Styloiditis radial and ulnar. Treatment, symptoms, causes

Styloiditis is an inflammation at the junction of the tendon and the process of the radius or ulna, usually against the background of degenerative changes. Essentially, styloiditis is the same tendinitis, but with a more precise indication of the location.

There are two forms of this disease - radial, or wrist styloiditis (in the wrist area) and ulnar styloiditis (in the elbow joint area).

In recent decades, due to total computerization, it is radial styloiditis, or wrist tendonitis, that has become the most common form of this disease and one of the most common fatigue diseases of the tendons.

The most effective conservative treatment for styloiditis is shock wave therapy (SWT).

Symptoms of styloiditis of the wrist joint

You can suspect a degenerative-inflammatory process in the right or left wrist joint based on the following signs:

• Pain and limited wrist movement;
• Decreased sensitivity of the hands;
• The presence of local inflammation – swelling, redness, fever;
• Increased discomfort when moving the thumb;
• Decreased quality of fine motor skills of the fingers;
• A “crunching” sensation when moving the joint;
• Mild burning or tingling in the fingers.

In chronic form, styloiditis of the left or right wrist joint leads to thickening of the tendons, accumulation of salts (visually “bumps” under the skin), and compression of nerve endings.

Results of using shock wave therapy for styloiditis

The high effectiveness of shock wave therapy for styloiditis has been clinically proven. Using this method, the following results are achieved:

• The pain in the wrist and elbow is significantly relieved and completely disappears.
• The range of motion in the hand and elbow and the physical strength of the hand are completely restored.
• There is no need for surgical treatment.

The results of shock wave therapy treatment are achieved without the use of non-steroidal anti-inflammatory drugs, it has no side effects, is completely safe and has virtually no contraindications.

Treatment of styloiditis of the wrist joint

If the patient presents with the disease at an initial or middle stage, he is prescribed therapeutic treatment, including:

• Temporary immobilization of the joint;
• Anti-inflammatory drugs;
• Drugs that activate blood flow.

Of the physiotherapeutic procedures, ultrasound, electrophoresis, magnetic therapy, and ozokerite have proven their effectiveness.

In an advanced stage, the disease requires surgical intervention - an experienced surgeon will remove deformed tissues, excise calcifications and degenerative bone growths, thereby ensuring decompression of the neurovascular bundle and muscles.

Causes of styloiditis

Styloiditis is considered a disease that occurs due to periodically repeated microtraumas, functional overstrain, and the performance of the same type of movements, which causes a dystrophic-inflammatory process in the joint. Thus, this disease can be safely called a disease of professionals whose work is in one way or another connected with frequent flexion/extension of the hand.

In the modern world, styloiditis is often diagnosed in people whose life activities are closely connected with the computer (middle managers, system administrators, active users of Internet resources, etc.).

The disease can also be caused by systemic diseases such as diabetes mellitus or rheumatoid arthritis.

Hypothermia may be an aggravating factor.

Unlike allopathic medicine, Tibetan medicine denies the exact location of the disease - any manifestation of the disease is perceived as an imbalance of the whole organism. “Indignation” of the constitutions “wind” “bile”, “mucus” according to the “cold” scenario.

VI. Local administration of drugs in the treatment of de Quervain's disease

Local injection therapy for the relief of symptoms of de Quervain's tenosynovitis, especially in patients with comorbidities, is preferred (evidence level 1+).
An analysis of articles conducted in the MedLine and Ovid databases showed that this type of therapy was used in 83% of patients with de Quervain’s disease [5]. The administration of corticosteroids allows you to quickly stop the inflammatory process, relieve pain, and restore hand function [6, 7]. These drugs have a powerful anti-inflammatory effect and can act indirectly by inhibiting the proliferation of fibroblasts and inhibiting the synthesis of collagen and mucopolysaccharides.

After injection therapy, 91.3% of patients remain satisfied with the results achieved; for many of them, this type of treatment allows them to avoid surgical intervention [8, 9]. The success of treatment is ensured by taking into account indications and contraindications for the administration of glucocorticoids, the choice and amount of the administered drug, and the correct manipulation technique, which is determined by the level of training of the doctor.

Indications:

severe pain syndrome, ineffectiveness of conservative therapy. According to A.I. Ashkenazi [10], steroid therapy is indicated not only for relatively fresh lesions (up to 2–4 months), but also for old ones (over 9–12 months), when the stenosis is aggravated due to fairly deep changes in the ligament covering the canal.

Contraindications:

age under 18 years, local or systemic infection, severe osteoporosis of the hand bones, blood clotting disorders, patient resistance to steroids, individual intolerance to the drug.

For administration, water-insoluble injectable glucocorticoid preparations are used, the effect of which develops relatively slowly but persists for a long time. This achieves maximum local anti-inflammatory effect with minimal risk of systemic effects. Typically, methylprednisolone, Kenalog-40 and diprospan (betamethasone) are used.

The advantages of betamethasone include painlessness of administration and the possibility of its use without an anesthetic, which reduces the risk of allergic reactions, as well as the high clinical effectiveness of the drug at a minimum administered dose, which allows you to lengthen the interval between injections and reduces the risk of side effects. In general, topical use of betamethasone has more advantages over other glucocorticoids due to its reliable, fast and long-lasting action, and good tolerability.

The results of the meta-analysis [11] confirm the higher effectiveness of using a mixture of corticosteroids with an anesthetic compared to the “pure” use of glucocorticoids.

Before performing the injection, the patient is informed about the purpose of the manipulation, possible complications, short-term discomfort after the injection or increased pain, the appearance of stiffness in the joints of the first finger (occurs in 33% of cases). Patients should understand that some transient worsening of symptoms may occur as local anesthesia wears off and steroids do not demonstrate an immediate therapeutic effect. Increased pain and the appearance of swelling on the 1st day after injection are recorded in 33% of patients [12].

It must be emphasized that the expected effect from the administration of the drug may not occur immediately, but after several days; instruct the patient to immediately contact the patient if signs of inflammation appear at the injection site. It is important to warn diabetic patients about the possibility of a transient increase in blood sugar levels. It is advisable to obtain written informed consent for the procedure.

Despite the fact that local administration of the drug seems to be a fairly easy manipulation, it requires serious treatment.

The injection is performed in the treatment room in compliance with the rules of asepsis: the injection area must be thoroughly treated with an antiseptic, and rubber gloves must be used. Irrigation with chlorethyl is used only when necessary, since most patients tolerate this procedure well. A very superficial injection should be avoided as it may lead to skin depigmentation, which is especially undesirable in dark-skinned and dark-skinned patients.

Injection technique:

1. The skin is carefully treated with an antiseptic.

2. The patient’s hand is positioned either palm down or resting on the edge of the elbow (in this case, you can place a small cushion under the wrist joint). The first finger is abducted as much as possible (if the palm is down) or adducted towards the palm if the hand rests on the ulnar surface. In this position, the abductor tendon of the first finger is well contoured.

3. Mix 40 mg (1 ml) of the drug with a small amount of local anesthetic (usually 2 ml) in a syringe.

4. The needle is inserted at an angle of 30–45° proximal to the styloid process of the radius between the tendons m

.
abductor pollicis longus
and
m
.
extensor pollicis brevis
, but not in them, as direct injection can cause potential tendon rupture! The drug is injected into the area of ​​the “anatomical snuffbox” towards the tendons.

If paresthesia appears, indicating that the needle has entered a sensitive branch of the radial nerve, it is necessary to stop the injection, remove the needle and reinsert it, moving 2–3 mm to the side.

After the injection, immobilization with an orthosis is possible for 2–3 days. For 1 day, limit the load on the affected hand. 1–2 days after the injection, normal activities are allowed, but in patients engaged in intensive manual labor, workloads are limited for 5–7 days.

If the first injection does not give the desired effect, it is repeated after 2-3 weeks.

Regarding the frequency of repeated injections, the words of A.I. should be cited. Ashkenazi [10]: “You need to understand that the standard administration of steroids at short intervals of 2, 3, 4 days, with maximum dosages (1.0 ml or more) and the total number of injections, is still widely practiced in some places in the treatment of hand lesions at least 4-5 (or even more, “to the bitter end”) often does not achieve the desired, and sometimes causes considerable harm. Finally, we all need to realize that steroids are not a harmless anesthetic solution and they can turn into “oil that spoils the porridge.”

As a rule, complications do not occur after the administration of corticosteroids, although some authors have observed adverse reactions after the administration of corticosteroids in 25% of patients [13].

Common complications may include allergic reactions to injected drugs and increased blood sugar levels in patients with diabetes.

Local complications:

1. Bleeding or hematoma formation at the injection site, especially if the patient suffers from blood diseases or is taking anticoagulants.

2. Temporary transient anesthesia in the area of ​​drug administration and the back of the hand, since the superficial branch of the radial nerve passes close here. Prolonged lack of sensitivity (several hours) after injection indicates injury to the radial nerve.

3. Introduction of infection. The risk is minimized by following the rules of asepsis and antisepsis.

4. Tendon ruptures m. abductor pollicis longus

[14].

5. Skin depigmentation [15, 16]. The patient may complain of changes in temperature sensitivity in the depigmentation area, its increased trauma when exposed to minimal factors. The mechanism of corticosteroid-induced hypopigmentation is unclear, but biopsy findings suggest decreased melanocyte function rather than actual loss of melanocytes. However, this fact does not explain the darkening of the skin observed in some cases after injection of corticosteroids.

6. Atrophy of soft tissues at the site of drug administration. In some patients, tissue atrophy may be combined with changes in skin color (Fig. 6).

Rice. 6. Patient S. Soft tissue atrophy and skin depigmentation after two injections of diprospan performed in the treatment of de Quervain’s disease.

An analysis of literature data conducted using the MedLine, Embase, CINAHL, AMED, PsycINFO and Cochrane Library databases confirms the effectiveness of this treatment method [17]. The immediate results of injection therapy, especially in the early stages of the disease, are positive - in 77.4–78.0% of patients it is possible to relieve pain, and this effect lasts up to 1 year after 1–2 injections [9, 18]. A single administration of the drug allows achieving a positive result in 58% of patients, 2-3 times administration of the mixture - in 73.4% [19, 20]. In women and patients with a body mass index of more than 30, the effectiveness of treatment is worse.

According to B. Earp et al. [21], a single injection of triamcinolone or dexamethasone can stop the process in 82% of patients; in more than ½ patients, regression of symptoms persists for 12 months. Recurrence of symptoms is observed during the first 6 months after injection.

N. Sakai [22], when administering a mixture of triamcinolone with a local anesthetic, obtained a stable regression in 46 out of 50 patients after one injection, the rest required 2-3 injections. In general, all patients were satisfied with the results of treatment; no surgical treatment was required.

The administration of corticosteroids has a more pronounced therapeutic effect in combination with orthotics [23]. A comparative analysis of the results of treatment of patients with de Quervain's disease showed that with the combined use of these two methods, good results were achieved in 93% of cases, while with the introduction of only corticosteroids - only in 69% [24].

Quite different figures are given by C. Richie and W. Briner [5]: they obtained good results from injection therapy in 83% of patients, combined administration of corticosteroids and orthotics in 61%, and orthotics alone in 14%. Rest and taking NSAIDs were ineffective. Similar data were obtained by Iranian specialists [25]: 86.5% of successful results with injection therapy in combination with orthosis and only 36.1% with the use of an orthosis.

Failures of injection therapy with corticosteroids in the treatment of de Quervain’s disease are determined by errors in the technique of performing the procedure and the peculiarities of the anatomical structure of the first dorsal canal [26, 27]. The presence of a ganglion in the first dorsal canal, which occurs in approximately 7.5% of cases, may also be a reason for the failure of injection therapy [28]. It has been proven that if the drug does not enter the canal or enters near it, the effect of the injection is short-lived and a relapse of symptoms is inevitable. Failures to inject the drug into the canal may be due to the presence of additional partitions, which are found in 40–86% of cases during surgery after ineffective treatment with corticosteroids [29, 30]. Therefore, to monitor the accuracy of needle insertion into the canal, many authors suggest using ultrasonography, considering it absolutely safe and effective [31]. The administration of corticosteroids under ultrasonography control allowed 91–93.8% of patients to obtain positive long-term results [32, 33].

In addition to corticosteroids, methotrexate injections have been used in the treatment of de Quervain's disease [34].

If there is no effect, surgical intervention is recommended - usually open ligamentotomy.

Diagnostics

A traumatologist diagnoses the disease. He studies the patient's medical history, asks about symptoms, and examines the wrist or elbow.

To confirm the diagnosis, the following procedures are prescribed:

• tests for flexion and extension of fingers. The person is asked to bring his thumb together with the rest. If he has the disease, he feels severe pain. This is how styloiditis of the wrist joint is diagnosed;
• CT scan;
• ultrasonography;
• X-ray of the joint.

In 95% of cases, after carrying out diagnostic measures, the traumatologist makes a diagnosis of “styloiditis of the styloid process” (if inflammatory processes are detected). The remaining 5% of cases are due to ulnar styloiditis, the development of which causes degenerative changes in the ligaments of the elbow joint.

The use of folk remedies

When resorting to natural remedies, you should remember the principle “Do no harm!” Before using them, you should consult a specialist. The table contains the best recipes.

Table 5. Folk remedies:

Kinds

Articular styloiditis comes in two varieties, depending on the location of the inflammatory process and the duration of the inflammatory process.

By location they are distinguished:

1. Styloiditis of the elbow joint.

It develops as a result of narrowing of the lumen of the sixth canal of the dorsal ligament in the wrist, which occurred due to fibrous changes in the tendons of the extensor ulnaris and its ligaments. The cause of the development of pathology is constant overload of the elbow or its traumatization.

1. Styloiditis of the wrist joint.

This form of the disease is much more common. It is characterized by pain in the area of ​​the wrist joint due to inflammation of the tendons that attach to the styloid process.

In addition to the location, styloiditis is divided into acute, the symptoms of which appear within a few days, and chronic, the symptoms of which bother a person for many months with periods of subsidence and exacerbation of clinical signs.

Why is it developing?

Styloiditis is an inflammation of the tendons of the wrist joint and the styloid process. More often it is aseptic in nature, but sometimes bacteria that enter the joint tissues through the bloodstream can join the pathological process. The development of the disease is associated with injury to the ligaments or disruption of their trophism. Mostly the process is localized in the canal of the first finger, but sometimes transverse or annular fibers can be affected.

Styloiditis of the radius or ulna can be provoked by the influence of the following predisposing factors on the human body:

• history of severe wrist or forearm injuries;
• hypothermia;
• playing sports;
• features of work activity;
• auto-aggression;
• hereditary predisposition;
• arthritis of the wrist joint;
• hormonal imbalances;
• trophic disorders;
• lack of calcium, vitamins or protein in the body;
• the presence of a focus of chronic bacterial infection.

The use of push-ups in the form of frequent physical activity is a provoking factor in the progression of the disease.

Hand block: what is it?

Blockade is an injection into the affected area to instantly relieve pain.

The injection is indicated for the following symptoms:

• Severe persistent pain that is not relieved by taking pills;
• swelling or redness of the wrist tissue;
• Decreased mobility;
• Diagnosed arthritis, styloiditis and other joint diseases;
• Tunnel syndrome;
• Nerve compression;
• Hygroma (tendon inflammation);
• Fracture or dislocation.

Injecting the drug into the affected joint relieves pain and relieves inflammation. The use of the blockade method does not require a large number of injections and drugs, speeds up treatment, and is performed on an outpatient basis.

Effect of blockade on the wrist joint

The procedure is performed with local anesthetics and corticosteroids. The positive effect is rapid relief of pain and restoration of hand mobility. Unfortunately, the improvement will be temporary. The blockade has no effect on the cause of the disease.

Contraindications to medical manipulation will be: allergic reactions, infections and skin diseases, pregnancy, childhood.

Hand block: technique

Injections into the wrist joint or soft tissues of the affected hand are carried out by experienced specialists: rheumatologists, orthopedists, neurologists. The blockade is recommended and prescribed by the attending physician after undergoing tests and conducting the necessary examinations.

The hand joint blockade involves intra-articular injection of the required volume of the drug into the dorsal radial zone of the diseased hand. Usually this is 5-7 ml of the drug. The needle penetrates between the bones exactly into the joint cavity. The drug is administered slowly. To reduce pain before the procedure, you can first numb the injection site with 2-4 ml of a two percent lidocaine solution.

The procedure does not cause any discomfort and takes no more than 10-15 minutes. Blocking the nerves of the hand and blocking the finger of the hand eliminate pain. Hand mobility increases. The patient's general condition improves significantly. The effect of the procedure depends on the degree of neglect of the existing disease, as well as the age of the patient. As a maintenance therapy, it is recommended to combine the blockade with taking vitamins and chondroprotectors.

Establishing a diagnosis

When identifying pathology, the doctor may encounter difficulties

Styloiditis does not have specific symptoms that would distinguish it from other articular lesions.

Note! The examination reveals only isolated manifestations of the inflammatory process occurring in the tendons.

For this reason, the specialist undertakes to refer the patient for differential diagnosis.

Styloiditis is detected using:

• x-ray;
• ultrasound examination;
• analyses;
• echography;
• MRI;
• CT.

The price of MRI is slightly higher than CT. The cost of the study varies from 2.0 to 5.0 thousand rubles. The cost of CT scan ranges from 1.5 to 4.0 thousand rubles.

Why does my hand hurt with tendinitis?

The fact is that the muscles that work on the hand are mostly quite long and begin on the forearm just below the elbow. The contractile part of the muscle (belly) is located on the forearm, and the tendon (a thin cord connecting the muscle to the bone) passes past the wrist in special osteo-fibrous canals. There are six of them for the extensor muscles. The wrist that is most susceptible to tendinitis is the first one, which contains the abductor pollicis longus and extensor pollicis brevis muscles. With excessive load, chronic inflammation occurs and the channel becomes tight for the tendon to slide freely, which causes pain.