Ultrasound-guided steroid injection for the treatment of de Quervain's disease: an anatomy-based approach

Efficacy of Ultrasound-Guided Hydrodissection for Treating De Quervain's Tenosynovitis

Objective

This study evaluated the effectiveness of ultrasound-guided hydrodissection treatment for De Quervain's stenosing tenosynovitis, characterized by the narrowing of the first extensor compartment of the wrist. Notably, approximately 2% of cases involve a fibrous septum that divides the compartment.

Subjects and Methods

Ninety-five patients diagnosed with De Quervain's disease using ultrasound underwent hydrodissection treatment. When a septum was present, the needle was redirected into each sub-compartment to distribute the therapeutic solution evenly and facilitate the breaking of the septum.

Results

Ninety patients reported significant improvements in pain and functionality within 2 months of the initial treatment, with a marked decrease in the mean visual analog scale score from 7.65 ± 1.31 to 1.65 ± 2.32. A second infiltration, administered 2 months later, further alleviated pain and enhanced hand functionality. However, 5 patients with septum required surgical intervention after nonconclusive results from the infiltrative treatment.

Conclusions

This study confirms that ultrasound-guided hydrodissection is an effective treatment for approximately 95% of patients with De Quervain's disease, achieving substantial pain relief and improved joint mobility after the first treatment. These findings support the continued use of ultrasound guidance to enhance the precision and efficacy of treatment in complex cases.

Ultrasound versus palpation-guided corticosteroid injection for de Quervain disease: A randomized controlled trial

INTRODUCTION

Corticosteroid injection effectively treats de Quervain disease, and due to the high prevalence of the intracompartmental septum in the first extensor compartment, ultrasound guidance improves injection accuracy.

OBJECTIVE

To compare the effectiveness, adverse events, and the recurrence rate between ultrasound-guided and palpation-guided injection in patients with de Quervain disease.

DESIGN

Prospective, single-blind, randomized controlled trial.

SETTING

Rehabilitation department of a private teaching hospital.

PARTICIPANTS

We enrolled 49 patients, ≥20 years of age, clinically diagnosed with de Quervain disease based on their medical history and physical examination.

INTERVENTIONS

Patients were randomized into two groups: ultrasound-guided and palpation-guided injection. Both groups received a mixture of 10 mg triamcinolone acetonide (10 mg/1 mL) and 0.3 mL 1% lidocaine.

MAIN OUTCOME MEASURES

The primary outcome measure was the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score at 1 week. The secondary outcome measures were visual analog scale for pain (pain VAS) score, patient satisfaction, and adverse events or complications from the interventions at 1 week, 3 months, and 6 months.

RESULTS

Both groups showed improvement over time in QuickDASH scores and pain VAS (p < .001); however, no statistically significant differences were noted between the groups for either QuickDASH scores (p = .22) or pain VAS (p = .30). In addition, no statistically significant differences were found between the groups in terms of patient satisfaction (p = .76) and adverse events (p = .47, .33, .58) at the 1-week, 3-month, and 6-month follow-ups.

CONCLUSIONS

Both ultrasound-guided and palpation-guided injections effectively treated de Quervain disease. During a 6-month follow-up, there were no statistically significant differences between the groups in pain relief, upper limb function, or patient satisfaction. However, the palpation-guided group showed a tendency for more recurrence and skin side effects.

Morphological differences between the dorsal and palmar septa of the first extensor compartment in relation to the brachioradialis and pronator quadratus

BACKGROUND

The first extensor compartment of the wrist is known as a frequent site of stenosing tenosynovitis, referred to as de Quervain's disease. De Quervain's disease occurs more frequently in the dorsal part of the first extensor compartment than in the palmar part; however, the anatomical reason why the dorsal part is worse remains poorly elucidated. This study clarified the morphological differences between the dorsal and palmar parts by examining their relationship with the surrounding structures.

METHODS

In this study, a total of 35 wrists from 23 Japanese cadavers were used. Twenty-five wrists were randomly assigned for macroscopic analysis, and the remaining 10 wrists were used for histological analysis.

RESULTS

The palmar septum of the first extensor compartment was connected to the brachioradialis tendon and superficial head of the pronator quadratus and was histologically stout compared to the dorsal septum. Despite several anatomical variations, such as the septum between the abductor pollicis longus/extensor pollicis brevis and the multiple tendons of these muscles, the aforementioned characteristics of the fibrous sheath in the first extensor compartment were identical in all specimens.

CONCLUSION

In contrast to the fragile structure of the dorsal septum, the stout structure of the palmar septum could be related to the low occurrence of symptoms of de Quervain's disease. The present results could play a role in revealing the pathogeny and establish the precise treatment for de Quervain's disease and provide an anatomical basis for kinesiological/biomechanical studies.

Cutaneous nerve distribution around first extensor compartment of the wrist: Clinical implications for ultrasound-guided injections

Purpose

To evaluate the course of the cutaneous nerve regarding the first extensor compartment to determine whether the dorsal or volar approach is safer for local injection into the first extensor compartment guided by ultrasound.

Methods

We dissected the radial side of the wrists from 28 cadavers (52 wrists). Four-points along the imaginary line were set: the styloid process and 1 cm, 2 cm, and 3 cm proximal to the styloid process. The numbers of superficial radial nerve (SRN) and lateral antebrachial cutaneous nerve (LACN) branches were counted, and distances from the imaginary line at these points and nerve diameters were recorded. Digital images were superimposed to observe overall distribution of cutaneous nerve.

Results

There were means of 3.3 SRN and 0.9 LACN branches observed in each wrist. The mean number of both SRN and LACN branches was 2.3 on the dorsal side and 1.9 on the volar side. The superimposed images indicated that both the dorsal and volar sides comprised abundant cutaneous nerves and that their paths varied markedly between patients. However, we observed that larger nerves with meaningful diameters were more abundant on the dorsal than the volar side.

Conclusion

There were similar numbers of cutaneous nerves on both the dorsal and volar sides; however, we observed greater abundance of thicker cutaneous nerves on the dorsal side, and these were closer to the reference line than on the volar side. This anatomical study suggests that the risk imposed to cutaneous nerves would therefore be reduced when injection on the volar side.

Unblinding de Quervain: A systematic review of ultrasound-guided injection of corticosteroids for treatment of stenosing tenosynovitis of the 1st extensor compartment

A systematic review was conducted on studies reporting steroid injections with ultrasound for de Quervain. From 10 studies included and 379 wrists, 73.9% reported complete resolution of symptoms, 18.2% with partial and 7.9% without resolution. When compared to the landmark-guided technique, ultrasound guidance showed significantly higher rates of symptom resolution (P = 0.0132) and lower pain scores (P < 0.0001). Twenty-nine patients out of 163 who initially showed complete resolution of symptoms reported subsequent recurrence. We conclude that steroid injections guided by ultrasound present high rates of symptomatic relief through precise needle insertion, especially in cases of anatomic variability with subcompartments.

De Quervain's tenosynovitis: a non-randomized two-armed study comparing ultrasound-guided steroid injection with surgical release

PURPOSE

Ultrasonography is currently used for both diagnostic and therapeutic purposes in de Quervain's tenosynovitis. There is a dearth of information on how effective an ultrasound-guided (USG) steroid injection is when compared to surgical release of the first extensor compartment. Hence, we performed a non-randomized two-armed comparison study to test our hypothesis that USG guided steroid injection is equally effective as surgery.

METHOD

62 consecutive patients participated in the study with 32 of them selecting the option of USG guided injection (Set A), and the rest undergoing surgical release (Set B). We reviewed them after 3 and 6 weeks and 6 months for functional outcome using DASH, PRWE and VAS scores, recurrence, or any complications. They were further followed if they were symptomatic.

RESULTS

The DASH/PRWE/VAS scores improved at the end of 6 months from 81.7/79.3/6.8 to 1.0/1.7/1.0, respectively for patients undergoing USG guided steroid injection. Similarly, for the patient undergoing surgery, the scores improved from 82.2/81.5/6.7 to 1.7/3.4/1.0, respectively. This was statistically significant in both the groups (p < 0.05) and was comparable to each other. Two patients in Set A came back with recurrence at eight and 10 months and two reported occasional pain on heavy work. Three patients had tenderness and two had numbness in Set B at the scar site.

CONCLUSION

We observed that USG guided steroid injections are comparable to surgical release in terms of pain relief, functional outcome, complications.

Is a Steroid Injection in Both Compartments More Effective than an Injection in the Extensor Pollicis Brevis Subcompartment Alone in Patients with de Quervain Disease? A Randomized, Controlled Trial

BACKGROUND

Ultrasonography (US)-guided steroid injections can improve the accuracy of injection in patients with de Quervain disease, especially in those with an intracompartmental septum. Although the main lesion of de Quervain disease in patients with a septum is a stenosing tenosynovitis of the extensor pollicis brevis (EPB), no report we know of has compared injection into the EPB subcompartment with an injection into both the abductor pollicis longus (APL) and EPB subcompartments. In this randomized trial, we compared the results of US-guided steroid injections targeting both subcompartments and the EPB subcompartment alone in patients with de Quervain disease.

QUESTIONS/PURPOSES

(1) Do patients who receive a steroid injection in the EPB subcompartment alone have lower pain scores at 6 weeks and at 3 months after US-guided injection compared with patients who receive an injection in both subcompartments? (2) Do patients who receive a steroid injection in the EPB subcompartment alone experience fewer steroid injection-related complications than patients who receive an injection in both subcompartments?

METHODS

A randomized controlled study was performed at a single center between August 2018 and March 2021. Patients with a diagnosis of de Quervain disease and with a complete intracompartmental septum between the APL and the EPB tendons were included. In total, 112 patients had a diagnosis of de Quervain disease during the study period. Definite, complete subcompartmentalization was seen in 50 patients. Patients were randomly assigned to US-guided injections targeting both subcompartments (n = 25) or the EPB subcompartment alone (n = 25). There were no between-group differences in age, gender, affected wrist, or disease duration, and all patients had US evidence of tendinosis of the EPB, with or without tendinosis of the APL. Although 33% of patients (16 of 48) showed tendinosis of the APL, no patient showed tendinosis of the APL alone. In all patients, a dorsal-to-palmar side injection of 0.5 mL of 2% lidocaine and 0.5 mL of triamcinolone acetonide (40 mg/mL) was administered by two experienced hand surgeons. In the both-subcompartments group, US-guided injections were performed in each of the APL and EPB subcompartments. In the EPB subcompartment group, US-guided injections were administered in the EPB subcompartment only. All patients underwent the same protocol after the procedure. Four percent (n = 2, 1 in each group) of patients were excluded after randomization because their pain level was not registered. Pre- and postinjection clinical outcome assessments were completed by orthopaedic surgery residents not involved in patient management. Patients were regularly examined at baseline, 6 weeks, and 3 months to evaluate the intensity of pain. We assessed pain by the VAS score, where 0 indicated no pain and 100 the most pain. At baseline, the VAS score was 67 ± 14 in the both-subcompartment group and 67 ± 16 in the EPB subcompartment group (mean difference 0.17 [95% CI -8.45 to 8.82]; p = 0.97). Complications related to the steroid injection, including numbness, tendon rupture, and skin hypopigmentation, were also recorded at final follow-up examinations. To determine statistical power, the VAS score for pain at 6 weeks after the injection was used as the primary outcome variable. The minimum clinically important difference for the VAS score was deemed to be 20 mm, and we estimated an SD of 23. A sample size calculation indicated that a sample of 21 patients per group would provide 80% power to detect an effect of this size between the groups at the p = 0.05 level using a t-test.

RESULTS

There were no differences in the VAS scores between the both-subcompartment group and the EPB group at 6 weeks (10 ± 6 versus 10 ± 7, mean difference -0.08 [95% CI -4.08 to 3.91]; p = 0.97). The same was true at 12 weeks (12 ± 13 versus 11 ± 15, mean difference 0.38 [95% CI -7.74 to 8.49]; p = 0.09). No adverse events related to treatment (such as tendon rupture, infections, and numbness) occurred in either group. However, skin hypopigmentation occurred at the final follow-up examination in both groups. The proportion of patients experiencing skin hypopigmentation in the EPB subcompartment group was lower than in the both-subcompartment group (33% [8 of 24] versus 67% [16 of 24]; odds ratio 0.25 [95% CI 0.08 to 0.83]; p = 0.02).

CONCLUSION

Our data suggest that a US-guided steroid injection targeting the EPB subcompartment alone is as effective in terms of pain reduction as targeting both subcompartments in patients with de Quervain disease who have complete septation. Furthermore, an injection targeting the EPB subcompartment alone can reduce the dose of steroids used, perhaps thereby decreasing complications related to steroid injections. We recommend using only single-compartment injections in this context, even among patients with an intracompartmental septum.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Management of de Quervain Tenosynovitis: A Critical Analysis Review

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Most cases of de Quervain tenosynovitis can be managed with nonoperative measures, and the mainstay of treatment is corticosteroid injection (CSI). The use of ultrasound may improve the accuracy of injections and can help to identify and localize injections to separate subcompartments.

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For patients who are in the third trimester of pregnancy or breastfeeding, there is no contraindication to CSI as studies have shown that it can provide optimal symptomatic relief to the mother without impacting the baby.

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When nonoperative treatment is unsuccessful, surgical release of the first dorsal compartment (FDC) can provide excellent symptom relief. Open release performed through a longitudinal incision allows for better visualization of the underlying anatomy, resulting in fewer injuries to underlying structures and a lower incidence of hypertrophic scarring compared with a transverse incision.

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For surgeons who are comfortable performing endoscopic techniques, endoscopic FDC release can result in quicker symptom improvement, superior scar cosmesis, and a lower incidence of radial sensory nerve injury.

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Studies have shown that FDC release can safely and effectively be performed using the WALANT (wide-awake local anesthesia no tourniquet) technique, which has the potential for cost savings without compromising quality or patient comfort.

Ultrasound Imaging and Guidance in Common Wrist/Hand Pathologies

ABSTRACT

Wrist/hand pain is a prevalent musculoskeletal condition with a great spectrum of etiologies (varying from overuse injuries to soft tissue tumors). Although most of the anatomical structures are quite superficial and easily evaluated during physical examination, for several reasons, the use of ultrasound imaging and guidance has gained an intriguing and paramount concern in the prompt management of relevant patients. In this aspect, the present review aims to illustrate detailed cadaveric wrist/hand anatomy to shed light into better understanding the corresponding ultrasonographic examinations/interventions in carpal tunnel syndrome, trigger finger, de Quervain tenosynovitis, rhizarthrosis, and the radiocarpal joint arthritis. In addition, evidence from the literature supporting the rationale why ultrasound guidance is henceforth unconditional in musculoskeletal practice is also exemplified.

Can Ultrasonography Be Useful in Planning Surgery for De Quervain Tenosynovitis?: A Prospective Study With Emphasis on Detection of the Superficial Radial Nerve and Dominant Pathologic Tendon

OBJECTIVES

We performed preoperative ultrasonography (US) to detect the anatomic course of the superficial radial nerve (SRN) and dominant pathologic tendon of the first extensor compartment in de Quervain tenosynovitis.

METHODS

We prospectively studied 27 patients (29 wrists) with de Quervain tenosynovitis who underwent surgical release of the first extensor compartment. Preoperatively, US was performed to evaluate the presence of the dominant pathologic tendon and the septum in the subcompartment, number of SRNs in the area of the surgical incision, and anatomic running course of the SRN. These variables were also checked intraoperatively. Cohen κ statistics were calculated to investigate agreement between US and surgical field findings.

RESULTS

There were 7 men and 20 women (mean age, 47.8 years; range, 26-67 years). For the dominant pathologic tendon, there were 2 cases (6.9%) of an abductor pollicis longus, 11 cases (37.9%) of an extensor pollicis brevis, and 16 cases (55.2 %) of a nondominant tendon (κ = 0.94). For the subcompartment, there were 10 cases (34.5%) without a septum, 8 (27.6%) with an incomplete septum, and 11 (37.9%) with a complete septum (κ = 0.95). Most SRNs crossed over the first extensor compartment (κ = 0.78).

CONCLUSIONS

Preoperative US can be useful in detecting the anatomic running course of the SRN and dominant pathologic tendon before surgery for de Quervain tenosynovitis. Classifying the anatomic course of the SRN could be essential to planning surgery, and it could be helpful to prevent injury of the SRN during surgery.

Conservative Management of de Quervain Stenosing Tenosynovitis: Review and Presentation of Treatment Algorithm

BACKGROUND

Nonsurgical management of de Quervain disease relies mainly on the use of oral nonsteroidal antiinflammatory drug administration, splint therapy, and corticosteroid injections. Although the latter is most effective, with documented success rates of 61 to 83 percent, there exists no clear consensus pertaining to conservative treatment protocols conferring the best outcomes. This article reports on all present conservative treatment modalities in use for the management of de Quervain disease and highlights specific treatment- and patient-related factors associated with the best outcomes.

METHODS

A systematic search was performed using the PubMed database using appropriate search terms; two independent reviewers evaluated retrieved articles using strict inclusion and exclusion criteria.

RESULTS

A total of 66 articles met the inclusion criteria for review, consisting of 22 articles reporting on outcomes following a single conservative treatment modality, eight articles reporting on combined treatment approaches, 13 articles directly comparing different conservative treatment regimens, and 23 case reports.

CONCLUSIONS

A multimodal approach using splint therapy and corticosteroid injections appears to be more beneficial than either used in isolation. Although there exists some evidence showing that multipoint injection techniques and multiple injections before surgical referral may provide benefit over a single point injection technique and a single injection before surgery, corticosteroid use is not benign and should thus be performed with caution. Ultrasound was proven valuable in the visualization of an intercompartmental septum, and ultrasound-guided injections were shown to both be more accurate and confer better outcomes. Several prior and concurrent medical conditions may affect conservative treatment outcome. A Level I to II evidence-based treatment protocol is recommended for the optimal nonsurgical management of de Quervain disease.

Injection Techniques for Common Chronic Pain Conditions of the Hand: A Comprehensive Review

INTRODUCTION

This compilation presents a comprehensive review of the literature on common chronic pain conditions of the hand. It briefly presents these common conditions with their biological background, diagnosis, and common management options. It then presents and compares the latest literature available for injection techniques to treat these diagnoses and compares the available evidence.

METHODS

A comprehensive literature review was performed in MEDLINE, PubMed, and Cochrane databases from 1996 to 2019 using the terms "hand pain", "injection techniques", "steroid injection", "chronic pain", "osteoarthritis", "rheumatoid arthritis", "carpal tunnel syndrome", "De Quervain's tenosynovitis", "ganglion cyst", "gout", "Raynaud's", and "stenosing tenosynovitis".

RESULTS

Hand pain is a common condition with 9.7% prevalence in men and 21.6% in women and can cause significant morbidity and disability. It also carries a significant cost to the individuals and the healthcare system, totaling in $4 billion dollars in 2003. Injection therapy is an alternative when conservative treatment fails. Osteoarthritis is the most common chronic hand pain syndrome and affects about 16% of the population. Its mechanism is largely mechanic, and as such, there is controversy if steroid injections are of benefit. Hyaluronic acid (HA) appears to provide substantial relief of pain and may increase functionality. More studies of HA are required to make a definite judgment on its efficacy. Similarly, steroid ganglion cyst injection may confer little benefit. Carpal tunnel syndrome is a compressive neuropathy, and only temporarily relieved with injection therapy. US-guidance provides significant improvement and, while severe cases may still require surgery, can provide a valuable bridge therapy to surgery when conservative treatment fails. Similar bridging treatments and increased efficacy under US-guidance are effective for stenosing tenosynovitis ("trigger finger"), though, interestingly, inflammatory background is associated with decreased effect in this case. When the etiology of the pain is inflammatory, such as in RA, corticosteroid (CS) injections provide significant pain relief and increased functionality. They do not, however, change the course of disease (unlike DMARDs). Another such example is De-Quervain tenosynovitis that sees good benefit from CS injections, and an increased efficacy with US-guidance, and similarly are CS injections for gout. For Raynaud's phenomenon, Botox injections have encouraging results, but more studies are needed to determine safety and efficacy, as well as the possible difference in effect between primary and secondary Raynaud's.

CONCLUSIONS

Chronic hand pain is a prevalent and serious condition and can cause significant morbidity and disability and interferes with independence and activities of daily living. Conservative treatment remains the first line of treatment; however, when first-line treatments fail, steroid injections can usually provide benefit. In some cases, HA or Botox may also be beneficial. US-guidance is increasing in hand injection and almost ubiquitously provides safer, more effective injections. Hand surgery remains the alternative for refractory pain.

Nonsurgical Treatment of De Quervain Tenosynovitis: A Prospective Randomized Trial

Background: De Quervain tenosynovitis is commonly seen in patients who perform repetitive wrist ulnar deviation with thumb abduction and extension. Previous studies comparing nonsurgical options have contributed to a lack of consensus about ideal management. This study's purpose was to analyze results in prospectively randomized patients treated with either corticosteroid injection (CSI) alone versus CSI with immobilization. Methods: Radial sided wrist pain, first dorsal compartment tenderness, and positive Finkelstein test were used to define De Quervain. Pain score of 4 or higher on a visual analog scale (VAS) was utilized for inclusion. Following exclusion criteria, patients underwent randomization into groups: (1) CSI alone; or (2) CSI with 3 weeks of immobilization. We followed at 3 weeks and 6 months for further evaluation, where resolution of symptoms and improvements in VAS and Disabilities of the Arm, Shoulder, and Hand (DASH) scores were assessed to evaluate treatment success. Results: Nine patients with CSI alone and 11 patients with CSI and immobilization were followed. At 6 months in both groups, patients experienced significant improvement in VAS and DASH scores, while 88% of patients with CSI alone and 73% of patients with CSI and immobilization experienced complete resolution of at least 2 out of 3 of their pretreatment symptoms. Between groups, outcomes were comparable except for resolution of radial-sided wrist pain, which was superior in patients with CSI alone (100% vs 64%). Conclusions: Immobilization following injection increases costs, may hinder activities of daily living, and did not contribute to improved patient outcomes in this study. Further prospective studies are warranted.