Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

trigger finger

1st line – flexor tendon sheath injection

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ACUTE
|
trigger finger
1st line – 

flexor tendon sheath injection

Frequently, a trial of flexor tendon sheath corticosteroid injection is offered as a first-line treatment. However, tendon sheath injections do not effectively treat locked cases (grades 3 and 4); direct referral for surgery is recommended in these cases.

Several techniques exist; all involve injecting the mixture into the flexor tendon sheath.

Following a trial of corticosteroid injection, follow-up is scheduled within 1 month for repeat exam. If the injection fails, a second injection may be given or the patient may be referred to surgery.

Opinion varies as to the choice of corticosteroid and its preparation. Methylprednisolone, triamcinolone, and betamethasone are among the most commonly used.[6][7][8][23][43][44][45][46][47]

The corticosteroid is mixed with a local anesthetic, most commonly 1% lidocaine.[48] Some treating physicians add sodium bicarbonate in a 1:10 mixture.

Total volume injected is about 1 to 3 mL depending on the site and preference. A small needle is preferred (e.g., 25- or 27-gauge). The injection may be repeated on several occasions, but caution should be exercised after multiple injections due to the risk of skin thinning, fat atrophy, or tendon rupture.[7][49]​​[47]

Injection of hyaluronic acid as an alternative treatment for trigger digits has been studied and has shown equivalent outcomes compared with corticosteroid injections in a randomized trial.[52]​​ Another randomized trial has shown equivalent outcomes of hyaluronic acid and corticosteroid injections, although corticosteroid seemed to have a greater impact on relief of pain and inflammation.[53]

Primary options

methylprednisolone acetate: 20 mg (1 mL) injected into flexor tendon sheath as a single dose, may repeat

or

triamcinolone acetonide: 5 mg (1 mL) injected into flexor tendon sheath as a single dose, may repeat

or

betamethasone sodium phosphate/betamethasone acetate: 6 mg (1 mL) injected into flexor tendon sheath as a single dose, may repeat

-- AND --

lidocaine: (1%) 1 mL injected into flexor tendon sheath as a single dose with corticosteroid

2nd line – surgery

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ACUTE
|
trigger finger
2nd line – 

surgery

If surgery is necessary, such as when injection fails or the digit cannot be unlocked, open surgery or percutaneous techniques can be used to incise the A1 pulley, allowing the flexor tendons to glide freely.[33][55][56][57][58][59][60][61][62]​​

In the presence of rheumatoid arthritis, synovectomy rather than pulley release is preferred to avoid bow-stringing and further ulnar deviation of the digits.

de Quervain disease

1st line – nonsteroidal anti-inflammatory drugs + splinting

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ACUTE
|
de Quervain disease
1st line – 

nonsteroidal anti-inflammatory drugs + splinting

Treatment commonly starts with splinting and oral nonsteroidal anti-inflammatory drugs (NSAIDs) for a period of 4 to 6 weeks.

Thumb and wrist immobilization (with a forearm-based thumb spica splint) is used for comfort and resting.[9][22]

NSAIDs are generally contraindicated in pregnancy. In pregnancy and lactation, nonoperative treatment is highly effective; the condition tends to resolve after cessation of lactation. Splinting is sufficient in most cases.[14][72][73]

Primary options

diclofenac potassium: 50 mg orally (immediate-release) three times daily when required

OR

ibuprofen: 400-800 mg orally every 6-8 hours when required, maximum 2400 mg/day

OR

naproxen: 500 mg orally twice daily when required, maximum 1250 mg/day

OR

meloxicam: 15 mg once orally daily

OR

celecoxib: 200 mg orally once daily

2nd line – first dorsal compartment injection ± splinting

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ACUTE
|
de Quervain disease
2nd line – 

first dorsal compartment injection ± splinting

A trial of first dorsal compartment corticosteroid injection can be performed next.[2][5]​​[22][46][64][65]​ Corticosteroid injection combined with splinting has also been described.[66]

Following a trial of corticosteroid injection, follow-up is scheduled within 1 month for repeat exam. If the injection fails, a second injection may be given or the patient may be referred to surgery.

Opinion varies as to the choice of corticosteroid and its preparation. Methylprednisolone, triamcinolone, and betamethasone are among the most commonly used.[6][7][8][23][43][44][45][46][47]

The corticosteroid is mixed with a local anesthetic, most commonly 1% lidocaine.[48] Some treating physicians add sodium bicarbonate in a 1:10 mixture.

Total volume injected is about 1 to 3 mL depending on the site and preference. A small needle is preferred (e.g., 25- or 27-gauge). The injection may be repeated on several occasions, but caution should be exercised after multiple injections due to risk of skin thinning, fat atrophy, or tendon rupture.[7][49]​​[47]​ Care must be taken to place the injectate in the extensor sheath and not subcutaneously, as skin thinning and fat atrophy can result from a superficial corticosteroid injection at this site.

Primary options

methylprednisolone acetate: 20 mg (1 mL) injected into flexor tendon sheath as a single dose, may repeat

or

triamcinolone acetonide: 5 mg (1 mL) injected into flexor tendon sheath as a single dose, may repeat

or

betamethasone sodium phosphate/betamethasone acetate: 6 mg (1 mL) injected into flexor tendon sheath as a single dose, may repeat

-- AND --

lidocaine: (1%) 1 mL injected into flexor tendon sheath as a single dose with corticosteroid

3rd line – surgery

Back
ACUTE
|
de Quervain disease
3rd line – 

surgery

If surgery is necessary, such as when injection fails, the first dorsal compartment is incised longitudinally, allowing the extensor tendons to glide freely. It is imperative to positively identify the extensor pollicis brevis (EPB) because it might be in a separate subsheath, separate from the abductor pollicis longus, which is frequently formed of multiple slips.[17][22] Failure to recognize and release an EPB subcompartment can be a cause of treatment failure or recurrence.[68][69][70]

Endoscopic release of the first dorsal compartment has been described.[71]

extensor pollicis longus tenosynovitis

1st line – surgery

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ACUTE
|
extensor pollicis longus tenosynovitis
1st line – 

surgery

Although oral nonsteroidal anti-inflammatory drugs can be offered for pain, surgical exploration should be planned as soon as possible (within days to weeks) to avoid attritional rupture of the tendon. The third dorsal compartment is released, and extensor pollicis longus tendon is transposed outside the compartment.

Consider – nonsteroidal anti-inflammatory drugs + splinting

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ACUTE
|
extensor pollicis longus tenosynovitis
Consider – 

nonsteroidal anti-inflammatory drugs + splinting

Treatment recommended for SOME patients in selected patient group

Oral nonsteroidal anti-inflammatory drugs and splinting can be offered for pain relief for a period of 4 to 6 weeks.

Primary options

diclofenac potassium: 50 mg orally (immediate-release) three times daily when required

OR

ibuprofen: 400-800 mg orally every 6-8 hours when required, maximum 2400 mg/day

OR

naproxen: 500 mg orally twice daily when required, maximum 1250 mg/day

OR

meloxicam: 15 mg once orally daily

OR

celecoxib: 200 mg orally once daily

extensor carpi ulnaris tendon tenosynovitis

1st line – nonsteroidal anti-inflammatory drugs + splinting

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ACUTE
|
extensor carpi ulnaris tendon tenosynovitis
1st line – 

nonsteroidal anti-inflammatory drugs + splinting

A trial of oral nonsteroidal anti-inflammatory drugs for a period of 4 to 6 weeks can be attempted initially, together with splinting. A volar-based wrist splint is applied with the wrist immobilized in the neutral position.

Primary options

diclofenac potassium: 50 mg orally (immediate-release) three times daily when required

OR

ibuprofen: 400-800 mg orally every 6-8 hours when required, maximum 2400 mg/day

OR

naproxen: 500 mg orally twice daily when required, maximum 1250 mg/day

OR

meloxicam: 15 mg once orally daily

OR

celecoxib: 200 mg orally once daily

1st line – extensor carpi ulnaris sheath injection

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ACUTE
|
extensor carpi ulnaris tendon tenosynovitis
1st line – 

extensor carpi ulnaris sheath injection

A trial of corticosteroid injection is frequently attempted early on.[40][41][74][75][76] An injection is often offered as a first-line treatment and is considered coequal to nonsteroidal anti-inflammatory drugs (NSAIDs) by many. This applies to all categories that do not require urgent intervention.

Following the injection, follow-up is scheduled within 1 month for repeat exam. If the injection fails, a second injection may be given or the patient may be referred to surgery.

Opinion varies as to the choice of corticosteroid and its preparation. Methylprednisolone, triamcinolone, and betamethasone are among the most commonly used.[6][7][8][23][43][44][45][46][47]

The corticosteroid is mixed with a local anesthetic, most commonly 1% lidocaine.[48] Some treating physicians add sodium bicarbonate in a 1:10 mixture.

Total volume injected is about 1 to 3 mL depending on the site and preference. A small needle is preferred (e.g., 25- or 27-gauge). The injection may be repeated on several occasions, but caution should be exercised after multiple injections due to risk of skin thinning, fat atrophy, or tendon rupture.[7][47]

Primary options

methylprednisolone acetate: 20 mg (1 mL) injected into flexor tendon sheath as a single dose, may repeat

or

triamcinolone acetonide: 5 mg (1 mL) injected into flexor tendon sheath as a single dose, may repeat

or

betamethasone sodium phosphate/betamethasone acetate: 6 mg (1 mL) injected into flexor tendon sheath as a single dose, may repeat

-- AND --

lidocaine: (1%) 1 mL injected into flexor tendon sheath as a single dose with corticosteroid

2nd line – surgery

Back
ACUTE
|
extensor carpi ulnaris tendon tenosynovitis
2nd line – 

surgery

Surgical treatment consists of release of the sixth dorsal compartment. Tenosynovectomy and retinacular sheath repair and/or reconstruction may be deemed necessary intraoperatively.

all other tenosynovitides

1st line – nonsteroidal anti-inflammatory drugs + splinting

Back
ACUTE
|
all other tenosynovitides
1st line – 

nonsteroidal anti-inflammatory drugs + splinting

Conservative management with a trial of oral nonsteroidal anti-inflammatory drugs and splinting for a period of 4 to 6 weeks can be attempted initially.

Primary options

diclofenac potassium: 50 mg orally (immediate-release) three times daily when required

OR

ibuprofen: 400-800 mg orally every 6-8 hours when required, maximum 2400 mg/day

OR

naproxen: 500 mg orally twice daily when required, maximum 1250 mg/day

OR

meloxicam: 15 mg once orally daily

OR

celecoxib: 200 mg orally once daily

1st line – sheath/compartment injection

Back
ACUTE
|
all other tenosynovitides
1st line – 

sheath/compartment injection

A trial of corticosteroid injection is frequently attempted early on. An injection is often offered as a first-line treatment and is considered coequal to nonsteroidal anti-inflammatory drugs by many. This applies to all categories that do not require urgent intervention.

Following the trial injection, follow-up is scheduled within 1 month for repeat exam. If the injection fails, a second injection may be given or the patient may be referred to surgery.

Opinion varies as to the choice of corticosteroid and its preparation. Methylprednisolone, triamcinolone, and betamethasone are among the most commonly used.[6][7][8][23][43][44][45][46][47]

The corticosteroid is mixed with a local anesthetic, most commonly 1% lidocaine.[48] Some treating physicians add sodium bicarbonate in a 1:10 mixture.

Total volume injected is about 1 to 3 mL depending on the site and preference. A small needle is preferred (e.g., 25- or 27-gauge). The injection may be repeated on several occasions, but caution should be exercised after multiple injections due to risk of skin thinning, fat atrophy, or tendon rupture.​[7][49]​[47]

Primary options

methylprednisolone acetate: 20 mg (1 mL) injected into flexor tendon sheath as a single dose, may repeat

or

triamcinolone acetonide: 5 mg (1 mL) injected into flexor tendon sheath as a single dose, may repeat

or

betamethasone sodium phosphate/betamethasone acetate: 3 mg (1 mL) injected into flexor tendon sheath as a single dose, may repeat

-- AND --

lidocaine: (1%) 1 mL injected into flexor tendon sheath as a single dose with corticosteroid

2nd line – surgery

Back
ACUTE
|
all other tenosynovitides
2nd line – 

surgery

Surgery consists of surgical release of the corresponding compartment.[34]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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