De Quervain's Tenosynovitis

Original Editor - Elizabeth Dallas, Boris Alexandra

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Clinically Relevant Anatomy

APL & EPB

De Quervain's tenosynovitis involves the abductor pollicis longus and the extensor pollicis brevis tendons.

M. extensor pollicis brevis (EPB)

• origin: ½ dorsal side of the radius, the membrana interossea
• insertion: base of the proximal phalanx of the thumb
• function: - wrist joint: radial abduction
               - thumb: extension
• innervations: N. radialis
• artery: A. interossea posterior

M. abductor pollicis longus (APL)

• origin: dorsal side of the radius and the ulna, the membrana interossea
• insertion: base of ossis metacarpi I
• function: - wrist joint: radial abduction
               - thumb: abduction
• innervations: N. radialis
• artery: A. interossea posterior

The retinaculum mm. extensorum is a strong, fibrous structure that holds all the wrist extensors into place. I’is located on the dorsal side of the wrist.

Definition/Description

De Quervain’s tenosynovitis is an inflammation of the tendons of m. extensor pollicis brevis (EPB) and the m. abductor pollicis longus (APL). These muscles are located on the dorsal side of the forearm and go to the lateral side of the thumb through a fibrous-osseous tunnel made of the processus styloideus radii and the retinaculum mm. extensorum. [1]

Epidemiology /Etiology

It’s common in sports like golf, bowling, tennis, mountain bike and it includes mothers of young children, computer keyboards operators, engine drivers,… .

It’s caused by repetitive use of the thumb in combination with radial deviation of the wrist. (pinching, wringing, lifting, grasping, gardening, knitting). In this position the tendons of the EPB and the APL are pressed to the processus styloideus and when the movement is repeated frequently it can cause irritation of the tendons by friction. The tendons swell, the tunnel becomes too small. [1]  It is often diagnosed in patients between 30-50 years. De Quervain syndrome is 10 times more frequent in women than men.

In the technology age is has been nicknamed “Blackberry Thumb”

Clinical Presentation

DeQuervains occurs in women 8-10 times more often than men. The condition can be sudden or gradual. Presents most commonly with pain, swelling and tenderness on the radial side of the wrist at the base of the thumb (first dorsal compartment) as well in rest as in radial deviating of the wrist. Abduction of the thumb is also painful. The pain can radiate into the forearm and distally into the thumb. [3] [4] Symptoms increase with pinching, grasping, and gripping activities. New mothers are prone to this due to child care tasks with lifting, holding and feeding placing the hand in awkward positions; as well as hormonal changes.

Differential Diagnosis

1. Osteoarthritis of the first CMC 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 - isolated neuritis of the superficial radial nerve, can be caused by tight jewelry

Diagnostic Procedures

Finkelstein's Test

Symptoms 

• Pain, tenderness and swelling at the base of the thumb.
• Pain can also radiate proximally into the forearm and distally into the thumb.
• Difficulty of movement of the thumb and wrist with activities such as grasping, pinching and crepitus (creaking sound).

Finkelstein-test 

It’s a pain provocation test.[3]

Examination

Finkelstein test 

The patient has to make an thumb adduction or an clenched fist in combination with an ulnar deviation. The patient feels pain on the radial side of the wrist around the processus styloideus.

Medical Management (current best evidence)

Surgery is indicated if conservative therapy doesn’t help to improve the symptoms and complains of the patient. It’s also indicated when the patient relapses. [3]

Surgery:
The sheath of the first dorsal compartment is opened longitudinally for decompression.

Physical Therapy Management (current best evidence)

The goals are to decrease the pain and the inflammation

Conservative therapy consists of:
- Rest by activity modification and the use of a thumb and wrist splint for 6 weeks
- Ice or cold packs
- Use of Non-Steroidal Anti-Inflammatory Drugs (NSAID’s): oral medication, phonophoresis or iontophoresis
- corticosteroid injections

Exercise is not practised because it can increase the pain and irritation of the tendons. There is not enough information about the benefit of exercise on De Quervain's syndrome.

Key Research

• KANEKO, S., TAKASAKI, H., MAY, S., ‘Application of Mechanical Diagnosis and Therapy to a Patient Diagnosed with de Quervain’s Disease: A Case Study’, Journal of hand therapy, 2009.
• KNOBLOCH, K., GOHRITZ, A., SPIES, M., VOGT, M.P., ‘Neovascularisation in de Quervain’s disease of the wrist: novel combined therapy using sclerosing therapy with polidocanol and eccentric training of the forearms and wrists—a pilot report’, Springer, 2008.
• FOURNIER, K., BOURBONNAIS, D., BRAVO, G., ARSENAULT, J., HARRIS, P., GRAVEL, D., ‘Reliability and Validity of Pinch and Thumb Strength Measurements in de Quervain’s Disease’, Journal of hand therapy, 2006.
• ANDERSON, M., TICHENOR, C.J., ‘A Patient With De Quervain's Tenosynovitis: A Case Report Using an Australian Approach to Manual Therapy’, Physical therapy, 1994, nr 4, vol 74, p. 314 – 326.

Resources

• http://www.medicinenet.com/de_quervains_tenosynovitis/article.htm
  

Recent Related Research (from Pubmed)

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