De Quervain's Tenosynovitis Injection


OVERVIEW

INDICATIONS
  • Clinically apparent de Quervain's disease
CONTRAINDICATIONS
  • Uncooperative patient
  • Bleeding diathesis or coagulopathy
  • Steroid administration if clinical appearance of gonococcal tenosynovitis
  • Bacteremia or localized cellulitis of wrist area
  • Uncontrolled diabetes
TECHNIQUE
The two abductor tendons of the thumb can be observed outlining the radial border of the anatomic snuff box. The tendons appear prominently when the thumb is fully abducted


(1) Location of the two abductor tendons of the thumb: abductor pollicis longus tendon and extensor pollicis brevis tendon.

The thumb is flexed firmly into the palm (Figure 2A). The remaining four fingers close over the thumb, and then the wrist is deviated to the ulnar side (Figure 2B). Finkelstein's test produces marked discomfort for most individuals with de Quervain's disease 



(2) Finkelstein's test

Identify the point of maximal tenderness. After skin preparation, the needle enters the skin at a 45-degree angle (Figure 3A). The needle can enter the tendon sheath angled toward or away from the hand. Insert the needle until the tip is felt to touch the tendon; then withdraw the needle tip 1 to 2 mm. If the needle tip is within the tendon sheath, injection will offer no resistance, and the sheath can often be observed to distend with fluid (Figure 3B).


(3) Insert the needle at a 45-degree angle until the tip is felt to touch the tendon and then withdraw the needle tip 1 to 2 mm.

PITFALL:
The tendon can be weakened by intratendinous injection. Avoid injecting directly into the tendon. If the physician is uncertain about the position of the needle tip, ask the patient to abduct the thumb; slight movement of the tendon produces marked movement of the syringe and needle.

A bandage is placed over the injection site. Some physicians advocate limited activity and nighttime splinting for 1 to 2 weeks following the injection. Nonsteroidal antiinflammatory medications should be taken for at least 72 hours to reduce the incidence of postinjection flare (i.e., increased pain induced by the steroid crystals).



(4) Place a bandage over the injection site, and ask patient to limit activity and apply a splint at nighttime for 1 to 2 weeks following the injection.