Steroid Injections in the Upper Extremity: Experienced Clinical Opinion Versus Evidence-based Practices

Abstract

A survey regarding upper-extremity steroid injection practices was distributed to all active members of the American Society for Surgery of the Hand (ASSH) and American Shoulder and Elbow Surgeons (ASES) using SurveyMonkey. Response rates for the ASSH and ASES were 26% and 24%, respectively. The potency-adjusted dose of steroid injected for common hand and wrist injections ranged from 0.375 to 133.33 mg and for shoulder injections ranged from 0.375 to 250 mg. These ranges span 356-fold and 667-fold differences, respectively. Potency-adjusted doses differed significantly between steroid types for all injections evaluated in this study. American Society for Surgery of the Hand members gave significantly smaller doses of steroid for the glenohumeral and acromioclavicular joints than ASES members. Only 9% of respondents based injection practice on a scientific reference. Sixteen percent of ASSH and 31% of ASES respondents reported no specific rationale for their steroid injection practice; 78% of ASSH and 52% of ASES respondents attributed their rationale to some kind of instruction from their mentors or colleagues. Upper-extremity surgeons demonstrate substantial variability in their practice of steroid injections, with up to a 667-fold range in steroid dose. Experienced clinical opinion is the principal rationale for these injection practices; little rationale is based on formal scientific evidence.

Disc Golf, a Growing Sport

“…The SurveyMonkey website is protected by many mechanisms that keep transmissions over the Internet confidential and has been used in many studies in medical literature. 1 , 9 Only the members of the research team had access to the SurveyMonkey data.…”

Soft Tissue Atrophy Related to Corticosteroid Injection: Review of the Literature and Implications for Hand Surgeons

“…The choice of corticosteroid to be used, along with the volume, potency, and diluent, varies substantially amongst practitioners. Kegel et al, 21 in an American Society for Surgery of the Hand member survey, found that for trigger finger injections, 31.4% prefer triamcinolone acetonide plus lidocaine, 27.1% use betamethasone plus lidocaine, and 15.3% use methylprednisolone plus lidocaine. The remaining 26.2% use 1 of 27 other individual preparations.…”

“…Of those surveyed, 91% listed fellowship training, colleague recommendations, or no specific rationale as the reasoning behind their CI practice. 21 The most common corticosteroids used for injection today are triamcinolone, betamethasone, methylprednisolone, and dexamethasone. Triamcinolone and methylprednisolone preparations contain ester compounds, which make them highly insoluble in water and leads to the formation of microcrystalline suspensions.…”

Is the lateral extension of the acromion related to the outcome of shoulder injections?

“…Shoulder impingement was diagnosed by Neer's sign, Hawkin's test, and the painful arc test [10,17,18]. Patients with clinical symptoms for an intra-articular source of pain such as adhesive capsulitis (frozen shoulder), biceps-related disorders (tendinopathy and SLAP lesion [superior labral tear from anterior to posterior]), or osteoarthritis of the glenohumeral joint were referred for glenohumeral joint injection [19][20][21]. All therapeutic subacromial or glenohumeral injections were performed under fluoroscopy guidance using sterile conditions by one of five fellowship-trained musculoskeletal radiologists or by one of three board-certified radiologists during their musculoskeletal radiology fellowship programme.…”