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Northern Indiana Hand and Wrist
Sticking It to the Man
Cardinal Richelieu declared “the pen is mightier than the sword”, but it is equally true that the needle can be mightier than the knife.
Patients often present with complaints of pain and disability that can be easily and effectively treated with injection. Knowing which maladies can be cured by injection, which will resolve spontaneously, and which will prove refractory to steroid are crucial to success.
The typical injection consists of 1.5cc of Xylocaine (without epinephrine), and 1.5cc of steroid. The three usual steroids available for injection are Dexamethasone, Kenalog and Celestone. Dexamethasone often leaves a patch of skin de-pigmentation at the injection site and is, therefore, my last choice. Kenalog and Celestone are equally effective.
The most common complaints which respond to injection are:
DeQuervain’s Tendinitis:
95% of patients will get permanent relief of their symptoms from injection. Most patients need one or two injections, but a third injection is indicated if the first two fail. The injections should be spaced about four weeks apart since there can be a lag between the time of injection and symptomatic relief.
15% of the general population has a separate tendon sheath for the EPB tendon, but 85% of the patients who do not improve with injection have this anomaly. It is likely that the patients who fail to improve with injection just have not received enough medication into this separate and small sheath.
Carpal Tunnel Syndrome:
The main benefit for a carpal tunnel syndrome is to establish the presence of the condition when the differential diagnosis is confusing or the physical exam is ambiguous. Patients will generally get the same relief from surgery as they will from an injection, though the surgical relief will be lasting and the relief from injection transient. If a patient’s symptoms do not improve even temporarily after injection then the complaints are not coming from carpal tunnel syndrome, and the surgery will not work well.
Trigger Finger:
Catching or locking of the finger can be permanently relieved in 70% of patients by one steroid injection. Half of the remainder will respond to a second injection improving the overall care rate to 85%. Unless the finger is locked or the patient is a brittle diabetic, an injection should always be tried before deciding upon surgery.
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