scale (VAS).

RESULTS

The VAS pain scores for corticosteroid needle insertion in both SSIDB groups were significantly lower than the VAS pain scores in control group (p < 0.001). The VAS pain score during corticosteroid infiltration in 2 ml of 1% lidocaine group was significantly lower than 1 ml of 1% lidocaine group (p = 0.008), and in control group (p < 0.001). Pain during nerve block procedure in both SSIDB groups was significantly lower than the pain from corticosteroid injection in the control group (p < 0.05 and p < 0.05).

CONCLUSIONS

Subcutaneous single-injection digital block with 2 ml of 1% lidocaine was highly effective in reducing pain associated with injection of corticosteroid for trigger finger.

Different Dosages of Triamcinolone Acetonide Injection for the Treatment of Trigger Finger and Thumb: A Randomized Controlled Trial

BACKGROUND

This study was designed to compare the efficacy and complications between 3 different dosages of triamcinolone acetonide for the treatment of trigger finger.

METHODS

Ninety-three patients with a total of 120 trigger digits were included in the study. The involved digits were randomized to 3 groups. Each group received treatment consisting of injection with 5, 10 or 20 mg triamcinolone acetonide. The clinical response to the steroid was evaluated during the first six weeks after injection. The success rate was determined at 3, 6, 9 and 12 months after injection.

RESULTS

After the injections, pain and triggering improved gradually and nearly resolved completely at 6 weeks in all dosages. A dose related pattern was found at 3 and 6 months after the injection. The 20 mg group had a significant higher success rate when compared to the 5 and 10 mg at 3 and 6 months. The 10 mg group has significant higher success rate when compare to 5 mg at 3 months. There were no differences of success rate between groups at 9 and 12 months. At 12 months, 7 of 40 digits (17.5%) in the 5 mg group, 7 of 40 digits (17.5%) in the 10 mg group, and 9 of 40 digit (22.5%) in the 20 mg group were without triggering (p = 0.806).

CONCLUSIONS

A dose-response characteristic was demonstrated in the treatment of trigger finger with triamcinolone acetonide. Triamcinolone acetonide 5 mg seems to have the lowest success rate.

Tendinopathy: a review of the pathophysiology and evidence for treatment

The understanding of tendinopathy has evolved over the past several decades. Initially thought to be a primarily inflammatory process, histologic evaluation has revealed that there is an absence of inflammatory cells, and rather, tendinopathy is more of a degenerative process. Various types of medications, rehabilitation, modalities, injections, and minimally invasive procedures have been described as treatment for this condition. The purpose of our article is to describe the pathophysiology of tendinopathy as currently understood and the evidence for the various available treatments. We performed a literature search to determine the types of reviews that have been performed previously regarding treatment for tendinopathy, and summarized these reviews. We then performed a systematic review of randomized controlled trials for treating patients with tendinopathy. It is our hope that our review of trial data will help providers to determine optimal management for their patients with tendinopathy.

How to perform local soft-tissue glucocorticoid injections?

Inflammation of periarticular soft-tissue structures such as tendons, tendon sheaths, entheses, bursae, ligaments and fasciae is the hallmark of many inflammatory rheumatic diseases, but inflammation or rather irritation of these structures also occurs in the absence of an underlying rheumatic disease. In both these primary and secondary soft-tissue lesions, local glucocorticoid injection often is beneficial, although evidence in the literature is limited. This chapter reviews local injection therapy for these lesions and for nerve compression syndromes.

Percutaneous surgery: a safe procedure for trigger finger?

BACKGROUND

Trigger finger is relatively common problem among hand disorders. There are open and percutaneous surgical methods for the treatment.

AIM

This study was designed to examine the mid-term results of the percutaneous surgical technique on patients with chronic trigger finger.

MATERIALS AND METHODS

We included 48 trigger fingers of 48 patients (36 females and 12 males). They were between the ages of 42-68 years (mean age, 52 years). We performed release of the trigger finger by using a 14-gauge needle via the percutaneous technique. We performed open surgery on the trigger fingers of 20 patients in order to evaluate the results obtained from percutaneous surgery. The patients were followed for 30 months on average (18-46 months) following the procedure.

RESULTS

Following the procedure, pain and locking of the fingers were resolved completely. On the fingers that had open surgery, we observed that the release of the pulley was successful. Only 2 patients had minor abrasions, without any tendon injury. During the follow-up period, no complications were reported in either of the patient groups.

CONCLUSIONS

Percutaneous surgical technique in the treatment of trigger finger is an effective, convenient and cost-effective method with a low complication rate, and is therefore a preferable alternative to open surgery.