When are steroid injections indicated for hand finger flexion problems?

Steroid Injections for Hand Finger Flexion Problems

Corticosteroid injections are indicated for trigger finger (stenosing tenosynovitis) causing finger flexion problems after conservative measures have been attempted, and they are effective for painful flares of hand osteoarthritis, particularly at the trapeziometacarpal (thumb base) joint. 1, 2

Primary Indications for Steroid Injection

Trigger Finger (Stenosing Tenosynovitis)

• Corticosteroid injection into the flexor tendon sheath is effective for trigger finger and should be considered as second-line treatment after initial conservative management fails. 1
• The injection combines 1 mL of triamcinolone acetonide (10 mg/mL) with 1 mL of 1% lidocaine without epinephrine, injected directly into the flexor tendon sheath. 3
• Steroid injection combined with lidocaine is significantly more effective than lidocaine alone, with a number needed to treat of 3 at four weeks (relative risk 3.15,95% CI 1.34 to 7.40). 4, 5
• Effects can last up to four months following injection. 5

Hand Osteoarthritis with Painful Flares

• Intra-articular corticosteroid injection is conditionally recommended for hand OA, particularly for painful flares of the trapeziometacarpal (thumb base) joint. 2
• The American College of Rheumatology conditionally recommends intra-articular glucocorticoid injections for hand OA, though evidence specific to this anatomic location is limited compared to knee or hip. 2
• The EULAR guidelines support corticosteroid injection as effective for painful flares, especially for trapeziometacarpal joint OA. 2

Psoriatic Dactylitis

• Steroid injection into the digital flexor tendon sheath is highly effective for hand psoriatic dactylitis, with 87% of digits showing clinically meaningful response at one month versus 17% with systemic treatment alone (p < 0.001). 6

Treatment Algorithm

Step 1: Initial Conservative Management (First-Line)

• Activity modification and education about avoiding adverse mechanical factors should be attempted first. 1
• Heat application (paraffin wax or hot packs) before exercise may provide symptomatic relief. 1
• Range of motion and strengthening exercises to maintain finger mobility. 1
• Topical NSAIDs for mild to moderate pain affecting few fingers. 1
• Oral analgesics (paracetamol up to 4g/day) as first-choice oral medication. 1
• Splinting: For trigger finger, a fixed metacarpophalangeal joint orthosis in neutral position worn at least 8 hours daily for 6 consecutive weeks. 3

Step 2: Corticosteroid Injection (Second-Line)

Proceed to injection when:

• Conservative measures have failed to provide adequate relief. 1, 2
• Patient has moderate to severe symptoms or inadequate response to first-line treatment. 1
• Painful flares occur, particularly in trapeziometacarpal joint OA. 2

Important clinical considerations:

• For trigger finger, splinting alone is as effective as steroid injection alone or combination therapy at 6,12, and 52 weeks, so splinting should be tried first. 3
• However, steroid injection provides faster relief and may be preferred when rapid symptom control is needed. 4, 5
• No adverse events or side effects were reported in randomized trials of trigger finger injection. 4, 5

Step 3: Surgical Intervention (Third-Line)

• Surgical release should be considered when conservative treatments and injections have failed and the patient has marked pain and/or disability. 1, 7

Common Pitfalls and Caveats

Avoid These Mistakes:

• Do not combine steroid injection with splinting for trigger finger initially – the combination provides no additional benefit over either treatment alone, making it unnecessarily invasive. 3
• Do not inject without attempting conservative management first – the treatment algorithm requires stepwise progression through non-pharmacological options. 1, 2
• Do not use hyaluronic acid injections – these are conditionally recommended against for first carpometacarpal joint OA due to lack of evidence of benefit when limited to low-risk-of-bias trials. 2

Key Technical Points:

• For trigger finger, inject directly into the flexor tendon sheath, not just subcutaneously. 3
• Use triamcinolone acetonide 10 mg/mL combined with lidocaine for optimal results. 3, 4
• Ultrasound guidance is not required for hand injections but may improve accuracy. 2

Patient Selection Factors:

• Patients with symptom duration less than 3 months and absence of sensory impairment respond better to conservative treatment and may not need injection. 8
• Patients with thenar wasting or obvious underlying causes should be evaluated for surgical intervention rather than prolonged conservative treatment. 8

FDA-Approved Indications:

• Triamcinolone acetonide is FDA-approved for intra-articular or soft tissue administration as adjunctive therapy for acute and subacute bursitis, acute nonspecific tenosynovitis, rheumatoid arthritis, and synovitis of osteoarthritis. 9