bjbjLULU Hello everyone, my name's Adrian
Richards.
I'm a plastic surgeon and the Surgical Director
of Aurora Clinics.
In this subject, which is one of our series
on how to do injections for common hand conditions,
I'm going to be talking about De Quervain's
tenosynovitis.
Now, what is De Quervain's tenosynovitis?
It's basically inflammation in the first extensor
compartment, which is the extensor tendons
which run on the thumb side of the wrist.
It's characterised by pain and swelling in
the area.
When you're looking to see if a patient has
it, the first thing to do is where is the
pain.
It will always be just on the base of the
thumb.
Is there any swelling in this area here?
Sometimes when they move the thumb up and
down, you will feel bulky swelling, and it's
all crepitus in this area.
The sign that you're really looking for, and
I believe you can only do this test once,
is called the Finkelstein's test.
This is very characteristic for De Quervain's
tenosynovitis.
What you do is you ask the patient to hold
their hands out and then clasp their thumb
in their palm, and then cup their fingers
around the finger.
Now, sometimes that will elicit pain here
in the first extensor compartment.
Then what you ask them to do is bend their
thumb down.
Now, in me, actually that hurts a little bit
because my tendon's a little bit tight.
Probably, if you did it on yourself, it will
be a little bit painful.
Someone with acute De Quervain's syndrome,
they would be jumping off the bed if they
did that.
So they probably wouldn't even get to the
stage of doing that, it would be too painful.
So let's just review the anatomy.
The first extensor compartment contains two
tendons, an abductor pollicis longus and an
extensor pollicis, which lie here.
The first extensor compartment is the one
we're interested in De Quervain's disease,
and that contains two tendons, one of which
is the abductor pollicis longus, and the other
is the extensor pollicis.
Basically, they lie along here, and they go
to the base of the thumb.
So that's the first extensor compartment.
You can normally see it, it lies on me, if
I can just show you, if you raise your thumb
up.
If you raise your thumb up, I don't know if
you can see on me.
I'm going to have to draw on myself now.
This here is the compartment we're interested
in, and this is the radial styloid here.
So it's this compartment here.
This area here is the anatomical snuff box.
It's called that because, in the olden days,
people supposedly put snuff in there and sniffed
it from there.
So that's the first compartment here.
The extensor pollicis longus is this tendon
here, which borders the anatomical snuff box.
So, we've got the tendon coming down, the
extensor pollicis longus comes here, and then
there, around this little tubercle there.
Then here, we've got an abductor pollicis
longus and extensor pollicis brevis, and this
is the snuff box in the middle.
In the bottom of the snuff box come the EC,
extensor carpi radialus longus and brevis
tendons and also the radial artery comes around
there as well.
From where you feel with the pulse, it sort
of flicks around.
We've also got the radial nerve branches coursing
through here.
The area we're looking for, for swelling for
De Quervain's, is the first extensor compartment
here.
That's where you get the swelling, and we're
aiming to inject just proximal to the radial
styloid.
Now, out of all hand steroid injections, I
think De Quervain's is the most difficult.
The reason for this is because the skin is
thin in this area.
If you don't get the steroid in the right
place, if you get it too superficial, you're
in danger of causing atrophy of the skin.
Most hand surgeons see patients with either
depigmentation or loss of thickness of their
skin over the first extensor compartment because
of De Quervain's injections.
It's very, very difficult to treat, almost
irreversible when you start losing the thickness
of the tissue there.
So perhaps start with carpal tunnel syndrome
and trigger finger injections, they're a bit
safer, I think.
Then, when you're confident with those, move
on to De Quervain's injections.
The first stage, as always, is to prep the
skin using the no-touch technique.
Then, you've got your local anaesthetic and
a steroid.
I normally use Adcort, 10 milligrams per mil,
and some local anaesthetic, Lidocaine.
Then locate the compartment by asking the
patient to bend their wrist up, you'll feel
it moving.
Bevel up again, like with all injections,
and numbers of the syringe towards you.
Pop through the skin, the first layer, through
the skin.
If there's any pain, you may have hit a radial
nerve branch, so pull out and start again
in a different area.
Through the skin, and then you feel a pop
through the tendon.
Then when you inject, it should be really,
really easy.
Sometimes you see a sort fullness going down,
proximal and distal, down the compartment.
You see it sort of fill up.
Then you know you're in the right place.
If you see just a swelling under the skin,
you're in the wrong place, you're too superficial.
So don't do that.
Sometimes a patient will tell you they feel
a sort of whoosh up and down the tendon sheath.
So, do your injection, and then at the end
of the injection, swab on the injection site.
Out we go.
Then, we're going to lift the hand up and
hold the hand up in that position because
the higher the hand, the less swelling, the
less arterial pressure, the less bruising.
So, always hold it up.
Then I would normally get the patient to move
their wrist around for a couple of minutes,
and that helps disperse the local anaesthetic
and the steroids.
Often, the patient will notice an immediate
improvement in the tenderness in the wrist,
which is quite gratifying.
Then, just a light dressing on there, and
the patient can go about their normal activities.
As I mentioned, out of the three injection
techniques we talked about trigger finger,
carpal tunnel and De Qquervain's De Quervain's
is probably the trickiest.
The reason for this is that it's got more
risk.
If you don't get the local anaesthetic in
the right place, if you get it under the skin,
you can cause atrophy and depigmentation of
the skin.
The other problem is that these tendons do
not run, in many cases, in one compartment.
They have sectors.
They have divisions between them, so you can
get three or four different compartments.
Your local anaesthetic may go into one compartment,
but because of the sector, because of the
divisions, it may not disperse into the other
compartments.
De Quervain's is slightly more tricky because
the risks are higher.
Also, even if you do get it into the right
compartment, it may not go through all the
compartments and the patients may still have
residual pain.
What I'd just advise you to do is start, if
you're not confident, on carpal tunnel and
trigger fingers.
You're going to get great results.
The patient is going to be very happy.
Then move on to De Quervain's.
The majority of patients are going to be very
happy.
If you've got any concerns about De Quervain's,
please feel free to refer it to a local hand
surgeon who'd be delighted to see your patient
and sort them out.
Thanks very much for watching the video.
If you'd like any more information about any
of our teaching modules, please contact us
at Aurora Clinics.
hdS, Hello everyone, my name's Adrian Richards
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Hello everyone, my name's Adrian Richards
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