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First Dorsal Compartment Injection

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Other Names

  • First Dorsal Compartment Injection
  • Abductor Pollicis Longus and Extensor Pollicis Brevis Injection
  • De Quervain Injection
  • De Quervain's Injection

Background

Illustration of the first dorsal compartment[1]

Key Points

  • Needle: Use a 25 gauge, 1-1.5 inch needle
  • Transducer: high frequency, linear
  • Note: about 1/3 of EPB tendons are separated from the APL tendon by a septa
  • Preferred technique: Short axis, in plane

Anatomy of the First Dorsal Compartment

Palpation Guidance vs Ultrasound Guidance

  • Success rate of unguided injections ranges from 58% to 93% accross multiple studies[3][4][5]
  • Ultrasound guided success rate has been reported at 93.75%[6]
    • Ultrasound allows visualization of any septum in first dorsal compartment, identify each individual tendon and exact area of tenosynovitis
  • Sawaizumi et al: Complications of palpation guided injections is estimated at 36%[7]
    • Includes: atrophy of subcutaneous fat tissue and/or depigmentation around the needle insertion site
  • Jeyapalan et al: no complications when performed under US guidance[6]

Indications


Contraindications

  • Absolute
    • Anaphylaxis to injectates
    • Overlying cellulitis, skin lesion or systemic infection
  • Relative
    • Can be treated with less invasive means
    • Hyperglycemia or poorly controlled diabetes
    • Lack of symptom improvement with previous injection

Procedure

Short axis sonographic view of De Quervains. There is an overall thickening of the overlying extensor retinaculum (white arrowheads) and enlargement of both the EPB and APL tendons, which appear rounder on cross section, as a result of edematous changes[8]
Needle and transducer position for short axis, in plane technique[9]
Ultrasound image of short axis in plane approach. Arrow represents needle approach, small arrow represents distal radius[9]
Needle and transducer position for short axis, out of plane technique[9]
Ultrasound image of short axis, out of plane approach. Dots represent needle vector, asterisks identifies peritendinous fluid[9]

Equipment

  • Sterile including chloraprep, chlorhexadine, iodine
  • Gloves
  • Needle: typically 21-25 gauge, 1.5 inch
  • Syringe: 5-10 mL
  • Gauze
  • Ethyl Chloride
  • Bandage
  • Injectate
    • Local anesthetic
    • Corticosteroid
  • Sterile probe cover

Ultrasound Findings

  • Best visualized in short axis using high frequency, linear transducer
  • Common ultrasound findings include:
    • Anechoic fluid surrounding the tendon
    • Tendon thickening
    • Intrasubstance tears
  • Normal variations
    • Multilamellar APL tendon (looks like a split or tear)
    • Septum between APL or EPB[10]

Technique: Short Axis, In Plane

  • Patient position
    • Seated with arm resting on a neutral surface for the proceduralist
    • Ulnar aspect is down, thumb and radial wrist are pointed up
  • Transducer position
    • Short axis to the first extensor compartment
  • Needle Approach/ Orientation
    • In plane
    • Lateral to medial
  • Target
    • Tendon sheath of APL, EPB
  • Pearls and Pitfalls
    • Identifying location of tenosynivitis may increase precision
    • Do not confuse multilamellar APL tendon with a tear
    • Observe the injectate as it courses through the tendon sheath(s)
    • Avoid the radial artery

Technique: Short Axis, Out of Plane

  • Patient position
    • Seated with arm resting on a neutral surface for the proceduralist
    • Ulnar aspect is down, thumb and radial wrist are pointed up
  • Transducer position
    • Short axis to the first extensor compartment
  • Needle Approach/ Orientation
    • Out of plane
    • Proximal to distal or distal to proximal
  • Target
    • Tendon sheath of APL, EPB
  • Pearls and Pitfalls
    • See above

Aftercare

  • No significant restrictions
  • Can augment with ice, NSAIDS
  • Consider placement in a Thumb Spica Splint

Complications

  • Skin: Subcutaneus fat atrophy, skin atrophy, skin depigmentation
  • Painful local reaction
  • Infection
  • Hyperglycmia
  • Tendon, nerve or blood vessel injury

See Also


References

  1. Image courtesy of https://www.ntxortho.com/, "De Quervain’s Tenosynovitis"
  2. Motoura H, Shiozaki K, Kawasaki K. Anatomical variations in the tendon sheath of the first compartment. Anat Sci Int. 2010 Sep;85(3):145–151. Epub December 29, 2009.
  3. Anderson BC, Manthey R, Brouns MC. Treatment of De Quervain’s tenosynovitis with corticosteroids. A prospective study of the response to local injection. Arthritis Rheum. 1991;34:793–798.
  4. Harvey FJ, Harvey PM, Horsley MW. De Quervain’s disease: surgical or nonsurgical treatment. J Hand Surg Am. 1990;15:83 87.
  5. Jirarattanaphochai K, Saengnipanthkul S, Vipulakorn K, Jianmongkol S, Chatuparisute P, Jung S. Treatment of de Quervain disease with triamcinolone injection with or without nimesulide. A randomized, double-blind, placebocontrolled trial. J Bone Joint Surg Am. 2004;86:2700–2706.
  6. 6.0 6.1 Jeyapalan K, Choudhary S. Ultrasound-guided injection of triamcinolone nd bupivacaine in the management of De Quervain’s disease. Skeletal Radiol. 2009 Nov;38(11):1099–1103. Epub June 1, 2009
  7. Sawaizumi T, Nanno M, Ito H. De Quervain’s disease: efficacy of intra-sheath triamcinolone injection. Int Orthop. 2007 Apr;31(2):265–268. Epub June 8, 2006.
  8. Corvino, Antonio, et al. "“Daddy wrist”: A high‐resolution ultrasound diagnosis of de Quervain tenosynovitis." Journal of Clinical Ultrasound (2023).
  9. 9.0 9.1 9.2 9.3 Malanga, Gerard, and Kenneth Mautner. Atlas of ultrasound-guided musculoskeletal injections. McGraw-Hill, 2014.
  10. Choi SJ, Ahn JH, Lee YJ, et al. de Quervain disease: US identification of anatomic variations in the first extensor compartment with an emphasis on subcompartmentalization. Radiology. 2011 Aug;260(2):480–486. Epub May 25, 2011.
Created by:
John Kiel on 6 February 2024 17:00:41
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Last edited:
6 February 2024 18:04:32
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