De Quervain Tendinopathy: Difference between revisions
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==Aetiology== | ==Aetiology== | ||
The | The disease affects the first dorsal compartment which contains the extensor pollicis brevis (EPB) and abductor pollicis longus (APL) tendons. These tendons can be contained within a single sheath or there can be a septum between them. It can be considered a fibro-osseous tunnel. The APL and EPB allow thumb radial abduction. | ||
The aetiology is not well understood but is thought to be due to friction of the EPL and APB against the zone 7 pulley of the extensor compartment. There is an initial tendinopathy followed by a reactive thickening. The aetiopathogenesis is based on mostly observational data. Histologically the disease is noninflammatory, with thickening of the tendons and the tunnel. | |||
== Epidemiology and Risk Factors == | |||
It is most common in the 6-12 month postpartum period in young women. It also commonly affects early childcare workers. | It is most common in the 6-12 month postpartum period in young women. It also commonly affects early childcare workers. | ||
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==Clinical Features== | ==Clinical Features== | ||
Symptoms are often bilateral. | === History === | ||
Patients report pain over the radial aspect of the distal radius. The pain is exacerbated by ulnar deviation, a strong grasp combined with flexion and radial deviation, or by firm opposition of the thumb and index finger.<ref name=":0">{{Cite journal|last=Goubau|first=J. F.|last2=Goubau|first2=L.|last3=Van Tongel|first3=A.|last4=Van Hoonacker|first4=P.|last5=Kerckhove|first5=D.|last6=Berghs|first6=B.|date=2014-03|title=The wrist hyperflexion and abduction of the thumb (WHAT) test: a more specific and sensitive test to diagnose de Quervain tenosynovitis than the Eichhoff’s Test|url=http://journals.sagepub.com/doi/10.1177/1753193412475043|journal=Journal of Hand Surgery (European Volume)|language=en|volume=39|issue=3|pages=286–292|doi=10.1177/1753193412475043|issn=1753-1934}}</ref> Symptoms are often bilateral. | |||
=== Examination === | |||
There is tenderness and swelling over the first dorsal compartment. | |||
There are several special tests, with Finkelstein and Eichoff being the most commonly performed. The Finkelstein and Eichoff tests are commonly confused in the literature. | |||
'''Finkelstein''': One hand of the examiner holds the thumb of the patient, while the examiners other hand holds the forearm on teh ulnar side in a position of neutral pro-supination. The examination places firm longitudinal traction on the patient's thumb, in the direction of slight ulnar deviation. A positive test is where the index pain is reproduced. | |||
'''Eichoff''': The patient opposes their thumb into the palm and flexes their fingers over the thumb. The examiner applies passive ulnar deviation to the patient's wrist while their other hand holds their forearm on the ulnar side. A positive test is where the index pain is reproduced. This test has a high rate of false positive.s The positive LR is 1.04, and negative LR is 0.75.<ref name=":0" /> | |||
{{PDF|De Quervain WHAT Test - Goubau 2013.pdf|caption=Overview of Eichoff, Finkelstein, and WHAT tests}} | '''WHAT test:''' This stands for wrist hyperflexion and abduction of the thumb. It was designed to more specifically apply force to the first dorsal compartment and be an active rather than passive test. The patient is asked to flex their wrist to the limit of pain while keeping their thumb in full extension and abduction. The examiner applies a gradually increasing resistance to the patient abducting their thumb. A positive test is where the index pain is reproduced. The positive LR is 1.39, and negative LR is 0.04. This test has a superior ability to correctly diagnosed the absence of de Quervain's.<ref name=":0" />{{PDF|De Quervain WHAT Test - Goubau 2013.pdf|caption=Overview of Eichoff, Finkelstein, and WHAT tests}} | ||
==Diagnosis== | ==Diagnosis== |
Revision as of 09:50, 12 Mayıs 2024
Background
De Quervain's causes radial-sided wrist pain.
Aetiology
The disease affects the first dorsal compartment which contains the extensor pollicis brevis (EPB) and abductor pollicis longus (APL) tendons. These tendons can be contained within a single sheath or there can be a septum between them. It can be considered a fibro-osseous tunnel. The APL and EPB allow thumb radial abduction.
The aetiology is not well understood but is thought to be due to friction of the EPL and APB against the zone 7 pulley of the extensor compartment. There is an initial tendinopathy followed by a reactive thickening. The aetiopathogenesis is based on mostly observational data. Histologically the disease is noninflammatory, with thickening of the tendons and the tunnel.
Epidemiology and Risk Factors
It is most common in the 6-12 month postpartum period in young women. It also commonly affects early childcare workers.
It is usually atraumatic but may result after a direct blow.
Clinical Features
History
Patients report pain over the radial aspect of the distal radius. The pain is exacerbated by ulnar deviation, a strong grasp combined with flexion and radial deviation, or by firm opposition of the thumb and index finger.[1] Symptoms are often bilateral.
Examination
There is tenderness and swelling over the first dorsal compartment.
There are several special tests, with Finkelstein and Eichoff being the most commonly performed. The Finkelstein and Eichoff tests are commonly confused in the literature.
Finkelstein: One hand of the examiner holds the thumb of the patient, while the examiners other hand holds the forearm on teh ulnar side in a position of neutral pro-supination. The examination places firm longitudinal traction on the patient's thumb, in the direction of slight ulnar deviation. A positive test is where the index pain is reproduced.
Eichoff: The patient opposes their thumb into the palm and flexes their fingers over the thumb. The examiner applies passive ulnar deviation to the patient's wrist while their other hand holds their forearm on the ulnar side. A positive test is where the index pain is reproduced. This test has a high rate of false positive.s The positive LR is 1.04, and negative LR is 0.75.[1]
WHAT test: This stands for wrist hyperflexion and abduction of the thumb. It was designed to more specifically apply force to the first dorsal compartment and be an active rather than passive test. The patient is asked to flex their wrist to the limit of pain while keeping their thumb in full extension and abduction. The examiner applies a gradually increasing resistance to the patient abducting their thumb. A positive test is where the index pain is reproduced. The positive LR is 1.39, and negative LR is 0.04. This test has a superior ability to correctly diagnosed the absence of de Quervain's.[1]
Diagnosis
Based on characteristic history of atraumatic radial sided wrist pain with tenderness and enlargement of the first dorsal compartment over the radial styloid, and pain at the radial styloid with active or passive stretch of the tendons over the radial styloid in thumb flexion.
Differential Diagnoses
- Scaphoid Fracture (missed)
- Non-union of scaphoid fracture
- De Quervain Tendinopathy
- Scaphoid impaction syndrome
- Intersection Syndrome
- Flexor carpi radialis tendinopathy
- Dorsal pole of lunate impingement on distal radius (gymnasts)
- Scapholunate dissociation
- First Carpometacarpal Joint Osteoarthritis
- Scaphotrapeziotrapezoid (STT) Joint Osteoarthritis
- Osteoarthritis of the radiocarpal joint
- Ganglia
- Radial sensory nerve entrapment in the forearm
- Crystal-induced arthritis
- C6 radicular syndrome
Imaging
- Ultrasound may show a thickened extensor retinaculum with hypervascularity. There may be thickening of the APL and APB tendons, however the EPB may be thinned due to stenosis from a thickened extensor retinaculum.
- Xray may help evaluate other causes such as OA of the 1st CMC joint.
Management
The condition is normally self-limited. It generally resolves after a year, and doesn't usually recur.
- Activity Modification
- Splinting
Forearm-based thumb spica splint with the interphalangeal joint free
- Steroid Injection
See page on De Quervain Injection. There is moderate evidence for doing an ultrasound guided steroid injection as a first line therapy over splinting alone.[2]
- Surgery
There are no placebo-controlled trials. It involves releasing the the first dorsal compartment. Complications included an erythematous, raised, and tender incision area for 6 to 12 months, injury of the superficial radial sensory nerve, failure to improve symptoms, and inability to use the wrist for a few weeks postoperatively.
References
- ↑ 1.0 1.1 1.2 Goubau, J. F.; Goubau, L.; Van Tongel, A.; Van Hoonacker, P.; Kerckhove, D.; Berghs, B. (2014-03). "The wrist hyperflexion and abduction of the thumb (WHAT) test: a more specific and sensitive test to diagnose de Quervain tenosynovitis than the Eichhoff's Test". Journal of Hand Surgery (European Volume) (in English). 39 (3): 286–292. doi:10.1177/1753193412475043. ISSN 1753-1934. Check date values in:
|date=
(help) - ↑ Stephens, Mark B.; Beutler, Anthony I.; O'Connor, Francis G. (2008-10-15). "Musculoskeletal injections: a review of the evidence". American Family Physician. 78 (8): 971–976. ISSN 0002-838X. PMID 18953975.
Literature Review
- Reviews from the last 7 years: review articles, free review articles, systematic reviews, meta-analyses, NCBI Bookshelf
- Articles from all years: PubMed search, Google Scholar search.
- TRIP Database: clinical publications about evidence-based medicine.
- Other Wikis: Radiopaedia, Wikipedia Search, Wikipedia I Feel Lucky, Orthobullets,