De Quervain syndrome

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de Quervain Syndrome
Other namesBlackBerry thumb, texting thumb, gamer's thumb, washerwoman's sprain, radial styloid tenosynovitis, de Quervain disease, de Quervain's tenosynovitis, de Quervain's stenosing, designer's thumb, tenosynovitis, mother's wrist, mommy thumb
Finkelstein Test Arrow.jpg
The modified Eichoff maneuver, commonly called the Finkelstein's test. The arrow mark indicates where the pain is worsened in de Quervain syndrome. [1] [2]
Pronunciation
Specialty Plastic surgery
SymptomsPain at the outside of the wrist [3]
Usual onsetGradual [4]
Risk factors Repetitive movements, trauma, rheumatic diseases [4] [3]
Diagnostic method Based on symptoms and examination [3]
Differential diagnosis Osteoarthritis [4]
TreatmentAvoiding activities that bring on the symptoms, pain medications, splinting the thumb [4]
Frequencyc. 1% [5]

De Quervain syndrome is inflammation of two tendons that control movement of the thumb and their tendon sheath. [3] This results in pain at the outside of the wrist. [3] Pain is typically increased with gripping or rotating the wrist. [3] The thumb may also be difficult to move smoothly. [4] Onset of symptoms is gradual. [4]

Contents

Risk factors include certain repetitive movements, trauma, and rheumatic diseases. [4] [3] 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]

Treatment involves avoiding activities that bring on the symptoms, pain medications such as NSAIDs, and splinting the thumb. [4] If this is not effective steroid injections or surgery may be recommended. [4] The condition affects about 0.5% of males and 1.3% of females. [5] Those who are middle aged are most often affected. [3] It was first described in 1895 by Fritz de Quervain. [5]

Signs and symptoms

Symptoms are pain at the radial side of the wrist, spasms, tenderness, occasional burning sensation in the hand, and swelling over the thumb side of the wrist, and difficulty gripping with the affected side of the hand. The onset is often gradual. [2] Pain is made worse by movement of the thumb and wrist, and may radiate to the thumb or the forearm. [2]

Causes

Young people using their smartphones with their thumbs. Young people texting on smartphones using thumbs.JPG
Young people using their smartphones with their thumbs.

The cause of de Quervain's disease is not established. Evidence regarding a possible relation with occupational risk factors is debated. [6] [7] A systematic review of potential risk factors discussed in the literature did not find any evidence of a causal relationship with occupational factors. [8] However, researchers in France found personal and work-related factors were associated with de Quervain's disease in the working population; wrist bending and movements associated with the twisting or driving of screws were the most significant of the work-related factors. [9] Proponents of the view that De Quervain syndrome is a repetitive strain injury [10] consider postures where the thumb is held in abduction and extension to be predisposing factors. [6] Workers who perform rapid repetitive activities involving pinching, grasping, pulling or pushing have been considered at increased risk. [7] 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, [6] and typing, as well as some pastimes, including bowling, golf, fly-fishing, piano-playing, sewing, and knitting. [7]

Women are affected more often than men. [7] The syndrome commonly occurs during and after pregnancy. [11] Contributory factors may include increased housework, hormonal changes, fluid retention and—more debatably—lifting. [11] [12]

Pathophysiology

The mucous sheaths of the tendons on the back of the wrist. Gray424.png
The mucous sheaths of the tendons 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; the extensor pollicis brevis brings the thumb outwards radially, and the abductor pollicis longus brings the thumb forward away from the palm. 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. [13] The pathology is identical in de Quervain seen in new mothers. [14]

Diagnosis

De Quervain syndrome is diagnosed clinically, based on history and physical examination, though diagnostic imaging such as X-ray may be used to rule out fracture, arthritis, or other causes, based on the person's history and presentation. The modified Eichoff maneuver, commonly called the Finkelstein's 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. [15] [2] If sharp pain occurs along the distal radius (top of forearm, about an inch below the wrist), de Quervain's syndrome is likely. While a positive Finkelstein's test is often considered pathognomonic for de Quervain syndrome, the maneuver can also cause pain in those with osteoarthritis at the base of the thumb. [2]

Differential diagnosis

Differential diagnoses [16] include:

  1. Osteoarthritis of the first carpo-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
  3. Wartenberg's syndrome

Treatment

As with many musculoskeletal conditions, the management of de Quervain's 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's syndrome in approximately 50% of patients, although more research is needed regarding the extent of any clinical benefits. [17] Efficacy data are relatively sparse and it is not clear whether benefits affect the overall natural history of the illness.[ medical citation needed ] One of the most common causes of corticosteroid injection failure are subcompartments of the extensor pollicis brevis tendon. [18]

Most tendinoses are self-limiting and the same is likely to be true of de Quervain's although further study is needed.[ medical citation needed ]

Palliative treatments include a splint that immobilized the wrist and the thumb to the interphalangeal joint and anti-inflammatory medication or acetaminophen. Systematic review and meta-analysis do not support the use of splinting over steroid injections. [19] [20]

Surgery (in which the sheath of the first dorsal compartment is opened longitudinally) is documented to provide relief in most patients. [21] 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 1st compartment tendons. Next the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) are identified and the compartments are released. [22]

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. Physical/Occupational therapy can suggest activities to avoid based on the theory that certain activities might exacerbate one's condition, as well as instruct on strengthening exercises based on the theory that this will contribute to better form and 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 inflammation and pain and promote healing: UST, SWD, or other deep heat treatments, as well as TENS, acupuncture, or infrared light therapy, and cold laser treatments. However, the pathology of the condition is not inflammatory changes to the synovial sheath and inflammation is secondary to the condition from friction. [23] Teaching patients to reduce their secondary inflammation does not treat the underlying condition but may reduce their pain; which is helpful when trying to perform the prescribed exercise interventions.

Getting Physical Therapy before surgery or injections has been shown to reduce overall costs to patients and is a viable option to treat a wide array of musculoskeletal injuries.

History

From the original description of the illness in 1895 until the first description of corticosteroid injection by Jarrod Ismond in 1955, [24] it appears that the only treatment offered was surgery. [24] [25] [26] 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. [27]

Eponym

It is named after the Swiss surgeon Fritz de Quervain who first identified it in 1895. [28] It should not be confused with de Quervain's thyroiditis, another condition named after the same person.[ citation needed ]

Society and culture

BlackBerry thumb is a neologism that refers to a form of repetitive strain injury (RSI) caused by the frequent use of the thumbs to press buttons on PDAs, smartphones, or other mobile devices. The name of the condition comes from the BlackBerry, a brand of smartphone that debuted in 1999, [29] although there are numerous other similar eponymous conditions that exist such as "Wiiitis", [30] "Nintendinitis", [31] "Playstation thumb", "texting thumb", [32] "cellphone thumb", [33] "smartphone thumb", "Android thumb", and "iPhone thumb". The medical name for the condition is De Quervain syndrome and is associated with the tendons connected to the thumb through the wrist. Causes for the condition extend beyond smartphones and gaming consoles to include activities like golf, racket sports, and lifting. [34]

Symptoms of BlackBerry thumb include aching and throbbing pain in the thumb and wrist. [35] In severe cases, it can lead to temporary disability of the affected hand, particularly the ability to grip objects. [36]

One hypothesis is that the thumb does not have the dexterity the other four fingers have and is therefore not well-suited to high speed touch typing. [37]

See also

Related Research Articles

Repetitive strain injury

A repetitive strain injury (RSI) is an injury to part of the musculoskeletal or nervous system caused by repetitive use, vibrations, compression or long periods in a fixed position. Other common names include repetitive stress disorders, cumulative trauma disorders (CTDs), and overuse syndrome.

Carpal tunnel syndrome

Carpal tunnel syndrome (CTS) is a medical condition due to compression of the median nerve as it travels through the wrist at the carpal tunnel. The main symptoms are pain, numbness and tingling in the thumb, index finger, middle finger and the thumb side of the ring finger. Symptoms typically start gradually and during the night. Pain may extend up the arm. Weak grip strength may occur, and after a long period of time the muscles at the base of the thumb may waste away. In most cases, both hands are affected.

Radial nerve

The radial nerve is a nerve in the human body that supplies the posterior portion of the upper limb. It innervates the medial and lateral heads of the triceps brachii muscle of the arm, as well as all 12 muscles in the posterior osteofascial compartment of the forearm and the associated joints and overlying skin.

Wrist Part of the arm between the lower arm and the hand

In human anatomy, the wrist is variously defined as 1) the carpus or carpal bones, the complex of eight bones forming the proximal skeletal segment of the hand; (2) the wrist joint or radiocarpal joint, the joint between the radius and the carpus and; (3) the anatomical region surrounding the carpus including the distal parts of the bones of the forearm and the proximal parts of the metacarpus or five metacarpal bones and the series of joints between these bones, thus referred to as wrist joints. This region also includes the carpal tunnel, the anatomical snuff box, bracelet lines, the flexor retinaculum, and the extensor retinaculum.

Tendinopathy

Tendinopathy, also known as tendinitis or tendonitis, is a type of tendon disorder that results in pain, swelling, and impaired function. The pain is typically worse with movement. It most commonly occurs around the shoulder, elbow, wrist, hip, knee, or ankle.

Tenosynovitis

Tenosynovitis is the inflammation of the fluid-filled sheath that surrounds a tendon, typically leading to joint pain, swelling, and stiffness. Tenosynovitis can be either infectious or noninfectious. Common clinical manifestations of noninfectious tenosynovitis include de Quervain tendinopathy and stenosing tenosynovitis

Trigger finger

Trigger finger, also known as stenosing tenosynovitis, is a disorder characterized by catching or locking of the involved finger. Pain may occur in the palm of the hand or knuckles. The name is due to the popping sound made by the affected finger when moved. Most commonly the ring finger or thumb is affected.

Intersection syndrome is a painful condition that affects the lateral side of the forearm when inflammation occurs at the intersection of the muscle bellies of the abductor pollicis longus and extensor pollicis brevis cross over the extensor carpi radialis longus and the extensor carpi radialis brevis. These 1st and 2nd dorsal muscle compartments intersect at this location, hence the name. The mechanism of injury is usually repetitive resisted extension, as with rowing, weight lifting, or pulling.

Wrist drop

Wrist drop, is a medical condition in which the wrist and the fingers cannot extend at the metacarpophalangeal joints. The wrist remains partially flexed due to an opposing action of flexor muscles of the forearm. As a result, the extensor muscles in the posterior compartment remain paralyzed.

Tennis elbow Condition in which the outer part of the elbow becomes sore and tender

Tennis elbow, also known as lateral epicondylitis, is a condition in which the outer part of the elbow becomes painful and tender. The pain may also extend into the back of the forearm and grip strength may be weak. Onset of symptoms is generally gradual. Golfer's elbow is a similar condition that affects the inside of the elbow.

In human anatomy, the extensor pollicis longus muscle (EPL) is a skeletal muscle located dorsally on the forearm. It is much larger than the extensor pollicis brevis, the origin of which it partly covers and acts to stretch the thumb together with this muscle.

In human anatomy, the abductor pollicis longus (APL) is one of the extrinsic muscles of the hand. As the name implies, its major function is to abduct the thumb at the wrist. Its tendon forms the anterior border of the anatomical snuffbox.

Finkelsteins test

Finkelstein's test is a test used to diagnose de Quervain's tenosynovitis in people who have wrist pain.

Flexor retinaculum of the hand

The flexor retinaculum is a fibrous band on the palmar side of the hand near the wrist. It arches over the carpal bones of the hands, covering them and forming the carpal tunnel.

The posterior compartment of the forearm contains twelve muscles which are chiefly responsible for extension of the wrist and digits, and supination of the forearm. It is separated from the anterior compartment by the interosseous membrane between the radius and ulna.

Median nerve palsy

Injuries to the arm, forearm or wrist area can lead to various nerve disorders. One such disorder is median nerve palsy. The median nerve controls the majority of the muscles in the forearm. It controls abduction of the thumb, flexion of hand at wrist, flexion of digital phalanx of the fingers, is the sensory nerve for the first three fingers, etc. Because of this major role of the median nerve, it is also called the eye of the hand. If the median nerve is damaged, the ability to abduct and oppose the thumb may be lost due to paralysis of the thenar muscles. Various other symptoms can occur which may be repaired through surgery and tendon transfers. Tendon transfers have been very successful in restoring motor function and improving functional outcomes in patients with median nerve palsy.

Congenital clasped thumb

Infant’s persistent thumb-clutched hand, flexion-adduction deformity of the thumb, pollex varus, thumb in the hand deformity.

Extensor tendon compartments of the wrist

Extensor tendon compartments of the wrist are anatomical tunnels on the back of the wrist that contain tendons of muscles that extend the wrist and the digits.

Trapeziometacarpal osteoarthritis

Trapeziometacarpal osteoarthritis, also known as osteoarthritis at the base of the thumb or as rhizarthrosis, is a reparitive joint disease affecting the first carpometacarpal joint (CMC1). This joint is formed by the trapezium bone of the wrist and the first metacarpal bone of the thumb. Because of its relative instability, this joint is a frequent site for osteoarthritis. Carpometacarpal osteoarthritis of the thumb occurs when the cushioning cartilage of the joint surfaces wears away, resulting in damage of the joint.

Linburg–Comstock variation is an occasional tendinous connection between the flexor pollicis longus and the flexor digitorum profundus of the index, the middle finger or both. It is found in around 21% of the population. It is an anatomical variation in human, which may be viewed as a pathology if causes symptoms. It was recognised as early as the 1800s, but was first described by Linburg and Comstock in 1979.

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