American Journal of Physical Medicine & Rehabilitation:
Di Sante, Luca PhD, MD; Martino, Milvia; Manganiello, Iole MD; Tognolo, Lucrezia MD; Santilli, Valter MD
From the Physical Medicine and Rehabilitation Unit, Azienda Policlinico Umberto I, Rome, Italy (LDS, VS); and Physical Medicine and Rehabilitation, Department of Orthopaedic Science, “Sapienza” University, Rome, Italy (LDS, MM, IM, LT, VS).
All correspondence and requests for reprints should be addressed to: Luca Di Sante, PhD, MD, Department of Physical Medicine and Rehabilitation, Piazzale Aldo Moro 3, 00185, Rome, Italy.
Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.
This feature is a unique combination of text (voice) and video that presents and explains more clearly procedures in musculoskeletal medicine. These videos will be available on the journal’s Website. We hope that this new feature will change and enhance the learning experience.
Walter R. Frontera, MD, PhD, Editor-in-Chief
Video Gallery: To view the online video of these procedures, use your smartphone camera QR Reader App to scan and capture this QR Code or visit www.AJPMR.com to locate this digital video content.
FIGURE. No caption a...Image Tools
ULTRASOUND EXAMINATION AND BRIEF DESCRIPTION OF DE QUERVAIN’S TENOSYNOVITIS
De Quervain’s tenosynovitis is a condition that causes wrist pain and that can lead to dysfunction of the affected hand. It is caused by impaired gliding of the tendons of the abductor pollicis longus and extensor pollicis brevis muscles.1 The abductor pollicis longus and extensor pollicis brevis muscles have almost the same function: the movement of the thumb away from the hand in the plane of the hand (radial abduction). The tendons run in synovial sheaths, which contain them and allow them to exercise their function whatever the position of the wrist. The gliding impairment of these tendons is most likely caused by thickening of the extensor retinaculum (the thickened part of the general tendon sheath that holds the tendons of the extensor muscles in place) of the wrist, which causes a conflict between the tendons and fibrous-bone structures (Fig. 1).
Usually, the criteria for the diagnosis are the following: (1) pain at the radial wrist, sometimes radiating to the thumb, the forearm, or the shoulder; (2) tenderness at the first dorsal wrist extensor compartment; (3) swelling at the radial styloid, with tenderness and crepitations on palpation; and (4) a positive Finkelstein test (deviating the wrist to the ulnar side while grasping the thumb, resulting in pain). Treatment options for de Quervain’s tenosynovitis include nonsurgical measures such as workplace modification, neutral wrist splinting, anti-inflammatory medication, and intrasheath steroid injection. Surgical release of the first dorsal compartment is performed in refractory cases, usually when two injections fail to produce results and symptoms and signs are present for 4 mos.2
ULTRASOUND-GUIDED INJECTION PROCEDURE
From a comparison of various studies, it can be seen that ultrasound (US)–guided injection has better accuracy than blind technique has.2,3 Correct needle placement with US guidance avoids intratendinous injection and local complications such as fat atrophy and depigmentation.4
The authors describe the technique and usefulness of US-guided (GE Healthcare, Logiq P5 pro, Japan) intrasynovial injection of triamcinolone and bupivacaine in the treatment of de Quervain’s tenosynovitis.
At US examination, the affected tendons are inflamed and seemed more thinned compared with those of healthy subjects. The tendon sheaths are distended and surrounded by a fluid that gives the appearance of a circumferential hypoecogenicity.5
In de Quervain’s tenosynovitis, corticosteroid injection must be carried out into the tendon sheath of the abductor pollicis longus and/or extensor pollicis brevis muscles. To better expose these tendons, the patient’s arm must be placed with the radial side of his/her forearm facing upward, with a small cushion placed under the carpus line so that his/her wrist is slightly tilted toward the ulna. The styloid process is then identified, and a 12-Hz linear transducer is positioned over the skin in plane to the forearm’s axis, proximally or distally to the styloid, at the site of maximum tenderness until the aforementioned tendons can be seen on the screen. A metal wire is placed between the transducer and the skin, with its axis in plane to the transducer’s surface, until the artifact indicating its position can be localized on the screen right above the tendon in question (Fig. 2A). The transducer is removed and the wire profile is marked on the skin with a dermographic pencil near the injection site. The transducer is then repositioned over the tendon; the skin is disinfected with an iodine-based solution and draped with a sterile drape, and a 1-in, 25-gauge, 20-mm needle is placed on this line, in plane to the transducer, with an angle of 30–45 degrees relative to the skin (Fig. 2B). The syringe needle is moved forward until its tip is visualized within the tendon sheath, and 1 ml of drug is injected (Fig. 2C). Here, the authors prefer to introduce the needle in plane to the transducer. In reading the previously described summary of text and figures, readers are encouraged to view the attached video for a demonstration of this procedure.
1. Peters-Veluthamaningal C, van der Windt DA, Winters JC, et al.: Corticosteroid injection for de Quervain’s tenosynovitis. Cochrane Database Syst Rev 2009; 8: CD005616
2. Jeyapalan K, Choudhary S: Ultrasound-guided injection of triamcinolone and bupivacaine in the management of de Quervain’s disease. Skeletal Radiol 2009; 38: 1099–103
3. Peters-Veluthamaningal C, Winters JC, Groenier KH, et al.: Randomised controlled trial of local corticosteroid injections for de Quervain’s tenosynovitis in general practice. BMC Musculoskelet Disord 2009; 10: 131
4. Coombes BK, Bisset L, Vicenzino B: Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: A systematic review of randomised controlled trials. Lancet 2010; 376: 1751–67
5. Kamel M, Moghazy K, Eid H, et al.: Ultrasonographic diagnosis of de Quervain’s tenosynovitis. Ann Rheum Dis 2002; 61: 1034–5