CORR Insights®: 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

Where Are We Now?

de Quervain tenosynovitis is one of the most common tendinopathies of the upper extremity, often occurring in women in their 40s to 60s. Although somewhat common in women who have just delivered children (1% of patients in a recent national database study), diabetes was the biggest risk factor, as 33% of diagnosed patients had diabetes. [1]. Corticosteroid injections are a mainstay of treatment, with as many as 60% to 90% of patients reporting improvement in symptoms after one injection [1, 2, 5, 8], while studies have differed as to the benefit of adding immobilization after corticosteroid injection [2, 5].

Persistent symptoms of de Quervain tenosynovitis after corticosteroid injection may be caused by an extensor pollicis brevis (EPB) subcompartment, occurring in 14% to 52% of patients who present with de Quervain tenosynovitis [4, 7]. This finding is represented disproportionately among the minority (about 10%) of patients who undergo surgery for the condition, some 63% of whom had an EPB subcompartment [6].

These findings prompt research like the current study by Jung and colleagues [3], which compared the efficacy and frequency of complications between patients who received ultrasound-guided corticosteroid injections into both subcompartments versus the EPB subcompartment alone. In 112 patients presenting with de Quervain tenosynovitis, 50 (45%) had a clear subcompartment and were randomized into this study. The authors showed no differences in improvements in pain scores at 3 months between the groups, but found that the complications of hypopigmentation or fat atrophy occurred much more frequently in patients who received injections into both subcompartments compared to the EPB-only injection group (67% vs 33%). There was no between-group difference in terms of the likelihood of having symptoms bothersome enough to result in surgery, and only three patients went on to have surgical decompression.

The current study may be of value even for providers administering injections based on anatomic landmarks and palpation or under ultrasound guidance alike, as often one can confirm that the needle is in the EPB subsheath with ROM of the thumb at the metacarpophalangeal joint. Based on these study findings, injecting into the EPB subsheath or combined compartment alone may decrease common side effects from these superficial corticosteroid injections while providing the same efficacy as injections into both subcompartments.

Where Do We Need To Go?

While ultrasound can confirm the location of the injection into a potential subcompartment, the additional benefit of an ultrasound injection over a well-performed injected guided only by anatomic landmarks and manual palpation is still unclear. One randomized controlled trial found 78% of patients reported improvements in pain and disability following anatomically (rather than ultrasonographically) guided injections given by general practitioners after a short course on how to perform these injections [9]. The added use of ultrasound must show clear clinical improvement over manual injections to offset the additional time and cost of the use of ultrasound. Unfortunately, there are still few comparative studies directly comparing ultrasound-guided versus anatomically guided corticosteroid injections in de Quervain tenosynovitis showing mixed results, and no double-blinded studies [4, 10].

The authors of the current study also note the benefits of less-frequent hypopigmentation and fat atrophy after EPB subcompartment injection only rather than injection of both compartments [3]. While this is certainly an added benefit, these complications still occurred frequently even in patients who received the one-compartment injections, and we still need to quantify how patients were affected by these side effects from their injections.

How Do We Get There?

In my experience, most hand surgeons do not utilize ultrasound-guided injections for de Quervain tenosynovitis, and the vast majority of their patients report symptomatic improvement after either one or two injections. The central question remains whether the adoption ultrasound-guided injections for de Quervain tenosynovitis by hand surgeons makes it even more likely that patients’ symptoms will improve after treatment; studies evaluating this should focus on endpoints like repeat injection or surgery, patient-reported outcomes scores, as well as added costs, time, and education associated with training and use of the ultrasound machine. This question would lend itself nicely to a large blinded, randomized controlled trial given how frequently surgeons treat patients with de Quervain tenosynovitis, as well as the facts that both treatments are easy to administer and widely available, and in light of the clinical equipoise on the topic. Alternatively, a large observational cohort study of the two treatments that carefully controls for patient demographics and risk factors for the condition could also provide a valid answer to the unanswered questions that remain.