Carpal Tunnel Corticosteroid Injection

Aka: Carpal Tunnel Corticosteroid Injection, Carpal Tunnel Steroid Injection

1. See Also
   1. Hand Injection
   2. Joint Injection
   3. Injectable Corticosteroid
2. Indications
   1. Carpal Tunnel Syndrome
3. Efficacy
   1. Short-term
      1. Relief in 60-70% cases
   2. Long-term (conflicting results)
      1. Significant symptom relief beyond one month has not been demonstrated
         1. Marshall (2007) Cochrane Database Syst Rev (2):CD001554
      2. Clinical outcome at one year for steroid injection is similar to surgery
         1. Ly-Pen (2005) Arthritis Rheum 52:612-9
4. Precautions
   1. Avoid Median Nerve
   2. Injection is harmful if improperly done
5. Anatomic relationships
   1. Flexor carpi radialis (radial side)
   2. Median Nerve
   3. Palmaris Longus (Ulnar side)
      1. Forms palmar aponeurosis at midline of wrist
      2. Oppose thumb and 5th finger to find palmaris longus
6. Preparation
   1. Needle: 27 gauge 1.25 inch (or 25 gauge 1.5 inch)
   2. Corticosteroid
      1. Methylprednisolone: 20-40 mg or
      2. Triamcinolone 20-40 mg or
      3. Celestone Soluspan: 1 ml
   3. Anesthetic
      1. Lidocaine 1%: 2 ml or
      2. Bupivacaine (Marcaine) 0.25%
7. Technique
   1. Wrist position
      1. Dorsiflex wrist to 30 degrees resting on towel roll
   2. Injection site
      1. Ulnar side of following landmark
         1. Wrist midline if palmaris longus absent or
         2. Palmaris longus tendon
            1. Find by opposing thumb with pinky or
            2. Flex middle finger against resistance
      2. Proximal wrist crease
   3. Needle insertion
      1. Apply antiseptic to skin (e.g. Betadine)
      2. Aim 30-45 degrees distally toward middle-ring finger
      3. Insert needle 1-2 cm until no resistance
      4. Do not inject if Paresthesias (see below)
   4. Warning: Distal Paresthesias with needle before steroid
      1. Indicates needle is at Median Nerve
      2. Do not inject here!
      3. Remove needle and replace further to the ulnar side
8. Follow-up
   1. Anticipate at least 2 weeks to see improvement
   2. Continue wrist splint use after injection
   3. May be repeated up to 2-3 times
9. References
   1. Pfenninger (1994) Procedures, Mosby, p. 1036-54
   2. Neustadt in Roberts (1998) Procedures, p. 914-5
   3. Boyer (2008) J Hand Surg Am 33(8): 1414-6
   4. Tallia (2003) Am Fam Physician 67(4):745-50