Medicine:De Quervain syndrome

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de Quervain Syndrome
Other namesPotentially misleading names related to speculative causes: BlackBerry thumb, texting thumb, gamer's thumb, washerwoman's sprain, mother's wrist, mommy thumb, designer's thumb. Variations on eponymic or anatomical names: radial styloid tenosynovitis, de Quervain disease, de Quervain tendinopathy, de Quervain tenosynovitis.
Finkelstein Test Arrow.jpg
The modified Eichoff maneuver, commonly referred to as the Finkelstein's test. The arrow mark indicates where the pain is worsened in de Quervain syndrome.[1][2]
Pronunciation
SpecialtyHand surgery, Plastic surgery, Orthopedic surgery.
SymptomsPain and tenderness on the thumb side of the wrist[3]
Usual onsetGradual[4]
Risk factorsRepetitive movements, trauma
Diagnostic methodBased on symptoms and examination[3]
Differential diagnosisBase of thumb Osteoarthritis[4]
TreatmentPain medications, splinting the wrist and thumb[4]

De Quervain syndrome occurs when two tendons that control movement of the thumb become constricted by their tendon sheath in the wrist.[3][5][6] This results in pain and tenderness on the thumb side of the wrist.[3] Radial abduction of the thumb is painful.[6] On occasion, there is uneven movement or triggering of the thumb with radial abduction.[4] Symptoms can come on gradually or be noted suddenly.[4]

The diagnosis is generally based on symptoms and physical examination.[3] Diagnosis is supported if pain increases when the wrist is bent inwards while a person is grabbing their thumb within a fist.[4][6]

Treatment for de Quervain tenosynovitis focuses on reducing inflammation, restoring movement in the thumb, and maintaining the range of motion of the wrist, thumb, and fingers.[6] Symptomatic alleviation (palliative treatment) is provided mainly by splinting the thumb and wrist. Pain medications such as NSAIDs can also be considered.[4][6] Steroid injections are commonly used, but are not proved to alter the natural history of the condition.[7] Surgery to release the first dorsal component is an option.[4] It may be most common in middle age.[3]

Signs and symptoms

Symptoms are pain and tenderness at the radial side of the wrist, fullness or thickening over the thumb side of the wrist, painful radial abduction of the thumb, and difficulty gripping with the affected side of the hand.[2] Pain is made worse by movement of the thumb and wrist and may radiate to the thumb or the forearm.[2] The onset is often gradual, but sometimes the symptoms seem to come on suddenly and the problem is often misinterpreted as an injury.[2]

Causes

The cause of de Quervain syndrome is not established. Critics of this association note the human mind's tendency to misinterpret activities that are painful as activities that make the problem worse.[8][9] It's important not to inappropriately reinforce such misconceptions because they are associated with greater discomfort and incapability. Evidence regarding a possible relation with activity and occupation is debated.[10][11] A systematic review of potential risk factors did not find any evidence of a causal relationship with activity or occupation.[12] One study found that personal and work-related factors were associated with diagnosis of de Quervain syndrome in a working population; wrist bending and movements associated with the twisting or driving of screws were the most significant of the work-related factors.[13] Proponents of the view that de Quervain syndrome is a repetitive strain injury[14] consider postures where the thumb is held in abduction and extension to be predisposing factors.[10] Workers who perform rapid repetitive activities involving pinching, grasping, pulling or pushing have been considered at increased risk.[11] These movements are associated with many types of repetitive housework such as chopping vegetables, stirring and scrubbing pots, vacuuming, cleaning surfaces, drying dishes, pegging out washing, mending clothes, gardening, harvesting, and weeding. Specific activities that have been postulated as potential risk factors include intensive computer mouse use, trackball use,[10] and typing, as well as some pastimes, including bowling, golf, fly-fishing, piano-playing, sewing, and knitting.[11]

Women are diagnosed more often than men.[11] The syndrome commonly occurs during and, even more so, after pregnancy.[15] Contributory factors may include hormonal changes, fluid retention and—again, more debatably—increased housework and lifting.[15][16]

Pathophysiology

The extensor tendon sheaths on the back of the wrist.

De Quervain syndrome involves noninflammatory thickening of the tendons and the synovial sheaths that the tendons run through. The two tendons concerned are those of the extensor pollicis brevis and abductor pollicis longus muscles. These two muscles run side by side and function to bring the thumb away from the hand (radial abduction). De Quervain tendinopathy affects the tendons of these muscles as they pass from the forearm into the hand via a fibro-osseous tunnel (the first dorsal compartment). Evaluation of histopathological specimens shows a thickening and myxoid degeneration consistent with a chronic degenerative process, as opposed to inflammation or injury.[17] The pathology is identical in de Quervain seen in new mothers.[18]

Diagnosis

De Quervain syndrome is diagnosed clinically based on patient history and physical examination, though diagnostic imaging may be used to rule out fracture, arthritis, or other causes. The modified Eichoff maneuver, commonly referred to as the Finkelstein test, is a physical exam maneuver used to diagnose de Quervain syndrome.[2] To perform the test, the examiner grasps and ulnar deviates the hand when the person has their thumb held within their fist.[1][2] If sharp pain occurs along the distal radius (top of forearm, about an inch below the wrist), de Quervain syndrome is likely. While a positive Finkelstein test is often considered pathognomonic for de Quervain syndrome, the maneuver can also cause some pain in those with osteoarthritis at the base of the thumb.[2]

Differential diagnosis

Differential diagnoses[6] include:

  1. Osteoarthritis of the trapezio-metacarpal joint
  2. Intersection syndrome—pain will be more towards the middle of the back of the forearm and about 2–3 inches below the wrist, usually with associated crepitus.
  3. Wartenberg's syndrome: The primary symptom is paresthesia (numbness/tingling).

Treatment

Most tendinoses and enthesopathies[19][20] are self-limiting and the same is likely to be true of de Quervain syndrome, although further study is needed.[21][22][23]

The mainstay of symptom alleviation (palliative treatment) is a splint that immobilizes the wrist and the thumb to the interphalangeal joint. Activities are more comfortable with such a splint in place. Anti-inflammatory medication or acetaminophen may also alleviate symptoms.[24]

As with many musculoskeletal conditions, the management of de Quervain disease is determined more by convention than scientific data. A systematic review and meta-analysis published in 2013 found that corticosteroid injection seems to be an effective form of conservative management of de Quervain syndrome in approximately 50% of patients, although they have not been well tested against placebo injection.[25] Consequently it remains uncertain whether or not injections are palliative and whether they can alter the natural history of the illness.[21][22][23] One of the most common causes of corticosteroid injection failure is the presence of subcompartments of the extensor pollicis brevis tendon.[26]

Surgery (in which the sheath of the first dorsal compartment is opened longitudinally) is documented to provide relief in most patients.[27] The most important risk is to the radial sensory nerve. A small incision is made and the dorsal extensor retinaculum is identified. Once it has been identified, the release is performed longitudinally along the tendon. This is done to prevent potential subluxation of the first compartment tendons. Next the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) are identified and the compartments are released.[26]

Some occupational and physical therapists suggest alternative lifting mechanics based on the theory that the condition is due to repetitive use of the thumbs during lifting. In addition, physical/occupational therapists can suggest activities to avoid (based on the theory that certain activities might exacerbate the condition) and can introduce strengthening exercises (based on the theory that this will contribute to better form and promote the use of other muscle groups, which might limit irritation of the tendons).[citation needed]

Some occupational and physical therapists use other treatments in conjunction with therapeutic exercises, based on the rationale that they reduce pain and promote healing: ultrasound, short-wave diathermy, or other deep heat treatments, as well as TENS, acupuncture, infrared light therapy, and cold laser treatments.

History

From the original description of the illness in 1895 until the first description of corticosteroid injection by Jarrod Ismond in 1955,[28] it appears that the only treatment offered was surgery.[28][29][30] Since approximately 1972, the prevailing opinion has been that of McKenzie (1972) who suggested that corticosteroid injection was the first line of treatment and surgery should be reserved for unsuccessful injections.[31]

Eponym

It is named after the Switzerland surgeon Fritz de Quervain, who first identified it in 1895.[32] It should not be confused with de Quervain's thyroiditis, another condition named after the same person.[citation needed]

See also

References

  1. ↑ 1.0 1.1 Campbell, William Wesley; DeJong, Russell N. (2005) (in en). DeJong's the Neurologic Examination. Lippincott Williams & Wilkins. p. 583. ISBN 978-0-7817-2767-9. https://books.google.com/books?id=CvgxUpZ7ZfUC&pg=PA583. 
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 "De quervain tenosynovitis of the wrist". J Am Acad Orthop Surg 15 (12): 757–64. 2007. doi:10.5435/00124635-200712000-00009. PMID 18063716. 
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 "De Quervain's Tendinosis - Symptoms and Treatment - OrthoInfo - AAOS". December 2013. https://orthoinfo.aaos.org/en/diseases--conditions/de-quervains-tendinosis/. 
  4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 Hubbard, MJ; Hildebrand, BA; Battafarano, MM; Battafarano, DF (June 2018). "Common Soft Tissue Musculoskeletal Pain Disorders.". Primary Care 45 (2): 289–303. doi:10.1016/j.pop.2018.02.006. PMID 29759125. 
  5. ↑ Satteson, Ellen; Tannan, Shruti C. (2022), "De Quervain Tenosynovitis", StatPearls (Treasure Island (FL): StatPearls Publishing), PMID 28723034, http://www.ncbi.nlm.nih.gov/books/NBK442005/, retrieved 2022-07-12 
  6. ↑ 6.0 6.1 6.2 6.3 6.4 6.5 "De Quervain tenosynovitis". Mayo Clinic. 4 August 2022. https://www.mayoclinic.org/diseases-conditions/de-quervain-tenosynovitis/symptoms-causes/syc-20371332. 
  7. ↑ Makarawung, D.; Becker, S.; Stijin, S.; Ring, D. (2013). "Disability and Pain after Cortisone versus Placebo Injection for Trapeziometacarpal Arthrosis and De Quervain Syndrome". American Association for Hand Surgery 8 (4): 375–81. doi:10.1007/s11552-013-9529-2. PMID 24426952. 
  8. ↑ Das De, Soumen; Vranceanu, Ana-Maria; Ring, David C (2013). "Contribution of kinesophobia and catastrophic thinking to upper-extremity-specific disability". J Bone Joint Surg Am 95 (1): 76–81. doi:10.2106/JBJS.L.00064. PMID 23283376. 
  9. ↑ Vranceanu, Ana-Maria; Barsky, Aurthur; Ring, David (2009). "Psychosocial aspects of disabling musculoskeletal pain". J Bone Joint Surg Am 91 (8): 2014–8. doi:10.2106/JBJS.H.01512. PMID 19651964. 
  10. ↑ 10.0 10.1 10.2 "Hand pain other than carpal tunnel syndrome (CTS): the role of occupational factors". Best Pract Res Clin Rheumatol 25 (1): 31–42. February 2011. doi:10.1016/j.berh.2010.12.001. PMID 21663848. 
  11. ↑ 11.0 11.1 11.2 11.3 O'Neill, Carina J (2008). "de Quervain Tenosynovitis". in Frontera, Walter R. Essentials of Physical Medicine and Rehabilitation: Musculoskeletal Disorders, Pain, and Rehabilitation. Elsevier Health Sciences. pp. 129–132. ISBN 978-1-4160-4007-1. https://books.google.com/books?id=FiMoQ-OtbB0C&pg=PA129. Retrieved 9 August 2013. 
  12. ↑ Stahl, Stéphane; Vida, Daniel; Meisner, Christoph; Lotter, Oliver; Rothenberger, Jens; Schaller, Hans-Eberhard; Stahl, Adelana Santos (December 2013). "Systematic Review and Meta-Analysis on the Work-Related Cause of de Quervain Tenosynovitis". Plastic and Reconstructive Surgery 132 (6): 1479–1491. doi:10.1097/01.prs.0000434409.32594.1b. PMID 24005369. 
  13. ↑ "Risk factors for de Quervain's disease in a French working population". Scandinavian Journal of Work, Environment & Health 37 (5): 394–401. September 2011. doi:10.5271/sjweh.3160. PMID 21431276. http://www.hal.inserm.fr/inserm-00679751/document. 
  14. ↑ "Repetitive strain injury". Lancet 369 (9575): 1815–22. May 2007. doi:10.1016/S0140-6736(07)60820-4. PMID 17531890. https://www.researchgate.net/publication/6303661. 
  15. ↑ 15.0 15.1 Allen, Scott D; Katarincic, Julia A; Weiss, Arnold-Peter C (2004). "Common Disorders of the Hand and Wrist". in Leppert, Phyllis Carolyn. Primary Care for Women. Lippincott Williams & Wilkins. p. 664. ISBN 978-0-7817-3790-6. https://books.google.com/books?id=PiiD0iUNhlIC&pg=PA664. Retrieved 9 August 2013. 
  16. ↑ "DE Quervain's Tenosynovitis". American Society for Surgery of the Hand. http://www.assh.org/handcare/Anatomy/Details-Page/ArticleID/27956/de-Quervain-syndrome. 
  17. ↑ "The histopathology of de Quervain's disease". J Hand Surg Br 23 (6): 732–4. December 1998. doi:10.1016/S0266-7681(98)80085-5. PMID 9888670. 
  18. ↑ "Histological appearances in post-partum de Quervain's disease". J Hand Surg Br 25 (1): 70–2. February 2000. doi:10.1054/jhsb.1999.0308. PMID 10763729. 
  19. ↑ Leopold, Seth S (2022). "Editor's Spotlight/Take 5: Persistent Tennis Elbow Symptoms Have Little Prognostic Value: A Systematic Review and Meta-analysis". Clin Orthop Relat Res 1 (480): 642–646. doi:10.1097/CORR.0000000000002149. PMID 35171124. 
  20. ↑ Ikonen, J; Lähdeoja, T; Ardern, CL; Buchbinder, R; Reito, A; Karjalainen, T (2022). "Persistent Tennis Elbow Symptoms Have Little Prognostic Value: A Systematic Review and Meta-analysis". Clin Orthop Relat Res 1 (480): 647–660. doi:10.1097/CORR.0000000000002058. PMID 34874323. 
  21. ↑ 21.0 21.1 Menendez, ME; Thornton, E; Kent, S; Kalajian, T; Ring, D (2015). "A prospective randomized clinical trial of prescription of full-time versus as-desired splint wear for de Quervain tendinopathy". Int Orthop 39 (8): 1563–9. doi:10.1007/s00264-015-2779-6. PMID 25916954. https://pubmed.ncbi.nlm.nih.gov/25916954/. 
  22. ↑ 22.0 22.1 Ring, D; Schnellen, A (2009). "A prospective randomized clinical trial of prescription of full-time versus as-desired splint wear for de Quervain tendinopathy". J Hand Microsurg 1 (2): 68–71. doi:10.1007/s12593-009-0018-3. PMID 23129936. 
  23. ↑ 23.0 23.1 Kachooei, AR; Nota, SP; Menendez, ME; Dyer, GS; Ring, D (2015). "Factors Associated with Operative Treatment of De Quervain Tendinopathy". Arch Bone Jt Surg 3 (3): 198–203. doi:10.22038/ABJS.2015.4272. PMID 26213704. 
  24. ↑ Satteson, Ellen; Tannan, Shruti C. (2022), "De Quervain Tenosynovitis", StatPearls (Treasure Island (FL): StatPearls Publishing), PMID 28723034, http://www.ncbi.nlm.nih.gov/books/NBK442005/, retrieved 2022-11-16 
  25. ↑ Ashraf, MO; Devadoss, VG (22 January 2013). "Systematic review and meta-analysis on steroid injection therapy for de Quervain's tenosynovitis in adults". European Journal of Orthopaedic Surgery & Traumatology 24 (2): 149–57. doi:10.1007/s00590-012-1164-z. PMID 23412309. 
  26. ↑ 26.0 26.1 Ilyas, Asif (2022). "De Quervain's Release (Cadaver)". Journal of Medical Insight 2022 (8). doi:10.24296/jomi/206.3. https://jomi.com/article/206.3. 
  27. ↑ "Treatment of de Quervain's disease". The Journal of Hand Surgery 19 (4): 595–8. July 1994. doi:10.1016/0363-5023(94)90262-3. PMID 7963313. 
  28. ↑ 28.0 28.1 Christie B. G. B. (Jun 1955). "Local hydrocortisone in de Quervain's disease". Br Med J 1 (4929): 1501–3. doi:10.1136/bmj.1.4929.1501. PMID 14378608. 
  29. ↑ "De Quervain's tendovaginitis". Am J Surg 83 (5): 691–4. Mar 1952. doi:10.1016/0002-9610(52)90304-8. PMID 14914998. 
  30. ↑ "De Quervain's disease: an analysis of 52 cases". Ann Surg 138 (6): 832–41. Dec 1953. doi:10.1097/00000658-195312000-00002. PMID 13105228. 
  31. ↑ McKenzie JM (Dec 1972). "Conservative treatment of de Quervain's disease". Br Med J 4 (5841): 659–60. doi:10.1136/bmj.4.5841.659. PMID 4645899. 
  32. ↑ "Fritz de Quervain, MD (1868-1940): stenosing tendovaginitis at the radial styloid process". J Hand Surg Am 29 (6): 1164–70. 2004. doi:10.1016/j.jhsa.2004.05.019. PMID 15576233. 

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