Hand and arm pain: A pictorial guide to injections

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Applied Evidence

Hand and arm pain: A pictorial guide to injections

J Fam Pract. 2017 August;66(8):492-502

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References

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16. Day CS, Gelberman R, Patel AA, et al. Basal joint osteoarthritis of the thumb: a prospective trial of steroid injection and splinting. J Hand Surg Am. 2004;29:247-251.

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Carpal tunnel syndrome: Moving slower to surgery

CTS is one of the most common conditions of the upper extremities. Researchers estimate that 491 women per 100,000 person-years and 258 men per 100,000 person-years will develop CTS, with 109 per 100,000 person-years receiving carpal tunnel release surgery.¹⁷Risk factors for the development of CTS include diabetes, hypothyroidism, rheumatoid arthritis, pregnancy, obesity, family history, trauma, and occupations that involve repetitive tasks or long hours working at a computer.¹⁸

CTS is caused by compression of the median nerve as it passes through the carpal tunnel.¹⁹ The elevated pressure in the carpal tunnel restricts epineural blood flow and supply, causing the pain felt with CTS.²⁰ Even after surgical decompression, recurrent or persistent CTS can be a problem.²¹

Making the Dx: Perform the Phalen maneuver, Durkan’s test

Patients typically present with complaints of weakness, pain, and/or numbness in at least 2 of 4 radial digits (thumb, index, middle, ring).^19,22 The most common time of day for patients to have symptoms is at night.²¹

The diagnostic tools. Tinel’s sign is a useful diagnostic tool when you suspect carpal tunnel syndrome. Tinel’s sign is positive if percussion over the median nerve at the carpal tunnel elicits pain or paresthesia.¹⁸

When employing the Phalen maneuver, be certain to have the patient flex his/her wrist to 90 degrees and to document the number of seconds it takes for numbness to present in the fingers. Pain or paresthesia should occur in <60 seconds for the test to be positive.¹⁸

Median nerve compression over the carpal tunnel, also known as Durkan’s test, may also elicit symptoms. With Durkan’s test, you apply direct pressure over the transverse carpal ligament. If pain or paresthesia occurs in <30 seconds, the test is positive.¹⁸ Often clinicians will combine the Phalen maneuver and Durkan’s test to increase sensitivity and specificity.¹⁸ Nerve conduction studies are often performed to confirm the clinical diagnosis.

Is more than one condition at play? It is important to determine whether cervical spine disease and/or peripheral neuropathy is contributing to the patient’s symptoms, along with CTS; patients may have more than one condition contributing to their pain. We routinely check cervical spine motion, tenderness, and nerve compression as part of the exam on a patient with suspected CTS. In the office, a monofilament test or 2-point discrimination test can help make the clinical diagnosis by uncovering decreased sensation in the thumb, index, and/or middle fingers.²³

The 5.07 monofilament test is performed with the clinician applying the monofilament to different dermatomal or sensory distributions while the patient has his/her eyes closed. The 2-point discrimination test is performed with a caliper device that measures the distance at which the patient can feel 2 separate stimuli. Often electromyography or nerve conduction studies are necessary.¹⁸

Treatment: Pursue nonoperative approaches

A survey of the membership of the American Society for Surgery of the Hand revealed that surgeons are utilizing nonoperative treatments for a longer duration of time and are employing narrowed surgical indications.²⁴ Thus, clinicians are more likely to try splints and steroid injections before proceeding to operative release.²⁴

Nonsurgical management. In our practice, we commonly recommend corticosteroid injections (TABLE 1^2-4) into the carpal tunnel (FIGURES 4 and 5) to patients who are poor candidates for surgery (ie, those who have too many medical comorbidities or wound healing concerns). This is one indication for which you may want to consider ultrasound-guided injections because the improved accuracy may provide symptom relief faster than “blind” or palpation-guided injections.²⁵

A recent randomized controlled trial from Sweden showed that injections of methylprednisolone relieved symptoms in patients with mild to moderate CTS at 10 weeks and reduced the rate of surgery one year after treatment; however, 3 out of 4 patients still went on to have surgery within a year.²² Patients in the study had failed a 2-month trial of splinting and were given either 80 mg or 40 mg of methylprednisolone or saline. There was no statistical difference between the doses of methylprednisolone in preventing surgery at one year. Compared to placebo, the 80-mg methylprednisolone group was less likely to have surgery with an odds ratio of 0.24 (P=.042).²²

Recent studies show discrete histologic changes in trigger finger tendons, similar to findings with Achilles tendinosis and tendinopathy.

There is evidence that oral steroids, injected steroids, ultrasound, electromagnetic field therapy, nocturnal splinting, and use of ergonomic keyboards are effective nonoperative modalities in the short term, but evidence is sparse for mid- or long-term use.¹⁹ In addition, at least one randomized trial found traditional cupping therapy applied around the shoulder alleviated carpal tunnel symptoms in the short-term.²⁶ Other nonoperative therapies include rest, NSAIDs, extracorporeal shock wave therapy, and activity modification.^19,27

Surgical outcomes by either endoscopic, mini-open, or open surgical techniques are typically good.^20,21 Surgical release involves cutting the transverse carpal ligament over the carpal tunnel to decompress the median nerve.²⁴ You should inform patients of the risks and inconveniences associated with surgery, including the cost, absence from work, infection, and chronic pain. Patients who have recurrent or persistent symptoms after surgery may have had an incompletely released transverse carpal ligament or there may be no identifiable cause.²¹ Overall, surgical treatment, combined with physical therapy, seems to be more effective than splinting or NSAIDs for mid- and long-term treatment of CTS.²⁸