Approach Considerations
Conservative treatment for this condition includes rest, ice, stretching and strengthening exercises, nonsteroidal anti-inflammatory drugs (NSAIDs), and thumb spica wrist splinting. [9, 10] If these measures fail, studies have demonstrated the efficacy of steroid injections in treating these symptoms. [11, 12, 13, 14] It has been suggested that the combination of steroid injection with thumb spica casting may yield better results than injection alone. [15, 16]
A pooled literature evaluation demonstrated an 83% cure rate with injection alone. [17] However, if symptoms recur or do not resolve after two injections, surgical consultation is indicated. Surgery involves decompressing the first dorsal compartment by making an incision through the tendon sheath. For more information on surgical technique, see De Quervain Tenosynovitis.
Injection Into Thumb
Obtain informed consent. Prepare the steroid/anesthetic mixture (0.5-1 mL of local anesthetic with 1-2 mL of corticosteroid). Position the patient as described previously (see Patient Preparation), and mark the area to be injected. Sterilize the area with povidone-iodine solution.
With sterile technique, use a 27-gauge 0.5-in. (1.25 cm) needle to inject the steroid-anesthetic solution. Hold the needle at a 45º angle in line with the two tendons (see the image below). Advance the needle until it strikes the tendons, then withdraw slightly. Inject the solution. The injected material should flow in easily. If it does not, the needle may be in the tendon. Do not inject if the needle is in the tendon; instead, withdraw slightly and inject when less resistance is met.
Ultrasonography (US) is a valuable asset in the diagnosis and treatment of de Quervain tenosynovitis. [18] Not only does it show the thickening of the tendons, but it also allows direct visualization of the needle entering the tendon sheath. It helps decrease cases of intratendinous injection and some complications of subcutaneous corticosteroid injection (eg, fat atrophy and skin hypopigmentation). It is especially beneficial in confirming injection into the correct subcompartment when a dividing septum is present in the tendon sheath. [19, 20]
After the injection, compress the area and apply a bandage. Apply ice for 10-15 minutes every 4-6 hours after the procedure. (See the videos below.)
In a study of 20 patients with de Quervain tenosynovitis who were treated with either corticosteroid injection alone (n = 9) or corticosteroid injection plus immobilization (n = 11), Ippolito et al found that at 6 months, both groups showed significant improvement in visual analogue scale (VAS) and Disabilities of the Arm, Shoulder, and Hand (DASH) scores. [21] Outcomes were generally comparable for the two groups, except that resolution of radial-side wrist pain was better in the injection-only group (100% vs 64%). Postinjection immobilization increased costs and potentially hindered activities of daily living.
Complications
Complications of thumb injection include the following:
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Bleeding
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Infection
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Local skin hypopigmentation (white spot around the injection site)
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Fat atrophy (depression of skin at the location of the injection [19] )
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First dorsal compartment of hand, including abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons.
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Thumb injection: equipment (corticosteroid, anesthetic).
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Corticosteroid injection into thumb for de Quervain tenosynovitis.
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Right trigger thumb injection. Video courtesy of James R Verheyden, MD.
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Separate right trigger thumb injection. Video courtesy of James R Verheyden, MD.
