From the Guidelines
I strongly recommend proceeding with the scheduled corticosteroid injection for this 49-year-old male with trigger thumb symptoms, as it can provide symptom relief for several months in approximately 70% of patients. The patient presents with a jumping sensation in the right thumb DIP joint without complete locking, and reports diminishing pain since March. We've discussed the benefits and risks of steroid injection therapy, which typically involves injecting a mixture of lidocaine (for immediate pain relief) and a corticosteroid such as triamcinolone or methylprednisolone (1-2 ml) into the flexor tendon sheath.
Key Considerations
- The patient has agreed to this plan of care with an appointment scheduled in two weeks, understanding he can cancel if symptoms resolve spontaneously.
- Conservative measures like rest, NSAIDs, and gentle stretching exercises can be continued in the meantime.
- If symptoms persist after 1-2 injections, surgical release of the A1 pulley may be considered as a more definitive treatment option.
Evidence-Based Decision
The decision to proceed with the corticosteroid injection is based on the evidence from 1, which suggests that intra-articular injection of long-acting corticosteroid is effective for painful flares of OA, especially trapeziometacarpal joint OA. Additionally, 1 notes that locally injected corticosteroids may be more effective than oral NSAIDs for relief in the acute phase of tendon pain. However, it's essential to weigh the potential benefits against the risks, including temporary pain at the injection site, skin depigmentation, or rarely, tendon rupture, as mentioned in 1.
Treatment Approach
The treatment approach should prioritize the patient's individual needs and preferences, taking into account the severity of symptoms, medical history, and potential risks and benefits of the treatment options. By proceeding with the scheduled corticosteroid injection, we can provide the patient with a potentially effective treatment for his trigger thumb symptoms while closely monitoring his response and adjusting the treatment plan as needed.
From the Research
Trigger Finger Treatment
- The patient presents with complaints of trigger finger, characterized by a jump in the DIP joint of the right thumb, but without locking, and reports that the pain has faded since March.
- The patient has requested a steroid injection, and after reviewing the pros and cons, an appointment for the injection has been scheduled for two weeks.
Effectiveness of Steroid Injections
- Studies have shown that corticosteroid injections are effective in treating trigger finger, with a success rate of 61% after a single injection 2.
- A meta-analysis of randomized control trials found that corticosteroid injections have better outcomes compared to control injections, with a pooled estimate of successful treatment of 63.68% 3.
- Another study found that combining intra-articular corticosteroid and anti-TNF agent led to prolonged anti-inflammatory response in patients with recurrent inflammatory monoarthritis 4.
Patient Decision Making
- The patient's decision to undergo a steroid injection is a shared decision-making process, where the patient's priorities and values are taken into account 5.
- The patient has been informed that they can cancel the appointment at any time if they feel better, and has agreed to the plan of care.
Steroid Injection Safety
- Studies have shown that corticosteroid injections are safe and well-tolerated, with minimal adverse effects 2, 3, 6.
- A study comparing the efficacy of methylprednisolone acetate and triamcinolone acetonide intra-articular knee injections found no significant differences in efficacy or safety between the two preparations 6.