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De Quervain Tenosynovitis

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De Quervain Tenosynovitis

BASICS

DESCRIPTION

Ultrasound can help to detect anatomic variations in the 1st dorsal extensor compartment of the wrist and target corticosteroid injections (3),(4)[C],(5)[B].

Inflamed and thickened retinacular sheath of the tendon

Referral to a hand surgeon is indicated if there is no improvement with conservative therapy.

Admission Criteria/Initial Stabilization

Hospitalization for care associated with surgical treatment

Extremely good with conservative treatment. Complete resolution can take up to 1 year. 95% success rates have been shown with conservative therapy over 1 year. Up to â…“; of patients will have recurrence (7)[A].

11 Wolf JM, Sturdivant RX, Owens BD. Incidence of de Quervain's tenosynovitis in a young, active population. J Hand Surg Am. 2009;34(1):112-115.22 Huisstede BM, Coert JH, Frid ©n J, et al. Consensus on a multidisciplinary treatment guideline for de Quervain disease: results from the European HANDGUIDE study. Phys Ther. 2014;94(8):1095-1110.33 Lee KH, Kang CN, Lee BG, et al. Ultrasonographic evaluation of the first extensor compartment of the wrist in de Quervain's disease. J Orthop Sci. 2014;19(1):49-54.44 Di Sante L, Martino M, Manganiello I, et al. Ultrasound-guided corticosteroid injection for the treatment of de Quervain's tenosynovitis. Am J Phys Med Rehabil. 2013;92(7):637-638.55 Kang HJ, Koh IH, Jang JW, et al. Endoscopic versus open release in patients with de Quervain's tenosynovitis: a randomised trial. Bone Joint J. 2013;95-B(7):947-951.66 Goel R, Abzug JM. de Quervain's tenosynovitis: a review of the rehabilitative options. Hand (N Y). 2015;10(1):1-5.77 Ashraf MO, Devadoss VG. Systematic review and meta-analysis on steroid injection therapy for de Quervain's tenosynovitis in adults. Eur J Orthop Surg Traumatol. 2014;24(2):149-157.88 Kume K, Amano K, Yamada S, et al. In de Quervain's with a separate EPB compartment, ultrasound-guided steroid injection is more effective than a clinical injection technique: a prospective open-label study. J Hand Surg Eur Vol. 2012;37(6):523-527.99 Kwon BC, Choi SJ, Koh SH, et al. Sonographic identification of the intracompartmental septum in de Quervain's disease. Clin Orthop Relat Res. 2010;468(8):2129-2134.1010 Rousset P, Vuillemin-Bodaghi V, Laredo JD, et al. Anatomic variations in the first extensor compartment of the wrist: accuracy of US. Radiology. 2010;257(2):427-433.1111 Orlandi D, Corazza A, Fabbro E, et al. Ultrasound-guided percutaneous injection to treat de Quervain's disease using three different techniques: a randomized controlled trial. Eur Radiol. 2015;25(5):1512-1519.1212 Pagonis T, Ditsios K, Toli P, et al. Improved corticosteroid treatment of recalcitrant de Quervain tenosynovitis with a novel 4-point injection technique. Am J Sports Med. 2011;39(2):398-403.1313 Scheller A, Schuh R, H ¶nle W, et al. Long-term results of surgical release of de Quervain's stenosing tenosynovitis. Int Orthop. 2009;33(5):1301-1303.1414 Jeyapalan K, Choudhary S. Ultrasound-guided injection of triamcinolone and bupivacaine in the management of de Quervain's disease. Skeletal Radiol. 2009;38(11):1099-1103.

Algorithm: Pain in Upper Extremity

727.04 Radial styloid tenosynovitis

  • First identified in 1895, de Quervain tenosynovitis is a painful condition due to stenosis of the tendon sheath in the first dorsal compartment of the radial aspect of the wrist.
  • Caused by repetitive motion of the extensor pollicis brevis (EPB) and abductor pollicis longus (APL) over the radial styloid with resultant irritation of the surrounding tendon sheath

EPIDEMIOLOGY

  • The predominant age range is 30 to 50 years.
  • Women are affected more commonly than men (1).
  • The overall incidence of de Quervain tenosynovitis is 0.9/1,000 person-years (1).
  • For patients age >40 years, the incidence is 1.4/1,000 person-years compared with 0.6/1,000 person-years for those younger than 20 years.
  • Women have an incidence rate ratio of 2.8/1,000 person-years compared with 0.6/1,000 person-years in men.
  • The incidence ratio rate of de Quervain tenosynovitis is 1.3/1,000 person-years in blacks and 0.8/1,000 person-years in whites.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Repetitive motions of the wrist and/or thumb result in microtrauma and thickening of the tendons (EPB, APL) and surrounding tendon sheath
  • EPB and APL movement is resisted as they glide over the radial styloid causing pain with movements of the thumb and wrist.

RISK FACTORS

  • Women age 30 to 50 years
  • Pregnancy (primarily 3rd trimester and postpartum)
  • African American
  • Systemic diseases (e.g., rheumatoid arthritis)
  • Participation in activities that include repetitive motion or forceful grasping with thumb and wrist deviation such as golf, fly fishing, racquet sports, rowing, or bicycling
  • Repetitive movements with the hand/thumb requiring forceful grasping with wrist involving ulnar/radial deviation; dental hygienists, musicians, carpenters, assembly workers, and machine operators

GENERAL PREVENTION

DIAGNOSIS

HISTORY

  • Repetitive motion activity; overuse of wrist or thumb
  • Gradually worsening pain along the radial aspect of the thumb and wrist with certain movements, particulary ulnar deviation of the wrist
  • Pregnancy
  • Sports, leisure, and occupational history
  • Trauma (rare)

PHYSICAL EXAM

  • Pain over the radial styloid exacerbated when patients move the thumb or make a fist.
  • Crepitus with movement of the thumb
  • Swelling over the radial styloid and base of the thumb
  • Decreased range of motion of the thumb
  • Pain over the 1st dorsal compartment on resisted thumb abduction or extension
  • Tenderness may extend proximally or distally along the tendons with palpation or stress.
  • Finkelstein test: The examiner grasps the affected thumb and deviates the hand sharply in the ulnar direction. A positive test occurs when there is pain along the distal radius.
  • Eickhoff test: Patient grasps a flexed thumb and the examiner deviates the wrist in an ulnar direction.
  • Finkelstein test is more sensitive for determining tenosynovitis of the APL and EPB tendons (2)[A].

DIFFERENTIAL DIAGNOSIS

  • Scaphoid fracture
  • Scapholunate ligament tear
  • Dorsal wrist ganglion
  • Osteoarthritis of the 1st carpometacarpal joint
  • Flexor carpi radialis tendonitis
  • Infectious tenosynovitis
  • Tendonitis of the wrist extensors
  • Intersection syndrome
  • Trigger thumb

DIAGNOSTIC TESTS & INTERPRETATION

  • Primarily a clinical diagnosis. Radiographs of the wrist to rule out other pathology, such as carpometacarpal (CMC) arthritis, if the diagnosis is in question.
  • MRI is the imaging test of choice to rule out coexisting soft tissue injury or wrist joint pathology.

TREATMENT

  • Most cases of de Quervain syndrome are self-limited.
  • Rest and NSAIDs (2)[A]
  • Ice (15 to 20 minutes 5 to 6 times a day)
  • Immobilization with a thumb spica splint (2)[A]
  • Occupational therapy (6)[A]
  • Corticosteroid injection (ultrasound guided) (7)[A]
  • Consider surgery if conservative measures fail >6 months.

GENERAL MEASURES

  • If full relief is not achieved, a corticosteroid injection of the tendon sheath can improve symptoms.
  • Anatomic variation, including two tendon sheaths in the 1st compartment or the EPB tendon traveling in a separate compartment may complicate treatment. Ultrasound can distinguish these variants and improve anatomic accuracy of injections (3),(8)[B],(9,10).
  • Surgical release may be indicated after 3 to 6 months of conservative treatment if symptoms persist. Surgery is highly effective and has a relatively low rate of complications.

MEDICATION

  • Corticosteroid injection of the tendon sheath has shown significant cure rates. An 83% success rate after single injection has been reported. Additional injections are sometimes required (7)[A].
  • Corticosteroid injection plus immobilization is more effective than immobilization alone (5)[B].
  • Addition of hyaluronic acid to the corticosteroid injection improves outcome and reduces recurrence (11)[B].
  • A 4-point injection technique may be preferred to 1- and 2-point injection techniques in high-resistance training athletes (12)[B].
  • Percutaneous tenotomy and/or injection of platelet-rich plasma are newer techniques that show promise for treatment of de Quervain tenosynovitis.

ISSUES FOR REFERRAL

ADDITIONAL THERAPIES

  • Hand therapy, along with iontophoresis/phonophoresis, may help improve outcomes in persistent cases.
  • Patients may use thumb-stretching exercises as part of their rehabilitation.

SURGERY/OTHER PROCEDURES

  • Indicated for patients who have failed conservative treatment
  • Endoscopic release may provide earlier relief, fewer superficial radial nerve complications, and greater patient satisfaction with resultant scar compared to open release (5)[B].

INPATIENT CONSIDERATIONS

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

  • Additional corticosteroid injection may be performed at 4 to 6 weeks if symptoms persist. Caution with repeat steroid injections.
  • Avoid repetitive motions and activities that cause pain.

DIET

PATIENT EDUCATION

PROGNOSIS

COMPLICATIONS

  • Most complications are secondary to treatment. This includes GI, renal, and hepatic injury secondary to NSAID use.
  • Nerve damage may occur during surgery (13)[B].
  • Hypopigmentation, fat atrophy, bleeding, infection, and tendon rupture have been reported as potential adverse events from corticosteroid injection. Ultrasound guidance reduces the rate of complications (14)[B].
  • If not appropriately treated, thumb flexibility may be lost due to fibrosis.

REFERENCES

ADDITIONAL READING

  • Choi SJ, Ahn JH, Lee YJ, et al. De Quervain disease: US identification of anatomic variations in the first extensor compartment with an emphasis on sub-compartmentalization. Radiology. 2011;260(2):480-486.
  • Peters-Veluthamaningal C, van der Windt DA, Winters JC, et al. Corticosteroid injection for de Quervain's tenosynovitis. Cochrane Database Syst Rev. 2009;(3):CD005616.

SEE ALSO

CODES

ICD10

ICD9

SNOMED

CLINICAL PEARLS

  • Repetitive movements of the wrist and thumb, and activities that require forceful grasping are the most common causes of de Quervain tenosynovitis.
  • Initial treatmentt is typically conservative.
  • Corticosteroid injections are helpful and have lower complication rates if done under ultrasound guidance.
  • Surgery is helpful for recalcitrant cases.