II. Indications

III. 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 [PubMed]

IV. Precautions

  1. Do not inject into Median Nerve
  2. Risk of tendon rupture
  3. Injection is harmful if improperly done

V. Anatomy: 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

VI. 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 (without Epinephrine)
    1. Lidocaine 1%: 2 ml or
    2. Bupivacaine (Marcaine) 0.25%

VII. Technique

  1. Consider Ultrasound guidance of injection
  2. Wrist position
    1. Dorsiflex wrist to 30 degrees resting on towel roll
  3. Injection site
    1. Proximal wrist crease (or 1 cm proximal to most distal wrist crease)
    2. 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
  4. 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 (nerve is very superficial)
    4. Do not inject if Paresthesias (see below)
  5. 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

VIII. 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

IX. 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 [PubMed]
  4. Tallia (2003) Am Fam Physician 67(4):745-50 [PubMed]

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