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De Quervain's Tenosynovitis

De Quervain's stenosing tenosynovitis is a painful inflammation of the tendons of Extensor Policis Brevis (EPB) and Abductor Policis Longus (APL) which together make up the first dorsal compartment. (Figure 1) Symptoms develop when the tendons cannot glide because of thickening of the sheath of the first Dorsal compartment. It commonly affects patients between 30 to 50 years of age with a strong predilection for women. Repetitive motion of the wrist is a strong risk factor.

Clinical examination usually reveals tenderness just over the radial styloid. Finkelsteins test is pathongomic of DeQuervains tenosynovitis. (Figure 2)

In this test, the patient makes a fist with his/her thumb placed under his/her little finger, and ulnar deviates the wrist. The patients symptoms are strongly reproduced with this test.

Treatment for early symptoms include rest, activity modification and analgesia. Steroid injections are useful for cases which do not respond to conservative treatment.

Surgical release is recommended for recalcitrant cases.

Figure 1

Figure 1.

Figure 2

Figure 2.

Technique

    Equipment

    • Use a 5 mL syringe and a 23-Gauge needle. A 25-Gauge needle is also acceptable.
    • Lignocaine can be used safely in dosages of less than 2 mg/kg bodyweight. Generally, 50 mg (5 mL of a one percent preparation) provides adequate analgesia within safe limits.
    • Triamcinolone or other steroid preparations are equally acceptable.
    • 2 mls each of steroid and Lignocaine is usually adequate for most cases.
    • Aseptic techniques should be strictly adhered to.

    Location
    The landmarks for DeQuervains injections are the first and second dorsal compartments and the radial styloid.

    1. Start off by identifying the radial styloid and the first 2 Dorsal compartments. This is best done by getting the patient to extend and abduct the thumb. Marking the course of the tendons is a useful way of making the procedure easier. (Figure 3)

    Figure 3

    Figure 3.

    2. Align the needle parallel to the APL and EPB tendons and aim the needle towards the radial styloid as you insert the needle through the skin to the first dorsal compartment. (Figure 4)

    Figure 4

    Figure 4.

    3. By aligning your syringe and needle with the your marking, you should be able to enter and infiltrate the compartment easily. There should be no resistance to flow and the patient should be comfortable throughout the procedure (Figure 5).

    Figure 5

    Figure 5.

Post op advice for patients

  • Effects of the lignocaine usually wear off in a few hours. However, the steroid should slowly take effect over the next few weeks.
  • Avoid strenuous activity for the following 24 hours.
  • If symptoms worsen within the next 2 days, seek medical attention at the clinic. This may be due to a "steroid flare", which can be managed with cold compresses, NSAIDs and adequate rest.

Contraindications

  • Skin abrasions or infections.
  • Known allergy to local anesthetics.