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De-Quervains Tenosynovitis

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Steroid injection of the 1st extensor compartment for De-Quervains tenosynovitis.

History
De-Quervains is a common cause for radial sided wrist pain.
It’s a stenosing tenovaginalitis of the 1st extensor compartment (containing Abductor Pollicis Longus and Extensor Pollicis Brevis).
It is more common in women, especially after birth of a child. 30-50 yr olds.

Examination
Pain and Swelling on the radial side of wrist, 1-2 cms proximal to radial styloid.
+ ve Finkelsteins test = pain with thumb in palm, fingers wrapped over and wrist ulna deviated.

Differential Diagnosis

  • Thumb base arthritis. Pain and crepitus 2 cms distal to radial styloid.
  • Intersection syndrome. Pain 4 cms proximal to radial styloid

Investigations
Normally a clinical diagnosis. Ultrasound can be helpful in showing fluid in the 1st extensor compartment, as well as tendon sheath thickening and restricted tendon glide.

Treatment
As with all conditions, start with simple treatment options and work up the therapeutic ladder as required.

  • Activity modification
  • Splint – Ask the therapists to supply a splint in slight extension and thumb abducted (out of the palm). Usually only short term relief.
  • Steroid injection – See below
  • Surgical release of 1st extensor compartment.

When to refer
Attempt at conservative management is definitely worth trying initially. A fairly large proportion can be treated successfully with rest, splints and injections.

Injections
Please refer to earlier section on steroid injections.

What’s the Evidence ?
Saki et al
 Orthopaedics Jan 2002:- 53 Patients, 46 have relief after 1 injection, 6 more after 2, 1 more after 3.  i.e everyone successful. Lower rate of success in diabetics.

How to Inject

  • Blue needle.
  • 1-2mls 0.5% marcaine, 10-20 mgs Kenalog.
  • Pt abducts and extends the thumb. Note where the 2 tendons disappear into the extensor tunnel. This is where you inject.
  • Level of Radial styloid and aim distal to prox.