De Quervain's Tenosynovitis and Steroid Injections TUTORIAL

Uploaded by clinicsaurora on 08.02.2012

bjbjLULU 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. hdS, Hello everyone, my name's Adrian Richards rjd1
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