De Quervain Tendinopathy: Difference between revisions
No edit summary |
No edit summary |
||
Line 71: | Line 71: | ||
{{Reliable sources | {{Reliable sources | ||
|synonym1=de quervain | |synonym1=de quervain | ||
|synonym2=de quervain tenosynovitis | |||
}} | }} |
Revision as of 10:09, 12 May 2024
De Quervain Tendinopathy | |
---|---|
Epidemiology | Common, 6 times more common in women then men. |
Causes | Overuse tendinopathy |
Clinical Features | Radial sided wrist pain worse with thumb and wrist movement. |
Treatment | Activity modification, thumb spica splint, steroid injection, surgery. |
Prognosis | Usually self-resolves after a year |
de Quervain tendinopathy is a common overuse disorder of the wrist affecting the first dorsal compartment at the radial styloid process.
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 is 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 with myxoid degeneration.[1]
Epidemiology and Risk Factors
It predominantly effects women with incidence rates of 2.8 per 1000 in women vs 0.6 per 1000 in men. Age greater than 40 is a risk factor. It is particularly common in the 4-6 weeks postpartum period in young women.[2] 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. They may also report swelling. 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.[3] The dominant hand is not more likely to be affected than the non-dominant hand, and symptoms can be bilateral.[4]
Examination
There is tenderness and swelling over the first dorsal compartment at the radial styloid. Patients with severe synovitis can have allodynia in the author's experience.
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.[3]
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.[3]
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
- Xray may help evaluate other causes such as OA of the 1st CMC joint. However in de Quervains, plain films are normal.
- 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.
Management
The condition is normally self-limited. It generally resolves after a year, and doesn't usually recur.[5][6]
- Activity Modification
- Splinting
Forearm-based thumb spica splint with the interphalangeal joint free. There is no difference between full-time and as required splinting in an RCT addressing this very question.[4]
- 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.[7]
- Surgery
Most cases resolve without 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
- ā Clarke, M. T.; Lyall, H. A.; Grant, J. W.; Matthewson, M. H. (1998-12). "The histopathology of de Quervain's disease". Journal of Hand Surgery (Edinburgh, Scotland). 23 (6): 732ā734. doi:10.1016/s0266-7681(98)80085-5. ISSN 0266-7681. PMID 9888670. Check date values in:
|date=
(help) - ā Wolf, Jennifer Moriatis; Sturdivant, Rodney X.; Owens, Brett D. (2009-01). "Incidence of de Quervain's tenosynovitis in a young, active population". The Journal of Hand Surgery. 34 (1): 112ā115. doi:10.1016/j.jhsa.2008.08.020. ISSN 1531-6564. PMID 19081683. Check date values in:
|date=
(help) - ā 3.0 3.1 3.2 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): 286ā292. doi:10.1177/1753193412475043. ISSN 1753-1934. Check date values in:
|date=
(help) - ā 4.0 4.1 Menendez, Mariano E.; Thornton, Emily; Kent, Suzanne; Kalajian, Tyler; Ring, David (2015-08). "A prospective randomized clinical trial of prescription of full-time versus as-desired splint wear for de Quervain tendinopathy". International Orthopaedics. 39 (8): 1563ā1569. doi:10.1007/s00264-015-2779-6. ISSN 1432-5195. PMID 25916954. Check date values in:
|date=
(help) - ā Menendez, Mariano E.; Thornton, Emily; Kent, Suzanne; Kalajian, Tyler; Ring, David (2015-08). "A prospective randomized clinical trial of prescription of full-time versus as-desired splint wear for de Quervain tendinopathy". International Orthopaedics. 39 (8): 1563ā1569. doi:10.1007/s00264-015-2779-6. ISSN 1432-5195. PMID 25916954. Check date values in:
|date=
(help) - ā Ilyas, Asif M. (2009). "Nonsurgical treatment for de Quervain's tenosynovitis". The Journal of Hand Surgery. 34 (5): 928ā929. doi:10.1016/j.jhsa.2008.12.030. ISSN 1531-6564. PMID 19410999.
- ā 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): 971ā976. 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,