I wanted to post a case on this very common condition, De Quervains Tenosynovitis. Ultrasound allows easy visualisation of the tendons and assists guidance of steroid injections if required. This is particularly common in young mothers through lifting their baby and also with occupations where repetitive thumb use is involved. Pain is localised to the radial aspect of the wrist, and there can be a localised effusion and redness to the skin.
There is inflammation of the cellular lining membrane of the fibrous tunnel through which the tendons of abductor pollicis longus (APL) and extensor pollicis (EPB) brevis move, at the radial styloid process beneath the extensor retinaculum. The tendons are found in the first compartment of the wrist. The Finkelstein test is often used, and a video of the test can be found here. Musculoskeletal Ultrasound allows clear visualisation of the two tendons in a transverse and longitudinal view. Longitudinal views are arguably more useful during dynamic scanning. A further useful text by Kamel et al (2002) discusses the use of musculoskeletal ultrasound for de quervains tenosynovitis. The image below, clearly demonstrates the anatomy involved in this condition. Also note the proximity of other structures such as the Radial Artery and the Radial Nerve. These can be clearly visualised on Musculoskeletal Ultrasound, and their proximity can be a surprise to those who perform blind injections. I hope to provide an article on the potential adverse effects of blind injections. When you start using musculoskeletal ultrasound, you certainly become aware of other structures that exist in the region.
This patient presented with localised tenderness over the tendons of APL and EPB, and there was pain with resisted thumb extension, and passive flexion. Wrist range was preserved with some discomfort on ulnar deviation. The patient also had an ultrasound scan in clinic, the images of which can be viewed within the gallery below.
There was a characteristic thickening of the tendon sheath and local effusion. You can also see from the video below, the presence of hyperaemia on colour doppler.
This patient had experienced several months of discomfort, and the condition had not improved with NSAID's, Ice and splint use. We discussed the option of a guided injection and they consented to the procedure. There were no contraindications to injection. This was performed by ultrasound guidance (sadly the machine cut out and missed recording it!), and the following image is a view of the steroid within the sheath. Steroid shows as a bright white (hyperechoic) solution on musculoskeletal ultrasound. Four weeks post procedure, the patient returned pain free!
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