De Quervain Injection

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De Quervain Injection
Indication De Quervain Tendinopathy
Syringe 1mL
Needle 25G 16mm
Steroid 0.5mL 20mg triamcinolone
Local 0.5mL 1% lidocaine
Volume 1mL


Background

Injection for De Quervain Tendinopathy.

Anatomy

A. One compartment.
B. Two subcompartments
From McDermott et al 2012[1]
  • The APL and EPB usually run together in the first dorsal compartment.
  • The tendons can often be seen with the thumb held in resisted extension.
  • They can also be palpated at the base of the 1st metacarpal.
  • Anatomic variation: septum with two sub compartments (24-76% in cadaver studies). Failure can occur if failure to inject into compartment or only one sub compartment.

First Dorsal Compartment.PNG

Indications

Contraindications

Technique

Long axis injection. From left to right: needle, EPB, APL.
  • Ultrasound guided is preferred with greater clinical improvement, and allows the identification of subcompartment anatomical variation [2][3][4]
  • Position: Ulnar side of hand resting on surface with thumbheld in slight flexion

Non-Ultrasound Guided

  • Identify: Radial styloid, the APB and EPL tendons, and the gap between them.
  • Injection site
    • Usual site: is between 5-10mm proximal to the tip of the radial styloid, between the two tendons, through the retinaculum, within the sheath.
    • Alternative site in very thin patients: inject distal to the retinaculum, 5mm distal to the radial styloid (due to limited subcutaneous tissue), then advance the needle proximally while injecting
  • Insert needle perpendicularly into the gap then slide proximally between the tendons (needle going distal to proximal)
  • Inject solution as a bolus

Ultrasound Guided

  • Preparation: Stand off gel recommended
  • Identify: APL and APB tendons in sagittal, retinaculum, radial styloid in transverse
  • Optional: initial infiltration of lidocaine.
  • Axis: Can be done long axis or short axis. Transverse view is best with the needle entering the sheath while in plan with the transducer.
  • Direction: Dorsal to palmar direction, at a site free of superficial veins and the superficial branch of the radial nerve
  • Injection
    • One sheath: deposit at one location in the sheath
    • Two sheaths: Pierce the septum between the sheaths. Deposit half around the APL, then draw back and deposit the remaining half around the EPB

Complications

  • Subcutaneous fat atrophy, particularly noticeable in dark skinned thin women. This may be permanent but generally resolves within 3 months. The risk can be reduced by using hydrocortisone.
  • Trauma to superficial radial nerve

Aftercare

Rest hand for one week with taping. Avoid provoking activities and start a graded load programme.

External Resources

References

  1. McDermott JD, Ilyas AM, Nazarian LN, Leinberry CF. Ultrasound-guided injections for de Quervain's tenosynovitis. Clin Orthop Relat Res. 2012;470(7):1925-1931. doi:10.1007/s11999-012-2369-5
  2. McDermott JD, Ilyas AM, Nazarian LN, et al. Ultrasound-guided injections for de Quervain's tenosynovitis. Clin Orthop Relat Res. 2012;470:1925–31.
  3. Jeyapalan K, Choudhary S. Ultrasound-guided injection of triamcinolone and bupivacaine in the management of de Quervain’s disease. Skelet Radiol. 2009;38:1099–103.
  4. Zingas C, Failla JM, Van Holsbeeck M. Injection accuracy and clinical relief of de Quervain’s tendinitis. J Hand Surg Am. 1998;23:89

Literature Review