Pain Intervention in

Hand Problems
Teddy H Wardhana
Hand, Upperlimb & Microsurgery Division
Orthopaedic & Traumatology Dept.
Airlangga University – Soetomo Academic General Hospital Surabaya

IOA Webinar Series, 18th May 2020

 Dislcosure
IOA Webinar Series, 18th May 2020

We have no financial relationships with any

commercial interest related to the content of
this activity
 Hand & Wrist Pain Problems
IOA Webinar Series, 18th May 2020

• Nerve Entrapment : CTS annual incidence : 2–5% for women & 1–3% for
men.
• Tenosynovitis : De Quervain, Trigger Finger
• Ligamentous Injury : TFCC, Collateral Ligament Injury, etc
• Fractures
• Osteoarthritic
 Steroid Injection ?
IOA Webinar Series, 18th May 2020

Blinded or US Guided

Others Modality

Complication
IOA Webinar Series, 18th May 2020

Steroid Injection
 Carpal Tunnel Syndrome
IOA Webinar Series, 18th May 2020

• CTS steroid injections was first reported by Kopell in 1958.

• Effective when compared to placebo injections *.
• Jenkins et al. reported that 33% px with mild to moderate CTS required
surgery at 5 years follow-up.
• RCT on the effect of steroid dose showed a surgery rate of 73% – 81% at one
year follow-up **.

*Randomised controlled trial of local corticosteroid injections for carpal tunnel syndrome in general practice; BMC Family Practice
volume 11, Article number: 54 (2010)
**Methylprednisolone injections for the carpal tunnel syndrome: a randomized, placebo-controlled trial.Atroshi I, Flondell M, Hofer M,

Ranstam J Ann Intern Med. 2013 Sep 3; 159(5):309-17.

 • Mackinnon et al. * :
IOA Webinar Series, 18th May 2020

o Hydrocortisone and triamcinolone caused widespread axonal and

myelin degeneration.
o Methylprednisolone was moderately toxic.
o Dexamethasone was the least neurotoxic agent.
o All steroids are neurotoxic when injected in intrafascicular plane.
o No association between the degree of nerve damage and the
hydrophilicity of agent.

• Injected agent : 1.0 ml of betamethasone / triamcinolone

together with 1.0 ml of 1% lidocaine

*Peripheral
nerve injection injury with steroid agents.Mackinnon SE, Hudson AR,
Gentili F, Kline DG, Hunter D;Plast Reconstr Surg. 1982 Mar; 69(3):482-90.
 Complication
IOA Webinar Series, 18th May 2020

• Nerve Injury ec needle injury, breakdown nerve blood barrier,

neurotoxicity, pressure effect
• Flexor tendon rupture
• Carpal tunnel infection
• Ischemia
• Skin depigmentation
• Skin & Fat atrophy
IOA Webinar Series, 18th May 2020
 US vs Blinded Injection
IOA Webinar Series, 18th May 2020

• BCTQ, DML, CMAP, SNCV, and CSA of the median nerve were statistically
better in steroid injection combined with MSN release group at week 12
after treatment *

54-y.o woman w/ combined

therapy of steroid injection and
MSN release. (a) The SNAP was
not detected before treatment.
(b) Four weeks after treatment,
the SNAP could be detected
although with low amplitude.

The Effectiveness of Ultrasound-Guided Steroid Injection Combined with Miniscalpel-Needle

Release in the Treatment of Carpal Tunnel Syndrome vs. Steroid Injection Alone: A Randomized
Controlled Study, BioMed Research International Volume 2019 |Article ID 9498656
 Two Approaches
IOA Webinar Series, 18th May 2020

•In-plane (IP)
– Needle lined up and parallel to transducer
– Able to see length of the needle as it approaches

•Out-of-plane (OOP)
– Needle perpendicular to transducer
– Transverse view
IOA Webinar Series, 18th May 2020
 Injection techniques
IOA Webinar Series, 18th May 2020

•Transverse approach in plane

– Radial to ulnar
– Ulnar to radial
•Mark ulnar artery
•Radial to ulnar artery
•Longitudinal in plane
•Out of plane
– Ulnar aspect
 Precaution !! • Vascular
Color Flow
IOA Webinar Series, 18th May 2020

• Anatomy
5mm
• Probe Direction
 • Failure of injection within 1 year were reduced 55%
IOA Webinar Series, 18th May 2020

• Significantly greater improvement in symptoms in

US guided groups, and greater improvement in
nerve conduction (*)
• Average time to symptom relief was shorter in the
US-guided group (**)
• Accuracy  a decreased risk of median nerve
and surrounding tissue damage.

*Arthritis Care & Research, 69(7), 1060–1065.

**American Journal of Physical Medicine & Rehabilitation. 92(11):999–1004, Nov 2013
 Tenosynovitis ( De Quervain, Trigger Finger )
IOA Webinar Series, 18th May 2020

• De Quervain Prevalence is estimated at 0.5% among men and 1.3%

among women.
• Trigger finger prevalence is about 2 – 3% population.
• Metaanalysis result of steroid injection resolution rates is 61% for injection
and splint (*).
• Corticosteroid injections are a useful treatment for de Quervain’s.
tenosynovitis, leading to treatment success 73.4% of the time within 2
injections (*).
• Injection must be carried out into the tendon sheath instead of tendon.

The Effectiveness of Corticosteroid Injection for De Quervain’s Stenosing Tenosynovitis (DQST): A

Systematic Review and Meta-Analysis, Open Orthop J. 2015; 9: 437–444.
 Complication
IOA Webinar Series, 18th May 2020

• Flexor tendon rupture

• Infection
• Ischemia
• Skin depigmentation
• Skin atrophy
• Osteoporotic
 US Guided Tendon Injection
IOA Webinar Series, 18th May 2020

• Accuracy >>
• Safety  avoids intratendinous injection, fat atrophy,
depigmentation
 Particulate or Non Particulate Steroid
IOA Webinar Series, 18th May 2020
 Prolotherapy ( PrT )
IOA Webinar Series, 18th May 2020

• Prolotherapy, also know as Non-Surgical Ligament and

Tendon Reconstruction and Regenerative Joint Injection.
• Founded in 1940s by George Hackett, MD
• Induce a low-grade inflamatory reaction  activating
fibroblasts, and promoting collagen deposition and
connective tissue repair.
• Strengthen the “weld” of disabled ligaments and tendons to
bone  stimulating the production of new bone and fibrous
tissue cells.
 • Traditional formulas such as dextrose, saline, and procaine or
IOA Webinar Series, 18th May 2020

lidocaine. In the last several years newer formulas include

Platelet Rich Plasma (PRP) and autologous (from the same
person) adult stem cell sources
 PrT (Prolotherapy) for CTS
IOA Webinar Series, 18th May 2020

• Wu et al, inj (D5W) in px w/ mild to moderate

median  Pain ↓, disability ↓,
electrophysiological responses ↑, all of which
persisted at 6 months (*).
• Effect of hydrodissection separates the nerve
from the flexor retinaculum, underlying
subsynovial connective tissue, and flexor
tendons
• Dose : 2 ml D5 / Injection , 3 times interval 2
wks

* Mayo Clin Proc. 2017; 92(8):1179-1189.

 PrP Injection
IOA Webinar Series, 18th May 2020

• PRP injection was significantly better than corticosteroids

injection as regard VAS, symptom severity scale (SSS),
functional status scale (FSS) of BCTQ as well as the distal
sensory latency.
• PrP Inj in TFCC Injury : improved resting pain, active pain,
upper functionality scale.
• De Quervain : Improved VAS, restored mobility up to 6 mts &
had antibiotic effect
 Others Indication
IOA Webinar Series, 18th May 2020

• Scaphoid Injuries
• Snuff Box Pain
• 70% involved in carpal fracture
• 0.5 – 1 cc / 4 wks

• AIN & PIN Impingement / Pain

 Others Indication
IOA Webinar Series, 18th May 2020

• Wrist Collateral Ligament Injury

• 2 – 3 cc ”peppered” inj technique
• IP Collateral Injury
• 0.5 – 1 cc
 Others indication
IOA Webinar Series, 18th May 2020

• AIN & PIN Impingement / Pain

• Collateral Ligament Injury
• Osteoarthritic condition
• Non displaced Fractures of Carpalia
 Conclussion
IOA Webinar Series, 18th May 2020

• Steroid injection still the most favourable injection in Hand

problems, but becareful for its complication.
• Sonographic visualization of the peripheral nerve and
surrounding anatomy can provide valuable information for
diagnostic purposes and procedure enhancement.
• Others modalities like Prolotherapy and PRP give promises
results in future