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De Quervain Tenosynovitis

Teynovitis De Quervain

De Quervain tenosynovitis is inflammation of the sheath surrounding the thumb tendons (extensor pollicis brevis (EPB) and abductor pollicis longus (APL)), which causes pain in the wrist when the thumb is being used.


Presentation

Patients with De Quervain tenosynovitis will present with pulling, burning or aching pain on the thumb side of the wrist that may extend to the arm [7]. Pain will be most obvious when the thumb is in use, especially when extending the thumb or grasping. Worsening of pain usually occurs with recurrent use of the hand, including twisting the wrist, grasping and lifting objects. Upon visual and physical exam, physicians may observe wrist tenderness and swelling (radial side), stiffening and thickening of the 1st dorsal compartment, diminished range of motion of the thumb, crepitus of the APL and EPB and weakness and tingling of the hand [8]. Patients with De Quervain tenosynovitis will have positive Finkelstein’s diagnostic tests.

Swelling
  • Non-surgical therapy includes avoiding activities that increase pain and swelling, applying ice, using a splint to support and immobilize the hand, and physical therapy. Anti-inflammatory drugs are helpful in relieving pain and swelling.[orangeorthopaedics.com]
  • De Quervain tenosynovitis is a condition that causes pain and swelling at the base of the thumb and the thumb side of the wrist.[uofmhealth.org]
  • De Quervain’s Tenosynovitis (Dee-quare-vanes-T-no-sigh-no-vie-tis) describes a problem of inflammation and swelling in the tendons on the thumb side of your wrist and up the side of your forearm.[ohmyarthritis.com]
  • Ice and non-steroidal anti-inflammatory medications, like ibuprofen, will also help with pain and swelling.[sportsmedtoday.com]
Arm Pain
  • There are both surgical and non-surgical options for treating De Quervain tenosynovitis which aim to diminish the wrist and arm pain due to inflammation and distension.[symptoma.com]
  • "Arm pain: Causes". Ashraf, MO; Devadoss, VG (22 January 2013). "Systematic review and meta-analysis on steroid injection therapy for de Quervain's tenosynovitis in adults".[en.wikipedia.org]
Soft Tissue Swelling
  • In longstanding cases, plain films may reveal bony changes of the radial styloid as well as soft tissue swelling (5a). Ultrasound may be used to detect the tenosynovitis but may fail to identify other conditions that may mimic the diagnosis.[radsource.us]
  • Signs include: soft-tissue swelling over the radial styloid focal abnormalities of the radial styloid including cortical erosion, sclerosis or periosteal reaction 6 Ultrasound Ultrasound is very often diagnostic.[radiopaedia.org]
Lymphedema
  • Growth hormone has some frequent side effects such as intracranial hypertension, lymphedema and diabetes mellitus. We report the case of a 14-year-old girl with a history of wrist pain and clumsiness.[ncbi.nlm.nih.gov]
Asymptomatic
  • MATERIALS AND METHODS: A retrospective review of 49 radiographs from 45 patients in whom the clinical diagnosis of de Quervain tenosynovitis was confirmed (positive findings on Finkelstein's test) and 64 radiographs from 62 asymptomatic patients was carried[ncbi.nlm.nih.gov]
Forgetful

Workup

Although radiographs of patients with De Quervain tenosynovitis do not provide enough evidence for a definitive diagnosis, they are recommended to determine whether there is another cause of symptoms, such as carpometacarpal osteoarthritis, fracture and osteomyelitis, which may also causes radial wrist pain. Nonspecific observations that may be found on radiographs include distension of the soft tissue found over the styloid of the radius and the radial styloid may display irregularities, such as scarring, erosion or new bone formation. Ultrasounds, on the other hand, provide useful information that may lead to a diagnosis [9]. De Quervain tenosynovitis is diagnosed using an ultrasound if patients display thickening of the abductor pollicis longus (APL), the extensor pollicis brevis (EPB) and the sheath superficial to the radial styloid, fluid buildup in the compartment housing the APL and EPB, hypoechoic halo sign indicating edema under the skin and/or increased local blood flow. Ultrasounds can also be used to determine whether a septum separating the APL and EPB is present as well as guiding administration of corticosteroids through injection directly into the compartment of the APL and EPB tendons. Magnetic resonance imaging (MRI) will reveal many of the same signs as an ultrasound but it is more sensitive and may detect the earlier mild signs of De Quervain tenosynovitis [10]. If present, MRI will identify debris within the fluid filled sheath of the APL and EPB.

Treatment

There are both surgical and non-surgical options for treating De Quervain tenosynovitis which aim to diminish the wrist and arm pain due to inflammation and distension. Non-surgical treatments include nonsteroidal anti-inflammatories (NSAIDs), bracing or splinting wrist and thumb for 4-6 weeks, ice, avoiding movements that may aggravate condition and corticosteroid injection within tendon sheath.

Physical therapy may also help patients affected with De Quervain tenosynovitis and disease progression can be monitored with ultrasounds. Clinical studies have demonstrated splinting of the wrist and thumb in combination with NSAIDs leads to an improvement in 57% of patients which is much higher than splinting alone which only led to improvements in 19% of patients [11]. Ultrasound guided corticosteroid injections have shown greater efficacy than manual injections [12]. Low dose steroid injections into the APL/EPB tendon sheath have also shown efficacy in managing the disorder. Up to 93% of patients respond positively to the combination of splinting, NSAIDs and corticosteroid injections [12] [13].

The majority of patients with De Quervain tenosynovitis respond well to non-surgical treatments. Surgery is only recommended for patients who do not respond to conservative measures and retain pain and inflammation [14]. Surgical procedures aim to relieve tendon pressure by opening the covering of the dorsal compartment. This will provide more space for the tendons and potentially decrease irritation and reestablish unimpeded gliding of the APL and EPB. Endoscopic release surgery of the 1st extensor compartment with partial surgical removal (1/4) of the extensor retinaculum is effective and associated with fewer complications than open release surgery. Longitudinal incisions during surgery have been shown to produce fewer and less painful scars compared to transverse incisions. If hypertrophic scarring occurs after surgery it can be treated with injections of corticosteroids. After surgery, a splint will be placed on the wrist and over time, patients who receive surgery should expect thumb and wrist function to return to normal.

Prognosis

Patients diagnosed with De Quervain tenosynovitis have an exceptional prognosis. After treatment and resolution of inflammation, patients typically regain complete function of their thumb and wrist. If patients continue to perform repeated thumb and wrist motions that contribute to this disease, a brace may be worn during these activities.

Etiology

De Quervain tenosynovitis is caused by frequent thumb usage along with wrist deviation towards the radius, trauma or inflammation associated with arthritis. Common movements associated with De Quervain tenosynovitis include grasping, pinching, knitting and texting. Individuals who constantly play video games or the piano, garden, golf, fly fish or knit are likely to perform these motions. Repeated movements, such as those listed, that squeeze the APL and EPB against the bony wrist processes, result in increased friction which causes the tendon to swell. Once the APL and EPB tendon swell and the sheath surrounding them becomes inflamed, they are no longer able to fit in the narrow canal in the wrist near the thumb. Patients with De Quervain tenosynovitis usually experience pain when moving the thumb and gripping objects [3]. Women have a much higher chance (10 times) of developing De Quervain tenosynovitis than men and the disease most commonly occurs after having children between the ages of 30 and 50 years of age [4].

Epidemiology

Of diseases affecting the tendons of the hand, De Quervain tenosynovitis is very common, second only to trigger finger. Approximately 77% of cases occur in women and the onset of this disease is most often in the 4th to 6th decade of life. Excessive use of the thumb is the most common cause of De Quervain tenosynovitis although trauma to the wrist or thumb is also a contributing factor. Women in the nursing, secretarial and childcare profession along with mothers are at especially high risk for developing this disease [5].

Sex distribution
Age distribution

Pathophysiology

The tendons of the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB) both pass from the wrist to the thumb through the first dorsal compartment. The APL is much larger than the EPB and is composed of multiple tendon strands. Some individuals may only have an APL due to congenital defects. Both of these tendons are innervated by the same nerve, have the same blood supply and function to abduct the wrist radially and extend the thumb. During surgical repair of the wrist, a septum is frequently observed which physically separates the APL and EPB [6].

Prevention

Prevention of De Quervain tenosynovitis is achieved through appropriate health and exercise practices. This may include properly warming up before physical activities, ensuring adequate rest in between physical activities and maintaining fitness, flexibly, strength and endurance. It is always important to utilize appropriate techniques while performing physical activities.

Summary

De Quervain tenosynovitis occurs when the fluid filled sheath surrounding the thumb tendons (abductor pollicis longus (APL) and extensor pollicis brevis (EPB)) is inflamed or when the tendons themselves are strained [1] [2]. Patients with De Quervain tenosynovitis will experience pain in the region of the wrist closest to the thumb, especially when the thumb is being used (eg. making a fist). The function of a tendon sheath is to produce and hold lubricating fluid around the tendon, which reduces friction and allows easy movement. Inflammation of the sheath around a tendon will hinder smooth tendon movement. The specific tendons involved in De Quervain tenosynovitis (APL and EPB) are essential for thumb, hand and wrist movement. Since both the APL and EPB pass through a narrowing opening where the thumb and wrist meet, pain is typically felt in this region. This condition has been observed for over 100 years and surgeons agree on a standard method to treat De Quervain tenosynovitis which is broadly used.

Patient Information

De Quervain tenosynovitis is a condition that causes pain in the wrist at the base of the thumb due to inflammation of the tendons that extend the thumb (the abductor pollicis longus (APL) and extensor pollicis brevis (EPB)). De Quervain tenosynovitis is most commonly caused by overuse of the thumb or wrist through repetitive actions such as knitting, playing video games and lifting a baby, but it can also be caused by trauma. Women are much more likely to develop De Quervain tenosynovitis (70% of cases are women) and women who are pregnant or have diabetes have the highest chance of developing this disease.

Patients who have De Quervain tenosynovitis may experience pain on the side of the wrist closest to the thumb, especially when grasping an object or twisting the wrist. Also, an audible sound may be observed when moving the thumb or wrist. Patients with De Quervain tenosynovitis may also observe swelling near the base of the thumb due to fluid buildup. If left untreated, pain may radiate up the arm and to the tip of the thumb.

De Quervain tenosynovitis is diagnosed through physical exams of the wrist and thumb, including the Finkelstein test. The Finkelstein test involves making a fist and twisting the wrist outwardly. If pain at the base of the thumb is experienced while performing this action you may have De Quervain tenosynovitis. X-rays and other imaging tests are not needed to diagnose the condition, but may be performed in order to rule out other causes of wrist pain.

Successful treatment of De Quervain tenosynovitis typically requires non-surgical means including rest, heat, nonsteroidal anti-inflammatories (NSAIDs) and splints. NSAIDs, splinting and injection of corticosteroids into the APL and EPB were shown to be effective in up to 90% of cases. If pain persists after these treatment measures, surgery to relieve pressure in the compartment that houses the APL and EPB will be performed. Treatments for De Quervain tenosynovitis are very effective and the majority of patients will experience a full recovery.

References

Article

  1. DeQuervain F. Ueber eine Form von chronischer Tendovaginitis. Corresp Blatt Schweizer Arzte. 1895; 25:389-94.
  2. De Quervain F. On a form of chronic tendovaginitis by Dr. Fritz de Quervain in la Chaux-de-Fonds. 1895. Am J Orthop. 1997; 26(9):641-4.
  3. Ashurst JV, Turco DA, Lieb BE. Tenosynovitis Caused by Texting: An Emerging Disease. JAOA. 2010; 110(5).
  4.  Gonzalez-Inglesias J, Huijbrets P, Fernández-de-Las-Peñas C, et al. Differential Diagnosis and Physical Therapy Management of a Patient With Radial Wrist Pain of 6 Months Duration: A Case Report. J Orthop Sports Phys Ther. 2010; 40(6). 
  5. Chien AJ, Jacobson JA, Martel W, et-al. Focal radial styloid abnormality as a manifestation of de Quervain tenosynovitis. AJR Am J Roentgenol. 2001; 177(6): 1383-6.
  6. Kulthanan T, Chareonwat B. Variations in abductor pollicis longus and extensor pollicis brevis tendons in the Quervain syndrome: a surgical and anatomical study. Scand J Plast Reconstr Surg Hand Surg. 2007; 41(1):36-8.
  7. Walker MJ. Manual Physical Therapy Examination and Intervention of a Patient With Radial Wrist Pain: A Case Report. J Orthop Sports Phys Ther 2004; 34(12).
  8. Anderson M, Tichenor C. A Patient With De Quervain’s Tenosynovitis: A Case Report Using an Australian Approach to Manual Therapy. Phys Ther 1994; 74(4).
  9. Diop AN, Ba-Diop S, Sane JC, et-al. Role of US in the management of de Quervain's tenosynovitis: review of 22 cases. J Radiol. 2008; 89 (9 Pt 1): 1081-4.
  10. Stoller DW, Tirman PF, Bredella MA. Diagnostic imaging, Orthopaedics. Amirsys Inc. 2004; ISBN:0721629202.
  11. Hajder E. The role of ultrasound-guided triamcinolone injection in the treatment of de Quervain’s disease: treatment and diagnostic tool?. Chirurgie de la main. 2013; vol.6, p. 403-7.
  12. Harvey FJ, Harvey PM, Horsley MW. De Quervain's disease: surgical or nonsurgical treatment. J Hand Surg. 1990; pp. 83–87.
  13. Ilyas AM. Nonsurgical treatment for de Quervain's tenosynovitis. J Hand Surg. 2009; 34(5):928-929.
  14. Scheller A, Schuh R, Hönle W, Schuh A. Long-term results of surgical release of de Quervain's stenosing tenosynovitis. Int Orthop. 2008; 28.

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Last updated: 2019-07-11 20:33