De Quervain Injection

==Background==
Injection for De Quervain Tendinopathy.
==Anatomy==
200px|thumb|A. One compartment.B. Two subcompartmentsFrom McDermott et al 2012McDermott JD, Ilyas AM, Nazarian LN, Leinberry CF. Ultrasound-guided injections for de Quervain's tenosynovitis. Clin Orthop Relat Res. 2012;470(7):1925-1931. doi:10.1007/s11999-012-2369-5
*The APL and EPB usually run together in the first dorsal compartment. 
*The tendons can often be seen with the thumb held in resisted extension. 
*They can also be palpated at the base of the 1st metacarpal.
*Anatomic variation: septum with two sub compartments (24-76% in cadaver studies). Failure can occur if failure to inject into compartment or only one sub compartment.
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==Indications==
==Contraindications==
==Technique==
300px|thumb|Long axis injection. From left to right: needle, EPB, APL.
*Ultrasound guided is preferred with greater clinical improvement, and allows the identification of subcompartment anatomical variation McDermott JD, Ilyas AM, Nazarian LN, et al. Ultrasound-guided injections for de Quervain's tenosynovitis. Clin Orthop Relat Res. 2012;470:1925–31.Jeyapalan K, Choudhary S. Ultrasound-guided injection of triamcinolone
and bupivacaine in the management of de Quervain’s disease. Skelet Radiol. 2009;38:1099–103.Zingas C, Failla JM, Van Holsbeeck M. Injection accuracy and clinical
relief of de Quervain’s tendinitis. J Hand Surg Am. 1998;23:89
*Position: Ulnar side of hand resting on surface with thumbheld in slight flexion
===Non-Ultrasound Guided===
*Identify: Radial styloid, the APB and EPL tendons, and the gap between them.
*Injection site
** Usual site: is between 5-10mm proximal to the tip of the radial styloid, between the two tendons, through the retinaculum, within the sheath.
** Alternative site in very thin patients: inject distal to the retinaculum, 5mm distal to the radial styloid (due to limited subcutaneous tissue), then advance the needle proximally while injecting
*Insert needle perpendicularly into the gap then slide proximally between the tendons (needle going distal to proximal)
*Inject solution as a bolus
===Ultrasound Guided===
* Preparation: Stand off gel recommended
* Identify: APL and APB tendons in sagittal, retinaculum, radial styloid in transverse
* Optional: initial infiltration of lidocaine.
* Axis: Can be done long axis or short axis. Transverse view is best with the needle entering the sheath while in plan with the transducer.
* Direction: Dorsal to palmar direction, at a site free of superficial veins and the superficial branch of the radial nerve
* Injection
**One sheath: deposit at one location in the sheath 
**Two sheaths: Pierce the septum between the sheaths. Deposit half around the APL, then draw back and deposit the remaining half around the EPB
==Complications==
*Subcutaneous fat atrophy, particularly noticeable in dark skinned thin women. This may be permanent but generally resolves within 3 months. The risk can be reduced by using hydrocortisone.
*Trauma to superficial radial nerve
==Aftercare==
Rest hand for one week with taping. Avoid provoking activities and start a graded load programme.
==External Resources==
<youtube>Y8BSLvsyRTg</youtube>
==References==
Category:Hand and Wrist Procedures
Category:Infoboxes
Category:Partially complete articles