Study Results
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Basic Information
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RECRUITING
NA
60 participants
INTERVENTIONAL
2024-07-03
2026-07-31
Brief Summary
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To reduce the pain of steroid injections for trigger finger, a different approach involves performing the injection from the back/dorsal side of the hand, which is thought to be less sensitive (and therefore less painful) than the front/palm side of the hand. This technique is sometimes used and has been previously studied, but it is not clear if it can offer less injection-related pain than standard treatment.
Accordingly, this study will be comparing short-term injection-associated pain between front/palm side and back/dorsal side steroid injections for trigger finger. The study will also seek to understand what area of the hand is numbed by the anesthetic when doing a front/palm side injection versus a back/dorsal side injection of the hand. Overall, the investigators hypothesize that back/dorsal side injections will be less painful than front/palm side injections for trigger fingers and that the area of numbing from the anesthetic will be equivalent between both types of injections.
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Detailed Description
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CSIs for trigger fingers are among the most common procedures performed by hand surgeons and are often administered multiple times in a single clinic day. CSIs are frequently mixed 50:50 with 1% lidocaine to provide post-injection analgesia for patients as well as symptomatic relief of the trigger finger if acutely inflamed. These injections are commonly administered from a palmar approach into the A1 pulley of the affected digit. Numerous technical variations of palmar trigger finger injections have been described involving either subcutaneous injection superficial to the flexor tendon sheath or intrasynovial (transthecal) injection into the flexor tendon sheath.
Unfortunately, given the rich sensory innervation of the palmar skin, palmar injections are associated with significant pain as the needle pierces the skin. An alternative technique is to provide digital anesthesia from a dorsal webspace approach, injecting the local anesthetic into the flexor tendon synovial sheath. This intrasynovial or transthecal technique has the benefit of a dorsal approach where the skin is less sensitive resulting in less pain (6). This technique has been described previously but is not familiar to many hand surgeons and is not routinely used in North America.
Anecdotally, patients report significantly decreased pain with the dorsal intrasynovial injection technique for trigger finger injections, but pain scores have not been quantitatively evaluated or compared to the pain scores of traditional palmar trigger finger injections. Furthermore, it is not known what distribution of digital sensory blockade is achieved with this intrasynovial technique, particularly on the dorsal surface of the digit which is discontinuous with the flexor tendon sheath and innervated by the sensory branch of the radial nerve.
Accordingly, it is hypothesized that injecting corticosteroids into the synovial sheath of the flexor tendon will result in less pain over 24 hours if performed through the dorsal webspace versus the palmar side of the affected digit.
Conditions
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Study Design
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RANDOMIZED
PARALLEL
TREATMENT
NONE
Study Groups
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Dorsal Webspace Approach
A dorsal approach involves passing the needle with a 1:1 triamcinolone and lidocaine mixture in the dorsal webspace skin aiming just palmar to the proximal phalanx bone such that the needle is directed into the flexor tendon sheath at the A1 annular pulley.
Dorsal webspace combined corticosteroid and anesthetic injection
The dorsal webspace injection consists of a 1cc mixture of 0.5cc triamcinolone (Kenalog) 10mg/mL and 0.5cc 1% lidocaine for analgesic purposes.
Palmar Approach
Standard approach for injecting the 1:1 triamcinolone and lidocaine mixture involves the needle passing through the cutaneous and subcutaneous layers of the palmar skin surface and into the flexor tendon sheath at the A1 annular pulley.
Palmar combined corticosteroid and anesthetic injection
The palmar injection consists of a 1cc mixture of 0.5cc triamcinolone (Kenalog) 10mg/mL and 0.5cc 1% lidocaine for analgesic purposes.
Interventions
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Dorsal webspace combined corticosteroid and anesthetic injection
The dorsal webspace injection consists of a 1cc mixture of 0.5cc triamcinolone (Kenalog) 10mg/mL and 0.5cc 1% lidocaine for analgesic purposes.
Palmar combined corticosteroid and anesthetic injection
The palmar injection consists of a 1cc mixture of 0.5cc triamcinolone (Kenalog) 10mg/mL and 0.5cc 1% lidocaine for analgesic purposes.
Eligibility Criteria
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Inclusion Criteria
* Have a diagnosis of trigger finger (can be any of the 5 digits)
* Opting to receive a CSI for their triggering finger
Exclusion Criteria
* Receiving multiple CSI for trigger finger management at the appointment
* Past CSI and/or surgery to the digit involved
* Unable to communicate in English
18 Years
ALL
No
Sponsors
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Kevin Zuo
OTHER
Responsible Party
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Kevin Zuo
Staff Surgeon, Plastic and Reconstructive Surgery
Principal Investigators
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Kevin Zuo, MD, MASc
Role: PRINCIPAL_INVESTIGATOR
University Health Network, Toronto
Locations
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University Health Network - Toronto Western Hospital
Toronto, Ontario, Canada
Countries
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Central Contacts
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Facility Contacts
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References
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Akhtar S, Bradley MJ, Quinton DN, Burke FD. Management and referral for trigger finger/thumb. BMJ. 2005 Jul 2;331(7507):30-3. doi: 10.1136/bmj.331.7507.30. No abstract available.
Makkouk AH, Oetgen ME, Swigart CR, Dodds SD. Trigger finger: etiology, evaluation, and treatment. Curr Rev Musculoskelet Med. 2008 Jun;1(2):92-6. doi: 10.1007/s12178-007-9012-1.
Fleisch SB, Spindler KP, Lee DH. Corticosteroid injections in the treatment of trigger finger: a level I and II systematic review. J Am Acad Orthop Surg. 2007 Mar;15(3):166-71. doi: 10.5435/00124635-200703000-00006.
Merry SP, O'Grady JS, Boswell CL. Trigger Finger? Just Shoot! J Prim Care Community Health. 2020 Jan-Dec;11:2150132720943345. doi: 10.1177/2150132720943345.
Patrinely JR Jr, Johnson SP, Drolet BC. Trigger Finger Corticosteroid Injection With and Without Local Anesthetic: A Randomized, Double-Blind Controlled Trial. Hand (N Y). 2021 Sep;16(5):619-623. doi: 10.1177/1558944719884663. Epub 2019 Nov 5.
Jimenez I, Garces GL, Marcos-Garcia A, Medina J. A randomized controlled trial of dorsal web space versus palmar midline injection of steroid in the treatment of trigger digits. J Hand Surg Eur Vol. 2020 Dec;45(10):1071-1077. doi: 10.1177/1753193420927999. Epub 2020 Jun 3.
Bitar H, Zachrisson AK, Bystrom M, Stromberg J. Day-by-day symptom relief after corticosteroid injection for trigger digit: a randomized controlled study of two techniques. J Hand Surg Eur Vol. 2023 Oct;48(9):849-856. doi: 10.1177/17531934231177422. Epub 2023 May 22.
Rosenbaum YA, Benvenuti N, Yang J, Ruff ME, Awan HM, Samora JB. The Effect of Trigger Finger Injection Site on Injection-Related Pain. Hand (N Y). 2018 Mar;13(2):164-169. doi: 10.1177/1558944717703134. Epub 2017 Apr 26.
Mathew A. Mid-axial injection of steroid into the flexor sheath for trigger fingers. J Hand Microsurg. 2014 Jun;6(1):49-52. doi: 10.1007/s12593-014-0120-z. Epub 2014 Feb 21. No abstract available.
Jimenez I, Medina J, Marcos-Garcia A, Garces GL. Out-of-sheath corticosteroid injections through the dorsal webspace for trigger finger and trigger thumb. A prospective cohort study. Rev Esp Cir Ortop Traumatol. 2022 Jul-Aug;66(4):260-266. doi: 10.1016/j.recot.2021.03.009. Epub 2021 Aug 6. English, Spanish.
Haefeli M, Elfering A. Pain assessment. Eur Spine J. 2006 Jan;15 Suppl 1(Suppl 1):S17-24. doi: 10.1007/s00586-005-1044-x. Epub 2005 Dec 1.
Melzack R. The McGill Pain Questionnaire: major properties and scoring methods. Pain. 1975 Sep;1(3):277-299. doi: 10.1016/0304-3959(75)90044-5.
Other Identifiers
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24-5288
Identifier Type: -
Identifier Source: org_study_id
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