How to perform a De Quervain's corticosteroid injection
Source
Surgeon:
Matti Mustaniemi (hand surgeon)
To access the full video and additional content on this subject, log in or subscribe
Summary
Focus: Corticosteroid injection for symptom relief in De Quervain’s tenosynovitis.
Key elements: Positioning, radial styloid landmarks, first extensor compartment injection, aftercare, pitfalls, and complications.
Indications and Clinical Context
General
Medical expert: Matti Mustaniemi (hand surgeon)
Names of Procedure: De Quervain’s corticosteroid injection, De Quervain's steroid injection, De Quervain's injection, De Quervain's tenosynovitis injection.
Goal of operation
Relief of symptoms caused by abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tenosynovitis.
Problem
Tightness of the first extensor compartment at the level of the radial styloid caused by thickening of the APL and EPB tendon sheaths.
Diagnosis
De Quervain’s tenosynovitis (ICD-10: M65.4)
Short pathophysiological description
The abductor pollicis longus and extensor pollicis brevis tendons are lined by individual tendon sheaths and run through the first extensor compartment of the extensor retinaculum over the radial styloid. The tunnel-like compartments make the tendons prone to entrapment caused by, for example, repetitive motion, increased loading, or trauma. In De Quervain's syndrome, the tendon sheaths swell in response to increased stress, which narrows the space through which the tendons can move, causing the symptoms. Corticosteroid injection reduces the swelling of the tendon sheath, relieving pain and improving function.
Key anatomical structures
Radius
Radial styloid
Extensor retinaculum
1st extensor tendon compartment
Abductor pollicis longus (APL)
Extensor pollicis brevis (EPB)
Step-by-Step Technique
Patient positioning and preparation
The patient is in supine position with the affected arm raised laterally. Alternatively, the patient can be seated with the affected hand laid on a surface.
The hand is slightly pronated with the thumb pointed upwards. The wrist may be ulnarly deviated to make the radial styloid more pronounced.
Prepare the injection solution. For example, 0.3–0.5 ml methylprednisolone 40 mg/ml, with or without lidocaine.
Landmarks and injection site
Palpate the radial styloid and the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons running on top of it. Have the patient lift their thumb to help with the identification.
The affected first extensor compartment is located right on top of the radial styloid and is often tender to palpation.
Having the needle enter the skin a bit more proximally makes the injection less painful.
Log in or subscribe to access full content and see all the images.
Injection
The goal is to inject the medicinal agent into the APL and EPB tendon sheaths inside the first extensor compartment.
Sterilize the skin and the surrounding area sufficiently.
Using a small needle, pierce the skin at a slight angle a bit proximal to the radial styloid and advance the needle down to the bone.
Apply gentle pressure to the plunger and gradually withdraw the needle very slowly. Once the needle clears the tendon, the injection should flow with almost no resistance into the tendon sheath.
Use of excessive force might lead to accidentally injecting the tendon. Also, avoid injecting too superficially into the subcutaneous tissue as this could cause fat necrosis and discoloration.Once the needle is removed, apply slight pressure to the injection site and move the thumb through full range of motion. This will help the medical agent spread along the affected area.
If the solution included anesthetic, it will relieve symptoms in 1–2 minutes. If the symptoms persist, the injection might have missed the target. On the other hand, in that case, reconsidering the diagnosis might be necessary.
To access the full video and additional content on this subject, log in or subscribe
Piftalls and Complications
Pitfalls
Wrong injection site
Injecting the medicinal agent in the wrong place could lead to ineffective treatment or potentially harming surrounding structures. Skin should be punctured according to landmarks: slightly proximal to the radial styloid. If the solution included anesthetic, symptom relief typically occurs within 1–2 minutes. If symptoms persist beyond this timeframe, it suggests the possibility of the injection missing its intended target.
Too superficial injection
Injecting too superficially might cause the medicinal agent to end up in fat tissue, and lead to fat necrosis or subcutaneous atrophy. It’s suggested to withdraw the needle after making contact to the bone, rather than trying to hit the compartment straight, so that the injection doesn’t end up too superficially.
Intra-tendinous injection
Injecting the medicinal agent into the tendon makes it susceptible to secondary tendon rupture. To avoid tendon injuries, steroid injections should always be administered with minimal resistance.
Complications
Fat necrosis, atrophy and hypopigmentation
Injecting too superficially might result in the medicinal agent reaching the fatty tissue, potentially causing fat necrosis.
Superficial injection can also cause dermal atrophy and hypopigmentation. Additionally, dermal atrophy and hypopigmentation can occur due to seepage of the glucocorticoid via the puncture canal.
Tendon rupture
Multiple injections within a short period may cause weakening of the tendons, causing thinning and eventual rupture. If symptoms fail to improve or recur after two steroid injections, operative treatment should be considered as an option.
Aftercare
General guidelines:
Tendon sheath injections often cause 2–3 days of discomfort. Slightly lighter duties are recommended for that time period. If the first injection provided notable but only temporary relief, a second injection may be considered. Also, surgical intervention should be considered if there still is a recurrence after one or two injections.
FAQ
What is the goal of De Quervain’s corticosteroid injection?
The goal is relief of symptoms caused by abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tenosynovitis.
Where should the medicinal agent be injected?
The goal is to inject the medicinal agent into the APL and EPB tendon sheaths inside the first extensor compartment.
What may happen if the injection is too superficial?
Injecting too superficially might cause the medicinal agent to end up in fat tissue and lead to fat necrosis or subcutaneous atrophy.
When should operative treatment be considered?
If symptoms fail to improve or recur after two steroid injections, operative treatment should be considered as an option.
To access the full video and additional content on this subject, log in or subscribe