II. Indications
III. Efficacy
- Short-term
- Reduced symptoms, and improved function and quality of life in 60-70% cases
- Short-term relief for at least 6 months, and reduced need for surgery at 12 months
- Ashworth (2023) Cochrane Database Syst Rev (2): CD015148 [PubMed]
- Long-term
- Clinical outcome at one year for steroid injection is similar to surgery
IV. Precautions
- Do not inject into Median Nerve
- Risk of tendon rupture
- Injection is harmful if improperly done
V. Anatomy: Anatomic relationships
- Flexor carpi radialis (radial side)
- Median Nerve
- Palmaris Longus (Ulnar side)
- Forms palmar aponeurosis at midline of wrist
- Oppose thumb and 5th finger to find palmaris longus
VI. Preparation
- Needle: 27 gauge 1.25 inch (or 25 gauge 1.5 inch)
-
Corticosteroid
- Methylprednisolone: 20-40 mg (0.5 to 1 ml of 40 mg/ml) or
- Triamcinolone 20-40 mg or
- Celestone Soluspan: 1 ml
-
Anesthetic (without Epinephrine)
- Lidocaine 1%: 1-2 ml or
- Bupivacaine (Marcaine) 0.25%
VII. Technique: Landmark
- Consider Ultrasound guidance of injection (see below)
- Non-Ultrasound landmarks offer accurate needle placement in 75% of cases
- However landmark-based injection results in Median Nerve penetration in 9% of cases
- Green (2020) Hand 15(1): 54-8 [PubMed]
- Non-Ultrasound landmarks offer accurate needle placement in 75% of cases
-
Wrist position
- Dorsiflex wrist to 30 degrees resting on towel roll
- Injection site
- Proximal wrist crease (or 1 cm proximal to most distal wrist crease) AND
- RADIAL side of following landmark
- Wrist midline (in-line with 4th digit) if palmaris longus absent or
- Palmaris longus tendon
- Find by opposing thumb with pinky or
- Flex middle finger against resistance
- References
- Needle insertion
- Apply antiseptic to skin (e.g. Chlorhexidine or Povidone-Iodine)
- Aim 30-45 degrees distally toward middle-ring finger
- Insert needle 1-2 cm until no resistance (under the flexor Retinaculum, nerve is very superficial)
- Do not inject if Paresthesias (see below)
- Warning: Distal Paresthesias with needle before steroid
- Indicates needle is at Median Nerve
- Do not inject here!
- Remove needle and replace further to the ulnar side
VIII. Technique: Ultrasound Guidance
- Prepare the skin as with landmark approach
- High frequency linear Ultrasound probe
- Position transverse (horizontally) across the wrist
- Needle Insertion
- Locate the Median Nerve
- Insert the needle from ulnar aspect, parallel to the table and in-line with the Ultrasound probe
- First needle direction toward superficial depth within the flexor Retinaculum
- Target the space anterior (superficial) and radial to the nerve and hydrodissect it from the overlying Retinaculum
- Inject the first half of the steroid-Anesthetic solution
- Second needle direction is directed at a deeper plan
- Target the space inferior (deep) and ulnar to the Median Nerve
- Inject remaining half of the steroid-Anesthetic solution
- Efficacy
- Ultrasound-guided injection is significantly more effective than landmark-based
IX. Follow-up
- Anticipate at least 2 weeks to see improvement
- Continue Wrist Splint use after injection
- May be repeated up to 2-3 times
X. References
- Pfenninger (1994) Procedures, Mosby, p. 1036-54
- Neustadt in Roberts (1998) Procedures, p. 914-5
- Boyer (2008) J Hand Surg Am 33(8): 1414-6 [PubMed]
- Pujalte (2024) Am Fam Physician 110(4): 402-10 [PubMed]
- Tallia (2003) Am Fam Physician 67(4):745-50 [PubMed]