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Role and efficacy of corticosteroid (40 Mg Methyl prednisolone acetate)

injection for non-surgical treatment of de-quervains tenosynovitis, and
incidence of complications of the pr...

Article in International Journal of Orthopaedics Sciences · January 2023

DOI: 10.22271/ortho.2023.v9.i3f.3453

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 International Journal of Orthopaedics Sciences 2023; 9(3): 423-426

E-ISSN: 2395-1958
P-ISSN: 2706-6630
IJOS 2023; 9(3): 423-426
© 2023 IJOS
Role and efficacy of corticosteroid (40 Mg Methyl
https://www.orthopaper.com
Received: 08-05-2023
prednisolone acetate) injection for non-surgical
Accepted: 13-06-2023 treatment of de-quervains tenosynovitis, and incidence
Dr. Ashootosh Batra of complications of the procedure in 55 limbs: A
Specialist Orthopedic Surgeon,
Medeor Hospital, Abu Dhabi, retrospective study
UAE

Dr. Mohammad Elbaz Dr. Ashootosh Batra, Dr. Mohammad Elbaz and Dr. Jaya Batra
HOD and Consultant Orthopedic
Surgeon, Medeor Hospital, Abu
Dhabi, UAE DOI: https://doi.org/10.22271/ortho.2023.v9.i3f.3453

Dr. Jaya Batra Abstract

Associate Staff Physician, Background: Open surgical release of the 1st extensor compartment is the gold standard of treatment for
Department of Anesthesia, De Quervain’s tenosynovitis, with reliable symptomatic relief. The purpose of this retrospective study is
Cleveland Clinic Abu Dhabi, to determine the effectiveness of corticosteroid injections for non-surgical treatment of this condition, and
UAE
the incidence of side effects of this procedure.
Methods: A retrospective study was done in evaluating the use of CPT code 20550 (Injection(s); tendon
sheath, ligament) used as intervention for the diagnosis of M65.4 (Radial styloid tenosynovitis [de
Quervain]). Success of the intervention was defined as clinical resolution of pain to the extent that the
patient did not seek further intervention after 1 or 2 injections. Failure was defined as a subsequent surgical
release or need for a third injection. Side effects of the procedure were documented on the basis of
documentation in subsequent visits as per the records.
Results: The treatment outcome of 55 limbs from 45 patients was studied. Of the 55 limbs, 80% (44/55)
experienced treatment success within 2 injections, and 61.82% (34/55) experienced success after 1
injection. Predominantly 3 side effects were documented which were 1. Whitening of the skin at site of
injection 14.55% (8/55) 2. Transient increase in pain which responded well to analgesics 10.91% (6/55) 3.
Numbness over the anatomical snuffbox persisting > 1 day 1.82% (1/55).
Conclusions: This study indicates that corticosteroid injections are a useful and safe treatment for de
Quervain’s tenosynovitis, leading to treatment success 80% of the time within 2 injections. This study also
documents possible side effects of this procedure.

Keywords: De Quervain’s tenosynovitis, first dorsal compartment tenosynovitis, nonsurgical treatment,

corticosteroid injection, side effects of intralesional steroid injection

Introduction
De Quervain's tenosynovitis is inflammatory stenosing tenosynovitis of 1st extensor
compartment of the wrist [1]. Nonoperative treatments include splinting, NSAIDs, therapy
exercises, and corticosteroid injections [2, 3]. Using a splint after the steroid injection has also
shown conflicting results in literature with Weiss et al. [4] reported that the use of a splint did not
provide added benefit in addition to an injection, whereas a randomized prospective study by
Mardani-Kivi et al. [5] demonstrated that the combination of thumb spica splinting with
corticosteroid injection yielded more satisfactory results when compared with injection alone.
Surgical release is considered when non-operative treatments fail. However as the surgical
intervention has its own potential complications along with prolonged recovery time, hence
alternative of intralesional steroid injection needs to be evaluated more. This retrospective study
investigates the effectiveness of corticosteroid injections, aiming to determine whether they can
Corresponding Author:
be reliably used as a treatment option as well as mentioning the incidence of side effects of this
Dr. Ashootosh Batra procedure.
Specialist Orthopedic Surgeon, We hypothesize that intralesional corticosteroid injection may be an effective treatment for de
Medeor Hospital, Abu Dhabi, Quervain’s tenosynovitis.
UAE
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The purpose of our study was to evaluate the effectiveness of utilised while giving the injection by the author (Image 1 and
corticosteroid injections and to mention the complications of Image 2). Pre injection, the patient was explained the
this procedure, which happened post procedure. possibility of infection, depigmentation of skin, transient
increase in pain, tendon injury, and a written informed consent
Material and Methods was taken for the same. The data was evaluated in records, from
A retrospective study was conducted using a patient list 1st Jan 2020 to 1st Jan 2023. The follow-up of the patient, the
obtained from SAP software using International Classification documented relief in symptoms, the documented
of Disease, version 10 (ICD-10) codes for de Quervain’s complications, and the subsequent need for surgery or a 3rd
tenosynovitis based on clinical exam. All patients in the injection were evaluated in the data. The patients were divided
collected cohort had at least 1 injection. At this first injection, into success and failure with success of the intervention defined
the ages of the patients ranged from 22 to 68 years. Treatment as clinical resolution of pain and symptoms to the extent that
success was measured as clinical relief from symptoms (of pain the patient did not seek further intervention after 1 or 2
and restriction of range of motion) as reported by the patient injections and failure defined as patient needing surgical
after 1 or 2 injections. Relief from symptoms is defined as release or a 3rd injection for his condition. Coexisting
resolution or improvement to the extent that the patient did not morbidities like diabetes, thyroid, rheumatoid arthritis were not
seek further intervention. Failure was defined as inadequate taken into account when evaluating the patient data. A total of
relief with patient undergoing surgical release or a 3rd injection. 55 limbs in 44 patients were evaluated in retrospective manner
Standard procedure of using methyl prednisolone Depomedrol with regards to relief, need for surgery or 3rd injection, and any
(40 mg) 1 ml diluted in 1 ml of plain lidocaine 2% injected in documented complications.
antegrade manner in region of 1st extensor compartment was

Image 1: Depemderol 40 mg, Lidocaine 2% used for injection Image 2: Standard technique of injection in 1st extensor compartment

Results 61.82. A second injection, where indicated, was given on

The treatment outcomes of 55 limbs from 44 patients were average 4-52 weeks after the first injection. In terms of side
analyzed. Of the 44 patients, 30 patients were female and 314 effects, 3 side effects were documented (Graph 1) which were
patients were male. At the first injection, the median age of the 1. Whitening of the skin at site of injection 14.55% (8/55)
treatment success group was 44 years (SD, ±14.03) and 49 2. transient increase in pain which responded well to
years (SD, ±12.72) in the treatment failure group (Table 1). Of analgesics 10.91% (6/55)
the reviewed cases, sufficient relief (ie, treatment success) was 3. Numbness over the anatomical snuffbox persisting > 1 day
reached in 80% of the interventions within 2 injections. With a 1.82% (1/55) and lasting till 3 weeks but resolved after that
single injection, the estimated rate of treatment success was by itself.

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Graph 1: There was no documentation of infection, tendon injury, or any other major complications.

Discussion experi- enced a decrease in symptoms after 1 injection. Of

Our study had results comparable with other retrospective and these patients, more than half did not experience recurring pain
prospective studies done for efficacy of intralesional steroid for 12 months. Upon analysis of our study, there was not an
injection for de-quervans tenosynovitis. Zingas et al. [6] apparent pattern concerning duration between injections and
evaluated outcomes of steroid injection into the tendon sheath treatment success or failure.
of the extensor pollicis brevis and/or the abductor pollicis As with all retrospective studies, out study has its limitation. 55
longus through a double-blind prospective study and limb data appear to be on the lower side. Our study relies on
demonstrated that injecting both tendon compartments might the documentation which was though personally done by the
lead to the most desirable outcome, with injection accuracy author himself. In addition, the 44 patients were chosen
potentially playing a critical role in treatment outcome.6 randomly, and comorobidities were not taken into account.
However, the author has noticed that injecting in the vicinity of Similarly, BMI, hand dominance, profession were also not
the 1st extensor compartment without confirming on ultrasound taken into account, which could potentially affect the quality of
is equally effective, while cost saving, and less painful for the the study. A single preparation of methylprednisolone 40 mg
patient. This observation has been also been mentioned by a was used, although good results have been reported with
study by Taras et al. [7] In contrast, a more recent study by different preparations [12]. In addition, some patients opted to
Kume et al. [8] reported a greater decrease in pain at follow-up use wrist brace, while others were reluctant to do the same.
in the ultrasound- guided group compared with the traditional Furthermore, resolution of symptoms is completely subjective,
injection group as measured by the visual analog scale. This and patient stating clinical resolution of pain and symptoms
supports that injection into this exact anatomical location, was taken on its face value. We do not have a definitive time
made more precise by technology, is an efficacious treatment point for the criteria of success or failure, but patients were
for de Quervain’s tenosynovitis. Furthermore, Lane et al. [9] always instructed to return for follow-up within 6 to 8 weeks,
reviewed their treatment of 300 patients (319 limbs) with de or if needed. All the patients included in the study had a follow-
Quervain’s tenosynovitis, comparing custom orthosis, up visit after 6-8 weeks for review, and hence the relief in
naproxen 500 mg, and corticosteroid injections with 4-mg symptoms or lack of the same were clearly documented.
betamethasone. They grouped patients based on severity as Our study demonstrates that corticosteroid injections are an
assessed by the authors, classifying as minimal, mild, and effective clinical treatment for de Quervain’s tenosynovitis
moderate to severe [9]. There were 249 patients in the moder- with a short-term success rate following 2 or fewer injections
ate to severe group who received injections, with 53 requiring is almost 80 percent with 4 out of 5 patients able to avoid
2 injections and 17 requiring 3 injections. Complete relief was surgery due to this intervention. Further investigation is needed
reported in 76% with 7% improved, and 4% not improved [9]. to better evaluate other potential predictors of treatment
Corticosteroid injections have potential side effects. Stepan et success and whether symptoms recur in the long term. (After
al. [10] reported that type I diabetics and insulin-dependent more than 1 year)
diabetics experienced elevated blood glucose levels for 2 days
following an injection. Goldfarb et al. [11] determined in a Conflict of Interest
double-blind randomized study that despite 33% of patients Not available
experiencing a flare reaction, patients responded to extra-
articular injections for trigger digits and de Quervain’s Financial Support
tenosynovitis with no difference between standard or pH- Not available
balanced injections. This 125-patient study included 37
patients with de Quervain’s tenosynovitis and 88 patients with References
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second injections is variable. Earp et al., [3] in a prospective 2. Leslie BM, Ericson WB Jr, Morehead JR. Incidence of a
study of 50 patients, showed that 82% of enrolled patients sep- tum within the first dorsal compartment of the wrist.
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How to Cite This Article

Batra A, Elbaz M, Batra J. Role and efficacy of corticosteroid (40 Mg
Methyl prednisolone acetate) injection for non-surgical treatment of de-
quervains tenosynovitis, and incidence of complications of the procedure
in 55 limbs: A retrospective study. International Journal of Orthopaedics
Sciences. 2023;9(3):423-426.

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