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de Quervain Tenosynovitis


One of the most common sites of tendon irritation around the wrist is in the first dorsal extensor compartment, a phenomenon known as de Quervain’s disease. The tendons involved are the extensor pollicis brevis and the abductor pollicis longus. At the level of the radial styloid, these two tendons pass through an osteoligamentous tunnel composed of a shallow groove in the radius and an overlying ligament. Anatomic studies have shown that a high percentage of patients have a divided first dorsal compartment, and this can account for failure of conservative treatment and injections

Synonyms

Washerwoman’s sprain; Stenosing tenosynovitis; Tenovaginitis; Tendinosis; Tendinitis; Peritendinitis

ICD-9 Codes

727.0 Synovitis and tenosynovitis

727.04 de Quervain tenosynovitis

727.05 Other tenosynovitis of hand and wrist

DEFINITION

Tenosynovitis is defined as inflammation of a tendon and its enveloping sheath. De Quervain tenosynovitis is classically defined as a stenosing tenosynovitis of the synovial sheath of tendons of abductor pollicis longus and extensor pollicis brevis in the first compartment of the wrist due to repetitive use.

Fritz de Quervain first described this condition in 1895. Histologic studies have found that this disorder is characterized by degeneration and thickening of the tendon sheath and that it is not an active inflammatory condition.

Overexertion related to household chores and recreational activities including piano playing, sewing, knitting, typing, bowling, golfing, and fly-fishing have been reported to cause de Quervain tenosynovitis. Workers involved with fast repetitive manipulations such as pinching, grasping, pulling, or pushing are also at risk.

  • Onset of de Quervain tenosynovitis : Major cases is gradual not associated with history of acute trauma, although several authors have noted traumatic etiology, such as falling on the tip of the thumb.
  • Ratio women and men : 10:1 between ages 35-55 years

Anatomy of the hand

SYMPTOMS

Patients may complain:

  • Pain in the lateral wrist during grasp and thumb extension.
  • They may also describe pain with palpation over the lateral wrist.
  •  Symptoms are often persistent for several weeks or months, and there is often a history of chronic overuse of the wrist and the hand.
  • Pain is the most prominent symptom quality, but some patients report stiffness or neuralgialike complaints; however, true paresthesia in the distribution of the superficial radial nerve is uncommon.

PHYSICAL EXAMINATION

  • On examination, the findings of local tenderness and moderate swelling aroung the radial styloid are likely to be present.
  • A positive Finkelstein test result can confirm the diagnosed. The Finkelstein test is performed by grasping the patient’s thumb and quikly abducting the hand in ulnar deviation. Pain resulted is positive assessment.
  • Axial traction or compression (the carpometacarpal grind test) and rotation of the thumb produce pain, the condition is most likely due to degenerative changes of the carpometacarpal joint of the thumb rather than from de Quervain disease.

The Finkelstein test draws the tendons of the first dorsal compartment distally and causes sharp, local pain when tendon entrapment has occurred and inflammation is present.

DIAGNOSTIC

  • Tenosynovitis of the wrist is a clinical diagnosis, but some authors recommend obtaining a wrist radiograph to rule out other potential causes of wrist pain.
  • Some clinicians report that relief of symptoms after injection of a local anesthetic into the first dorsal compartment is often helpful as a diagnostic tool.
  • Finkelstein stated that this test is probably the most pathognomonic objective sign.
  • The patient’s history and occupation, the radiographs, and other physical findings also must be considered

Differential Diagnosis

  • Carpal joint arthritis
  • Triscaphoid arthritis
  • Rheumatoid arthritis
  • Intersection syndrome
  • Radial nerve injury
  • Ganglion cyst
  • Cervical radiculopathy
  • Scaphoid fracture
  • Carpal tunnel syndrome
  • Radioscaphoid arthritis
  • Kienböck disease
  • Extensor pollicis longus tenosynovitis

TREATMENT

  • It is unclear whether conservative treatments are effective in de Quervain tenosynovitis. The current literature is limited to effectiveness of ice, nonsteroidal antiinflammatory drugs (NSAIDs), heat, splints, strapping, rest, and massage.
  • Conservative treatment, consisting of rest on a splint and the injection of a steroid preparation, is most successful within the first 6 weeks after onset.
  • Steroid injection therapy was recommended as the initial treatment once the disease began to interfere with activities of daily living or if symptoms were more severe.
  • In a retrospective study, 84% of 58 cases were effectively managed either with a single injection (60%) or with repeat injections (24%), with only 12% requiring surgical treatment.66 These data support a meta-analysis that found an 83% cure rate with injection alone among 495 subjects, in comparison with 61% for injection and splint, 14% for splint alone, and 0% for rest or NSAIDs.
  • Surgery

PROCEDURE OF CORICOSTEROID INJECTION

  1. Wristand hand position
    1. Maximally abduct thumb (accentuates abductor tendon)
  2. Injection site
    1. Snuffbox at base of thumb
    2. Between two tendons in dorsal wrist compartment 1
      1. Abductor pollicis longus
      2. Extensor pollicis brevis
  3. Needle insertion
    1. Apply antiseptic to skin (e.g. Betadine)
    2. Aim 30-45 degrees proximally toward radial styloid
    3. Insert needle between the 2 tendons (not in tendon)
    4. Do not inject if Paresthesias (see below)
  4. Warning
    1. Do not inject directly into tendon
    2. Distal Paresthesias with needle before steroid
      1. Indicates needle at sensory branch of Radial Nerve
      2. Do not inject here!
      3. Withdraw and redirect needle 2-3 mm to either side
  • Follow-up
  1. Consider Splinting after injection
  2. May be repeated up to 1-2 times at 7-14 day intervals

 

For de Quervain disease, the hand is positioned with the ulnar side of the wrist on the table and the radial side facing upward. A 2.2-cm, 25-gauge needle is introduced at the most tender point (about 1 cm distal to the radial styloid) through a skin wheal, and 10 to 20 mg of prednisolone or equivalent intermediate-acting steroid suspension mixed with 4 to 5 mL of lidocaine 1% is deposited adjacent and parallel to the tendon sheath (peritendinous infiltration) (see Fig. 52–19).

The injection should be under the edge of the first dorsal compartment retinaculum, within the first extensor compartment. If firm resistance is appreciated or if needle movement is noted when the patient abducts and extends the thumb, the needle should be redirected to prevent intratendinous injection. Because there are many superficial vessels in this area, it is important to aspirate before injecting to verify that the needle is not in a blood vessel. One should be generous with the injection volume, because a common reason for failure is the inability to get medication into both tendon sheaths.

This may be partially overcome by increasing the volume of steroid-lidocaine injected in a more diffuse area. Often, there is visible edema at the radial aspect of the  first metacarpal base and at the thumb metacarpophalangeal joint dorsally after successful injection. A lightweight thumb or wrist splint for wrist support and protection may be used at night for several weeks after the injection, but routine splinting after injection is not required.72 Oral NSAIDs may be prescribed for analgesia but will likely not affect a cure by themselves. There is no proven role for oral corticosteroids.

REFERENCE

  1. Clinical Procedure Emergency Medicine, Chapter 52.
  2. http://www.medscape.com
  3. Physical Medicine_Musculoskeletal Hand&wrist disorder_24

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