De Quervain Tenosynovitis
What
is De Quervain tenosynovitis?
De Quervain tenosynovitis is an entrapment tendinitis of the
tendons contained within the first dorsal compartment at the wrist. It is an
inflammatory condition affecting the tendon sheaths (tenosynovitis) that pass
over the wrist joint. The inflammatory response occurs following injury and leads to the symptoms of pain,
heat, redness, swelling and loss of function. This is particularly noticeable
when forming a fist, grasping or gripping things, or when turning the wrist.
Also known as:
- Radial styloid tenosynovitis
- de Quervain disease
- de Quervain's stenosing tenosynovitis
- mother's wrist and mommy thumb
- washerwoman's sprain
Etiology
of De Quervain tenosynovitis
The tendons of the abductor pollicis longusand the extensor pollicis brevis are tightly secured against the radial
styloid by the overlying extensor retinaculum. Any thickening of the tendons
from acute or repetitive trauma restrains gliding of the tendons through the
sheath.
De Quervain's
tendinitis is caused when tendons on the thumb side of the wrist are swollen or
irritated. The irritation causes the lining (synovium) around the tendon to
swell, which changes the shape of the compartment. This makes it difficult for
the tendons to move as they should.
Tendinitis may be
caused by overuse. It can be seen in association with pregnancy.
It may be found in inflammatory arthritis,
such as rheumatoid disease. De Quervain's tendinitis is usually most common in middle-aged
women.
Pathology of De Quervain tenosynovitis
The two tendons concerned are the
tendons of the extensor pollicis brevis and abductor pollicis longus muscles.
These two muscles, which run side by side, have almost the same function: the
movement of the thumb away from the hand in the plane of the hand—so called
radial abduction (as opposed to movement of the thumb away from the hand, out
of the plane of the hand -palmar abduction). The tendons run, as do all of the
tendons passing the wrist, in synovial sheaths, which contain them and allow
them to exercise their function whatever the position of the wrist. Evaluation
of histological specimens shows a thickening and myxoid degeneration consistent
with a chronic degenerative process. The pathology is identical in de Quervain
seen in new mothers. De Quervain is potentially more common in women; the
speculative rationale for this is that women have a greater styloid process
angle of the radius.
Signs
and Symptoms of De Quervain tenosynovitis
Patients with De
Quervain tenosynovitis note pain resulting from thumb and wrist motion, along
with tenderness and thickening at the radial styloid. Crepitation or actual
triggering is rarely noted.
Signs of De
Quervain's tendinitis:
- Pain may be felt over the thumb
side of the wrist. This is the main symptom. The pain may appear either
gradually or suddenly. Pain is felt in the wrist and can travel up the
forearm. The pain is usually worse when the hand and thumb are in use.
This is especially true when forcefully grasping objects or twisting the
wrist.
- Swelling may be seen over the thumb
side of the wrist. This swelling may occur together with a fluid-filled
cyst in this region.
- Pain and swelling may make it
difficult to move the thumb and wrist.
- A "catching" or
"snapping" sensation may be felt when moving the thumb.
- Numbness may be experienced on the
back of the thumb and index finger. This is caused as the nerve lying on
top of the tendon sheath is irritated.
Examination
The first dorsal
compartment over the radial styloid becomes thickened and feels bone hard; the
area becomes tender. Usually, the compartment's thickening so distorts the
sparsely padded skin in this area that a visible fusiform mass is created.
Finkelstein's
test is used to diagnose de
Quervain syndrome in people who have wrist pain. To perform the test, the
examining physician grasps the thumb and the hand is ulnar deviated sharply. If
sharp pain occurs during Finkelstein test along the distal radius (top of
forearm, about an in inch below the wrist), De Quervain's syndrome is likely.
Tenderness is absent
over the muscle bellies proximal to the first dorsal compartment. Tenderness
and pain on axial loading are absent at the carpometacarpal (CMC) joint unless
the patient has arthritis in that joint.
Imaging Studies
Radiographs are negative and are not
necessary for routine diagnosis. However, it should be emphasized that
radiographs should be obtained to rule out other conditions that may be
responsible for the patient's pain. Radiographs may be helpful in
differentiating the patient who has de Quervain tenosynovitis from one who has
osteoarthritis at the thumb carpometacarpal (CMC) joint or who is suffering
from both conditions.
Treatment
of De Quervain tenosynovitis
Rest, ice and NSAIDs
may provide relief and reversal of this condition, especially if it is caught
early enough. Splinting with a thumb-spica splint may be necessary to reduce
the movement of the wrist and lower joints of the thumb. If these interventions
do not work, then a cortisone shot into the irritated area may be the next
course of action. Physical therapy may also be used to retrain movements
to avoid or change the method of those daily actions that caused the
inflammation.
The final step, if
all other interventions fail, is surgery to release the tendons and provide
more space for them to move. Following the surgery physical therapy may still
be required to retrain the movements that caused the injury.
What can a physical therapist do to help in De Quervain
tenosynovitis?
In acute stage
- Provide a variety of hand splints
to support the thumb and the wrist
- Help identify aggravating
activities and suggest alternative postures
- Massage
- cryotherapy (eg, cold packs, ice
massage) to reduce the inflammation and edema
- ultrasound (ie, phonophoresis) or
electrically charged ions (ie, iontophoresis)
- suggest activity modifications
In
chronic stage
- Thermal modalities
- Transverse friction massage
- Cold laser treatments are becoming
more common with a high success rate for reducing localized swelling of
tendons (tendonitis). More and more physical therapy and hand centers are
finding this modality to be useful for De Quervain's syndrome.
- Splinting
- Sensory evaluation
- Therapeutic exercises—starting with
ROM exercises, and as the patient progresses, adding strengthening
exercises
- Ergonomic workstation assessment as
needed
- Educating the patient to either
avoid or decrease repetitive hand motions, such as pinching, wringing,
turning, twisting or grasping and
- A home-exercise program
Surgical Treatment for De Quervain tenosynovitis
Surgery may be recommended if symptoms
are severe or do not improve. The goal of surgery is to open the compartment
(covering) to make more room for the irritated tendons.
Complications
Although de Quervain
tenosynovitis features a simple tendon entrapment and the treatment is quick
and straightforward, complications can be profound and permanent. Careful
attention to surgical technique at the initial release is paramount to avoiding
complications.
Superficial radial
nerve injury is the most irksome complication. Sharp injury, traction injury,
or adhesions in the scar can cause neuritis in this high-contact area, greatly
limiting hand and wrist function. This complication is best avoided through
careful blunt dissection of the subcutaneous tissue and gentle traction.
Persistent
entrapment symptoms are possible if the tendon slips of the abductor pollicis
longus are mistaken for the tendons of the abductor pollicis longus and the
extensor pollicis brevis. In such a case, the extensor pollicis brevis tendon
may remain entrapped within the septated first dorsal compartment. Should
repeat cortisone injections fail to relieve symptoms, careful surgical
re-exploration may allow a previously overlooked tendon to be released.
Subluxation of
released tendons is possible. With wrist flexion and extension, the tendons of
a widely released first dorsal compartment snap over the radial styloid. This
complication is best avoided by carefully limiting the release to the thickest
mid – 2 cm of the first dorsal compartment or by reconstructing a loose roof to
the released sheath. Reconstruction of the sheath with a slip of local tissue
may relieve symptoms.
Preventive measures for De Quervain tenosynovitis
Prevention of overuse injuries
commonly requires breaking up sessions of work or practice involving a
particular area into shorter periods with more frequent breaks to allow that
area to rest and avoid the overuse.
- A proper warm up before doing any lifting,
grasping or holding for extended periods may prepare the tendons for the
task and prevent some of the strain placed on them.
- Avoidance of activities that cause pain is a
common sense prevention method that often gets ignored. If a movement
causes pain, find another activity or action that accomplishes the same
task without the pain.
- Flexible muscles reduce overall tension on the
tendons, which reduces the inflammation to the sheaths that cover them.
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