There is currently a lively correspondence on the safety or otherwise of steroid injections given for scar management and specific conditions of the hand and wrist – specifically, whether or not it is safe to give them with COVID-19 in the community. We have patients writing to the newspapers saying they are being denied previously helpful joint injections because of these concerns. We know that steroids depress the immune system to some extent so could it make COVID-19 infection worse if you were then caught the virus? Or, is it too low a dose to make a difference? In addition, we now have dexamethasone (which is another steroid) that is being used effectively for the treatment of severe COVID-19 infection (RECOVERY Trial). All rather confusing.
Where we use steroid injections
Triamcinolone injection 10mg (low dose long-acting steroid) is currently given for carpal tunnel syndrome, trigger finger, De Quervain’s tenosynovitis, small joint arthritis to name but a few. It is important to remember that many patients cannot access surgery at the moment or have themselves made the decision that there are surgery-related risks they do not wish to take at the present time. Therefore, non-surgical treatment becomes the mainstay of management and it is important that the professions take a balanced rather than automatically cautious or defensive view on the issue.
Absolute risk analysis
Steroid-related increase in infection risk (all infections not just COVID-19) appears to be dose-related and is further influenced by the medical status of the patient to whom it is given.1 One previous study2 looked at the extra risk of picking up seasonal flu after a single corticosteroid injection and estimated the additional risk was 1 in 1000 patients/year treated in this way. The dose of steroid given in this trial was round x6 higher than is used for steroid injections around the hand and wrist. Furthermore, this study did not look at the timing between administered injection and contracting flu so it is not known if there is a close relationship in terms of timing of any immune suppression and contracting flu.
Making a personal recommendation for treatment
Clearly, as an individual patient, you should be evaluated on your individual needs, how bad the symptoms are at the moment, and set in context of any other medical conditions you have. Corticosteroid injection may bring relief of the presenting condition and mean that surgery can be avoided or put back for a number of months whilst allowing you to get on with your day to day life. The absolute risk appears to be small but if you have been advised by your GP that you are in the group who should be shielding then the risks and benefits need to be carefully weighed up.
- COVID-19: A rethink of corticosteroid injection? Little CP, Birks ME, Horwitz MD, Ng CY, Warwick D. Bone and Joint Open 1(6)https://doi.org/10.1302/2046-3758.16.BJO-2020-0050.R1
Sytsma TT, Greenlund LK, Greenlund LS. Joint corticosteroid injection associated with increased influenza risk. Mayo Clin Proc Innov Qual Outcomes 2018;2: 194-198.