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Injections of the Hand and Wrist: Part II. Carpal Tunnel Syndrome, Ganglion Cyst, Intersection Syndrome, Triangular Fibrocartilage Complex Injury, and de Quervain Tenosynovitis

Injections of the Hand and Wrist: Part I. Trigger Finger, First Carpometacarpal Joint Osteoarthritis, and Palmar Fibromatosis

George G. A. Pujalte, MD
Rock Vomer, DO, DPT
Neil Shah, MD

American Family Physician. 2024;110(4):395-401.

Author disclosure: No relevant financial relationships.

This clinical content conforms to AAFP criteria for CME.

This is one of a series of articles produced in collaboration with the American Medical Society for Sports Medicine.

Family physicians are well-positioned to provide injections for patients who have pain due to hand and finger conditions, especially when initial treatments such as splinting and nonsteroidal anti-inflammatory drugs are ineffective. Corticosteroid injections can offer pain relief; however, potential risks such as infection, cartilage damage, and skin depigmentation should be discussed. Techniques and procedures for injections vary. Corticosteroid injections for ste-nosing flexor tenosynovitis (trigger finger) can be performed with or without ultrasound guidance. To maximize benefits of corticosteroid injection for carpometacarpal joint osteoarthritis, topical nonsteroidal anti-inflammatory drugs and other conservative treatment modalities should be used concurrently. Because of the risks of disease recurrence and adverse effects, corticosteroid injections for palmar fibromatosis should be approached with caution in the context of shared decision-making.

The hand and wrist complex comprises 27 bones and multiple tendons, muscles, ligaments, and nerves. This complex is integral for performing daily tasks. Hand and wrist injuries represent 25% of all sports-related injuries and can have a major effect on functional activities of daily living.1 The incidence of these injuries is on the rise as the number of people engaging in sports and active recreational activities is increasing. This article, part I of a two-part series on injections of the hand and wrist, addresses injections for trigger finger, first carpometacarpal joint osteoarthritis, and palmar fibromatosis. Part II addresses injections for carpal tunnel syndrome, ganglion cyst, intersection syndrome, triangular fibrocartilage complex injury, and de Quervain tenosynovitis.2

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating Comments
Point tenderness is an essential part of physical examination and may be especially helpful in determining the cause of hand pain.1,3,4 C Expert opinion and consensus guideline in the absence of clinical trials
Ultrasound guidance can ensure injectates, particularly corticosteroids, are introduced where they are needed without harming other structures within the hand and wrist.7–9 B Evidence from randomized controlled trials and a systematic review
Possible complications of injections, including infection, cartilage damage, collagen degradation, skin thinning, and change in skin color, should be discussed with the patient.14–16 C Expert opinion and consensus guideline in the absence of clinical trials

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

INITIAL EVALUATION

Point tenderness plays a crucial role in the physical examination when identifying the source of hand pain.1,3,4 It is critical to assess passive, active, and resisted movements of the hand, followed by evaluating sensation.3

IMAGING

Radiography is the first-line imaging test to assess for fractures and osseous alignment following hand or finger trauma.1 Radiography can additionally be used to monitor healing of conservatively treated fractures of the hand.1 Magnetic resonance imaging (MRI) can be used to assess injuries of the ligamentous structures. Further, MRI and computed tomography can be used to identify occult fractures of the carpal, including metacarpal, bones.5,6 Ultrasonography plays a valuable role in providing point-of-care and dynamic evaluation of tendons, nerves, and muscle and can be used to guide injection and aspiration to treat hand conditions. Although not mandatory, ultrasound guidance helps to ensure injectates, particularly corticosteroids, are introduced safely and accurately.7–9

GEORGE G. A. PUJALTE, MD, CAQSM, FACSM, FAMSSM, FAAFP, is a consultant in the departments of family medicine and orthopedics and sports medicine, an associate professor of family medicine, and an assistant professor of orthopedics at the Mayo Clinic College of Medicine and Science, Jacksonville, Fla. Dr. Pujalte is also the vice chair of research in the Department of Family Medicine at Mayo Clinic, Jacksonville.

ROCK VOMER, DO, DPT, is a primary care and sports and performance medicine physician, Avance Care, Wilmington, N.C.; and a research collaborator in the Department of Family Medicine at Mayo Clinic, Jacksonville.

NEIL SHAH, MD, is a resident physician in the department of family medicine at Mayo Clinic, Jacksonville.

Address correspondence to George G. A. Pujalte, MD, at pujalte.george@mayo.edu.

Author disclosure: No relevant financial relationships.

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Injections of the Hand and Wrist: Part II. Carpal Tunnel Syndrome, Ganglion Cyst, Intersection Syndrome, Triangular Fibrocartilage Complex Injury, and de Quervain Tenosynovitis

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