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
  • French pronunciation: [dəkɛʁvɛ̃]
Specialty Hand surgery, Plastic surgery, Orthopedic surgery.
Symptoms Pain and tenderness on the thumb side of the wrist [3]
Usual onsetGradual [4]
Risk factors Repetitive movements, trauma
Diagnostic method Based on symptoms and examination [3]
Differential diagnosis Base 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 some occasions, there is uneven movement or triggering of the thumb with radial abduction. [4] Symptoms can come on gradually or be noted suddenly. [4]

Contents

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 of 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 the 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]

The incidence of diagnosis of the condition is higher in women than in 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. Gray424.png
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 syndrome cases 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 the 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 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]

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 should be the first line of treatment and that surgery should be reserved for unsuccessful injections. [31]

Eponym

It is named after the Swiss surgeon Fritz de Quervain, who first identified it in 1895. [32]

See also

Related Research Articles

<span class="mw-page-title-main">Repetitive strain injury</span> Medical condition

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 injury, repetitive stress disorders, cumulative trauma disorders (CTDs), and overuse syndrome.

<span class="mw-page-title-main">Carpal tunnel syndrome</span> Medical condition

Carpal tunnel syndrome (CTS) is a nerve compression syndrome associated with the collected signs and symptoms of compression of the median nerve at the carpal tunnel in the wrist. Carpal tunnel syndrome is an idiopathic syndrome but there are environmental, and medical risk factors associated with the condition. CTS can affect both wrists.

<span class="mw-page-title-main">Radial nerve</span> Nerve in the human body that supplies the posterior portion of the upper limb

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.

<span class="mw-page-title-main">Median nerve</span> Nerve of the upper limb

The median nerve is a nerve in humans and other animals in the upper limb. It is one of the five main nerves originating from the brachial plexus.

<span class="mw-page-title-main">Tenosynovitis</span> Inflammation of the fluid sheath (synovium) around a tendon

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.

<span class="mw-page-title-main">Trigger finger</span> Locking of a finger when at full flexion

Trigger finger, also known as stenosing tenosynovitis, is a disorder characterized by catching or locking of the involved finger in full or near full flexion, typically with force. There may be tenderness in the palm of the hand near the last skin crease. The name "trigger finger" may refer to the motion of "catching" like a trigger on a gun. The ring finger and thumb are most commonly affected.

<span class="mw-page-title-main">Wrist drop</span> Medical condition

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.

<span class="mw-page-title-main">Tennis elbow</span> Condition in which the outer part of the elbow becomes sore and tender

Tennis elbow, also known as lateral epicondylitis or enthesopathy of the extensor carpi radialis origin, is an enthesopathy of the origin of the extensor carpi radialis brevis on the lateral epicondyle. The outer part of the elbow becomes painful and tender. The pain may also extend into the back of the forearm. Onset of symptoms is generally gradual, although they can seem sudden and be misinterpreted as an injury. Golfer's elbow is a similar condition that affects the inside of the elbow.

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

<span class="mw-page-title-main">Finkelstein's test</span> Test used to diagnose de Quervains tenosynovitis

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

<span class="mw-page-title-main">Radial styloid process</span> Bone projection on the radius

The radial styloid process is a projection of bone on the lateral surface of the distal radius bone.

The posterior compartment of the forearm contains twelve muscles which primarily extend the wrist and digits. It is separated from the anterior compartment by the interosseous membrane between the radius and ulna.

<span class="mw-page-title-main">Wrist pain</span>

Wrist pain or open wrist is a syndrome inhibiting use of a hand due to pain in anatomical structures of the wrist. It most commonly results from an injury to a ligament. The pain may be sharp from a traumatic injury or from chronic repetitive wrist activities.

<span class="mw-page-title-main">Cheiralgia paresthetica</span> Medical condition

Cheiralgia paraesthetica is a neuropathy of the hand generally caused by compression or trauma to the superficial branch of the radial nerve. The area affected is typically on the back or side of the hand at the base of the thumb, near the anatomical snuffbox, but may extend up the back of the thumb and index finger and across the back of the hand. Symptoms include numbness, tingling, burning or pain. Since the nerve branch is sensory there is no motor impairment. It may be distinguished from de Quervain syndrome because it is not dependent on motion of the hand or fingers.

<span class="mw-page-title-main">Median nerve palsy</span> Medical condition

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.

<span class="mw-page-title-main">Congenital clasped thumb</span> Medical condition

Congenital clasped thumb describes an anomaly which is characterized by a fixed thumb into the palm at the metacarpophalangeal joint in one or both hands. The incidence and genetic background are unknown. A study of Weckesser et al. showed that boys are twice as often affected with congenital clasped thumb compared to girls. The anomaly is in most cases bilateral . A congenital clasped thumb can be an isolated anomaly, but can also be attributed to several syndromes.

<span class="mw-page-title-main">Radial dysplasia</span> Medical condition

Radial dysplasia, also known as radial club hand or radial longitudinal deficiency, is a congenital difference occurring in a longitudinal direction resulting in radial deviation of the wrist and shortening of the forearm. It can occur in different ways, from a minor anomaly to complete absence of the radius, radial side of the carpal bones and thumb. Hypoplasia of the distal humerus may be present as well and can lead to stiffness of the elbow. Radial deviation of the wrist is caused by lack of support to the carpus, radial deviation may be reinforced if forearm muscles are functioning poorly or have abnormal insertions. Although radial longitudinal deficiency is often bilateral, the extent of involvement is most often asymmetric.

<span class="mw-page-title-main">Carpal tunnel surgery</span> Surgery to relieve carpal tunnel syndrome

Carpal tunnel surgery, also called carpal tunnel release (CTR) and carpal tunnel decompression surgery, is a nerve decompression in which the transverse carpal ligament is divided. It is a surgical treatment for carpal tunnel syndrome (CTS) and recommended when there is constant (not just intermittent) numbness, muscle weakness, or atrophy, and when night-splinting no longer controls intermittent symptoms of pain in the carpal tunnel. In general, milder cases can be controlled for months to years, but severe cases are unrelenting symptomatically and are likely to result in surgical treatment. Approximately 500,000 surgical procedures are performed each year, and the economic impact of this condition is estimated to exceed $2 billion annually.

<span class="mw-page-title-main">Trapeziometacarpal osteoarthritis</span> Medical condition

Trapeziometacarpal osteoarthritis (TMC OA) is, also known as osteoarthritis at the base of the thumb, thumb carpometacarpal osteoarthritis, basilar (or basal) joint arthritis, or as rhizarthrosis. This joint is formed by the trapezium bone of the wrist and the metacarpal bone of the thumb. This is one of the joints where most humans develop osteoarthritis with age. Osteoarthritis is age-related loss of the smooth surface of the bone where it moves against another bone (cartilage of the joint). In reaction to the loss of cartilage, the bones thicken at the joint surface, resulting in subchondral sclerosis. Also, bony outgrowths, called osteophytes (also known as “bone spurs”), are formed at the joint margins.

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 humans, 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.

References

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  22. 1 2 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. PMC   3453032 . PMID   23129936. S2CID   22618063.
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  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. S2CID   1393761.
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  29. ↑ Piver JD, Raney RB (March 1952). "De Quervain's tendovaginitis". Am J Surg. 83 (5): 691–4. doi:10.1016/0002-9610(52)90304-8. PMID   14914998.
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  31. ↑ McKenzie JM (December 1972). "Conservative treatment of de Quervain's disease". Br Med J. 4 (5841): 659–60. doi:10.1136/bmj.4.5841.659. PMC   1786979 . PMID   4645899.
  32. ↑ Ahuja NK, Chung KC (2004). "Fritz de Quervain, MD (1868-1940): stenosing tendovaginitis at the radial styloid process". J Hand Surg Am. 29 (6): 1164–70. doi:10.1016/j.jhsa.2004.05.019. PMID   15576233.
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