Life is journey not a destination
One of the most common sites of tendon irritation around the wrist is in the first dorsal extensor compartment, a phenomenon known as de Quervain’s disease. The tendons involved are the extensor pollicis brevis and the abductor pollicis longus. At the level of the radial styloid, these two tendons pass through an osteoligamentous tunnel composed of a shallow groove in the radius and an overlying ligament. Anatomic studies have shown that a high percentage of patients have a divided first dorsal compartment, and this can account for failure of conservative treatment and injections
Washerwoman’s sprain; Stenosing tenosynovitis; Tenovaginitis; Tendinosis; Tendinitis; Peritendinitis
727.0 Synovitis and tenosynovitis
727.04 de Quervain tenosynovitis
727.05 Other tenosynovitis of hand and wrist
Tenosynovitis is defined as inflammation of a tendon and its enveloping sheath. De Quervain tenosynovitis is classically defined as a stenosing tenosynovitis of the synovial sheath of tendons of abductor pollicis longus and extensor pollicis brevis in the first compartment of the wrist due to repetitive use.
Fritz de Quervain first described this condition in 1895. Histologic studies have found that this disorder is characterized by degeneration and thickening of the tendon sheath and that it is not an active inflammatory condition.
Overexertion related to household chores and recreational activities including piano playing, sewing, knitting, typing, bowling, golfing, and fly-fishing have been reported to cause de Quervain tenosynovitis. Workers involved with fast repetitive manipulations such as pinching, grasping, pulling, or pushing are also at risk.
Anatomy of the hand
Patients may complain:
The Finkelstein test draws the tendons of the first dorsal compartment distally and causes sharp, local pain when tendon entrapment has occurred and inflammation is present.
PROCEDURE OF CORICOSTEROID INJECTION
For de Quervain disease, the hand is positioned with the ulnar side of the wrist on the table and the radial side facing upward. A 2.2-cm, 25-gauge needle is introduced at the most tender point (about 1 cm distal to the radial styloid) through a skin wheal, and 10 to 20 mg of prednisolone or equivalent intermediate-acting steroid suspension mixed with 4 to 5 mL of lidocaine 1% is deposited adjacent and parallel to the tendon sheath (peritendinous infiltration) (see Fig. 52–19).
The injection should be under the edge of the first dorsal compartment retinaculum, within the first extensor compartment. If firm resistance is appreciated or if needle movement is noted when the patient abducts and extends the thumb, the needle should be redirected to prevent intratendinous injection. Because there are many superficial vessels in this area, it is important to aspirate before injecting to verify that the needle is not in a blood vessel. One should be generous with the injection volume, because a common reason for failure is the inability to get medication into both tendon sheaths.
This may be partially overcome by increasing the volume of steroid-lidocaine injected in a more diffuse area. Often, there is visible edema at the radial aspect of the first metacarpal base and at the thumb metacarpophalangeal joint dorsally after successful injection. A lightweight thumb or wrist splint for wrist support and protection may be used at night for several weeks after the injection, but routine splinting after injection is not required.72 Oral NSAIDs may be prescribed for analgesia but will likely not affect a cure by themselves. There is no proven role for oral corticosteroids.