What are the steps for administering steroid injections, specifically triamcinolone acetonide, for a patient with Dequervain Tenosynovitis?

Steroid Injection Technique for De Quervain Tenosynovitis

For De Quervain tenosynovitis, inject 1 mL of triamcinolone acetonide 10 mg/mL mixed with 1 mL of 1% lidocaine into the first dorsal compartment of the wrist using a 24- or 26-gauge needle, directed proximally toward the radial styloid process and parallel to the tendons. 1, 2, 3

Pre-Injection Preparation

Patient Assessment

• Confirm diagnosis with positive Finkelstein test and tenderness over the first dorsal compartment 2, 4
• Document baseline pain severity using Visual Analog Scale (VAS) 2, 4, 3
• Verify the patient has failed conservative treatment with NSAIDs for at least 4-6 weeks 4
• Exclude active infection at the injection site, hypersensitivity to triamcinolone, and uncontrolled diabetes 5, 6

Medication Preparation

• Mix 1 mL (10 mg) of triamcinolone acetonide with 1 mL of 1% lidocaine hydrochloride in a 5-cc syringe 2, 3
• Shake the vial before use to ensure uniform suspension 1
• Inspect for clumping or granular appearance (agglomeration); discard if present 1
• Inject without delay after withdrawal to prevent settling in the syringe 1

Injection Technique

Anatomical Landmarks and Needle Placement

• Identify the area of maximum tenderness over the first dorsal compartment 3
• Use a 24- or 26-gauge needle for injection 3
• Insert the needle into the first extensor compartment, directed proximally toward the radial styloid process 3
• Align the needle parallel to the abductor pollicis longus and extensor pollicis brevis tendons 3
• Inject into the tendon sheath, NOT into the tendon substance itself 1

Critical Technical Points

• Employ strict aseptic technique 1
• Consider ultrasound guidance to ensure accurate placement in the first extensor compartment 7
• Observe for swelling of the synovial sheath due to volume effect, confirming proper placement 3
• Avoid injecting into surrounding tissues, as this may lead to tissue atrophy 1
• Avoid entering a blood vessel during injection 1

Post-Injection Management

Immediate Care

• Allow NSAIDs for pain relief as needed post-injection 3
• Advise patients that pain relief typically occurs within 3-5 days 8

Follow-Up Schedule

• Assess response at 2 weeks after first injection 2, 4
• If inadequate response (35% of patients), administer second injection 2 weeks after the first 4
• Continue monthly follow-up for up to 28 weeks 4
• Expected outcomes: 65% symptom-free at 2 weeks, 80% at 4 weeks, 95% at 6 weeks, and 98.75% at 12 weeks 4

Repeat Injection Protocol

• A single injection is frequently sufficient, but several injections may be needed 1
• Up to 2-3 local steroid injections can be administered for adequate symptom relief 4
• Long-term beneficial effects are sustained for 12 months in steroid responders 2

Common Pitfalls and Adverse Effects

Technical Errors to Avoid

• Do not inject into the tendon substance itself—ensure injection is into the tendon sheath 1
• Avoid injecting into surrounding tissues, particularly in areas prone to atrophy 1
• Do not use agglomerated product (white precipitate in vial) 1

Expected Adverse Effects

• Skin depigmentation occurs in some patients, appearing 1 week post-injection and spontaneously resolving after 9 months 8
• Local adverse effects (skin atrophy, telangiectasia, pigmentary changes) occur in 25% of patients and typically subside within 20 weeks 5, 6, 4
• Counsel patients about depigmentation risk, which can have profound cosmetic impact 8

Contraindications

• Active infection at injection site 5, 6
• Previous hypersensitivity to triamcinolone 5, 6
• Use with caution in patients with uncontrolled diabetes, heart failure, or severe hypertension 5, 6

Efficacy Data

The evidence strongly supports steroid injection as first-line treatment after conservative measures fail. In a randomized controlled trial, triamcinolone acetonide demonstrated 78% treatment response versus 25% for placebo at 1 week (absolute risk reduction 0.55, number needed to treat = 2) 2. Multiple studies confirm efficacy rates of 86-98% for pain relief 4, 3. Importantly, a 2025 study found that while corticosteroids provide faster pain relief at 1 week compared to platelet-rich plasma, both treatments show equivalent outcomes at 12 weeks 7. This supports the use of corticosteroid injection as the standard of care for De Quervain tenosynovitis.