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SCIENTIFIC ARTICLE

Shower Emboli and Digital Necrosis After a Single

Corticosteroid Injection for Trigger Thumb:

Case Report

Jonathan Park, BS, Gregory A. Dumanian, MD

Local corticosteroid injection into the hand is the preferred initial step in the management oftrigger finger owing to its safety and efficacy. We report the case of a patient with showeremboli and digital necrosis after a local corticosteroid injection for the treatment of triggerthumb. Given the patient’s subsequent negative hypercoagulability workup, we suspect thatthe patient’s symptoms resulted from the injection of steroids into the princeps pollicisartery, with subsequent retrograde flow into multiple other arteries of the hand. The patientwas managed conservatively and ultimately her symptoms resolved. No new areas of digitalnecrosis have appeared in 8 years of follow-up. (J Hand Surg 2009;34A:313–316. © 2009Published by Elsevier Inc. on behalf of the American Society for Surgery of the Hand.)

Key words Injection, ischemia, embolus, trigger thumb.

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RIGGER FINGER, OR stenosing tenosynovitis ofthe digital flexor tendons, is a common condi-tion seen by the hand surgeon. This condition

as historically managed with surgical release of the1 pulley, until nonoperative treatment with steroid

njections into the tendon sheath was first reported inhe literature in 1953.1 Although it was first proposed inhe 1970s that steroid injection be considered as thenitial therapeutic option in the early disease course,2 itppears that it did not become the standard first-lineherapy until the 1980s and early 1990s.3–7

Major reasons for favoring injections over surgerynitially are cost, the speed of treatment, and their highafety profile. The most hazardous complication is aypersensitivity reaction resulting from multiple injec-ions8; other reported complications include hypopig-entation of the skin and fat atrophy at the injection

From the Division of Plastic Surgery and the Department of Surgery, Northwestern Feinberg School ofMedicine, Chicago, IL.

Received for publication June 10, 2008; accepted in revised form October 3, 2008.

No benefits in any form have been received or will be received related directly or indirectly to thesubject of this article.

Corresponding author: Gregory A. Dumanian, MD, Division of Plastic Surgery, NorthwesternFeinberg School of Medicine, 675 N. St. Clair, Suite 19-250, Chicago, IL 60610; e-mail:gdumania@nmh.org.

0363-5023/09/34A02-0018$36.00/0

mdoi:10.1016/j.jhsa.2008.10.006

ite.9 A review of 11 studies on steroid injections forrigger finger from 1972 to 2007 demonstrated that for246 cumulative digits treated, no serious long-termdverse side effects were noted.2–6,10–15 Isolated caseeports of adverse events of steroid injections into theand for various conditions include tendon rupture afterntratendinous steroid injection.16–18

ASE REPORT

44-year-old, nonsmoking woman presented to ourffice 1 month after receiving a steroid injection to hereft hand for trigger thumb, by a Board-certified sur-eon whose practice was limited to the field of handurgery. The patient recalled feeling significant painuring the injection, as well as seeing her hand becom-ng pale after the event. Before the injection for herhumb and aside from her thumb symptoms of pain andocking, her hand had been completely asymptomatic.he had no history of a hypercoagulability disorder.ne month after the injection, she presented to ourffice with persistent painful ulcers at the tips of the leftndex and middle fingers. The appearance and Dopplerndings were consistent with the presentation of digital

schemic necrosis (Fig. 1). The thumb was viable andithout lesions. The surgeon was contacted and re-

embered nothing unusual about the injection at the

© Published by Elsevier, Inc. on behalf of the ASSH. � 313

314 DIGITAL NECROSIS AFTER STEROIDAL TREATMENT

base of the thumb at the level of the metacarpophalan-geal joint. He provided no additional details.

The patient underwent a full workup to evaluate theischemic necrosis of her fingers. Her blood work indi-cated that she did not have systemic lupus erythemato-sis, a lupus anticoagulant, or other collagen vasculardisease. Her echocardiogram did not show vegetations.Upper-extremity Doppler examinations demonstratednormal wrist waveforms and a patent palmar arch, butsignals were absent in the left index and middle fingersand reduced in the ring and small digits, consistent withdigital ischemia.

A bilateral upper-extremity arteriogram showed nolesions of the opposite arm. On the affected arm therewere no abnormalities of the arteriogram from the archdown to the wrist. Views of the hand showed multiplefocal occlusions within the proper digital arteries of theleft index, middle, ring, and little fingers, consistentwith microemboli (Fig. 2).

The patient was managed conservatively withnonsteroidal anti-inflammatory medicines, narcoticanalgesic medicines, and silver sulfadiazine to hernecrotic fingertips. Her symptoms slowly im-proved, with total resolution of her pain and fin-gertip wounds 5 months later. The patient was seen 8years later for another issue. She is healthy, withoutdevelopment of collagen vascular disease (Fig. 3).She has not developed new ischemic lesions any-where else in her body, which lends further supportto the conclusion that the ischemic lesions of herfingers resulted from the original cortisone injection

FIGURE 1: Appearance of the patient’s injected hand 4 weeksafter steroid injection. Note fingertip tissue loss consistent withdigital ischemia.

for trigger thumb.

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DISCUSSIONWe found no reported cases of hand ischemia after

FIGURE 2: Angiogram of the affected hand shows multiplefocal occlusions within the proper digital arteries of the leftindex, middle, ring, and little fingers, compatible withmicroembolic disease. Right upper-extremity angiogram wasnormal.

FIGURE 3: Eight-year follow-up photograph of left fingers.

steroid injection; however, rare cases of tissue necrosis

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DIGITAL NECROSIS AFTER STEROIDAL TREATMENT 315

after steroid injections around the eye and spine havebeen reported.19–24 The proposed mechanisms foracute spinal cord infarction after transforaminal epi-dural steroid injections include arterial spasm, intimalflap development, or arterial penetration with subse-quent particulate steroid embolism.21,24 All mecha-nisms could theoretically lead to stasis of flow, clotformation, and hypoperfusion of the spinal cord.24 Ithas been shown by light microscopy that steroid parti-cles (especially triamcinolone and methylprednisolone)tend to coalesce into aggregates exceeding 100 �m,which may contribute to microvascular sludging, withresultant occlusion and infarction.21 These particulatesizes could occlude capillaries, metarterioles, and somearterioles and arteries, which lends credence to theembolic hypothesis.21,24 These mechanisms are similarto those postulated for the relatively more commoninadvertent intra-arterial injections seen in drug abusepatients.

We can extrapolate from mechanisms of spinal isch-emia to our case of digital necrosis to explain ourpatient’s findings. Given our patient’s clinical presen-tation and negative hypercoagulability workup, as wellas the lack of any other potential etiology for digitalischemia, we believe that her symptoms resulted fromunintentional steroid injection into a hand artery, withsubsequent embolism into digital arteries. We hypoth-esize that given its proximity, the princeps pollicis ar-tery was inadvertently injected, followed by retrogradeflow of steroids into the palmar arch, anterograde flowdown the common digital arteries, and, finally, embo-lization into the second through fifth proper digitalarteries. If a complete arch had existed before the in-jection, it would have facilitated the embolization fromthe princeps pollicis toward the common digital arteryof the fourth web space. A complete arch was notapparent at the time of the arteriogram. A sizeablevessel connecting the apparently separate ulnar andradial vascular systems also was not apparent at thetime of the arteriogram, and was either small, far prox-imal in the forearm, or else possibly thrombosed at thetime of the injection.

Although the details of this patient’s steroid injectionare not known, it is probable that 0.5 to 1.0 mL of fluidwas injected through a 25-gauge needle and a 3-mLsyringe. This needle and syringe combination couldpotentially have generated pressures far above systemicpressure. Stevenson et al. demonstrated that pressures inexcess of 800 mm Hg can be produced during forcefulinjection using a 6-mL syringe with a 16-mm-long,25-gauge needle. As the syringe size decreases (as was

probable in this case) the pressure generated increases,

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because the force applied to the plunger is distributedover a smaller cross-sectional area.25 An intra-arterialinjection might have occurred at a pressure far abovesystemic pressures, and the cortisone could have trav-eled retrograde toward the forearm. This could explainthe widespread shower emboli found on this patient’sarteriogram, with digital occlusions noted even for thesmall finger.

The patient presented after tissue loss had alreadyoccurred. Pulsatile blood flow heard by Doppler exam-ination on the volar pads of the index and middlefingers at the time of presentation influenced our deci-sion not to perform a surgical intervention, such as adigital sympathectomy. If the intra-arterial injection ofsteroids and resultant digital ischemia had been notedinitially, the patient’s pain and loss of tissue might havebeen lessened with systemic anticoagulation, thrombol-ysis, chemical sympathectomy, or surgical sympathec-tomy.

This isolated case has not changed our practice ofoffering patients with trigger finger a corticosteroidinjection as first-line therapy. The case is a reminderalways to aspirate before injecting medicine into thebody. This patient’s case may reemphasize the practiceof using soluble corticosteroid solutions (such as beta-methasone sodium phosphate) in place of suspensions21

in efforts to minimize embolization. Trigger finger is acommon cause of hand pain, and although complica-tions of steroid injection to the hand are rare, this casereport reinforces the importance of understanding thepotential adverse outcomes of all types of treatment, aswell as how to manage potential complications thatarise.

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