De Quervain's Tenosynovitis

De Quervain's Tenosynovitis

Definition

- 드 꾀르벵병은 신전 지대의 제 1구획의 APL 및 EPB의 협착성 건막염

  : De Quervain's tenosynovitis refers to a painful inflammatory process of the first dorsal retinacular compartment containing the tendons of the abductor pollicis longus and extensor pollicis brevis.

Synonyms

• Stenosing tenosynovitis of the radial styloid process
• Stenosing tenovaginitis of the first dorsal compartment
• De Quervain's disease
• De Quervain's tendonitis
• De Quervain's stenosinig tenosynovitis
• Tendinosis

ICD-9CM CODES

727.04 Radial styloid tenosynovitis, de Quervain disease727.0 Synovitis and tenosynovitis727.05 Other tenosynovitis of hand and wrist

Epidemiology & Demographics

- 30~50대 사이의 여성에서 호발, 특히 임신 말기나 수유기에 흔함.

• More common in women than in men (10:1)
• Usually occurs between the ages of 30 and 50
• Associated with rheumatoid arthritis (RA)
• Can be seen in new mothers or daycare providers due to holding the babies with an outstretched thumb
• Seen more frequently in certain occupations involving repetitive wrist motion (e.g., clerical, assembly, and manual labor)

Physical Findings & Clinical Presentation

• Pain over the styloid process of the radius with grasping and isometric thumb abduction
• Swelling on the radial styloid
• Tenderness in the anatomic snuffbox
• Positive Finkelstein's test ( Fig. 1-271 )

FIGURE 1-271  : Finkelstein's test is positive in de Quervain's stenosing synovitis.  Ulnar flexion of the wrist produces pain over the dorsal compartment containing the extensor pollicis brevis and abductor pollicis longus. (From Noble J [ed]: Textbook of primary care medicine, ed 2, St Louis, 1996, Mosby.)

• Crepitance
• Numbness of the dorsum of the thumb is rarely noticed.
• Absence of local heat on examination

Etiology

- 대개 수부나 수근 관절을 과도하게 사용하는 반복적인 활동에 의해 발생

- 2차적으로 신전 지대의 섬유화가 진행

- 해부학적 변이(APL의 이상 분지, 이상 건 부착, 비정상적인 중격)

• The cause is usually repetitive use or overuse of the hand and thumb involving pinching with the thumb while moving wrist in radial and ulnar directions causing thickening of the fibrous tendon sheath (e.g., typing, writing, nailing, golfing, fly-fishing, etc.).
• Acute trauma to the first extensor dorsal compartment can also lead to tenosynovitis.
• It can also occur in inflammatory joint conditions like RA and conditions causing calcium apatite deposition.

Diagnosis

• The diagnosis of de Quervain's tenosynovitis is based on the clinical triad of:

1. Tenderness over the radial styloid

               2. Swelling over the first dorsal retinacular compartment

3. Pain on ulnar movement of the wrist with the thumb adducted and flexed (Finkelstein's test; see Fig. 1-271).

• Consideration can be given to injecting 1.5 ml of 1% Xylocaine into the tenosynovial sac, and if all three physical signs resolve, the diagnosis is confirmed, allowing for differentiation from carpometacarpal (CMC) osteoarthritis (OA).
• Finkelstein maneuver can also be present in first CMC joint OA; therefore it should also be evaluated if this test is positive.

Differential Diagnosis

• Carpal tunnel syndrome
• Arthritis (e.g., degenerative OA or RA)
• Gout
• Infiltrative tenosynovitis
• Radiculopathy
• Compression neuropathy (e.g., superficial branch of the radial nerve "bracelet syndrome")
• Ganglia
• Infection (e.g., tuberculosis, bacterial)
• Scaphoid fracture
• Intersection syndrome

Laboratory Tests

• ESR is usually normal in patients with de Quervain's tenosynovitis.
• Arthrocentesis can be used to rule out gout (crystals) and infection (Gram stain and culture of aspirate).

Imaging Studies

• Imaging of the wrist and thumb is not necessary unless a fracture or arthritis is suspected.

Treatment

Nonpharmacologic Therapy

• Rest
• Avoiding repetitive movements of the hand or thumb
• Splinting (thumb spica)
• Icing (4-6 times day for 15 minutes)
• Physiotherapy

Acute General Rx

• Corticosteroid injection using 20 to 40 mg triamcinolone acetonide and 1% Xylocaine is effective in relieving pain.
• NSAIDs (ibuprofen 800 mg tid or naproxen 500 mg bid)
• Topical hydrocortisone on the radial styloid for mild conditions

Chronic Rx

• Once signs of active inflammation have resolved after 3-4 wk, gentle stretching exercises involving abductor and extensor tendons usually help recovery.
• Surgical release is generally reserved for patients not responding to NSAIDs and corticosteroid injection therapy.

Disposition

• ∼90% of patients have relief of symptoms with either single or multiple steroid injections.
• Rarely, steroid injection use can cause infection and tendon rupture.
• If left untreated, can lead to fibrosis and decrease in mobility (stenosing tenosynovitis).
• Surgical control of symptoms achieved in 90% of referred cases
• Complications of surgery include:

                  - 수술 후 합병증으로

                      1. 건의 탈구(신전 지대의 지나친 절제, 건막 절개시에 가능한 배측에서 시행),

                      2. 표재 요골 신경 분지의 손상(신경통)

• Radial nerve damage
• Paresthesia (∼10%)
• Neuroma
• Scarring

                       

                    Campbell P.4300

                         failure to obtain relief after surgery may result from

                          - formation of neuroma in a branch of ther superficial radial nerves

                          - volar subluxation of the tendon when too much of ther sheath is removed

                          - failure to find and release a seperate aberrant tendon within a seoerate compartment

                          - hypertrophy of scar from a longuitudinal skin incision

• Recovery rates are higher with early treatment to ∼80% after 6 wk but >40% after 4 yr.

Pearls & Considerations

• Steroid injection is generally recommended after failure of conservative treatment for 2-6 wk.
• Pain relief is usually noted within 48 hr with patient becoming asymptomatic by the first or second week after corticosteroid injection.
• If there is no improvement by 6 wk post second corticosteroid injection, referral to an orthopedic hand surgeon is recommended.
• Without treatment it will not improve and can get worse.
• Condition can recur if triggering activity continues.

Suggested Readings

available at INTER REF www.expertconsult.com

Related Content

• De Quervain's Tenosynovitis (Patient Information)

AUTHOR: SYEDA M. SAYEED, M.D.

Suggested Readings

Asif et al., 2009Asif M., Ilyas A.M.: Surgical treatment for de Quervain's tenosynovitis. J Hand Surg 2009; 34: 928-929

Bouras et al., 2010Bouras Y.: Surgical treatment in de Quervain's tenosynovitis. Ann Chir Plast Esthet 2010; 55: 42-45

Capasso et al., 2002Capasso G., Testa V., Maffulli N.,

et al

: Surgical release of de Quervain's stenosing tenosynovitis postpartum: can it wait?. Int Orthop 2002; 26: 23

Graham et al., 2007Graham J.B., Hulkower S.D., Bosworth M.,

et al

: Are steroid injections effective for tenosynovitis of the hand?. J Fam Pract 2007; 56: 1045-1047

Ilyas et al., 2007Ilyas A.M.: De Quervain tenosynovitis of the wrist. J Am Acad Orthop Surg 2007; 15: 757-764

Jirarttanphochai et al., 2004Jirarttanphochai K.: Treatment of de Quervain disease with triamcinolone injection with or without nimesulide A randomized, double-blind, placebo-controlled trial. J Bone Joint Surg Am 2004; 86-A: 2700

Richie and Briner, 2003Richie C.A., Briner W.W.: Corticosteroid injection for treatment of de Quervain's tenosynovitis: a pooled quantitative literature evaluation. J Am Board Fam Pract 2003; 16: 102

Reference

Ferri's Clinical Advisor 2014 Fred F. Ferri , 327-327.e1 Copyright © 2014 by Mosby, an imprint of Elsevier Inc.