eMedicine Specialties > Clinical Procedures > Anesthetic and Analgesic Techniques

Steroid Injection, Carpal Tunnel

Zita Konik, MD,, Resident Physician, Division of Emergency Medicine, Stanford University School of Medicine
Jeffrey S Peterson, MD,, Clinical Assistant Professor of Surgery/Emergency Medicine, Stanford University School of Medicine, Stanford University Hospital; Founder and Sports Medicine Physician, Innovative Sports Medicine

Updated: Nov 18, 2009

Introduction

Carpal tunnel syndrome is a compressive focal mononeuropathy that is brought on by compression of the median nerve as it travels through the carpal tunnel. Patients commonly experience pain, paresthesias, and weakness in the median nerve distribution. Median nerve corticosteroid (steroid) injection at the wrist is used to treat the symptoms of carpal tunnel syndrome by injecting a steroid solution into the ulnar bursa surrounding the median nerve. This procedure is also commonly called a carpal tunnel injection.

Median nerve steroid injection can be used in conjunction with other conservative measures such as splinting, physical therapy, ergonomic modifications, rest, and regular exercise for mild to moderate carpal tunnel syndrome.^1,2,3,4 Conservative modalities, including median nerve steroid injections, should generally be attempted prior to pursuing surgical options.⁵ Historically, median nerve steroid injections were typically used for only mild median nerve entrapment (as documented by electroneurography) as well as for temporary pain relief in anticipation of definitive flexor retinaculum surgical release. In general, injected corticosteroids appear effective in reducing subjective symptoms for 1-3 months when compared to placebo.⁶ While short-term relief of symptoms after injection appears superior to relief after carpal tunnel release surgery, the advantage is lost over the course of a year.⁷

Electrodiagnostic studies such as nerve conduction studies and electromyography are typically obtained to determine the severity of nerve damage prior to performing the procedure.⁸ Steroid injections should be avoided prior to planned electrodiagnostic testing, as the presence of steroids may alter test results. Clinical tests to diagnose carpal tunnel syndrome include Tinel sign, elicited by reproducing the paresthesias by tapping with a reflex hammer over the median nerve at the volar crease at the wrist. The Phalen test involves holding the flexed wrists against each other for several minutes to provoke the symptoms in the median nerve distribution.

Indications

Carpal tunnel syndrome not relieved by conservative measures
Electrodiagnostic changes consistent with mild-to-moderate median nerve entrapment

Contraindications

Adverse reaction to injectable steroid or anesthetic
Uncontrolled diabetes mellitus
Active systemic or local infection
Compromised skin integrity over the area
Immunosuppression
Planned electrodiagnostic study

Anesthesia

Lidocaine (Xylocaine) 1% without epinephrine, 2-3 mL
Bupivacaine (Marcaine) 0.25%, 2-3 mL
For more information, see Local Anesthetic Agents, Infiltrative Administration.

Equipment

Needle, 1 in, 27 or 30 gauge (ga)
Syringe, 5 mL
Antiseptic solution with skin swabs
Small rolled towel
Triamcinolone acetonide (Kenalog), 10-20 mg; or methylprednisolone acetate (Depo-Medrol), 10-20 mg
Lidocaine 1% or bupivacaine 0.25%

Positioning

Patient should be positioned comfortably in a seated or supine position.
The affected arm should be supinated with the palmar aspect of the wrist resting over a small rolled towel.

Technique

First, locate the flexor carpi radialis (FCR) and palmaris longus (PL) tendons. The palmaris longus tendon is medial to the flexor carpi radialis and is best located by opposing the thumb and fifth digit while the wrist is flexed. For more information, see Flexor Tendon Anatomy.
Solid blue line - palmaris longus tendon; solid red line - flexor carpi radialis tendon; dotted blue line - proximal palmar crease.
Carefully disinfect the skin.
Draw up 1 mL of 1% lidocaine and make a skin wheal ulnar to the palmaris longus and proximal to the proximal wrist crease.
In another syringe, draw up the steroid with or without lidocaine or bupivacaine.
Insert the needle 1 cm proximal to the proximal wrist crease and directly ulnar to the palmaris longus tendon at the skin wheal. Direct the needle distally toward the ring finger at an angle of 30 degrees.
Needle placement - Medial of palmaris longus tendon.
Advance the needle approximately 1.5-2 cm or until the tendon is touched.
Aspirate to verify that no vasculature is affected, and inject the steroid solution with little or no resistance.
Lastly, remove the needle and place the wrist in a gravity-dependent position.
Advise the patient to actively move the fingers for several minutes to distribute the solution evenly.
Steroid injection, carpal tunnel.
Video available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-81306-103333-114167.flv.

Pearls

Some people do not have a palmaris longus (PL) tendon.⁹¹⁰ In these cases, the needle is inserted at the midline between the radial and ulnar aspects of the wrist, proximal to the wrist crease, and is directed toward the ring finger.
Needle placement in absence of palmaris longus tendon.
If contact is made with the palmaris longus tendon while advancing the needle, retract slightly and redirect.
The use of a needle smaller in diameter may require increased effort and slower injection time but dramatically reduces pain at the site of injection.
Sudden worsening pain or paresthesia indicates the possibility of improper needle placement. If this occurs, retract the needle and redirect more medially (ulnar).
To avoid potential complications of vascular or nerve ischemia, tissue necrosis, and serious damage to nerve, lidocaine with epinephrine should not be used.

Complications

Bleeding
Infection
Injury to nerve^11,12
Temporary paresthesia
Alteration in blood glucose levels in patients with diabetes mellitus
Pain¹³

Multimedia

Media file 1: Steroid injection, carpal tunnel.

Video available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-81306-103333-114167.flv.

Media file 2: Solid blue line - palmaris longus tendon; solid red line - flexor carpi radialis tendon; dotted blue line - proximal palmar crease.

Media file 3: Needle placement - Medial of palmaris longus tendon.

Media file 4: Needle placement in absence of palmaris longus tendon.

References

Marshall S, Tardif G, Ashworth N. Local corticosteroid injection for carpal tunnel syndrome. Cochrane Database Syst Rev. Apr 18 2007;CD001554. [Medline].
Aroori S, Spence RA. Carpal tunnel syndrome. Ulster Med J. Jan 2008;77(1):6-17. [Medline].
Piazzini DB, Aprile I, Ferrara PE, Bertolini C, Tonali P, Maggi L, et al. A systematic review of conservative treatment of carpal tunnel syndrome. Clin Rehabil. Apr 2007;21(4):299-314. [Medline].
Bland JD. Treatment of carpal tunnel syndrome. Muscle Nerve. Aug 2007;36(2):167-71. [Medline].
[Guideline] Michael Warren Keith, Victoria Masear, Peter C. Amadio, Michael Andary, Richard W. Barth, Brent Graham, et al. Treatment of carpal tunnel syndrome. J Am Acad Orthop Surg. 2009;17:397-405.
Marshall S; Tardif G; Ashworth N. Local corticosteroid injection for carpal tunnel syndrome. Cochrane Database Syst Rev. April 18 2007;2:CD001554. [Full Text].
Hui AC; Wong S; Leung CH; Tong P; Mok V; Poon D; Li-Tsang CW; Wong LK; Boet R. A randomized controlled trial of surgery vs steroid injection for carpal tunnel syndrome. Neurology. June 28 2005;64 (12):2074-8. [Medline].
Jarvik JG, Yuen E, Kliot M. Diagnosis of carpal tunnel syndrome: electrodiagnostic and MR imaging evaluation. Neuroimaging Clin N Am. Feb 2004;14(1):93-102, viii. [Medline].
Sebastin SJ, Puhaindran ME, Lim AY, Lim IJ, Bee WH. The prevalence of absence of the palmaris longus--a study in a Chinese population and a review of the literature. J Hand Surg [Br]. Oct 2005;30(5):525-7. [Medline].
Kose O, Adanir O, Cirpar M, Kurklu M, Komurcu M. The prevalence of absence of the palmaris longus: a study in Turkish population. Arch Orthop Trauma Surg. May 2009;129 (5):609-11. [Medline].
Linskey ME, Segal R. Median nerve injury from local steroid injection in carpal tunnel syndrome. Neurosurgery. Mar 1990;26(3):512-5. [Medline].
Hennink S, van der Horst CM, Breugem CC. Complications following steroid treatment for carpal tunnel syndrome. J Hand Surg Eur Vol. Jun 2007;32(3):362-3. [Medline].
Kasten SJ, Louis DS. Carpal tunnel syndrome: a case of median nerve injection injury and a safe and effective method for injecting the carpal tunnel. J Fam Pract. Jul 1996;43 (1):79-82. [Medline].
Ly-Pen D, Andreu JL, de Blas G, Sanchez-Olaso A, Millan I. Surgical decompression versus local steroid injection in carpal tunnel syndrome: a one-year, prospective, randomized, open, controlled clinical trial. Arthritis Rheum. Feb 2005;52(2):612-9. [Medline].
Nonsurgical treatment is effective for carpal tunnel syndrome. J Fam Pract. Sep 2004;53(9):685. [Medline].

Keywords

carpal tunnel injection, carpal tunnel, carpal tunnel syndrome, CTS, steroid injection, wrist steroid injection, palmaris longus tendon, flexor carpi radialis tendon, nerve conduction study, electromyography

Contributor Information and Disclosures

Author

Zita Konik, MD,, Resident Physician, Division of Emergency Medicine, Stanford University School of Medicine
Zita Konik, MD, is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Emergency Medicine Residents Association
Disclosure: Nothing to disclose.

Coauthor(s)

Jeffrey S Peterson, MD,, Clinical Assistant Professor of Surgery/Emergency Medicine, Stanford University School of Medicine, Stanford University Hospital; Founder and Sports Medicine Physician, Innovative Sports Medicine
Jeffrey S Peterson, MD, is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Sports Medicine, Massachusetts Medical Society, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Luis M Lovato, MD, Associate Clinical Professor, David Geffen School of Medicine at UCLA; Director of Critical Care, Department of Emergency Medicine, Olive View/UCLA Medical Center
Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Chief Editor

Rick Kulkarni, MD, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the assistance of Lars Grimm with the literature review and referencing for this article.

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Arie Gluzman, BS, MD, to the development and writing of this article.

Further Reading

eMedicine from WebMD: Physical Medicine and Rehabilitation Journal

American Family Physician: Diagnostic and Therapeutic Injection of the Wrist and Hand Region

Family Practice Notebook: Procedure Chapter

Wheeless' Textbook of Orthopaedics: Carpal Tunnel Injection/Median Nerve Block