DE QUERIAN SYNOVITIS

DEQUERVAINS TENOSYNOVITIS

De Quervain's tenosynovitis is caused by stenosing tenosynovitis of the first dorsal compartment of the wrist.

The first dorsal compartment at the wrist includes the tendons of the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB).

Patients with this condition usually report pain at the dorsolateral aspect of the wrist, with referral of pain toward the thumb and/or the lateral forearm.

This condition responds well to nonsurgical treatment.

PATHOPHYSIOLOGY

In the first dorsal compartment of the wrist, a tendon sheath encloses the abductor pollicis longus and the extensor pollicis brevis tendons at the lateral border of the anatomical snuffbox.

Inflammation at this site commonly is seen in patients who use their hands and thumbs in a repetitive fashion. Thus, de Quervain's tenosynovitis can result from cumulative (repetitive) microtrauma. Inflammation also may occur after an isolated episode of acute trauma to the site.

FREQUENCY

De Quervain's tenosynovitis is relatively prevalent, especially among individuals who perform repetitive activities using their hands (eg, certain assembly line workers, secretaries).

MORTALITY/MORBIDITY

Mortality is not associated with de Quervain's tenosynovitis. Some morbidity may result as the patient experiences progressive pain, with limitations occurring in activities requiring use of the affected hand.

SEX

Although this condition is commonly seen in females and males, the incidence of de Quervain's tenosynovitis appears to be significantly greater in women.

Some sources even quote a female-to-male ratio as high as 8:1. Interestingly, many women suffer from de Quervain's tenosynovitis during pregnancy or the postpartum period.

AGE

De Quervain's tenosynovitis is much more common in adults than in children.

CLINICAL

HISTORY

Patients with de Quervain's tenosynovitis typically report localized pain at the dorsolateral aspect of the wrist.

• Occasionally, a patient's history may indicate isolated, acute trauma to the involved site.

• More commonly, the history includes chronic, repetitive activities using the involved hand or thumb.

• Inquire about specific repetitive activities that may have contributed to the onset of symptoms. Examples include work activities (eg, computer use, materials handling) or recreational activities (eg, knitting, golf, racket sports).

• A thorough understanding of the ergonomics of precipitating activities contributes to making an accurate diagnosis and forms the basis for necessary ergonomic interventions.

• Ask how the patient's symptoms limit the patient's ability to perform vocational or avocational activities.

PHYSICAL

The most classic finding in de Quervain's tenosynovitis is a positive Finkelstein test.

• Perform the Finkelstein test by having the patient make a fist with the thumb inside the fingers. The clinician then applies passive ulnar deviation of the wrist to reproduce the chief complaint of dorsolateral wrist pain.

• Perform the Finkelstein test bilaterally to compare the involved side with the uninvolved one.

• Carefully access the first carpometacarpal (CMC) joint, since pathology at this site can cause a false-positive Finkelstein test.

• Look for swelling at the first dorsal compartment of the wrist.

• Sensory examination specifically includes careful evaluation in distributions of the median and radial nerves, since either of these could cause pain/dysesthesias radiating into the thumb.

• Because cervical radiculopathy also can cause thumb pain/dysesthesias, evaluation includes assessment for upper limb strength, muscle stretch reflexes, sensation, and provocative neck maneuvers (eg, the Spurling test to assess for cervical root impingement).

• Because some cases of dorsolateral forearm pain are caused by lateral epicondylitis, evaluate for point tenderness in the region of the lateral epicondyle, at the elbow.

• In some cases, de Quervain's tenosynovitis may be associated with rheumatoid arthritis; therefore, assess the hands for rheumatologic deformities and malalignment.

CAUSES

Minor cumulative (ie, repetitive) trauma commonly contributes to the development of de Quervain's tenosynovitis.

Activities that may cause repetitive trauma to the wrist include factory work, secretarial duties, golfing, or racket sport playing.

Isolated acute trauma also may contribute to the development of de Quervain's tenosynovitis. In addition, the disorder may occur in association with rheumatoid arthritis.

DIAGNOSIS

LABORATORY STUDIES

• No lab studies support the diagnosis of de Quervain's tenosynovitis. The clinician may consider serologic testing for rheumatoid arthritis (ie, checking serum rheumatoid factor) if the patient has no history of either acute or repetitive trauma or other risk factors.

IMAGING STUDIES

• As a rule, no imaging studies are required for diagnosing de Quervain's tenosynovitis.

• If a sufficient history of acute trauma exists, radiographs of the wrist are indicated to assess for fracture.

• If the radiographs are negative but there is nonetheless a suggestion of fracture or osteonecrosis, further imaging studies can be pursued (eg, 3-phase bone scan). Triple-phase scintigraphy includes the following:

  • Phase 1 - Flow phase (radionuclide angiography)

  • Phase 2 - Blood pool phase (soft-tissue scintigraphy)

  • Phase 3 - Late phase (skeletal bone scintigraphy)

• After a fracture, increased flow and pooling may be seen in phases 1 and 2, but these findings are due only to local inflammation, which is not specific for fracture. Thus, increased uptake in phase 3 is the most important feature for diagnosis of a fracture, and this indicator may remain positive for months.

• For fracture at the scaphoid, the 3-phase bone scan is believed to have a sensitivity of 100%, and many research studies use this test as the criterion standard for diagnosis of de Quervain's tenosynovitis; in clinical practice, however, bone scanning is needed only if the plain radiographs are negative. 

TREATMENT

PHYSICAL THERAPY

Various forms of physical therapy (PT) or occupational therapy (OT) may be used in the treatment of patients with de Quervain's tenosynovitis. In the acute stage, the therapist may use cryotherapy (eg, cold packs, ice massage) to reduce the inflammation and edema.

Local inflammation also can be treated with topical corticosteroids (eg, hydrocortisone), which are driven into the subcutaneous tissues using ultrasonography (ie, phonophoresis) or electrically charged ions (ie, iontophoresis).

PT or OT also may be indicated for individuals who have undergone surgical correction at the first dorsal compartment.

Once the patient has recovered, the goals of therapy are to strengthen and regain range of motion (ROM) at the thumb, hand, and wrist.

OCCUPATIONAL THERAPY

An occupational therapist can perform an assessment of a patient's activities of daily living (ADL) to help determine possible precipitating factors in the development of de Quervain's syndrome; he/she can then suggest activity modifications.

Although off-the-shelf orthotic devices usually are adequate, sometimes a custom-made thumb spica can be fabricated by a trained occupational therapist.

SURGICAL INTERVENTION

For severe, unresponsive cases of de Quervain's tenosynovitis in which injections, splinting, and ergonomic modification of activities have failed, a referral for surgical treatment to decompress the first dorsal compartment is needed.

OTHER TREATMENT

Using a thumb spica splint or performing local corticosteroid injection can be very effective in treating de Quervain's tenosynovitis.

• Splinting with a thumb spica - Unlike a typical wrist splint, a spica has a component that wraps around the thumb, providing some degree of immobilization at the first CMC joint but, classically, leaving the interphalangeal joint free.

• Corticosteroid injection for de Quervain's tenosynovitis

  • Mix 40 mg (1 mL) of corticosteroid with a few milliliters of local anesthetic.

  • Inject the mixture into the tendon sheath of the first dorsal compartment.

  • Take care to avoid injecting directly into the tendons, since direct injection can cause weakening and potential rupture.

  • Avoid injecting within the very superficial layer of the subcutaneous tissue, because of the possibility of skin depigmentation, which is particularly noticeable in dark-skinned individuals.

  • Inform the patient that the procedure may cause a mild, transient increase in local tenderness; this will disappear within a few days, when the corticosteroid begins to have a noticeable, therapeutic effect.

  • Evaluate the patient immediately for sensation in the first web space of the hand to assess for any anesthetic effect to the superficial radial nerve.

  • If sensory deficit is present, reassure the patient that the deficit is usually transient and should most likely resolve within a few hours.

  • An orthopedic study compared different techniques for corticosteroid injections for de Quervain's disease; the investigation examined outcomes in 38 hands (of 36 patients).

    • Half of the patients received corticosteroid injections made at a single point immediately above the indurated tendon sheath in the first dorsal compartment. The rest of the patients received injections at 2 points (each point receiving half of the therapeutic injectate volume), which corresponded with the paths of the extensor pollicis brevis (EPB) and abductor pollicis brevis (APB) tendons.

    • Repeat injections, for the patients receiving them, were performed after a 2-week interval, with no significant difference in the number of repeat injections between the groups.

    • Comparing the 1-point injection and the 2-point injection, the outcomes were, respectively, excellent in 50% versus 75% of patients, good in 28% versus 25% of patients, and fair in 22% versus 0% of patients. Thus, the 2-point injections seemed to be superior to the 1-point injections.

  • A prospective study of 103 patients found suprafibrous injection with corticosteroids to be easier to perform than is intrasynovial injection and to have the same effects.

Several potential complications of injection must be taken into account. They include the following:

• Bleeding or bruising can occur, especially in individuals with bleeding disorders or in patients taking anticoagulants.

• Infection at the injection site is rare but possible. Minimize risk through the use of sterile technique for the procedure.

• In patients with diabetes, a transient elevation of the blood glucose level may occur after corticosteroid injection.

• Allergic reactions to injected medications are rare, but possible.

• Given the proximity to the superficial radial nerve, injection at this site may cause transient anesthesia in the first web space of the dorsal hand. Lack of sensation at the site generally resolves within a few hours unless significant direct needle trauma has been delivered to the radial nerve. Such trauma is a rare complication that can cause persistent pain within the distribution of that nerve (cheiralgia paresthetica).

• Skin hypopigmentation can occur, particularly if injection is performed within superficial layers of the skin, rather than within the tendon sheath alone.

• Tendon weakening and rupture is rare, but possible.

• A combination of cheiralgia paresthetica and linear atrophy have been observed as a rare complication of local steroid injection for de Quervain's tenosynovitis. The atrophy is thought to result from a lymphatic spread of the steroid.

MEDICATION

Medications for de Quervain's tenosynovitis serve primarily to decrease pain and inflammation. The most commonly used agents are oral nonsteroidal anti-inflammatory drugs and focally injected corticosteroid medication; these are employed in conjunction with the rest of the rehabilitation plan.

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS

Oral NSAIDs may decrease pain and inflammation in de Quervain's tenosynovitis. Various oral NSAIDs may be used, although, none holds a clear distinction as the drug of choice.

The choice of NSAID is largely a matter of convenience (eg, how frequently doses must be taken to achieve adequate analgesic and anti-inflammatory effects) and cost. Many NSAIDs are available either with or without a prescription.  

IBUPROFEN (Motrin, Advil, Nuprin, Rufen)

DOC for patients with mild to moderate pain. Ibuprofen inhibits inflammatory reactions and pain, possibly by decreasing prostaglandin synthesis.

Adult: 200-800 mg PO tid/qid

Pediatric:

<6 months: Not established

6 months to 12 years: 4-10 mg/kg/dose PO tid/qid

>12 years: Administer as in adults

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Avoid coadministration of other NSAIDs to minimize side effects; special caution in patients on anticoagulants or systemic corticosteroids, with bleeding disorder, or significant alcohol use; avoid during third trimester of pregnancy (potential risk of affecting closure of ductus arteriosus); caution in patients with history of GI bleed, hypertension, CHF, and in elderly patients; please see manufacturer's product information for further details

CORTICOSTEROIDS

In contrast with the widespread systemic distribution of an oral anti-inflammatory drug, a local corticosteroid injection can achieve focal placement of a potent anti-inflammatory agent at the site of maximal tenderness or inflammation.

A variety of corticosteroid preparations are available. Mix the corticosteroid with a local anesthetic agent prior to injection. 

METHYLPREDNISOLONE (Depo-Medrol)

Decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and by reversing increased capillary permeability.

Adult:

20-40 mg of methylprednisolone intralesionally, either 0.5 or 1 mL, respectively, of 40 mg/mL solution; may be mixed with a few mL of lidocaine or other local anesthetics.