#24 De Quervain's Tenosynovitis and Steroid Injections TUTORIAL8th February 2012
Facelift SurgeryVideo tutorial for General Practitioners and the medically qualified individuals on how to inject steroids to treat De Quervain's Tenosynovitis syndrome by UK leading plastic surgeon Adrian Richards of Aurora clinics in Buckinghamshire. For more information on Minor surgery training courses for GPs led by Mr. Adrian Richards, please call our FREE office number: 0800 3285743
Hello everyone, my name’s Adrian Richards. I’m a plastic surgeon and the Surgical Director of Aurora Clinics. In this subject, which is one of our series on how to do injections for common hand conditions, I’m going to be talking about De Quervain’s tenosynovitis.
Now, what is De Quervain’s tenosynovitis? It’s basically inflammation in the first extensor compartment, which is the extensor tendons which run on the thumb side of the wrist. It’s characterised by pain and swelling in the area.
When you’re looking to see if a patient has it, the first thing to do is where is the pain. It will always be just on the base of the thumb. Is there any swelling in this area here? Sometimes when they move the thumb up and down, you will feel bulky swelling, and it’s all crepitus in this area.
The sign that you’re really looking for, and I believe you can only do this test once, is called the Finkelstein’s test. This is very characteristic for De Quervain’s tenosynovitis. What you do is you ask the patient to hold their hands out and then clasp their thumb in their palm, and then cup their fingers around the finger.
Now, sometimes that will elicit pain here in the first extensor compartment. Then what you ask them to do is bend their thumb down. Now, in me, actually that hurts a little bit because my tendon’s a little bit tight. Probably, if you did it on yourself, it will be a little bit painful. Someone with acute De Quervain’s syndrome, they would be jumping off the bed if they did that. So they probably wouldn’t even get to the stage of doing that, it would be too painful.
So let’s just review the anatomy. The first extensor compartment contains two tendons, an abductor pollicis longus and an extensor pollicis, which lie here. The first extensor compartment is the one we’re interested in De Quervain’s disease, and that contains two tendons, one of which is the abductor pollicis longus, and the other is the extensor pollicis. Basically, they lie along here, and they go to the base of the thumb. So that’s the first extensor compartment. You can normally see it, it lies on me, if I can just show you, if you raise your thumb up. If you raise your thumb up, I don’t know if you can see on me. I’m going to have to draw on myself now. This here is the compartment we’re interested in, and this is the radial styloid here. So it’s this compartment here.
This area here is the anatomical snuff box. It’s called that because, in the olden days, people supposedly put snuff in there and sniffed it from there. So that’s the first compartment here.
The extensor pollicis longus is this tendon here, which borders the anatomical snuff box. So, we’ve got the tendon coming down, the extensor pollicis longus comes here, and then there, around this little tubercle there. Then here, we’ve got an abductor pollicis longus and extensor pollicis brevis, and this is the snuff box in the middle.
In the bottom of the snuff box come the EC, extensor carpi radialus longus and brevis tendons and also the radial artery comes around there as well. From where you feel with the pulse, it sort of flicks around. We’ve also got the radial nerve branches coursing through here.
The area we’re looking for, for swelling for De Quervain’s, is the first extensor compartment here. That’s where you get the swelling, and we’re aiming to inject just proximal to the radial styloid.
Now, out of all hand steroid injections, I think De Quervain’s is the most difficult. The reason for this is because the skin is thin in this area. If you don’t get the steroid in the right place, if you get it too superficial, you’re in danger of causing atrophy of the skin. Most hand surgeons see patients with either depigmentation or loss of thickness of their skin over the first extensor compartment because of De Quervain’s injections. It’s very, very difficult to treat, almost irreversible when you start losing the thickness of the tissue there. So perhaps start with carpal tunnel syndrome and trigger finger injections, they’re a bit safer, I think. Then, when you’re confident with those, move on to De Quervain’s injections.
The first stage, as always, is to prep the skin using the no-touch technique. Then, you’ve got your local anaesthetic and a steroid. I normally use Adcort, 10 milligrams per mil, and some local anaesthetic, Lidocaine. Then locate the compartment by asking the patient to bend their wrist up, you’ll feel it moving.
Bevel up again, like with all injections, and numbers of the syringe towards you. Pop through the skin, the first layer, through the skin. If there’s any pain, you may have hit a radial nerve branch, so pull out and start again in a different area. Through the skin, and then you feel a pop through the tendon.
Then when you inject, it should be really, really easy. Sometimes you see a sort fullness going down, proximal and distal, down the compartment. You see it sort of fill up. Then you know you’re in the right place. If you see just a swelling under the skin, you’re in the wrong place, you’re too superficial. So don’t do that. Sometimes a patient will tell you they feel a sort of whoosh up and down the tendon sheath.
So, do your injection, and then at the end of the injection, swab on the injection site. Out we go. Then, we’re going to lift the hand up and hold the hand up in that position because the higher the hand, the less swelling, the less arterial pressure, the less bruising. So, always hold it up.
Then I would normally get the patient to move their wrist around for a couple of minutes, and that helps disperse the local anaesthetic and the steroids. Often, the patient will notice an immediate improvement in the tenderness in the wrist, which is quite gratifying. Then, just a light dressing on there, and the patient can go about their normal activities.
As I mentioned, out of the three injection techniques we talked about – trigger finger, carpal tunnel and De Qquervain’s – De Quervain’s is probably the trickiest. The reason for this is that it’s got more risk. If you don’t get the local anaesthetic in the right place, if you get it under the skin, you can cause atrophy and depigmentation of the skin.
The other problem is that these tendons do not run, in many cases, in one compartment. They have sectors. They have divisions between them, so you can get three or four different compartments. Your local anaesthetic may go into one compartment, but because of the sector, because of the divisions, it may not disperse into the other compartments.
De Quervain’s is slightly more tricky because the risks are higher. Also, even if you do get it into the right compartment, it may not go through all the compartments and the patients may still have residual pain.
What I’d just advise you to do is start, if you’re not confident, on carpal tunnel and trigger fingers. You’re going to get great results. The patient is going to be very happy. Then move on to De Quervain’s. The majority of patients are going to be very happy. If you’ve got any concerns about De Quervain’s, please feel free to refer it to a local hand surgeon who’d be delighted to see your patient and sort them out.
Thanks very much for watching the video. If you’d like any more information about any of our teaching modules, please contact us at Aurora Clinics.