3. AUTHORS
• JUAN CASTELLANOS, MD,
• ERNESTO MUÑOZ-
MAHAMUD, MD, ENRIC
DOMÍNGUEZ, MD,
• PABLO DEL AMO, MD,
• OSCAR IZQUIERDO, MD,
• PERE FILLAT, MD
3
PRESENTATION
TITLE
SOURCE
J Hand Surg Am. 2015;40(1):121-
126. Copyright 2015 by the American
Society
for Surgery of the Hand
4. 4
PRESENTATION
TITLE
Study Design
Observational study of a prospectively recruited series of
patients
Objective of study
To analyze the long-term response to corticosteroid
injection in the management of trigger digit.
5. INTRODUCTION
PRESENTATION
TITLE
5
Trigger finger is a common pathology in
adults. It has a prevalence of up to 3%
(1) and is more frequent inwomen.(2) in
the vast majority of trigger fingers and
thumbs, the site of obstruction is A1
pulley.
6. CONT.
The disease characterised by pain and
catching as the patient flexes and extends
digits because of disproportion between the
diameter of flexor tendons and the A1 pulley.
Diagnosis is made by physical examination
with presence of active triggering and
tenderness at the A1 pulley.
6
PRESENTATION
TITLE
7. METHOD
This was an observational study of a prospectively recruited
series of patients with first-time diagnosis of trigger finger.
Efficacy of the injections, comorbidities, digit injected, and
related complications were compared and statistically
analyzed.
8. INCLUSION CRITERIA
8
PRESENTATION
TITLE
• Age of 18 years or older,
• Diagnosis of trigger finger of at least grade 2 according to the Quinnell
classification,21
• Duration of symptoms of at least 3 months
• Absence of previous treatment of the affected finger.
EXCLUSION CRITERIA
• All patients presenting with an allergy to any component of the
injections or refusing treatment were excluded from the study.
9. DIAGNOSIS
• The diagnosis of trigger finger was made after we obtained a history of
triggering and physical examination (pain over the flexor tendon, tenderness
or nodule over the A1 pulley, stiffness, and reproducible locking or
triggering).
9
PRESENTATION
TITLE
10. PROCEDURE
• All patients’ fingers were infiltrated by the same surgeon following the
same technique.
• Injected with a mixture of 1.0 mL (20 mg) paramethasone acetate
(derivate from dexamethasone) and 1.0 mL mepivacaine chlorhydrate
2%.
• Injections were performed through a palmar approach with a needle
inserted parallel to the tendon fibers at the A1 pulley level.
• The needle was introduced directly into the flexor tendon sheath only
until slight resistance was felt.
• Then the patient was asked to wiggle the finger and slight grating could
be felt at the end of the needle to ascertain its correct position.
• No ultrasound or sonographic monitoring was used to confirm
intrathecal placement.
• No adjuvant therapy or orthoses were applied and patients were
1 0
PRESENTATION
TITLE
11. 1 1
PRESENTATION
TITLE
TCA 2 WEEKS POST 1ST INJECTION
ASYMPTOMATIC
NO FURTHER
INJECTION
TCA 3
MONTHS
TCA 12
MONTHS
TCA 36
MONTHS
FINAL
FOLLOW
UP
SYMPTOMATIC
GIVEN 2ND
INJECTION
SURGICAL
RELEASE
TCA 3
MONTHS
TCA 12
MONTHS
TCA 36
MONTHS
FINAL
FOLLOW
UP
SYMPTOM
ATIC
12. • SUCCESS was defined as complete resolution of symptoms for the
entirety of the follow-up period such that surgical intervention was not
required.
• FAILURE was defined when the patient was referred for surgical
release of the A1 pulley.
• RECURRENCE was defined when symptoms reappeared after a
minimum of a 3-month symptom-free period or required additional
injections, which were offered to this group of patients.
• Those who refuse the additional injection were also recorded as
1 2
PRESENTATION
TITLE
17. DISCUSSION
• Several studies have demonstrated that trigger digits can be
successfully treated with steroid injections, with a success incidence
ranging from 47% to 92% according to the published series.
• Murphy et al: 64% success
• Lambert et al: 60% success
• Peters-Veluthamaningal et al: 88% success
• Duration of follow-up after injection is highly variable among the
published studies, ranging from 1 to 27 months.20
• Our results are slightly better, with an incidence of success of 69%
after a median 8 years of follow-up.
1 7
PRESENTATION
TITLE
18. CONT.
• Some studies have demonstrated that the prevalence of trigger digit is
substantially higher in patients with diabetes than those in the general
population.
• In these cases related to diabetes, it seems that treatment with steroid
injections is less effective.
• In our series, the success incidence in patients with and without diabetes was
57% and 72%, respectively.
1 8
PRESENTATION
TITLE
19. • We followed a staged protocol supporting a 2-week interval between
injections. According to the literature, it seems that no standard
protocol has been established or adopted as best practice for trigger
fingers.
• Some studies propose weekly intervals between injections, whereas
some others propose waiting 4 weeks, 6 weeks, 8 weeks, or even 3
months. However, most studies do not specify how long the
researchers waited between the first and the second injection.
• We decided to follow an algorithm in which all patients were evaluated
after 2 and 4 weeks and then offered another injection if they were
symptomatic, or surgery if they refused another injection. Nonetheless,
we are aware that some patients might have resolved symptoms if
more time had been allowed to elapse between injections.
1 9
PRESENTATION
TITLE
20. CONCLUSION
2 0
PRESENTATION
TITLE
Steroid injections were an effective first-line intervention
for the treatment of trigger finger. At long-term follow-
up, the success incidence may be as high as 69%. In
this study, the efficacy of this treatment increases when
treating the thumb compared with other digits.
