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Transient vasospastic response following the injection of corticosteroid into the hand.

Abstract

A sixty-year-old right hand dominant woman with long-standing left basal joint arthritis and right small trigger finger presented for corticosteroid injections to both areas. She had previously received injections with no adverse effects and good relief of symptoms. Following this most recent injection of corticosteroid, she experienced transient ischemia of the left hand and the right long and ring fingers. Corticosteroid injections can rarely cause local vasospasm, even when not inadvertently injected into the vascular system. This condition is self-limited following supportive treatment.

Corticosteroid injections are among the most common procedures performed by hand surgeons as non-operative alternatives for conditions ranging from osteoarthritis to tenosynovitis and nerve compression disorders. While generally considered safe, corticosteroids can be associated with adverse effects, including skin discoloration, (1) tendon or pulley rupture, (2-4) fat atrophy, (5,6) and systemic effects, such as transient hyperglycemia. (7) While vascular insufficiency after corticosteroid administration in the spine and nasal sinuses is well recognized, vascular compromise following injection in the hand has been rarely reported in the past. (8,9) We present a case of transient, global vasospastic changes in the hand following a corticosteroid injection.

Case Report

A sixty-year-old right hand dominant woman with a history of right small finger stenosing tenosynovitis and left thumb carpometacarpal joint arthritis presented for corticosteroid injections of both hands. She had been injected at both sites approximately 1 year prior with temporary relief of symptoms. She had no prior history of vasospastic condition, known inflammatory or autoimmune disorders, relevant allergies, or Raynaud's phenomenon. She had no history of smoking. She was not on any chronic medications.

Physical examination upon initial evaluation in the office demonstrated a swollen and painful left basal joint and a tender nodule over the right small finger A1 pulley with visible and palpable locking of the digit in flexion. The patient's skin was normal-appearing, and her digits were warm and well-perfused. Left hand radiographs demonstrated thumb carpometacarpal joint arthritis with no other notable abnormalities. The patient was given corticosteroid injections into both areas under sterile conditions. The right hand was injected with 1 cc 1% lidocaine without epinephrine and 1 cc of triamcinolone acetonide (40 mg/cc) into the small finger A1 pulley. Next, the left thumb carpometacarpal joint was injected with 1 cc 1% lidocaine without epinephrine and 1 cc of triamcinolone acetonide (40 mg/cc) from the radial-volar side of the joint assisted by gentle manual traction on the thumb. Both injections were performed using a 25 gauge, 1.25 inch needle attached to a sterile 5 cc syringe. The patient experienced the expected numbness immediately post-injection, and the skin post injection did not appear abnormal. The patient was discharged from the office with plans for follow-up as needed.

The patient returned to the office several minutes later complaining of discoloration of the skin. On examination, the patient's skin was blanched throughout the entirety of the left hand distal to the wrist crease dorsally and volarly. No masses or localized injection site reactions were noted, and the patient's sensation and motor function were intact. The right hand was unaffected at this time (Fig. 1). Warm compresses were applied to the patient's left wrist and hand. After approximately 10 minutes, the patient's capillary refill returned. Shortly thereafter, blanching of the right long, index, and ring fingers was noted (Fig. 2). This resolved spontaneously over the course of minutes. Upon symptom resolution, the patient was found to have palpable radial and ulnar pulses, and Allen's testing was normal with flow through both the radial and ulnar arteries with occlusion.

The patient denied any systemic symptoms, including palpitations, dizziness, lightheadedness, shortness of breath, chest pain, or hand and wrist pain. The patient was monitored and discharged once these findings resolved. The patient did not experience any further episodes after discharge. Follow-up evaluation 3 months after the injection revealed normal perfusion to the hand without any sequelae.

Discussion

Corticosteroids have been demonstrated to cause local vasoconstriction and skin blanching followed by rebound vasodilation, and the observed skin changes can be evidence of corticosteroid bioavailability. (10) This vasoconstriction is accomplished by sensitization of smooth muscle cells' response to catecholamines, and its strength is determined in part by genetic polymorphisms. (11) The administration of corticosteroid injection for inflammatory and degenerative conditions in the hand is commonplace. In the upper extremity, skin, tendon, and nerve tissue complications relative to these interventions are well recognized. However, compromise to the vascular system is exceedingly rare in the extremities.

The vasoconstrictive effects of corticosteroids can have significant deleterious effects in the spine. Brouwers and colleagues reported a case of spinal cord ischemia resulting from a triamcinolone acetonide injection to the C5 vertebral foramen. (12) While contrast administration confirmed that there was no intra-arterial injection, the patient developed an infarction in the distribution of the anterior spinal artery seconds after the injection, leading to complete paralysis below the C3 level. While the investigators theorized that that the infarction was likely due to vasospasm, it is unclear whether the cord infarction was mechanically or chemically induced. Similarly, blindness has been reported due to retinal artery embolism following corticosteroid administration into the sinuses. While some cases were embolic in nature, with post-incident fundoscopy demonstrating intra-arterial steroid crystals, fundoscopic exam of other patients demonstrated only vasospasm. (13)

We identified only two reports detailing vascular changes in the hand, both following corticosteroid injections into the carpal tunnel. Hussain and coworkers reported ischemia after an injection for carpal tunnel syndrome. (9) In this case, a rush of blood was noted immediately after needle removal, and the three ulnar-sided digits rapidly demonstrated ischemic changes. An arteriogram demonstrated poor flow in the affected digits. The patient responded to systemic vasodilators, and the patient's tissues were not compromised. Intravascular administration of the corticosteroid into the ulnar artery was suspected in this case. In a similar report, Payne and associates describe a patient who exhibited coolness and blanching of the hand following carpal tunnel injection. (8) Circulation returned to the hand after 20 minutes of rewarming, but the patient experienced persistent paresthesias and developed ecchymoses and petechial hemorrhages over the course of 2 weeks despite normal capillary refill and a normal Allen's test. A magnetic resonance angiogram demonstrated a patent radial-dominant deep palmar arch.

In contrast to the previously reported cases, which occurred after carpal tunnel injection (in close proximity to the ulnar neurovascular bundle), in our patient, the injections were performed at the thumb carpometacarpal joint and the flexor tendon sheath. Inadvertent intra-arterial injection or direct arterial injury is unlikely given the location and subcutaneous nature of the injections. Furthermore, the global nature of the dysvascular changes in our patient is more consistent with a generalized vasospastic response and not a specific arterial injury. While we are unsure of the exact mechanism of the transient ischemic episode in this case, it is possible that sympathetic mediated vasospasm may account for the observed reaction.

Given the striking appearance of this vasospastic response and its resemblance to potentially devastating forms of vascular compromise, awareness of this reaction is important. This response, characterized by skin blanching without paresthesias throughout the entire hand, is a self-limited process that responds to application of warm compresses. Patients should be observed in the office for a brief period of time, allowing the hand time to reperfuse.

Disclosure Statement

None of the authors have a financial or proprietary interest in the subject matter or materials discussed, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony.

References

(1.) Stapczynski JS. Localized depigmentation after steroid injection of a ganglion cyst on the hand. Ann Emerg Med. 1991 Jul;20(7):807-9.

(2.) Yamada K, Masuko T, Iwasaki N. Rupture of the flexor digitorum profundus tendon after injections of insoluble steroid for a trigger finger. J Hand Surg Eur Vol. 2011 Jan;36(1):77-8.

(3.) Gyuricza C, Umoh E, Wolfe SW. Multiple pulley rupture following corticosteroid injection for trigger digit: case report. J Hand Surg Am. 2009 Oct;34(8):1444-8.

(4.) Mills SP, Charalambous CP, Hayton MJ. Bilateral rupture of the extensor pollicis longus tendon in a professional goalkeeper following steroid injections for extensor tenosynovitis. Hand Surg. 2009;14(2-3):135-7.

(5.) Anderson B, Kaye S. Treatment of flexor tenosynovitis of the hand ('trigger finger') with corticosteroids: A prospective study of the response to local injection. Arch Intern Med. 1991 Jan;151(1):153-6.

(6.) Brinks A, Koes BW, Volkers AC, et al. Adverse effects of extra-articular corticosteroid injections: a systematic review. BMC Musculoskelet Disord. 2010 Sep 13;11:20(6.)

(7.) Stepan JG, London DA, Boyer MI, et al. Blood glucose levels in diabetic patients following corticosteroid injections into the hand and wrist. J Hand Surg Am. 2014 Apr;39(4):706-12.

(8.) Payne JM, Brault JS. Digital ischemia after carpal tunnel injection: a case report. Arch Phys Med Rehab. 2008 Aug;89(8):1607-10.

(9.) Hussain SS, Taylor C, Van Rooyen R. Ulnar artery ischaemia following corticosteroid injection for carpal tunnel syndrome. N Z Med J. 2011 May 27;124(1335):80-3.

(10.) Smit P, Neumann HA, Thio HB. The skin-blanching assay. J Eur Acad Dermatol Venereol. 2012 Oct;26(10):1197-202.

(11.) Walker BR, Williams BC. Corticosteroids and vascular tone: mapping the messenger maze. Clin Sci (Lond). 1992 Jun;82(6):597-605.

(12.) Brouwers PJ, Kottink EJ, Simon MA, Prevo RL. A cervical anterior spinal artery syndrome after diagnostic blockade of the right C6-nerve root. Pain. 2001 Apr;91(3):397-9.

(13.) Mabry RL. Visual loss after intranasal corticosteroid injection: Incidence, causes, and prevention. Arch Otolaryngol. 1981 Aug;107(8):484-6.

Caption: Figure 1 The patient's hands on return to the office demonstrate left-sided skin blanching distal to the wrist crease with normal skin color contralaterally. To view this figure in color, see www.hjdbulletin.org.

Caption: Figure 2 The patient's hands following rewarming with warm compresses, demonstrating reactive hyperemia throughout the left hand and new blanching in the right ring, long, and index fingers. To view this figure in color, see www.hjdbulletin.org.

Jacob E. Tulipan, M.D., Kevin F. Lutsky, M.D., and Pedro K. Beredjiklian, M.D.

Jacob E. Tulipan, M.D., Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania. Kevin F. Lutsky, M.D., and Pedro K. Beredjiklian, M.D., Department of Orthopaedic Surgery, Thomas Jefferson University, Division of Hand Surgery, Rothman Institute, Marlton, New Jersey.

Correspondence: Jacob E. Tulipan, M.D., Department of Orthopaedic Surgery, Thomas Jefferson University, 1025 Walnut Street, Room 516 College, Philadelphia, Pennsylvania 19107; jacob.tulipan@gmail.com.
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Article Details
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Author:Tulipan, Jacob E.; Lutsky, Kevin F.; Beredjiklian, Pedro K.
Publication:Bulletin of the NYU Hospital for Joint Diseases
Article Type:Report
Geographic Code:1USA
Date:Jul 1, 2017
Words:1754
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