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Three Part Question

In [adults (over 18 years) with de Quervain’s tenosynovitis] whether [steroid injections are more effective than splinting] in [resolution of symptoms].

Clinical Scenario

A 42 year old women presents with pain on thumb movements in her dominant hand. On examination, she has tenderness over the radial styloid process and crepitations over the first dorsal compartment of the distal radius. Finkelstein test was positive. You diagnose de Quervain’s tenosynovitis and plan to give her a splint, but wonder if steroid injection is better than splinting for the treatment of de Quervain’s tenosynovitis.

Search Strategy

MEDLINE 1950 to 20th March 2012 via NHS Evidence, and Cochrane Library via Cochrane Collaboration.

Synonyms and free texts were used to locate studies.

MEDLINE
[exp DE QUERVAIN DISEASE/ OR exp TENOSYNOVITIS/ OR exp TENDON ENTRAPMENT/ OR "de quervain".ti,ab OR "abductor pollicis longus".ti,ab OR "extensor pollicis brevis".ti,ab OR "strain injury".ti,ab] AND [exp STEROIDS/ OR exp GLUCOCORTICOIDS/ OR triamcinolone.ti,ab OR corticosteroid*.ti,ab OR kenalog.ti,ab OR exp HYDROCORTISONE/ OR exp METHYLPREDNISOLONE/ OR exp METHYLPREDNISOLONE HEMISUCCINATE/ OR exp BETAMETHASONE/ OR exp BETAMETHASONE 17-VALERATE/ OR "steroid injection".ti,ab] AND [exp SPLINTS/ OR "futura splint".ti,ab OR "FRC splint".ti,ab OR exp CASTS, SURGICAL/ OR "thumb spica".ti,ab OR "POP cast".ti,ab OR "plaster of paris cast".ti,ab] 22 results

COCHRANE
[de Quervain and steroid injections] 6 results

Search Outcome

Medline search revealed 22 articles out of which 6 were relevant to the three-part question. There was one Cochrane Review, 2 randomised controlled trials and 3 prospective studies. Cochrane search found 6 articles, out of which one randomised controlled trial was relevant and was included in the bestbet.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Avci, et al. 2002 Turkey	18 pregnant and lactating women Group1: 9 randomised to receive injection of 0.25 ml methylprednisolone (10 mg) with 0.5% bupivacaine Group 2: 9 randomised to thumb spica splinting F/U 12 months (9-17 months)	RCT	Success defined as complete relief of pain and negative Finkelstein test result	Group1: Success in 9/9 patients. Group 2: Failure in 9/9 patients.	Small number of participants who were pregnant and lactating women. Inadequate randomisation, no allocation concealment and blinding of treatments
Mehdinasab and Alemohammad 2010 Iran	73 patients 9 men and 64 women. Group 1: 37 patients had 1 mL (40 mg) methylprednisolone acetate and well-padded wrist thumb spica cast. Group 2: 36 patients were treated with a thumb spica cast for one month Follow up for six months.	RCT	Resolution of wrist pain, tenderness and negative Finkelstein test, and patient had at least 90% improvement in the pain score.	Group 1: Success in 32 patients (86.5%)Failure in 5 patients (13.5%). Group 2: Success in 13 patients (36.1%)Failure in 23 patients (63.9%)	Lack of proper randomisation, non-blinding of treatments and short duration of follow up.
Kosuwon 1996 Thailand	140 patients Group I 72 patients were given steroid injection followed by application of splint Group II 68 patients were given steroid injection only.	RCT	Resolution of symptoms	Success rate was 74% in patients having both treatments while it was 75% in patients having steroid injection only.	No blinding of treatments, leading to treatment allocation bias. Study conducted in a private hospital by a single person indicating bias in collecting outcome.
Witt, et al. 1991 Massachusetts, USA	87 wrists of 83 patients injected with a mixture of methylprednisolone and lidocaine injection. A thumb spica splint was used to immobilise the wrist for three weeks	Prospective cohort study	Satisfactory outcome defined as non-tender wrist and negative Finketstein test.	Successful in 54 wrists (62%) and were unsuccessful in 33 wrists (38%)	No randomisation of patients and no control group for comparison.
Weiss, et al. 1994 Rhode Island, USA	93 patients in total; 42 of these had a steroid injection treatment, 37 were treated by splint therapy and 14 patients were given both steroid injection and a splint	Prospective study	Treatment was deemed successful if no surgical treatment was undertaken and was considered a failure if surgical treatment was performed.	Significant symptomatic improvement was noted between steroid injection alone and splint alone groups (p<0.005) and between splint alone and injection/splint groups (p< 0.05).	No randomisation performed
Lane, et al. 2001 New York, USA	Classified patients according to the severity of symptoms into three groups; namely group I (minimal pain), group II (mild pain) and group III (moderate to severe pain). They offered splint and oral NSAID treatment to 17 patients of group I who have minimal symptoms and prescribed steroid injection to 249 patients of group II and III.	Retrospective study	Patients were classified as complete resolution of symptoms, improvement or no improvement.	15 out of 17 patients in minimal symptom group (group I) had a complete resolution of symptoms with splint and oral NSAID therapy. 249 patients in group III with moderate to severe symptoms, had betamethasone with bupivacaine injection. 76% of them were completely cured, while 7 % had some improvement and 4% did not improve at all.	No randomisation of patients. Classification of patients was purely based on subjective assessment. Retrospective study with only those patients included in the study who had a full record of the physical findings and management (selection bias)
Peters-Veluthamaningal, et al. 2009 The Cochrane Collaboration	One randomized trial included which had 18 pregnant and lactating women	Cochrane Review	The only primary outcome measure assessed was complete relief	Number needed to treat (NNT) was 1 (95%CI 0.8 to 1.2).	Only one trial included with small number of participants

Comment(s)

The overall success rate of steroid injections in treating de Quervain’s tenosynovitis is from 62% to 100%. This shows that steroid injection therapy is an effective form of conservative treatment for de Quervain’s disease and should be offered to all patients with or without concomitant use of splinting. Splint therapy alone is not effective in resolution of symptoms when compared to steroid injections. The Cochrane Review concluded that every patient who had steroid injection would get the benefit of the treatment. Adverse effects noted were flare reactions, skin hypo-pigmentation and sensory radial nerve impairment.

Clinical Bottom Line

Steroid injections are better than splinting for control of symptoms in de Quervain’s disease.

References

1. Avci, S., Yilmaz, C. & Sayli, U. Comparison of nonsurgical treatment J Hand Surg [Am]. 2002; 27(2). pp. 322-324.
2. Mehdinasab, S.A. & Alemohammad, S.A. Methylprednisolone acetate injection plus casting versus casting alone for the treatment of de Quervain's tenosynovitis Arch Iran Med. 2010; 13 (4) pp. 270-4
3. Kosuwon, J Treatment of de Quervain tenosynovitis: a prospective randomized controlled study comparing the results of steroid injection with and without immobilization in a splint Journal of Clinical Epidemiology 1996; 1 (1) pp. 5S
4. Witt, J., Pess, G. & Gelberman, R.H. Treatment of de Quervain tenosynovitis. A prospective study of the results of injection of steroids and immobilization in a splint J Bone Joint Surg Am. 1991; 73 (2) pp. 219-22.
5. Weiss, A.P., Akelman, E. & Tabatabai, M. Treatment of de Quervain’s disease J Hand Surg Am. 1994; 19 pp. 595 – 598.
6. Lane, L.B., Boretz, R.S. & Stuchin, S.A. Treatment of de Quervain’s disease: role of conservative management J Hand Surg Br. 2001; Jun 26 (3) pp. 258-60.
7. Peters-Veluthamaningal, C., van der Windt, D.A.W.M., Winters, J.C. & Meyboom-de Jong, B. Corticosteroid injection for de Quervain's tenosynovitis Cochrane Database of Systematic Reviews. Issue 3. The Cochrane Collaboration. JohnWiley & Sons, Ltd. 2009