Hand and arm pain: A pictorial guide to injections

Treatment: Consider corticosteroids first

First-line treatment for patients with trigger finger or thumb is a corticosteroid injection into the subcutaneous tissue around the tendon sheath (FIGURES 1 and 2). (For this indication and for the others discussed throughout the article, there isn’t tremendous evidence for one particular type of corticosteroid over another; see TABLE 1^2-4 for choices.) Up to 57% of cases resolve with one injection, and 86% resolve with 2,⁸ but keep in mind that it may take up to 2 weeks to achieve the full clinical benefit.

Patients with multiple trigger fingers can be treated with oral corticosteroids (eg, a methylprednisolone dose pack). Peters-Veluthamaningal et al performed a systematic review in 2009 and found 2 randomized controlled trials involving 63 patients (34 received injections of a corticosteroid [either methylprednisolone or betamethasone] and lidocaine and 29 received lidocaine only).² The corticosteroid/lidocaine combination was more effective at 4 weeks (relative risk [RR]=3.15; 95% confidence interval [CI], 1.34 to 7.40).²

If 2 corticosteroid injections 6 weeks apart fail to provide benefit, or the finger is irreversibly locked in flexion, surgical release of the pulley is required and is performed through a palmar incision at the level of the A1 pulley. Complications from this surgery, including nerve damage, are exceedingly rare, but injury can occur, given the proximity of the digital nerves to the A1 pulley.

Patient is a child? Refer children with trigger finger or thumb to a hand surgeon for evaluation and management because the indications for nonoperative treatment in the pediatric population are unclear.⁹

Carpometacarpal arthritis: Common, with many causes

Osteoarthritis of the first carpometacarpal (CMC) joint is the most common site of arthritis in the hand/wrist region, affecting up to 11% of men and 33% of women in their 50s and 60s.¹⁰ Because the CMC joint lacks a bony restraint, it relies on a number of ligaments for stability—the strongest and most important of which is the palmar oblique “beak” ligament.¹¹ A major cause of degenerative arthritis of this joint is attenuation and laxity of these ligaments, leading to abnormal and increased stress loads, which, in turn, can lead to loss of cartilage and bony impingement. While the exact mechanism of this process is not fully understood,^10,12 acute or chronic trauma, advanced age, hormonal factors, and genetic factors seem to play a role.¹¹

Many believe there is a relationship between a patient's occupation and the development of CMC arthritis, but studies are inconclusive.¹³ At risk are secretarial workers, tailors, domestic helpers/cleaners, and individuals whose jobs involve repetitive thumb use and/or insufficient rest of the joint throughout the day.

Making the Dx: Perform the Grind test

A detailed patient history (which is usually void of trauma to the hand) and physical examination are the keys to making the diagnosis of CMC arthritis. A history of pain at the base of the thumb during pinching and gripping tasks is often elucidated. Classically, patients describe pain upon turning keys, opening jars, and gripping doorknobs.¹¹

It's important to focus on the dorsoradial aspect of the thumb during the physical exam and to rule out other causes of pain, such as de Quervain’s tenosynovitis, flexor carpi radialis tendinitis, CTS, and trigger thumb.¹¹ Typical findings include pain with palpation directly over the dorsoradial aspect of the CMC joint and pain with axial loading and upon circumduction during a Grind test of the CMC joint. (The Grind test is performed by moving the metacarpal bone of the thumb in a circle and loading it with gentle axial forces. People with thumb joint arthritis generally experience sudden sharp pain at the CMC joint.)

Radiographic findings can be useful as a diagnostic adjunct, with staging of the disease, and in determining who can benefit from conservative management.¹¹

Treatment: Start with NSAIDs and splinting

Depending on the degree of arthritis, management may include both conservative and surgical options.¹⁰ Patient education describing activity modification is useful during all stages of CMC arthritis. Research has shown that avoiding inciting activities, such as key turning, pinching, and grasping, helps to alleviate symptoms.¹⁴ Patients may also obtain relief from NSAIDs, especially when they are used in conjunction with activity modification and splinting. NSAIDs, however, do not halt or reverse the disease process; they only reduce inflammation, synovitis, and pain.¹¹

Splinting. Studies have shown splinting of the thumb CMC joint to provide pain relief and to potentially slow disease progression.¹⁵ Because splints decrease motion and increase joint stability, they are especially useful for patients with joint hypermobility. The long opponens thumb spica splint is commonly used; it immobilizes the wrist and CMC, while leaving the thumb interphalangeal joint free. Short thumb spica and neoprene splints are also commercially available, and studies have shown that they provide good results.¹⁵ Splinting is most beneficial in patients with early-stage disease and may be used for either short-term flares or long-term treatment.¹¹

Cortisone injections. For those patients who do not respond to activity modification, NSAIDs, and/or splinting, consider cortisone injections (FIGURE 3). Intra-articular cortisone injections can decrease inflammation and provide good pain relief, especially in patients with early-stage disease. The effectiveness of cortisone injections in patients with more advanced disease is not clear; no benefit has been shown in studies to date.¹⁶ Equally unclear is the long-term benefit of injections.¹¹ Patients who do not respond to conservative treatments will often require surgical care.