Regarding “Corticosteroid Injection With or Without Thumb Spica Cast for de Quervain Tenosynovitis”

Abstract

To the Editor: I was interested in the January 2014 article by Mardani-Kivi et al concerning the efficacy of a thumb spica cast when used to supplement corticosteroid injection for de Quervain tendinopathy. Their findings differ markedly from those of Weiss et al, that immobilization did not add to the benefit of injection alone, and I applaud the authors for studying this in a prospective fashion. However, I am concerned that the authors used methylprednisolone acetate (Depo-Medrol 40 mg) for their injections. Depo-Medrol, a fat-soluble glucocorticoid preparation, is not specifically indicated for use in subdermal locations in the United States. The package insert contains abundant bold-font warnings concerning the risk of subcutaneous placement of the drug (shown below). A quick review of the literature demonstrates several serious complications from the injection of fat-soluble corticosteroids in patients with de Quervain disease, including but not limited to subcutaneous atrophy, skin depigmentation, capillary fragility, bleeding, scar revision, and tendon rupture. Mardani-Kivi et al reported no complications in their series, and I would like to know whether they identified any of the complications mentioned above, or others in longer-term follow-up. It is difficult to inject the first dorsal compartment without at least some leakage of the injected material into the surrounding subcutaneous tissue. Most authors document a 2to 3-month lag time before the appearance of skin depigmentation. I advise considerable caution with the use of methylprednisolone acetate injection for the treatment of de Quervain disease. From the package insert LAB-0160-3.0 Pfizer, Inc. (New York, NY), revised August 2008: