Introduction
Stenosing tenosynovitis of the short and long thumb abductor tendons (i.e., abductor pollicis longus and extensor pollicis brevis) is a common cause of dorsal wrist pain near the radial styloid. Commonly known as de Quervain 's tenosynovitis or Quervain 's disease, the condition is usually related to overuse and chronic microtrauma to the first and second dorsal compartment tendons as they pass through a fibroosseous tunnel. This region is predisposed to stenosing tendosynovitis because of the confined space in the tunnel. Jobs requiring repetitive hand and wrist motion, especially those with frequent thumb extension and extreme lateral wrist deviations, increase the risk of this disorder. Certain sports (e.g., golf, racquet sports, fishing) have also been commonly associated with the condition. Additionally, pregnancy and care of a new born infant is associated with this tenosynovitis. Gonococcal infection historically was a cause of de Quervain 's disease, but this is a very uncommon cause today. � �
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De Quervain 's disease produces marked discomfort on gripping. Ulnar deviation, as reproduced with Finkelstein 's test, causes marked pain. Visible swelling can often be observed over the abductor and extensor tendons, and palpable crepitus may be observed. Pain, tenderness, swelling, and warmth over the dorsal wrist on the radial side are common features on examination. Finkelstein 's test is the classic diagnostic maneuver for De Quervain 's. The differential diagnosis includes wrist arthritis, radial nerve compression at the wrist (Wartenberg 's syndrome), and intersection syndrome (i.e., tendonitis and associated bursitis of the dorsal wrist extensors). Corticosteroid injection can resolve or cure the condition, especially if given early in the course of the disease. Some physicians believe that injection therapy offers the best prognosis for improvement in symptoms. Many physicians prefer to postpone injections until a trial of physical therapy, anti-inflammatory medication, and rest (with or without splinting or casting) have been prescribed. Up to three injections, given at monthly intervals, can be tried before surgical referral for release of the dorsal compartment. � �
Equipment
- Povidone iodine (or equivalent skin antiseptic) (see Appendix E)
- Alcohol pads
- 3-cc syringe with 25- or 27-gauge needle
- Lidocaine 1% without epinephrine
- 0.5 cc of steroid such as Celestone or Triamcinolone
- Adhesive bandage
Indications
- DeQuevain 's tenosynovitis not improved with rest, anti-inflammatory medication, stretching, and ice
Contraindications
- Infection of overlying or nearby skin
- Bleeding disorders
- Allergic reaction to similar drug
The Procedure
Step 1
Finkelstein 's test can help reproduce the symptom of DeQuevain 's tenosynovitis. The test is performed by flexing the fingers around a flexed thumb and then passive ulnar deviation maximally at the wrist. The pain is experienced at the first and/or second dorsal compartments and radiates cephalad. � �
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Step 2
To perform the injection, maximally abduct thumb (accentuates abductor tendon) to help identify the first and second dorsal tendon and its sheath. Determine which dorsal tendon is affected. � �
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Step 3
Prep the skin with povidone-iodine or chlorhexadine solution, and allow it to dry (see Appendix E). Aim the needle 30 degrees proximally and parallel to tendon fibers. � �
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Step 4
Have patient gently flex and extend involved finger. Insert the needle distally toward proximal direction to avoid intra tendinous injection. The needle should be entered with the tendon flexed and then extended before injection, which will release the tendon from the needle if the tendon is accidentally entered. � �
- PEARL: Insert the needle until patient experiences scratchy sensation, which indicates you are juxtaposed to the tendon and the tendon sheath. Have the patient actively move the thumb prior to injection, if the needle moves it indicates that you are within the tendon. DO NOT INJECT. Withdraw a few millimeters and have the patient move the thumb again. Never inject against resistance.
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Step 5
The injection can also be performed by entering the skin in the opposite direction. � �
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Complications
- Infection
- Tendon rupture
- Elevations of blood sugar in diabetics
- Misplaced injection causing excessive pain
- Post injection flare (corticosteroid induced crystal synovitis)
- Skin atrophy
- Skin hypopigmentation or hyperpigmentation
Pediatric Considerations
This syndrome is rarely found in children and the procedure is usually not performed in this population. � �
Postprocedure Instructions
Advise the patient to rest the wrist after the procedure. Encourage the patient to wear their splint, if prescribed, which may improve the outcome. Also advise the patient that they may use ice and/or nonsteroidal anti-inflammatory drugs for pain relief if needed. � �
Coding Information and Supply Sources
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View Large CPT Code Description 2008 Average 50th Percentile Fee Global Period 20550 Injection(s); single tendon sheath, or ligament, aponeurosis (e.g., plantar "fascia " �) $140.00 0 CPT is a registered trademark of the American Medical Association.2008 average 50th Percentile Fees are provided courtesy of 2008 MMH-SI 's copyrighted Physicians ' Fees and Coding Guide.
Bibliography
1
Anderson � �LG. Aspirating and injecting the acutely painful joint.
Emerg Med.
1991;23:77 " �94. 2
Brown � �JS.
Minor Surgery: A Text and Atlas
. London: Chapman & Hall Medical; 1997:165. 3
Hanlon � �DP. Intersection syndrome: a case report and review of the literature.
J Emerg Med
. 1999;17:969 " �971. � �[View Abstract]
4
Kay � �NR. De Quervain 's disease: changing pathology or changing perception?
J Hand Surg Br
. 2000;25:65 " �69. � �[View Abstract]
5
Leversee � �JH. Aspiration of joints and soft tissue injections.
Prim Care
. 1986;13:579 " �599. � �[View Abstract]
6
Mani � �L, Gerr � �E
Work-related upper extremity musculoskeletal disorders.
Prim Care Clin Office Pract
. 2000;27:845 " �864. � �[View Abstract]
7
Marx � �RG, Sperling � �JW, Cordasco � �FA. Overuse injuries of the upper extremity in tennis players.
Clin Sports Med
. 2001;20:439 " �451. � �[View Abstract]
8
Owen � �DS, Irby � �R. Intra-articular and soft-tissue aspiration and injection.
Clin Rheumatol Pract
. 1986;Mar " �May:52 " �63. 9
Rettig � �AC. Wrist and hand overuse syndromes.
Clin Sports Med
. 2001;20:591 " �611. � �[View Abstract]
10
Ritchie � �JV, Munter � �DW. Emergency department evaluation and treatment of wrist injuries.
Emerg Med Clin North Am
. 1999;17:823 " �842. � �[View Abstract]
11
Tallia � �AF, Cardone � �DA. Diagnostic and therapeutic injection of the wrist and hand region.
Am Fam Physician
. 2003;67(4):745 " �750. � �[View Abstract]
12
Weiss � �AP, Akelman � �E, Tabatabai � �M. Treatment of DeQuervain 's disease.
J Hand Surg Am.
1994;19:595 " �598. � �[View Abstract]
13
2008 MAG Mutual Healthcare Solutions, Inc. 's
Physicians ' Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc.
2007.