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De Quervain tenosynovitis
From WikEM
Contents
Background
- Tenosynovitis of abductor pollicis longus (APL), extensor pollicis brevis (EPB)
- Groove of radial styloid
- First extensor compartment
- Middle-aged, more common in women
- Associated with rheumatoid arthritis, SLE
- Overuse of the thumb[1]
- Classically mothers that frequently lift infants
- Or secretarial, nursing occupations
- Recently, over-texting on phones has increasingly been the culprit
Clinical Features[2]
- Pain along radial aspect of wrist (may radiate to thumb or extend into the forearm)
- Painful abduction of thumb
- Decreased grip strength
- Swelling at tendon sheath along radial styloid
- Positive Finkelstein, pathognomonic
- Patient grasps thumb in palm of the hand and ulnar deviates the thumb and hand
- Stretches the tendons over the radial styloid producing sharp pain
- Negative Phalen and Tinel test
Differential Diagnosis
Hand and finger injuries
- Radiograph positive
- Radiograph negative
- Dupeytren contracture
- Boutonniere deformity
- Hand and finger tendon injuries
- Ganglion cyst
- De Quervain tenosynovitis
- Intersection syndrome
- Drummer's wrist
- Extensor digitorum tenosynovitis
- Vaughn Jackson syndrome
- Snapping Extensor Carpi Ulnaris
- Compressive neuropathy, "bracelet syndrome"
- Scaphoid fracture
- Osteoarthritis
- Infiltrative tenosynovitis
- Gout
- Rheumatoid arthritis
- Trigger finger
- Mallet finger
- Jersey finger
- Jammed finger
- Subungual hematoma
- Fingertip laceration
- Metacarpophalangeal (MCP) ulnar ligament rupture (Gamekeeper's thumb)
- Nail avulsion
- High-pressure injection injury
Workup
- ESR usually normal[3]
- Consider arthrocentesis for joint effusion to evaluate for crystals, gram stain, culture
Imaging[4]
- Plain films usually nondiagnostic
- May see soft tissue swelling or radial styloid sclerosis or erosion
- Important to rule out fracture, gas formation, late osteomyelitis
- US diagnostic
- Thickened extensor retinaculum overlying radial styloid
- Thickened APL and EPB under extensor retinaculum, as contrasted with unaffected wrist
- Edema surrounding tendons within first dorsal wrist compartment
- Surrounding hyperemia on Doppler within peritendinous subcutaneous area
- Intertendinous septum (hypoechoic area between EPB and APL) increases need for operative management[5]
Management
- Splint thumb and wrist
- Instruct patient to remove splint briefly each day to perform range-of-motion exercises
- NSAIDs for 10-14 days
- Persistent cases may require steroid injection or surgical decompression
- First steroid injection provides permanent relief in ~50%
- Intertendinous septum presence increases likelihood of needing surgery[8]
Disposition
- Rheumatology referral for joint injections and conservative treatment
- Hand surgery outpatient referral for failed conservative management
See Also
- Radiograph-Negative Hand and Finger Injuries
- See Dr. Nabil Ebraheim's video on dorsal wrist compartment syndromes
References
- Diop AN, Ba-Diop S, Sane JC et-al. [Role of US in the management of de Quervain's tenosynovitis: review of 22 cases] J Radiol. 2008;89 (9 Patient 1): 1081-4.
- Sawaizumi T, Nanno M, Ito H. De Quervain's disease: efficacy of intra-sheath triamcinolone injection. Int Orthop. 2007;31 (2): 265-8.
- ↑ Ashurst JV et al. Tenosynovitis Caused by Texting: An Emerging Disease. The Journal of the American Osteopathic Association, May 2010, Vol. 110, 294-296.
- ↑ Keon-Cohen B. De Quervain disease. J Bone Joint Surg Br. 1951;33-B(1):96-99 http://www.jbjs.org.uk/cgi/reprint/33-B/1/96.
- ↑ Ferri FF. Ferri's CLinical Advisor 2013. Elsevier Health Sciences, Jun 1, 2012.
- ↑ Kamel M, Moghazy K, Eid H, Mansour R. Ultrasonographic diagnosis of de Quervain tenosynovitis. Ann Rheum Dis. 2002;61(11):1034-1035. ../docss/v061p01034.pdf.
- ↑ Kwon BC et al. Sonographic Identification of the Intracompartmental Septum in de Quervain’s Disease. Clin Orthop Relat Res. 2010 Aug; 468(8): 2129–2134.
- ↑ Pagonis T, Ditsios K, Toli P, Givissis P, Christodoulou A. Improved corticosteroid treatment of recalcitrant de Quervain tenosynovitis with a novel 4-point injection technique. Am J Sports Med. 2011 Feb. 39(2):398-403.
- ↑ Stephens MB. Musculoskeletal Injections: A Review of the Evidence. Am Fam Physician. 2008 Oct 15;78(8):971-976.
- ↑ Stoller DW, Tirman PF, Bredella MA. Diagnostic imaging, Orthopaedics. Amirsys Inc. (2004) ISBN:0721629202.
