Sonographic findings in trigger fingers and outcome of sonographic guided injection Poster No.: C-1239 Congress: ECR 2011 Type: Scientific Paper Authors: R. Faschingbauer, F. Guerra, M. Kaserer, M. C. Wick, M. Gabl, G. Feuchtner, W. Jaschke, A. Klauser; Innsbruck/AT Keywords: DOI: Musculoskeletal system, Ultrasound, Ultrasound-Colour Doppler, Outcomes analysis, Inflammation 10.1594/ecr2011/C-1239 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 8
Purpose Trigger finger is a common hand problem, with a lifetime prevalence of 2.6% in the general population and 10% among those with diabetes. 1 The purpose of this study was to evaluate sonographic features in trigger fingers for the outcome after corticosteroid injection. Furthermore, sonographic findings between successfully treated trigger fingers with those undergoing finally surgery where compared. Methods and Materials In this retrospective study, 71 of 85 patients (totally number of trigger fingers = 83 of 100) with the clinical diagnosis of trigger finger were examined at the Department of Radiology at the Medical University of Innsbruck between 2004 and 2009. The standard clinical evaluation included all patients in all stages of life who had trigger finger symptoms ( triggering with or without locking of a finger or pain) in one or more fingers. The study protocol was approved by the university ethics committee. Each patient underwent a previously described standardized treatment and following criteria where assessed: a peritendinous injection of 10 mg triamcinolon/mepinest was given once or twice (after 6 weeks) by means of high-resolution sonographically guided injection. Patients with ongoing trigger finger complains where scheduled for operation. Gray-scale US was performed on a Acuson Sequoia ( Siemens, Mountain View, CA, USA) or a My Lab ( Esaote, Genoa, Italy) using high-resolution probes. The affected finger were scanned in two perpendicular planes, US images were taken in B- mode and PDUS. Sonographic criteria like thickening of the A1 Pulley, hyperemia, ganglion, tenovaginits, tendinopathy were evaluated in the triggering fingers. Swelling of the A1 pulley was determined by an hypoechoic annular strap surrounding the tendon at the level of the MCP joint. (Figure 1) Ganglion was defined as a well-defined oval or lobulated cystic mass, which may contain septations. (Figure 2) The diagnosis of tenovaginits was based on demonstrating an hypoechoic or anechoic thickened tissue with or without fluid within the tendon sheath with or without hyperemia. Page 2 of 8
Tendinopathy was defined by an segmental thickening of the flexor tendons, which may often be shown with a hypoechoic region in its centre. It was compared with other segments of the same tendon more distal and more proximal of the A1 Pulley. 10 mg triamcinolon/mepinest were injected ultrasound guided in the affected area (Figure 3). After 6 weeks, the response to the injection was evaluated, and if no complete symptom resolution was present, steroid injections were repeated up to three times. If no persistent improvement was observed, surgical release of the A1 pulley under local anaesthesia was performed. Images for this section: Fig. 1: Short-axis view of a trigger finger showing the US findings such as thickening of the A1 pulley and hyperemia. Page 3 of 8
Fig. 2: US image of a ganglion. Fig. 3: US image of a thickening of the A1 pulley during an infiltration. The needle is coming from the right upper side, marked with an arrow. Page 4 of 8
Results 71 patients with a mean age of 65 yrs. (arithmetic mean 65,11; standard deviation [SD] 13,32, 75 % female, 25 % male) with the clinical diagnosis of trigger finger were examined between 2004 and 2009. The number of treated trigger fingers added up to 83, 22 cases in male and 61 in female patients. There were 22 thumbs (27%), 8 second fingers (10%), 28 third fingers (33%), 17 fourth fingers (20%), 8 fifth fingers (10%) affected. The right hand was more involved with 55 cases, (66%) than the left hand with 28 cases (34%). Swelling of the A1 pulley was found in 83% (69 of 83) of all trigger fingers. In the non operated group there were 55 out of 69 (79%) cases. In the group, which were finally operated, all trigger fingers (100%) have shown very strong thickening of the A1 pulley. Ganglion cysts were found in 23% (19 of 83) of all trigger fingers. In the non operated group there were 14 out of 69 (20%) cases and in the operated group 5 out of 14 (35%). Tenovaginits was found in 67% (56 of 83) of all cases. 47 out of 69 (68%) cases in the non operated group and 9 out of 14 (64%) in the operated group. Tendinopathy (segmental thickening) was found in 13% (11 of 83) of the trigger fingers. In the non operated group only 8 out of 69 (12%) cases were found and in the operated group 3 out of 14 (21%). Hyperemia of the A1 pulley on power Doppler imaging was found in 36% (30 of 83) of the cases. In the non operated group there were 24 out of 69 (35%) cases and in the operated group 6 out of 14 (43%) cases counted. Infiltrations were made up to 3 times. After 6 weeks, the response to the injection was evaluated, and if no complete symptom resolution was present, steroid injections were repeated. In 7 cases patients had still so much pain they were scheduled to operation after the first infiltration. Outcome: We noted complete resolution of symptoms of all trigger finger cases for more than 1 year in 62% (52 of 83), 10% (8 of 83) up to one year and 7% (6 of 83) up to 6 month. 4% Page 5 of 8
(3 of 83) had still symptoms, but was not scheduled to operation, because of advanced age. 17% (14 of 83) had to be scheduled to operation due to continuing complains. 40% (33 of 83) had complete resolution of symptoms after the first infiltration, 19% (16 of 83) after the second infiltration and 4% (3 of 83) after the third infiltration. Conclusion There are many of studies showing that corticosteroid injections are an effective, inexpensive and easy practical application for the treatment of trigger finger. 4,6-10 Even better results are found in studies who were using ultrasound for a better drug targeting. 5,11 Therefore, we feel that the initial treatment for patients should be corticosteroid injection rather than surgery. However only our study addressed, if there is a correlation between the efficancy of US-guided corticosteroid injections and the different sonographic appearance of trigger finger. So we wanted to find out, if it would be more effective to inject the medication closer to the site of the abnormality. For that reason we had to figure out, how several sonographic appearances interact with steroid therapy. Another important aspect for us was, to estimate the prognosis of subcutaneous injection of each patient during an ultrasound examination. We could not find any significant difference between the different pathologies and the effect of corticosteroid injections. Furthermore we could not find out, that the severity of sonographic findings in term of multiple US findings predict unsuccessful longterm outcome, therefore we conclude that even in severe sonographic findings US guided injections is of benefit and can be used as a first line treatment regime. References 1. Akhtar S, Bradley MJ, Quinton DN, Burke FD. Management and referral for trigger finger/thumb. BMJ 2005; 331:30-33. 2. Carl Joachim Wirth, Ludwig Zichner, Orthopädie und orthopädische Chirurgie: Ellenbogen, Unterarm, Hand, 2003: Georg Thieme Verlag, p 435-436. Page 6 of 8
3. Serafini G, Derchi LE, Quadri P, et al. High resolution sonographyof the flexor tendons in trigger fingers. J Ultrasound Med 1996; 15:213-219. 4. 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; 15:166-171. 5. Bodor M, Flossman T. Ultrasound-Guided First Annular Pulley Injection for Trigger Finger. J Ultrasound Med 2009; 28:737-743. 6. Peters-Veluthamaningal C, Winters JC, Groenier KH, Meyboom-de Jong B. Corticosteroid injections effective for trigger finger in adults in general practice: a doubleblinded randomized placebo controlled trial. Ann Rheum Dis 2008; 67:1262-1266. 7. Murphy D, Failla JM, Koniuch MP. Steroid versus placebo injection for trigger finger (published erratum appears in J Hand Surg [Am] 1995; 20:1075). J Hand Surg [Am] 1995; 20:628-631. 8. Lambert MA, Morton RJ, Sloan JP. Controlled study of the use of local steroid injection in the treatment of trigger finger and thumb. J Hand Surg [Br] 1992; 17:69-70. 9. Maneerit J, Sriworakun C, Budhraja N, Nagavajara P. Trigger thumb: results of a prospective randomised study of percutaneous release with steroid injection versus steroid injection alone. J Hand Surg [Br] 2003; 28:586-589. 10. Taras JS, Raphael JS, Pan WT, Movagharnia F, Sotereanos DG. Corticosteroid injections for trigger digits: is intrasheath injection necessary? J Hand Surg [Am] 1998; 23:717-722. 11. Gajan Rajeswaran, Justin C. Lee, Rupert Eckersley, Effie Katsarma, Jeremiah C. Healy. Ultrasound-guided percutaneous release of the annular pulley in trigger digit. Eur Radiol (2009) 19: 2232-2237. Personal Information Ralph Faschingbauer, MD University Hospital Innsbruck Page 7 of 8
Departement for Radiology Anichstrasse 35 A-6020 Innsbruck e-mail: ralph.faschingbauer@i-med.ac.at Page 8 of 8