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Third Dorsal Compartment of the Wrist Injection

From WikiSM

Other Names

  • Third Dorsal Compartment of the Wrist Injection
  • 3rd Extensor Compartment Injection

Background

The extensor compartments of the wrist[1]

Key Points

  • Needle: 25 gauge, 1.5 inch
  • Transducer: high frequency, linear
  • Lister's tubercle is a landmark for identifying compartment

Anatomy of the Third Dorsal Compartment

Palpation Guidance vs Ultrasound Guidance

  • It is recommended that this injection be performed with ultrasound guidance
  • There is no literature comparing palpation and ultrasound guidance

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

Needle and probe position for short axis, in-plane approach[2]
Ultrasound depiction of short axis, in-plane approach with needle trajectory (white arrow)[2]
Ultrasound view of the long axis, in-plane approach with needle trajectory (white arrow) from distal to proximal[2]

Equipment

  • Sterile including chloraprep, chlorhexidine, 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

  • First locate Lister's Tubercle
    • Separates third and second dorsal compartment
    • Hyperechoic prominence of the dorsal radius
  • EPL is easily visualized in long and short axis
    • Step off can be helpful

Technique: Short Axis, In-Plane

  • Patient position
    • Seated/Supine
    • Hand pronated on surface
  • Transducer position
    • Short axis to the EPL tendon
  • Needle Approach/ Orientation
    • In-Plane
    • Radial to ulnar or ulnar to radial
  • Target
    • EPL tendon sheath
  • Pearls and Pitfalls
    • Scan the area with doppler to avoid nerves/ vessels
    • Counsel patients on risk of rupture

Technique: Long Axis, In-Plane

  • Patient position
    • Seated/Supine
    • Hand pronated on surface
  • Transducer position
    • Short axis to the EPL tendon
  • Needle Approach/ Orientation
    • In-Plane
    • Distal to proximal
  • Target
    • EPL tendon sheath
  • Pearls and Pitfalls
    • Scan the area with doppler to avoid nerves/ vessels
    • Counsel patients on risk of rupture

Aftercare

  • No significant restrictions
  • Can augment with ice, NSAIDS
  • Consider placement in a Cock Up Wrist Splint

Complications

  • Skin: Subcutaneous fat atrophy, skin atrophy, skin depigmentation
  • Painful local reaction
  • Infection
  • Hyperglycemia
  • Tendon, nerve or blood vessel injury
  • Extensor pollicis longus tendon rupture[3]

See Also

References

  1. ↑ Image courtesy of teachmeanatomy.info, "The Extensor Tendon Compartments of the Wrist"
  2. ↑ 2.0 2.1 2.2 Malanga, Gerard A., and Kenneth R. Mautner. "Atlas of ultrasound-guided musculoskeletal injections." (No Title) (2014).
  3. ↑ Mills SP, Charalambous CP, Hayton MJ. Bilateral rupture of the extensor pollicis longus tendon in a professional goalkeeper following steroid injections for extensor tenosynovitis. Hand Surg. 1009;14(2-3):135–137.
Created by:
John Kiel on 3 May 2024 01:33:07
Authors:
Last edited:
3 May 2024 02:20:04
Category:
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