Hand and arm pain: A pictorial guide to injections
This article, with illustrative figures, will help you get to the cause of your patient’s pain and guide your administration of corticosteroid injections.
PRACTICE RECOMMENDATIONS
› Diagnose common upper extremity conditions based on anatomic relationships. B
› Refer patients who do not respond to splinting, corticosteroid injections, or other conservative therapies to a surgeon for evaluation. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
De Quervain’s tenosynovitis: Common during pregnancy
De Quervain’s tenosynovitis (radial styloid tenosynovitis) involves painful inflammation of the 2 tendons in the first dorsal compartment of the wrist—the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB). The tendons comprise the radial border of the anatomic snuffbox.
The APL abducts and extends the thumb at the CMC joint, while the EPB extends the thumb proximal phalanx at the metacarpophalangeal joint. These tendons are contained in a synovial sheath that is subject to inflammation and constriction and subsequent wear and damage.29 In addition, the extensor retinaculum in patients with de Quervain’s disease demonstrates increased vascularity and deposition of dense fibrous tissue resulting in thickening of the tendon up to 5 times its normal width.30
As a result, degeneration and thickening of the tendon sheath, as well as radial-sided wrist pain elicited at the first dorsal compartment, are common pathophysiologic and clinical findings.31 Pain is often accompanied by the build-up of protuberances and nodulations of the tendon sheath.
De Quervain’s disease commonly occurs during and after pregnancy.32 Other risk factors include racquet sports, golfing, wrist trauma, and other activities involving repetitive hand and wrist motions.33 Often, however, de Quervain’s is idiopathic.
Making the Dx: Perform a Finkelstein's test
The major finding in patients with de Quervain’s tenosynovitis is a positive Finkelstein's test. To perform Finkelstein's test (FIGURE 6), ask the patient to oppose the thumb into the palm and flex the fingers of the same hand over the thumb. Holding the patient’s fingers around the thumb, ulnarly deviate the wrist. Finkelstein's test puts strain on the APL and EPB, causing pain along the radial border of the wrist and forearm in patients with de Quervain’s tenosynovitis. Since the maneuver can be uncomfortable, complete the exam on the unaffected side for comparison.
Stenosis of the tendon sheath may lead to crepitus over the first dorsal wrist compartment. This should be distinguished from intersection syndrome (tenosynovitis at the intersection of the first and second extensor compartments), which can also present with forearm and wrist crepitus. Patients usually have swelling of the wrist with marked discomfort upon palpation of the radial tendons. An x-ray can be useful to evaluate for CMC or radiocarpal arthritis, which may be an underlying cause.
