Carpal Tunnel Injection

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Carpal Tunnel Injection
Indication Carpal Tunnel Syndrome
Syringe 1mL
Needle 23G 30mm
Steroid 20mg triamcinolone
Local nil
Volume 0.5mL


Anatomy

The flexor retinaculum attaches to four areas. Namely the pisoform, the scaphoid, the hook of the hamate, and the trapezium. The proximal edge lies at the distal wrist crease. The median nerve normally lies under the palmaris longus tendon (if present) at the mid wrist, and is medial to the flexor carpi radialis (FCR) tendon. The FCU attaches to the pisiform. The distal wrist crease crosses the pisiform

Indications and Efficacy

Contraindications

Pre-procedural Evaluation

The clinician has the choice between various therapeutic agents and/or methods including corticosteroid, dextrose, PRP, low volume, and high volume with hydrodissection.

Corticosteroid versus dextrose: The injection of 5mLs of D5W was more effective than corticosteroid in one RCT.[1] Some authors have reported using 10mLs.[2]

Low volume versus hydrodissection: One RCT found no difference,[3] however the study was criticised for inadequate hydrodissection and unclear methodology.[4]

Equipment

Technique

  • Position:Hand palm up
  • Needle entry site options
    • Identify the point midway along the proximal wrist crease, between the FCR and median nerve.
  • Insert the needle then angle proximal to distal at a 45 degree angle.
  • Slide distally until it is under the midpoint of the retinaculum (feel it puncture the retinaculum)
  • Reposition medially if hit nerve
  • Inject as a bolus
  • Have patient open and close hand to spread the injectate around the carpal tunnel.

Complications

Mild exacerbation of symptoms immediately or in the hours following injection. Soft tissue atrophy. Ulnar artery injury. Median nerve injury.

Aftercare

Rest for one week. Use a night splint. Repeat injections can be done.

Videos

Carpal Tunnel Injection Video

External Links

References

  1. โ†‘ Wu et al.. Randomized double-blinded clinical trial of 5% dextrose versus triamcinolone injection for carpal tunnel syndrome patients. Annals of neurology 2018. 84:601-610. PMID: 30187524. DOI.
  2. โ†‘ Tsung-Ying Li, Si-Ru Chen, Yu-Ping Shen, Chih-Ya Chang, Yu-Chi Su, Liang-Cheng Chen, Yung-Tsan Wu, Long-term outcome after perineural injection with 5% dextrose for carpal tunnel syndrome: a retrospective follow-up study, Rheumatology, , keaa361, https://doi.org/10.1093/rheumatology/keaa361
  3. โ†‘ Wang JC, Hsu PC, Wang KA, Chang KV. Ultrasound-Guided Triamcinolone Acetonide Hydrodissection for Carpal Tunnel Syndrome: A Randomized Controlled Trial. Front Med (Lausanne). 2021 Sep 13;8:742724. doi: 10.3389/fmed.2021.742724. PMID: 34589506; PMCID: PMC8475784.
  4. โ†‘ Lam et al. Commentary: Ultrasound-Guided Triamcinolone Acetonide Hydrodissection for Carpal Tunnel Syndrome: A Randomized Controlled Trial. 13 January 2022. Frontiers in Medicine. DOI

Literature Review