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Digital Flexor Injection

  • Author: Jennifer Moriatis Wolf, MD; Chief Editor: Erik D Schraga, MD  more...
 
Updated: Jul 01, 2016
 

Background

Injection of a flexor tendon in the hand is most commonly performed for the treatment of stenosing tenosynovitis. Stenosing tenosynovitis, also known as trigger finger, involves a size mismatch between a thickened or stenotic first annular (A1) pulley in the hand and the flexor tendon trying to glide through the pulley. As the patient attempts to extend the finger, the flexor tendon catches, causing clunking or locking at the proximal interphalangeal (PIP) joint of the involved digit. This locking is termed triggering (see the image below).[1]

Ring and small finger locking with trigger finger. Ring and small finger locking with trigger finger.

In 1972, corticosteroid injection into the flexor tendon sheath for the treatment of trigger finger was advocated by Lapidus, who noted resolution of triggering in most fingers treated with steroid injection.[2]  Since then, corticosteroid injection for trigger finger has become the first-line conservative treatment in most patients who present with stenosing tenosynovitis.[3, 4]  A 2013 retrospective review that included 577 trigger digits found corticosteroid injection to be safe and effective (79.7% success rate).[5]

For information on surgical treatment of trigger finger that does not respond to conservative treatment, see Trigger Finger.

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Indications

Trigger finger or stenosing tenosynovitis is the usual indication for injection into the digital flexor sheath. Some patients present with pain over the A1 pulley without demonstrable locking or catching. When this is clinically suspected as pretriggering, corticosteroid injection is appropriate. Trigger finger is commonly graded according to the classification outlined by Wolfe (see Table 1 below).[6]

Table 1. Wolfe's Classification of Trigger Finger (Open Table in a new window)

Grade Type Description
I Pretriggering Pain in the palm; possible history of catching, but not seen on examination; tenderness over A1 pulley
II Active Patient demonstrates catching but can actively extend the finger
III Passive Patient demonstrates locking that requires passive extension (IIIa); may be unable to flex the finger (IIIb)
IV Contracture A locked trigger finger with a fixed flexion contracture of the proximal interphalangeal joint
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Contraindications

The main contraindication for injection into the digital flexor sheath is preexisting infection. Patients who present with suppurative flexor tenosynovitis or infection that extends throughout the flexor sheath in the finger and hand should be treated with surgical drainage of the flexor sheath to treat the infection.[7]

A previous allergic reaction to some component of the planned injection is also a contraindication for steroid injection. Allergies to corticosteroids[8] and multiple local anesthetics[9] have been reported.

A patient who presents with diabetes and trigger finger may present a relative contraindication for offering a corticosteroid injection as the first-line treatment.

Baumgarten et al published a randomized blinded study comparing corticosteroid injections with placebo injections in patients with diabetes, which found no significant differences in response between placebo and steroid.[10] More important, symptomatic relief and the need for surgery were not decreased by the use of corticosteroid injections in patients with diabetes. Griggs et al also demonstrated a poorer response to corticosteroid injections in patients with diabetes as compared with the general population.[11]

Patients with diabetes who choose to undergo corticosteroid injection into the flexor tendon sheath must be educated about the effects of such injections on blood glucose levels. Wang and Hutchinson studied the effects of corticosteroid injection for trigger finger on blood glucose levels in diabetic patients and found that in all patients, blood glucose levels rose after injection; those with type I diabetes were most affected.[12] The highest glucose level spike occurred the morning after injection, when average glucose levels were 72% higher than average preinjection levels.

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Technical Considerations

Anatomy

The palmar fascia consists of resistant fibrous tissue arranged in longitudinal, transverse, oblique, and vertical fibers. The longitudinal fibers originate at the wrist from the palmaris longus tendon, when present. These fibers spread out to the base of each digit, where minor fibers extend distally and attach to tissues.

This arrangement of fibers forms the fibrous flexor sheath and pulley system of each digit. The A1 pulley arises from the palmar plate and proximal portion of the proximal phalanx, overlies the membranous sheath at the level of the metacarpophalangeal (MCP) joint, and is approximately 8 mm in width.

For more information about the relevant anatomy, see Flexor Tendon Anatomy and Hand Anatomy.

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Contributor Information and Disclosures
Author

Jennifer Moriatis Wolf, MD Associate Professor, Department of Orthopedic Surgery, University of Connecticut Health Center

Jennifer Moriatis Wolf, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Society for Surgery of the Hand, Phi Beta Kappa

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

References
  1. Ryzewicz M, Wolf JM. Trigger digits: principles, management, and complications. J Hand Surg [Am]. 2006 Jan. 31(1):135-46. [Medline].

  2. Lapidus PW, Guidotti FP. Stenosing tenovaginitis of the wrist and fingers. Clin Orthop Relat Res. 1972 Mar-Apr. 83:87-90. [Medline].

  3. Nimigan AS, Ross DC, Gan BS. Steroid injections in the management of trigger fingers. Am J Phys Med Rehabil. 2006 Jan. 85(1):36-43. [Medline].

  4. Callegari L, Spanò E, Bini A, Valli F, Genovese E, Fugazzola C. Ultrasound-guided injection of a corticosteroid and hyaluronic Acid: a potential new approach to the treatment of trigger finger. Drugs R D. 2011. 11(2):137-45. [Medline].

  5. Schubert C, Hui-Chou HG, See AP, Deune EG. Corticosteroid injection therapy for trigger finger or thumb: a retrospective review of 577 digits. Hand (N Y). 2013 Dec. 8(4):439-44. [Medline]. [Full Text].

  6. Wolfe SW. Tenosynovitis. Green DP, Hotchkiss RN, Pedersen WC, Wolfe SW. Green's Operative Hand Surgery. 5th ed. Philadelphia, Pa: Elsevier; 2005. Vol 2: 2141-50.

  7. Gutowski KA, Ochoa O, Adams WP Jr. Closed-catheter irrigation is as effective as open drainage for treatment of pyogenic flexor tenosynovitis. Ann Plast Surg. 2002 Oct. 49(4):350-4. [Medline].

  8. Isaksson M. Systemic contact allergy to corticosteroids revisited. Contact Dermatitis. 2007 Dec. 57(6):386-8. [Medline].

  9. Caron AB. Allergy to multiple local anesthetics. Allergy Asthma Proc. 2007 Sep-Oct. 28(5):600-1. [Medline].

  10. Baumgarten KM, Gerlach D, Boyer MI. Corticosteroid injection in diabetic patients with trigger finger. A prospective, randomized, controlled double-blinded study. J Bone Joint Surg Am. 2007 Dec. 89(12):2604-11. [Medline].

  11. Griggs SM, Weiss AP, Lane LB, et al. Treatment of trigger finger in patients with diabetes mellitus. J Hand Surg [Am]. 1995 Sep. 20(5):787-9. [Medline].

  12. Wang AA, Hutchinson DT. The effect of corticosteroid injection for trigger finger on blood glucose level in diabetic patients. J Hand Surg [Am]. 2006 Jul-Aug. 31(6):979-81. [Medline].

  13. Murphy D, Failla JM, Koniuch MP. Steroid versus placebo injection for trigger finger. J Hand Surg [Am]. 1995 Jul. 20(4):628-31. [Medline].

  14. Taras JS, Raphael JS, Pan WT, et al. Corticosteroid injections for trigger digits: is intrasheath injection necessary?. J Hand Surg [Am]. 1998 Jul. 23(4):717-22. [Medline].

  15. Baack BR, Brown RE. Atypical mycobacterium soft-tissue infection of the dorsal radial wrist: a possible complication of steroid injection for de Quervain's disease. Ann Plast Surg. 1991 Jul. 27(1):73-6. [Medline].

  16. Taras JS, Iiams GJ, Gibbons M, et al. Flexor pollicis longus rupture in a trigger thumb: a case report. J Hand Surg [Am]. 1995 Mar. 20(2):276-7. [Medline].

  17. Fitzgerald BT, Hofmeister EP, Fan RA, et al. Delayed flexor digitorum superficialis and profundus ruptures in a trigger finger after a steroid injection: a case report. J Hand Surg [Am]. 2005 May. 30(3):479-82. [Medline].

  18. Oh J, Jo L, Lee JI. Do not rush to return to sports after trigger finger injection. Am J Phys Med Rehabil. 2015 Apr. 94 (4):e26-30. [Medline].

  19. Wong MW, Tang YN, Fu SC, et al. Triamcinolone suppresses human tenocyte cellular activity and collagen synthesis. Clin Orthop Relat Res. 2004 Apr. 277-81. [Medline].

  20. Akpinar S, Hersekli MA, Demirors H, et al. Effects of methylprednisolone and betamethasone injections on the rotator cuff: an experimental study in rats. Adv Ther. 2002 Jul-Aug. 19(4):194-201. [Medline].

 
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Equipment needed for injection of digital flexor tendon sheath.
Lidocaine and triamcinolone used for injection of digital flexor tendon sheath.
Ring and small finger locking with trigger finger.
Digital flexor injection. Needle is placed at 50º angle at base of finger flexion crease.
Table 1. Wolfe's Classification of Trigger Finger
Grade Type Description
I Pretriggering Pain in the palm; possible history of catching, but not seen on examination; tenderness over A1 pulley
II Active Patient demonstrates catching but can actively extend the finger
III Passive Patient demonstrates locking that requires passive extension (IIIa); may be unable to flex the finger (IIIb)
IV Contracture A locked trigger finger with a fixed flexion contracture of the proximal interphalangeal joint
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