De Quervain tenosynovitis: Difference between revisions

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==Background==
==Background==
*Tenosynovitis of abductor pollicis, extensor pollicis brevis (where tendons lie in groove of radial styloid)
[[File:Gray424.png|thumb|The mucous sheaths of the tendons on the back of the wrist.]]
[[File:Extensor compartments of wrist.JPG|thumbnail|extensor compartments of wrist]]
*Tenosynovitis of abductor pollicis longus (APL), extensor pollicis brevis (EPB)
**Groove of radial styloid
**First extensor compartment
*Middle-aged, more common in women
*Associated with [[rheumatoid arthritis]], [[SLE]]
*Overuse of the thumb<ref>Ashurst JV et al. Tenosynovitis Caused by Texting: An Emerging Disease. The Journal of the American Osteopathic Association, May 2010, Vol. 110, 294-296.</ref>
**Classically mothers that frequently lift infants
**Or secretarial, nursing occupations
**Recently, over-texting on phones has increasingly been the culprit


==Clinical Features==
==Clinical Features<ref>Keon-Cohen B. De Quervain disease. J Bone Joint Surg Br. 1951;33-B(1):96-99 http://www.jbjs.org.uk/cgi/reprint/33-B/1/96.</ref>==
[[File:Finkelstein Test Arrow.jpg|thumb|The modified Eichoff maneuver, commonly called the "Finkelstein's test." The arrow mark indicates where the pain is worsened in de Quervain syndrome.]]
*Pain along radial aspect of wrist (may radiate to thumb or extend into the forearm)
*Pain along radial aspect of wrist (may radiate to thumb or extend into the forearm)
*Finkelstein test is positive
*Painful abduction of thumb
**Pt grasps thumb in palm of the hand and ulnar deviates the thumb and hand
*Decreased grip strength
***This stretches the tendons over the radial styloid producing sharp pain
*Swelling at tendon sheath along radial styloid
*Positive Eichoff test
**Patient grasps thumb in palm of the hand and ulnar deviates the thumb and hand
**Stretches the tendons over the radial styloid producing sharp pain
*Positive Finkelstein's test<ref>Ilyas A, Ast M, Schaffer AA, Thoder J (2007). De quervain tenosynovitis of the wrist. J Am Acad Orthop Surg. 15 (12): 757–64.</ref>
**Practitioner grabs thumb and sharply ulnarly deviates, causing sharp pain
**Done appropriately, produces less false positives than Eichoff test
*Negative Phalen and Tinel test


==Differential Diagnosis==
==Differential Diagnosis==
{{Hand and finger injury DDX}}
{{Hand and finger injury DDX}}


==Diagnosis==
==Evaluation==
===Workup===
*ESR usually normal<ref>Ferri FF. Ferri's CLinical Advisor 2013. Elsevier Health Sciences, Jun 1, 2012.</ref>
*Consider [[arthrocentesis]] for joint effusion to evaluate for crystals, gram stain, culture


==Treatment==
===Imaging<ref>Kamel M, Moghazy K, Eid H, Mansour R. Ultrasonographic diagnosis of de Quervain tenosynovitis. Ann Rheum Dis. 2002;61(11):1034-1035. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1753934/pdf/v061p01034.pdf.</ref>===
*Plain films usually nondiagnostic
**May see soft tissue swelling or radial styloid sclerosis or erosion
**Important to rule out fracture, gas formation, late [[osteomyelitis]]
*[[ultrasound: Tendons|US]] diagnostic
**Thickened extensor retinaculum (>0.45mm)<ref>Ultrasonographic evaluation of the first extensor compartment of the wrist in de Quervain's disease. J Orthop Sci. 2014, PMID: 24132793 </ref> overlying radial styloid
**Thickened APL and EPB under extensor retinaculum, as contrasted with unaffected wrist
**Edema surrounding tendons within first dorsal wrist compartment
**Surrounding hyperemia on Doppler within peritendinous subcutaneous area
**Intertendinous septum (hypoechoic area between EPB and APL) increases need for operative management<ref>Kwon BC et al. Sonographic Identification of the Intracompartmental Septum in de Quervain’s Disease. Clin Orthop Relat Res. 2010 Aug; 468(8): 2129–2134.</ref>
[[File:Intertendinous septum.JPG|thumbnail|Presence of intertendinous septum]]
[[File:No intertendinous septum.JPG|thumbnail|APL and EPB not separated by septum]]
 
==Management==
*Splint thumb and wrist  
*Splint thumb and wrist  
**Instruct pt to remove splint briefly each day to perform range-of-motion exercises
**Instruct patient to remove splint briefly each day to perform range-of-motion exercises
*[[NSAIDs]] x 10-14d
*[[NSAIDs]] for 10-14 days
*Persistent cases may require steroid injection or surgical decompression
*Persistent cases may require steroid injection or surgical decompression
*First [[steroid]] injection provides permanent relief in ~50%
**Second steroid injection > 1 mo later curative in another 40%<ref>Pagonis T, Ditsios K, Toli P, Givissis P, Christodoulou A. Improved corticosteroid treatment of recalcitrant de Quervain tenosynovitis with a novel 4-point injection technique. Am J Sports Med. 2011 Feb. 39(2):398-403.</ref>
**0.5-1 cc of 1% [[lidocaine]]
**Plus 0.5-1 cc of long acting steroid ([[methylprednisolone]] acetate, [[triamcinolone]])<ref>Stephens MB. Musculoskeletal Injections: A Review of the Evidence. Am Fam Physician. 2008 Oct 15;78(8):971-976.</ref>
*Intertendinous septum presence increases likelihood of needing surgery<ref>Stoller DW, Tirman PF, Bredella MA. Diagnostic imaging, Orthopaedics. Amirsys Inc. (2004) ISBN:0721629202.</ref>
==Disposition==
*Rheumatology referral for joint injections and conservative treatment
*Hand surgery outpatient referral for failed conservative management


==See Also==
==See Also==
*[[Radiograph-Negative Hand and Finger Injuries]]
*[[Radiograph-Negative Hand and Finger Injuries]]
*See Dr. Nabil Ebraheim's video on [https://www.youtube.com/watch?v=ZKGB2sFaJzA dorsal wrist compartment syndromes]


==References==
==References==
<references/>


[[Category:Orthopedics]]
[[Category:Orthopedics]]
[[Category:Sports Medicine]]

Latest revision as of 16:19, 18 October 2019

Background

The mucous sheaths of the tendons on the back of the wrist.
extensor compartments of wrist
  • Tenosynovitis of abductor pollicis longus (APL), extensor pollicis brevis (EPB)
    • Groove of radial styloid
    • First extensor compartment
  • Middle-aged, more common in women
  • Associated with rheumatoid arthritis, SLE
  • Overuse of the thumb[1]
    • Classically mothers that frequently lift infants
    • Or secretarial, nursing occupations
    • Recently, over-texting on phones has increasingly been the culprit

Clinical Features[2]

The modified Eichoff maneuver, commonly called the "Finkelstein's test." The arrow mark indicates where the pain is worsened in de Quervain syndrome.
  • Pain along radial aspect of wrist (may radiate to thumb or extend into the forearm)
  • Painful abduction of thumb
  • Decreased grip strength
  • Swelling at tendon sheath along radial styloid
  • Positive Eichoff test
    • Patient grasps thumb in palm of the hand and ulnar deviates the thumb and hand
    • Stretches the tendons over the radial styloid producing sharp pain
  • Positive Finkelstein's test[3]
    • Practitioner grabs thumb and sharply ulnarly deviates, causing sharp pain
    • Done appropriately, produces less false positives than Eichoff test
  • Negative Phalen and Tinel test

Differential Diagnosis

Hand and finger injuries

Evaluation

Workup

  • ESR usually normal[4]
  • Consider arthrocentesis for joint effusion to evaluate for crystals, gram stain, culture

Imaging[5]

  • Plain films usually nondiagnostic
    • May see soft tissue swelling or radial styloid sclerosis or erosion
    • Important to rule out fracture, gas formation, late osteomyelitis
  • US diagnostic
    • Thickened extensor retinaculum (>0.45mm)[6] overlying radial styloid
    • Thickened APL and EPB under extensor retinaculum, as contrasted with unaffected wrist
    • Edema surrounding tendons within first dorsal wrist compartment
    • Surrounding hyperemia on Doppler within peritendinous subcutaneous area
    • Intertendinous septum (hypoechoic area between EPB and APL) increases need for operative management[7]
Presence of intertendinous septum
APL and EPB not separated by septum

Management

  • Splint thumb and wrist
    • Instruct patient to remove splint briefly each day to perform range-of-motion exercises
  • NSAIDs for 10-14 days
  • Persistent cases may require steroid injection or surgical decompression
  • First steroid injection provides permanent relief in ~50%
  • Intertendinous septum presence increases likelihood of needing surgery[10]

Disposition

  • Rheumatology referral for joint injections and conservative treatment
  • Hand surgery outpatient referral for failed conservative management

See Also

References

  1. ↑ Ashurst JV et al. Tenosynovitis Caused by Texting: An Emerging Disease. The Journal of the American Osteopathic Association, May 2010, Vol. 110, 294-296.
  2. ↑ Keon-Cohen B. De Quervain disease. J Bone Joint Surg Br. 1951;33-B(1):96-99 http://www.jbjs.org.uk/cgi/reprint/33-B/1/96.
  3. ↑ Ilyas A, Ast M, Schaffer AA, Thoder J (2007). De quervain tenosynovitis of the wrist. J Am Acad Orthop Surg. 15 (12): 757–64.
  4. ↑ Ferri FF. Ferri's CLinical Advisor 2013. Elsevier Health Sciences, Jun 1, 2012.
  5. ↑ Kamel M, Moghazy K, Eid H, Mansour R. Ultrasonographic diagnosis of de Quervain tenosynovitis. Ann Rheum Dis. 2002;61(11):1034-1035. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1753934/pdf/v061p01034.pdf.
  6. ↑ Ultrasonographic evaluation of the first extensor compartment of the wrist in de Quervain's disease. J Orthop Sci. 2014, PMID: 24132793
  7. ↑ Kwon BC et al. Sonographic Identification of the Intracompartmental Septum in de Quervain’s Disease. Clin Orthop Relat Res. 2010 Aug; 468(8): 2129–2134.
  8. ↑ Pagonis T, Ditsios K, Toli P, Givissis P, Christodoulou A. Improved corticosteroid treatment of recalcitrant de Quervain tenosynovitis with a novel 4-point injection technique. Am J Sports Med. 2011 Feb. 39(2):398-403.
  9. ↑ Stephens MB. Musculoskeletal Injections: A Review of the Evidence. Am Fam Physician. 2008 Oct 15;78(8):971-976.
  10. ↑ Stoller DW, Tirman PF, Bredella MA. Diagnostic imaging, Orthopaedics. Amirsys Inc. (2004) ISBN:0721629202.
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