What is the recommended dosage and administration protocol for steroid injections to treat trigger finger in the right hand and intra-articular (IA) injection in the left knee for a 71-year-old male patient?

From the Guidelines

For a 71-year-old male patient, the recommended steroid injection protocol involves using aseptic technique, considering the use of local anesthetics, and monitoring for potential side effects, with specific dosages and administration techniques for trigger finger and intra-articular injections. When performing the steroid injection for trigger finger in the right hand, a mixture containing 10 mg/ml triamcinolone acetonide (or equivalent corticosteroid) combined with 1 ml of 1% lidocaine without epinephrine is typically used, injected into the tendon sheath at the A1 pulley 1. For the left knee intra-articular injection, the standard dosage is 40 mg of triamcinolone acetonide (or equivalent) mixed with 4-5 ml of 1% lidocaine, injected using aseptic technique with a 21-22 gauge needle 1.

Key Considerations for the Procedure

• Aseptic technique should always be undertaken when performing intra-articular therapies, including the use of surgical gloves, skin preparation with alcohol, iodine disinfectant, or chlorhexidine, and changing needles between drawing the drug and injecting it into the joint 1.
• Patients should be offered local anesthetic, explaining the pros and cons, to reduce discomfort during the procedure and extend pain reduction effect 1.
• The risk of septic arthritis following intra-articular injection is very low, but proper precautions should be taken, and patients should be monitored for signs of infection 1.
• Diabetic patients should be informed about the risk of transient increased glycaemia following intra-articular glucocorticoid injection and advised to monitor glucose levels, particularly from the first to third day 1.

Post-Procedure Care

• Patients should avoid overuse of the injected joints for 24 hours following the procedure, but immobilization is discouraged 1.
• Restricted activities are often advised, but studies have shown that 24-48 hour post-injection immobilization adds no benefit compared with normal activity after intra-articular therapy 1.
• Monitoring for potential side effects such as pain flare, skin discoloration, or infection is crucial, and patients should be educated on what to expect and when to seek medical attention.

From the FDA Drug Label

The dose for intra-articular administration depends upon the size of the joint and varies with the severity of the condition in the individual patient. In chronic cases, injections may be repeated at intervals ranging from one to five or more weeks, depending upon the degree of relief obtained from the initial injection The doses in the following table are given as a general guide: Size of JointExamplesRange of Dosage Large Knees Ankles Shoulders 20 to 80 mg Medium Elbows Wrists 10 to 40 mg Small Metacarpophalangeal Interphalangeal Sternoclavicular Acromioclavicular 4 to 10 mg

For the treatment of trigger finger in the fifth digit of the right hand, the dosage is not explicitly stated, but based on the table, a dose of 4 to 10 mg can be considered for a small joint such as the metacarpophalangeal or interphalangeal joint. For the intra-articular injection in the left knee, a dose of 20 to 80 mg can be considered, depending on the severity of the condition. It is essential to note that the dosage requirements are variable and must be individualized based on the disease under treatment and the response of the patient 2.

From the Research

Trigger Finger Treatment

• The recommended treatment for trigger finger involves corticosteroid injections, with studies showing that symptoms and signs resolve in 61% of cases after a single injection 3.
• A study comparing different corticosteroid solutions found that patients receiving triamcinolone required additional injections compared to those receiving methylprednisolone and dexamethasone 4.
• Another study determined that a 20-mg dose of triamcinolone acetonide had a significantly higher rate of clinical effectiveness at 6-month follow-up compared to 5-mg and 10-mg doses 5.

Intra-Articular (IA) Injection in the Left Knee

• IA injections of corticosteroids can provide relief from pain and swelling in arthritic joints, but caution is advised due to potential complications such as post-injection flares, infections, and hematomata 6.
• A systematic review of intra-articular injections of hyaluronic acid for knee osteoarthritis found that IA-HA injections have a limited role in treatment, but are safe and effective for patients who do not have sufficient pain relief with topical or oral medication and physical therapy 7.

Administration Protocol

• The administration protocol for steroid injections in trigger finger and IA injections in the knee should be done cautiously, with consideration of the patient's medical history and potential contraindications 6.
• The choice of corticosteroid solution and dosage can significantly affect clinical outcomes, and clinicians should consider these factors when selecting a specific agent for trigger finger injections 4, 5.