Digital Flexor Tenosynovitis Injection

Aka: Digital Flexor Tenosynovitis Injection, Flexor Tendon Sheath Injection, Trigger Finger Corticosteroid Injection

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II. Indications

  1. Digital Flexor Tenosynovitis (Trigger Finger)
    1. Consider for lack of improvement after 4 to 6 weeks of conservative therapy (e.g. NSAIDS, Splinting)
    2. May consider for first-line management in more severe presentations (severe locking, reduced range of motion)

III. Contraindications

  1. Suppurative Tenosynovitis

IV. Preparation

  1. Needle: 25 to 27 gauge (1.0 to 1.5 inch)
  2. Corticosteroid
    1. Methylprednisolone: 20 mg (0.5 ml of 40 mg/ml) or
    2. Celestone Soluspan: 0.5 ml or
    3. Triamcinolone 20 mg
  3. Anesthetic
    1. Lidocaine 1%: 0.5 to 1 ml or
    2. Bupivacaine (Marcaine) 0.25% 0.5 to 1 ml

V. Technique: Landmark

  1. Wrist and hand position
    1. Maximally abduct thumb (accentuates abductor tendon)
  2. Injection site
    1. Locate tendon Nodule
    2. Palmar aspect of hand
      1. Between Metacarpal head and distal palmar crease
    3. Ultrasound guidance (high frequency linear probe)
      1. Ultrasound may be used to confirm location of tendon Nodule (landmark or real-time during injection)
  3. Needle insertion
    1. Apply antiseptic to skin (e.g. Betadine)
    2. Aim 30 degrees proximally parallel to tendon fibers
    3. Have patient gently flex and extend involved finger
      1. Insert until patient experiences scratchy Sensation
        1. Indicates needle is in tendon sheath
        2. Inject here
      2. Withdraw 1-2 mm if needle moves as finger moves
        1. Indicates needle is within tendon
        2. Do not inject here
        3. Continue to withdraw until scratchy Sensation
  4. Warning
    1. Do not inject directly into tendon

VI. Follow-up

  1. May be repeated up to 4 times at 8 week intervals

VII. References

  1. Greene (2001) Musculoskeletal Care, p. 285
  2. Neustadt in Roberts (1998) Procedures, p. 915-6
  3. Pfenninger (1994) Procedures, Mosby, p. 1036-54
  4. Tallia (2003) Am Fam Physician 67(4):745-50 [PubMed]
  5. Pujalte (2024) Am Fam Physician 110(4): 395-401 [PubMed]

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