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Journal of Hand Surgery

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A randomized comparison of 0(0) 1–6
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ultrasound-guided versus landmark-based Article reuse guidelines:
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corticosteroid injection for trigger finger DOI: 10.1177/1753193419839892
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Young Hak Roh1, Sangwoo Kim1, Hyun Sik Gong2 and

Goo Hyun Baek3

Abstract
One hundred and four patients who had been diagnosed with trigger finger and were to be treated by cor-
ticosteroid injection were randomized into two groups; one for landmark-based injection and the other for
ultrasound-guided injection. The response to treatment, including objective triggering, the visual analogue
scale score for pain and the Quick Disability of the Arm, Shoulder, and Hand (QuickDASH) score were
assessed at 12- and 24-weeks follow-up. No significant differences between the two groups were observed
in pain or QuickDASH scores at 24 weeks of follow-up. The incidences of adverse events were similar between
the two groups. Ultrasound-guided steroid injection provides no benefit in treating trigger finger.
Level of evidence: II

Keywords
Trigger finger, corticosteroid injection, ultrasound-guided injection, landmark-based injection, outcomes,
complications

Date received: 21st December 2018; accepted: 5th March 2019

Park and Dumanian, 2009; Yam et al., 2009).

Introduction
The reported long-term success rates of corticoster-
oid injections for trigger finger vary from 40% to 90%
(Castellanos et al., 2015; Moore, 2000; Ring et al.,
2008). The variation in outcomes may be attributable
to differences in disease severity (Shultz et al., 2018),
combined medical conditions (Chang et al., 2018;
Roh et al., 2016), mode of treatment (Lee et al.,
2011) and the methods and timing of assessment
(Wojahn et al., 2014).
The sites for corticosteroid injections into the A1
pulley are frequently identified by palpation using
anatomical landmarks, and injections have been
shown to lead to considerable improvements in
symptom severity and hand function (Amirfeyz
et al., 2017; Moore, 2000; Ring et al., 2008; Roh
et al., 2016). The landmark-based approach does
not ensure that the injected steroid is placed in the
tendon sheath (Lee et al., 2011) although there is
some evidence that the steroid does not need to be
injected into the sheath (Shinomiya et al., 2016).
Although rare, misplaced injectates may result in
severe complications, such as tendon rupture or digi-
tal necrosis (Fitzgerald et al., 2005; Lee et al., 2011;
Ultrasound (US) enables visualization of the tendon
structures around the palm of the hand and the
needle, allowing physicians to accurately place
the injectate into the flexor tendon sheath (Lee
et al., 2011).
The aim of this study was to compare the effective-
ness and complications of US-guided injections with
those of landmark-based injections for trigger finger.
1
Department of Orthopaedic Surgery, Ewha Womans University
Medical Center, Ewha Womans University College of Medicine,
Seoul, South Korea
2
Department of Orthopaedic Surgery, Seoul National University
College of Medicine, Seoul National University Bundang Hospital,
Sungnam, South Korea
3
Department of Orthopaedic Surgery, Seoul National University
College of Medicine, Seoul National University Hospital, Seoul,
South Korea
Corresponding Author:
Young Hak Roh, Department of Orthopaedic Surgery, Ewha
Womans University Medical Center, Ewha Womans University
College of Medicine, 1071 Anyangcheon-ro, Yangcheon-gu, Seoul
07985, South Korea.
Email: ryhak@hanmail.net
2 Journal of Hand Surgery (Eur) 0(0)
Methods
Our institutional review board approved the study,
and all patients gave informed consent. Between
March 2015 and August 2017, we prospectively
enrolled 123 patients who had been diagnosed with
trigger finger and were to be treated with a cortico-
steroid injection. The inclusion criteria are shown
in Figure 1. History and symptoms included pain,
catching or triggering along the A1 pulley. Physical
examination for tenderness over the A1 pulley, a
palpable nodule around the A1 pulley, pain along
the flexor tendon with resisted flexion or with passive
stretch in extension, and reproducible locking, trig-
gering or caching were used to confirm the diagnosis.
According to the Quinnell system, trigger fingers are
rated as: 0, normal movement of the digit; 1, uneven
movement (without obvious locking); 2, actively cor-
rectable locking of the digit; 3, passively correctible
locking; and 4, fixed deformity (Quinnell, 1980).
In cases of multiple or bilateral occurrence of trigger
finger, the more severely affected finger (or side) was
chosen for comparative analysis. Exclusion criteria
Figure 1. Flow chart for the randomized controlled trial comparing ultrasound-guided versus landmark-based cortico-
steroid injection for trigger finger.
US: ultrasound; F/U: follow-up.
and the numbers excluded are shown in Figure 1.
Based on these criteria, 104 of the original
123 patients were included in the study. The patients
were randomly allocated into either a landmark-
based injection group or a US-guided injection
group according to a computer-generated rando-
mized list. The following data were collected using
paper questionnaires: age, sex and symptom dura-
tion (Table 1). The patients’ mean age was 52 years
(range 21–69), and 65% (68/104) of patients were
women. The mean duration of symptoms before
injection was 14 months (range 3–48).
All injections were administered by an orthopaedic
hand specialist (highly experienced, Level IV) (Tang
and Giddins, 2016) with 13 years of experience.
Patients were injected under aseptic conditions
using a single injection that contained 1 ml of triam-
cinolone acetonide (20 mg/ml). A 23-gauge needle
was used for the injections in both groups. During
the injection, patients were asked to remain in a
seated position facing the physician, with their
wrists resting in a supinated position on the table.
Roh et al.
Table 1. Demographic and clinical characteristics of participants in the study.
Landmark-based
injection group (n ¼ 52)
Age 53 (21–67)
Female/male 34/18
BMI (kg/m2) 27.1 (17.1–34.9)
Symptom duration (weeks) 13 (3–48)
Multiple involvementa 12
Affected sidea
Unilateral
Dominant 29
Non-dominant 17
Bilaterala 6 7
Quinnell grades
2 29
3 19
4 4
Values are mean (range) or number.
a
In cases of bilateral or multiple occurrence, the more severely affected digit (or side) was chosen for comparative
analysis.
BMI: body mass index.
For patients in the landmark-based injection group,
the metacarpal head and flexor tendon sheath were
palpated, and the needle was placed at the level of
the first annular pulley. The needle was inserted par-
allel to the tendon fibres at an angle of 45 oriented
distal to proximal. The needle was introduced toward
the flexor tendon sheath until slight resistance was
felt. The patient was then asked to wiggle the finger
and motion of the needle could be noticed if it was in
the tendon sheath. Before injection, the proximal
phalangeal joint was flexed and extended passively,
and slight grating could be felt at the end of the
needle to ascertain its correct position. A single
injection was then given, aiming to place at least
some portion of the solution within the sheath.
For patients in the US-guided injection group, ultra-
sonography was applied using a 12–5 or 15–7 MHz
linear array transducer on a Toshiba Aplio
Diagnostic Ultrasound System (Toshiba Medical
Systems, Co, Ltd, Otawara, Japan). The injection
target was an area between the first annular pulley
and the flexor digitorum superficialis tendon.
The short axis approach was used for the
US-guided injection technique, in which the trans-
ducer was placed perpendicular to the long axis of
flexor tendon. The US probe was enclosed in a sterile
cover; the probe was placed along the palmar aspect
of the first annular pulley. The metacarpophalangeal
joint and overlying first annular pulley were identi-
fied. A needle was inserted into the flexor tendon
sheath, with care taken to avoid any harm to the
3
Ultrasound-guided
injection group (n ¼ 52) p-value
52 (23–69) 0.72
34/18 0.99
26.7 (18.9–35.4) 0.73
14 (4–48) 0.65
11 0.81
27 0.69
18 0.84
0.77
32 0.55
17 0.68
3 0.70
digital neurovascular structures. The triamcinolone
acetonide was injected after visualizing the tip
of the needle under the flexor sheath. After the
injection, patients were instructed to resume activity
as tolerated, and no further physical therapy or
splinting was recommended. None of the patients
were injected a second time within 6 months of the
first injection.
Patients returned for functional assessments at
12 weeks (range 11–14) and 24 weeks (range 22–26)
after the injection. Follow-up included assessment of
objective findings consistent with trigger finger (trig-
gering, tenderness at the A1 pulley) by an independ-
ent research assistant (a trained nurse). The Quick
Disability of the Arm, Shoulder and Hand score
(QuickDASH) (Beaton et al., 2005) was measured
during each visit after clinical examination. Patients
were also asked to grade their overall satisfaction
with the treatment on a 5-point scale (1, poor;
2, fair; 3, good; 4, very good; and 5, excellent). An
11-item QuickDASH has been shown to be reliable
and valid in patients with upper extremity disorders,
and has similar reliability when compared with
original DASH (Gummesson et al., 2006). The inves-
tigators checked all returned questionnaires for
completion, and the participants were assisted by a
research assistant in completing any missing
items. We defined treatment failure as recurrence
or persistence of objective triggering after the injec-
tion or A1 pulley release surgery within 6 months of
the corticosteroid injection. The decision to undergo
4 Journal of Hand Surgery (Eur) 0(0)

surgery was a mutual decision between the patient
and surgeon. Once this was decided, the mean wait-
ing period for surgery was 2 weeks.
Statistical analysis
An a priori power analysis indicated that a sample
consisting of 40 patients in each group would provide
80% statistical power for detecting a medium-
to-large effect size (d of 0.65) between the two
groups with a two-sided alpha level of 0.05 using
the t-test. Since it was predicted that about 20% of
the patients would not complete the study, 52 cases
were included in each group.
The analysis was according to intention-to-treat
principles, meaning that patients were considered
as belonging to their assigned initial treatment
group even if another treatment (surgery) was
used. Analysis by intention-to-treat tests the effect-
iveness of a treatment rather than the efficacy of a
specific and well-administered treatment protocol; it
is therefore a better reflection of the actual treat-
ment. The last observation carried forward was
used in discontinued patients with missing data.
Descriptive statistics were calculated in order to
determine patients’ demographics and clinical char-
acteristics. The Kolmogorov–Smirnov test was used
to determine the normality of variable distributions.
A two-sided Student’s t-test was used to identify
any significant differences between the two groups
for variables with normal distribution, such as age
and body mass index, whereas the nonparametric
Mann–Whitney U test was used for variables with
non-normal distributions, such as the DASH and
pain scores. The chi-squared or Fisher exact tests
were used to determine any significant differences
in the categorical variables. Statistical significance
was accepted when the p-value was <0.05.
Results
There were no significant differences in age, gender,
body mass index, symptom duration or bilateral
involvement between the landmark-based group
and the US-guided injection groups (Table 1).
The preoperative mean pain and QuickDASH scores
were also similar across the two groups. Five
patients in the landmark-based group and four in
the US-guided group were lost to follow-up before
the 24-week evaluation (p ¼ 0.73).
No significant differences were observed between
the two groups in QuickDASH scores at 12 weeks and
at 24 weeks of follow-up. Similarly, there were no
significant differences in pain visual analogue scale
score at 12 and 24 weeks (Table 2). Nor were the
proportions of treatment failure different between

Table 2. Comparison of functional outcomes and complications after steroid injection.

Landmark-based US-guided injection

Outcomes injection group (n ¼ 52) group (n ¼ 52) p-value

Pain VAS
Baseline 6.1 (1.4) 6.3 (1.5) 0.48
Week 12 1.9 (0.9) 1.7 (0.8) 0.23
Week 24 1.6 (0.7) 1.5 (0.7) 0.47
DASH
Baseline 29 (14) 32 (15) 0.29
Week 12 17 (13) 14 (12) 0.22
Week 24 15 (12) 12 (11) 0.19
Treatment failure 14 11 0.49
Surgical treatment 9 7 0.59
Overall satisfaction to treatment 3.7 (0.8) 4.1 (0.8) 0.01
Adverse events (n ¼ 9) (n ¼ 6) 0.40a
Steroid flare 4 3 0.69b
Skin discoloration or subcutaneous fat atrophy 4 2 0.40b
Symptoms of digital nerve irritation (tingling/numbness) 1 0 0.31b
Superficial infection 0 1 0.31b
Values are mean (standard deviation) or number. Significant p-values shown in bold font.
a
Chi-square.
b
Fisher’s exact test.
US: ultrasound; VAS: visual analogue scale; DASH: Disability of the Arm, Shoulder, and Hand.
Roh et al.
the two groups. Among them, nine patients in the
landmark-based group and seven patients in the
US-guided group underwent surgical release within
6 months of the injection (mean 18; range 5–23
weeks). By contrast, the level of overall satisfaction
with the treatment process was higher in the
US-guided group than in the landmark-based group.
There were no differences in other complications
(Table 2). There were seven cases of post-injection
pain (a two-point increase in the pre-injection visual
analogue scale) and/or inflammation around the
injection site within a few days after injection, a
post injection steroid flare (Cardone and Tallia, 2002).
Discussion
The purpose of this study was to assess the effect-
iveness of US-guided injections and their associated
complications, as compared with those of landmark-
based injections in the treatment of trigger finger.
Similar improvements in symptom severity and
hand function were observed in patients with both
approaches, although patients receiving US-guided
injection had a higher overall level of satisfaction
with treatment.
The factors influencing patient satisfaction to
treatment are patient tolerance and preference as
well as functional outcomes (Becker et al., 2015;
Middleton et al., 2004). It can be speculated that
there is closer personal contact with the physician
in US-guidance reassured patients during local
corticosteroid injection. However, the difference in
satisfaction may be spurious and might have been
eliminated using a sham US for the landmark-
based injections.
Some clinical studies on local steroid injection
for trigger finger have suggested that US-guided
steroid injection leads to better clinical benefits
than landmark-based injection (Bodor and
Flossman, 2009; Lee et al., 2011). By contrast,
other investigators have revealed that intra-sheath
injection offers no apparent advantage over extra-
sheath injection for treating trigger fingers because
both have similar effects on local structures
(Shinomiya et al., 2016). Our study results are con-
sistent with previous findings of Cecen et al. (2015)
that there is no significant difference in symptoms
and function between US-guided and landmark-
based injection for trigger finger.
There were a number of limitations to our study.
Patients were not blinded to the method of injection
administration for practical reasons resulting from
the nature of the intervention. Sonography is an
interactive examination; not only can the patient
and the examiner converse, but the patient can
5
observe the examination in real time and ask ques-
tions as they arise (Middleton et al., 2004), which
may have affected the level of overall satisfaction.
We used only one type of questionnaire to assess
the patients’ functional outcomes. The minimum
clinically important differences or responsiveness
of questionnaires after corticosteroid injection may
differ between functional assessments, and other
types of functional assessments may result in differ-
ent conclusions. Patients with multiple trigger digits
were included in the study. Although the proportions
of multiple trigger digits were similar between
the two groups, this factor can affect functional
outcomes and treatment satisfaction after the injec-
tion. Finally, 9% (9/104) of patients were lost during
follow-up before the 6-month assessment. Although
the last observation carried forward was used in
our intention-to-treat analyses, the assumption that
there was no change after drop-out may not be plaus-
ible because dropping out is likely to be associated
with the response to treatment (Herman et al., 2009).
The results of this study suggest that there is no
benefit to be gained from the added cost, time and
inconvenience of using US for steroid injection of
trigger digit.
Declaration of conflicting interests The authors
declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the
research, authorship, and/or publication of this article.
Ethical approval The authors certify that our institution
has approved the reporting of these cases, that all investi-
gations were conducted in conformity with ethical prin-
ciples of research, and that informed consent for
participating in the study was obtained.
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