Injection Technique for de Quervain Tenosynovitis

Indications and Clinical Considerations

De Quervain tenosynovitis is caused by inflammation and swelling of the tendons of the abductor pollicis longus and extensor pollicis brevis at the level of the radial styloid process. The inflammation and swelling are usually the result of trauma to the tendon from repetitive twisting motions. If the inflammation and swelling become chronic, a thickening of the tendon sheath occurs, with a resulting constriction of the sheath ( Figs. 83.1 and 83.2 ). A triggering phenomenon may result with the tendon catching within the sheath, causing the thumb to lock or “trigger.” Arthritis and gout of the first metacarpal joint also may coexist with and exacerbate the pain and disability of de Quervain tenosynovitis.

De Quervain tenosynovitis occurs in patients engaged in repetitive activities that include hand grasping, such as politicians shaking hands, or high-torque wrist turning, such as scooping ice cream at an ice cream parlor. De Quervain tenosynovitis also may develop without obvious antecedent trauma in the parturient.

The pain of de Quervain tenosynovitis is localized to the region of the radial styloid. It is constant and is made worse with active pinching activities of the thumb or ulnar deviation of the wrist. Patients note the inability to hold a coffee cup or turn a screwdriver. Sleep disturbance is common. Physical examination reveals tenderness and swelling over the tendons and tendon sheaths along the distal radius, with point tenderness over the radial styloid. Many patients with de Quervain tenosynovitis exhibit a creaking sensation with flexion and extension of the thumb. Range of motion of the thumb may be decreased because of the pain, and a trigger thumb phenomenon may be noted. Patients with de Quervain tenosynovitis demonstrate a positive Finkelstein test ( Fig. 83.3 ), which is performed by stabilizing the patient’s forearm, having the patient fully flex his or her thumb into the palm, and then actively forcing the wrist toward the ulna. Sudden severe pain is highly suggestive of de Quervain tenosynovitis.

Entrapment of the lateral antebrachial cutaneous nerve, arthritis of the first metacarpal joint, gout, cheiralgia paresthetica, and occasionally C6-C7 radiculopathy can mimic de Quervain tenosynovitis. Cheiralgia paresthetica is an entrapment neuropathy caused by entrapment of the superficial branch of the radial nerve at the wrist. Electromyography helps distinguish cervical radiculopathy and cheiralgia paresthetica from de Quervain tenosynovitis. Plain radiographs are indicated for all patients with de Quervain tenosynovitis to rule out occult bony disease. On the basis of the patient’s clinical presentation, additional testing may be indicated, including complete blood cell count, uric acid, sedimentation rate, and antinuclear antibody testing. Magnetic resonance imaging and/or ultrasound imaging of the wrist is indicated if joint instability is suspected. The injection technique described later serves as both a diagnostic and a therapeutic maneuver.

Clinically Relevant Anatomy

The nidus of pain from de Quervain tenosynovitis is the tendons and tendon sheaths of the abductor pollicis longus and extensor pollicis brevis at the level of the radial styloid process (see Figs. 83.1 and 83.2 ). As mentioned earlier, arthritis and gout of the first metacarpal joint may accompany de Quervain tenosynovitis and exacerbate the patient’s pain symptoms. The radial artery and the superficial branch of the radial nerve are in proximity to the injection site for de Quervain tenosynovitis and may be traumatized if the needle is placed too medially.