FIGURE 6.52 Tendinous (synovial) sheaths of long flexor tendons of the digits. An inflamed nodule is shown in the flexor tendon of the long finger. (From Tank PW, Gest TR. Lippincott Williams & Wilkins Atlas of Anatomy. Philadelphia, PA: Lippincott Williams & Wilkins, 2009.)

PATIENT POSITION

Supine on the examination table with the head of the bed elevated 30 degrees.
The affected wrist is held in a neutral position.
The wrist is fully supinated.
The hand is supported with the placement of chucks pads or towels.
Rotate the patient’s head away from the side that is being injected. This minimizes anxiety and pain perception.

LANDMARKS

1. With the patient supine on the examination table, the clinician stands anterior to the affected hand.

2. Identify and mark the tender nodule located in the finger’s flexor tendon and its sheath. This should be located over the metatarsal heads.

3. Mark a point 1 cm distal to the nodule.

4. At that site, press firmly on the skin with the retracted tip of a ballpoint pen. This indention represents the entry point for the needle.

5. After the landmarks are identified, the patient should not move the hand or the fingers.

ANESTHESIA

Local anesthesia of the skin using topical vapocoolant spray.

EQUIPMENT

3-mL syringe
25-gauge, 5/8-in. needle
0.5 mL of 1% lidocaine without epinephrine
0.5 mL of the steroid solution (20 mg of triamcinolone acetonide)
One alcohol prep pad
Two povidone–iodine prep pads
Sterile gauze pads
Sterile adhesive bandage
Nonsterile, clean chucks pad

TECHNIQUE

1. Prep the insertion site with alcohol followed by the povidone–iodine pads.

2. Achieve good local anesthesia by using topical vapocoolant spray.

3. Position the needle and syringe at a 45-degree angle to the skin with the needle tip directed proximally.

4. Using the no-touch technique, introduce the needle at the insertion site (Fig. 6.53).

5. Advance the needle until the needle tip is located at the tendon nodule. Back up the needle 1 to 2 mm.

6. Slowly inject the steroid solution around the nodule into the tendon sheath. A subtle bulge in the shape of a sausage may develop in the tendon sheath.

7. If increased resistance is encountered, advance or withdraw the needle slightly before attempting further injection.

8. Following injection of the corticosteroid solution, withdraw the needle.

9. Apply a sterile adhesive bandage.

10. Instruct the patient to move his or her finger through its full range of motion. This movement distributes the steroid solution throughout the tenosynovial sheath.

11. Reexamine the hand in 5 min to confirm pain relief.