de Quervain's Injection

Wrist
Equipment & Medications

Equipment

14 MHz Hockey Stick Probe 25g 1.5″ Needle 5 cc Syringe (lidocaine) 3 cc Syringe (steroid mix) Procedure Tray

Medications

Lidocaine 1% — 5 cc Kenalog 40 mg/cc — 1 cc Ropivacaine 0.5% — 1 cc
Procedure Steps
1

Standard pre-procedure workup: consent, indications, contraindications, allergies, and baseline pain level.

2

Position the patient seated with the wrist in slight ulnar deviation. Place a rolled towel or small pillow under the wrist for support.

3

Place the hockey-stick probe transversely over the radial styloid. Identify the first extensor compartment containing the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons within their common sheath. Note that a septum between APL and EPB subcompartments is present in approximately 30% of patients — if present, both subcompartments must be injected separately.

First extensor compartment transverse
Click for annotated view
APL EPB tendons
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4

Mark the needle entry site and ideal probe position. If a septum is present, plan entry sites for both subcompartments.

5

Prep with betadine or chlorhexidine × 3.

6

Place sterile drape and sterile probe cover.

7

Under ultrasound guidance, create a superficial skin wheal with 1% lidocaine using the 25g needle. Advance distally to proximally, parallel to the tendons.

8

Advance the 25g needle into the sheath surrounding the APL tendon. Test-inject with lidocaine — you should see sheath distention without resistance. The injectate should flow along the tendon, not into the tendon itself.

Needle in sheath
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Sheath distension
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9

If no resistance is felt and sheath distention is confirmed, exchange for the steroid/ropivacaine syringe and inject. If a septum is present, redirect the needle into the EPB subcompartment and inject the remaining mixture.

Post-injection
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10

Remove needle, clean skin with alcohol, and place bandage.

11

Reassess pain level and provide patient with a pain log.

References

  1. Bing JH, Choi SJ, Jung SM, et al. Ultrasound-guided steroid injection for the treatment of de Quervain's disease: an anatomy-based approach. Skeletal Radiol. 2018;47(11):1483–1490.
  2. Kang JW, Park JW, Lee SH, et al. Ultrasound-guided injection for de Quervain's disease: accuracy and its influenceable anatomical variances in first extensor compartment of fresh cadaver wrists. J Orthop Sci. 2017;22(2):270–274.
  3. Bhat AK, Vyas R, Acharya AM, et al. De Quervain's tenosynovitis: a non-randomized two-armed study comparing ultrasound-guided steroid injection with surgical release. Musculoskelet Surg. 2023;107(1):105–114.