Are There Differences in Pain Reduction and Functional Improvement Among Splint Alone, Steroid Alone, and Combination for the Treatment of Adults With Trigger Finger?

Abstract

Background Steroid injection and splinting, which are commonly recommended nonsurgical treatments in adults with trigger finger, have been demonstrated to effectively relieve pain and improve function. However, to our knowledge, there have been no direct comparisons of pain relief and function improvement with splinting alone, steroid injection alone, or a combination of splinting and steroid injection in patients with this diagnosis. Question/purpose Are there differences in pain reduction and functional improvement in adults with trigger finger treated with splinting alone, steroid injection alone, and a combination of splinting and steroid injection at 6, 12, and 52 weeks after the intervention? Methods Between May 2021 and December 2021, we treated 165 adult patients for trigger finger at an academic university hospital. Based on prespecified criteria, all patients we saw during that period were eligible, but 27% (45 of 165) were excluded because they had received a previous local corticosteroid injection (n = 10) or they had concomitant carpal tunnel syndrome (n = 14), first carpometacarpal joint arthritis (n = 3), osteoarthritis of the hand (n = 6), de Quervain disease (n = 3), multiple-digit trigger finger (n = 6), or pregnancy during the study period (n = 3). After screening, 120 patients were randomized to receive either splinting (n = 43), steroid injection (n = 40), or splinting plus steroid injection (n = 37). Patients were randomly assigned to the different treatments using computer-generated block randomization (block of six). Sequentially numbered, opaque, sealed envelopes were used in the allocation concealment process. Both the allocator and the outcome assessor were blinded. Splinting involved the patient wearing a fixed metacarpophalangeal joint orthosis in the neutral position at least 8 hours per day for 6 consecutive weeks. Steroid injection was performed using 1 mL of 1% lidocaine without epinephrine and 1 mL of triamcinolone acetonide (10 mg/mL) injected directly into the flexor tendon sheath. No patients were lost to follow-up or had treatment failure (that is, the patient had persistent pain or triggering with the trigger finger treatment and requested additional medical management including additional splinting, steroid injection, or surgery) at 6 or 12 weeks after the intervention, and at 52 weeks, there was no difference in loss to follow-up among the treatment groups. An intention-to-treat analysis was performed with all 120 patients, and a per-protocol analysis was conducted with 86 patients after excluding patients who were lost to follow-up or had treatment failure. Primary outcomes evaluated were VAS pain reduction and improvement in Michigan Hand Outcomes Questionnaire (MHQ) scores at 6, 12, and 52 weeks after the intervention. The minimum clinically important difference (MCID) values were 1 and 10.9 for the VAS and MHQ, respectively. Results There were no clinically important differences in VAS pain scores among the three treatment groups at any timepoint, in either the intention-to-treat or the per-protocol analyses. Likewise, there were no clinically important differences in MHQ scores at any timepoint in either the intention-to-treat or the per-protocol analyses. Conclusion Splinting alone is recommended as the initial treatment for adults with trigger finger because there were no clinically important differences between splinting alone and steroid injection alone in terms of pain reduction and symptom or functional improvement up to 1 year. The combination of steroid injection and splinting is disadvantageous because the benefits in terms of pain reduction and symptom or functional improvement are not different from those achieved with steroid injection or splinting alone. Level of Evidence Level I, therapeutic study.

CORR Insights®: Are There Differences in Pain Reduction and Functional Improvement Among Splint Alone, Steroid Alone, and Combination for the Treatment of Adults With Trigger Finger?

“…One specific finding of Atthakomol et al’s trial that I found intriguing is that splinting adherence did not alter the degree of improvement at 52 weeks [1]. This was not a primary study analysis, and it is also possible that all patients within this trial were adherent “enough” for positive outcomes (although this then calls into question the minimum necessary wearing schedule).…”

“…Atthakomol et al’s [1] findings provide additional support for splinting as a first-line treatment option for adult single-digit trigger finger. While there has been evidence supporting splinting as an option for decades, a survey of U.S. hand surgeons revealed that only a minority prefer splinting alone for nonoperative management [10].…”

“…Given the heterogeneity of existing recommendations, it is exciting to see in this month’s Clinical Orthopaedics and Related Research ® a randomized controlled trial offering a head-to-head comparison of several nonoperative treatments, including a combined option. Specifically, Atthakomol et al [1] compared (1) a single corticosteroid injection directly into the flexor tendon sheath, (2) a night-time prefabricated hand-based metacarpophalangeal joint blocking splint for 6 weeks, and (3) a combination of an injection and a splint. The authors found no differences in patient-reported outcomes for pain or function out to a year, nor did they see any differences in reduction of trigger finger severity at 52 weeks according to the Quinnell classification.…”

“…I am excited to share with therapist colleagues and students that the evidence for orthotic management of trigger finger has grown, thanks to this trial in CORR ® by Atthakomol et al [1], and I look forward to seeing additional…”

“…CORR Insights®: Are There Differences in Pain Reduction and Functional Improvement Among Splint Alone, Steroid Alone, and Combination for the Treatment of Adults With Trigger Finger? Brocha Z. Stern PhD, MOT 1 Where Are We Now? A dult trigger finger is a common condition encountered in hand surgery, rehabilitation, and even primary care contexts.…”