Word count: 1996



Word count: 1996

DeQuervains's Disease or Stenosing Tenosynovitis of the First Dorsal Compartment of the Wrist

Troy Birk

Kevin G. Shea

University of Utah Medical Center

Salt Lake City, Utah 84102

Nearly a century has passed since Fritz de Quervain (1) first published his studies of the disease which now bears his name. The disease consists of inflammation of the first extensor compartment of the wrist. Although given credit for the recognition of this disease it should be noted that both Tillaux and Gray wrote of this inflammatory process prior to the publications of de Quervain in 1895. The extensive studies of de Quervain in 1895 and then again in 1912 gained him credit for recognition of this disorder.

Anatomy

To understand de Quervain's disease it is essential to have a basic understanding of wrist anatomy. The human wrist consists of numerous compartments, or tunnels, through which muscle tendons pass as they travel from their origin in the forearm to their destination in the hand and fingers. The dorsal surface or back of the wrist contains six of these compartments. The first compartment, with the numbering beginning on the thumb side, normally contains the tendons of the abductor pollicis longus and the extensor pollicis brevis. These two muscles enable the thumb to move away from the body of the hand (abduction) and extend upwards from the hand (extension).

The forearm consists of two bones, the radius and ulna; references to their location provide anatomical orientation for the arm and wrist. The ulna is on the same side as the little finger while the radius is on the thumb side. The two tendons involved in de Quervain's disease are found along the border of the radius and form an edge of what is known of as the "anatomical snuff box." It can easily be identified on the back of the wrist. By placing the thumb in abduction-extension a depressed area forms proximal to the thumb. The radial border of this depression is formed by the tendons of the extensor pollicis brevis and the abductor pollicis longus while the ulnar border is formed by the tendon of the extensor pollicis longus.

The compartment, through which the tendons pass, is lined with synovium which secretes synovial fluid. This fluid, in turn, acts as a lubricant for the excursion of the tendons as they pass from the radius, over the radial styloid and on to their distal insertions in the thumb. These tendons undergo a normal amount of angulation in reaching their destination with an increase in the amount of angulation when tension is placed on the tendons. The degree of angulation has been shown to be greater in the female wrist than in the male wrist.

Etiology

Many causes have been proposed for de Quervain's disease. At the time of its discovery it was a common problem that housewives acquired from wringing clothes dry. It is also well described in assembly line workers. Recently it has been associated with strenuous off-road mountain biking. It has been associated with direct trauma to the radial aspect of the wrist through both falls and fractures. Metabolic abnormalities, including pregnancy and child birth, are also risk factors for the development of the disease. Anatomic variations, as well, contribute to an increased incidence of de Quervain's disease.

A factor that is common to a majority of cases has been found to be activities involving strong continuous repetitive motions of the wrist and thumb. (2) Grasping, pinching, flexion-extension, adduction-abduction of the thumb combined with wrist rotation while doing repetitive forceful vibratory actions seems to have the strongest association.(2-4) The washerwoman is repeatedly grasping and rotating her wrists while the mountain biker executes thousands of extension-abduction movements in one grueling ride.(5) These movements place the tendons of the first dorsal compartment at various degrees of angulation over and over again. It appears that this may eventually lead to inflammation as a result of friction where the tendons form sharp angles as they pass the radial styloid. Eventually this can lead to thickening of the tendon sheath causing constriction of the underlying tendons and thus producing symptoms of de Quervain's disease.

Clinical Features

Most patients that have de Quervain's disease are in the range of 30-50 years of age. It is found in women ten times more often than in men. Clinically the patient presents with a chief complaint of pain. The pain is mainly located over the radial styloid, but it may also radiate into the forearm proximally and into the thumb distally. Pain in the dorsum of the thumb can be constant and aching. The pain is aggravated by ulnar deviation of the wrist, thumb flexion and adduction, and also by simple abduction of the thumb.

Swelling is another commonly seen feature and will be localized mainly in the area of the radial styloid. The swelling may be visually apparent on some occasions and only palpable on others. The extensor sheath may both feel and appear thickened.

Weakness of hand functions involving the wrist or thumb can also be associated with de Quervain's disease. Some patients will report a sense of diminished grip or pinch strength which can be quite significant since the hand depends on normal thumb function to accomplish numerous tasks. This disease can make routine tasks seem impossible.

An additional finding in some patients is crepitation. This occurs as the tendons move through an inflamed sheath and gives the sensation of crackling or grinding.

Diagnosis

It is necessary to first obtain an accurate history consisting of when the pain began, the pain location, any precipitating factors, the patient's occupation, and any other pertinent information. The information a good history supplies will allow a more organized and complete physical exam to be conducted.

The patient will have pain and tenderness localized over the first dorsal compartment with radiation of the pain as previously described. Swelling will be noticeable in some patients. Crepitation and weakness may also be found on occasion.

A test that has been found to be sensitive, although not specific, for establishing the diagnosis of de Quervain's disease is known as the Finkelstein test.(6) It is accomplished by having the patient grip the affected thumb firmly in the palm of the hand while the examiner deviates the hand in an ulnar direction. This procedure places a maximal stress on the involved tendons and a positive result consists of excruciating pain. It must be understood that this test can be uncomfortable even in people with completely normal wrists. A thorough exam should always include a similar examination of the unaffected wrist with subsequent comparison and contrast of any findings.

Another test that can aid in the diagnosis has been referred to as the "hitchhikers test."(7) In this test pain is elicited by resisted thumb extension at the metacarpophalangeal joint. This too is indicative of de Quervain's disease.

Finally since it is possible to have a positive Finkelstein test in other diseases, specifically basal joint arthritis, an additional test should be utilized. The axial compression-rotation or torque test will be helpful to differentiate between the two diseases.(1, 8) This test applies a rotational motion to a compressed and slightly flexed thumb. This will result in severe pain in basal joint arthritis but not in de Quervain's disease.

Treatment

The primary treatment goals in de Quervain's disease are decreasing the pain and inflammation and returning the patient to normal function. Treatment can occur either by nonsurgical or surgical means.

Most physicians would initially advocate a nonsurgical approach. This would consist of first advising the patient to stop or decrease the inciting activity. This would probably be accompanied by a prescription for a nonsteroidal anti-inflammatory drug such as ibuprofen or naprosyn. The patient would be advised to apply ice to the area for 10-15 minutes three or four times a day. Some physicians would also apply a splint to immobilize the wrist and thumb with further instructions in daily range of motion exercises.

If these initial measures failed to resolve the pain and inflammation the next likely course of action would be the injection of steroids directly into the tendon compartment. This is accomplished by inserting the needle straight into the tendon and then withdrawing until the needle is in the tendon sheath. Correct placement of the needle is confirmed by free flow through the needle as well as a linear distention outward in the area of the tendon. A single steroid injection has been curative in the majority of patients but if symptoms persist one to two more injections may be attempted prior to considering surgical treatment.(9) Repetitive steroid injection is associated with loss of muscle mass, subcutaneous and cutaneous atrophy, and tendon rupture. These side effects demand careful usage of steroid injections.

A possible cause for steroid failure is the existence of a separate compartment for the tendon of the extensor pollicis brevis. Another possibility is the existence of multiple tendon slips from the abductor pollicis longus. These may also be found outside of the first compartment. The steroid injection would thus fail secondary to only delivering the steroid to one of the two offending tendons and tendon slips.

With failure of all nonsurgical measures it is necessary to proceed to surgical decompression of the tendon compartment. This is accomplished by incising the tendon sheath with a longitudinal incision. Some physicians will simply open the compartment while others feel it is necessary to remove the tendon sheath completely from around the tendon.

At the time of surgery it is important to verify that the tendons of both the extensor pollicis brevis and the abductor pollicis longus are in the compartment that has been released. The existence of a separate compartment for the extensor pollicis brevis appears to be a fairly common anatomical variation in patients with de Quervain's disease and is found in a large percentage of those that end up requiring surgery to cure this problem. Failure to release both tendons will result in persistent symptoms.

Although this is felt to be a simple procedure, there are many possible complications. The most common and possibly most significant is damage to the superficial radial nerve. It courses through this area and care must be taken to avoid injuring it. Its injury can result in a loss of sensation distal to the damage or in the development of a painful neuroma.

Summary

De Quervain's disease can occur in anyone; from washerwoman to mountain biker. Its presentation is one of pain and inflammation in the tendons of the first dorsal compartment of the wrist. A thorough history and physical exam will confirm the disease and

allow for appropriate treatment. Nonsurgical treatment is frequently effective but resistant cases may require surgical intervention.

References

1. De Quervain, F: Uber eine Form von chronischer tendovaginitis. Corresp.-Blatt Schweizer Arzte, 25: 389-394,1895.

2. Armstrong TJ, Fine LJ, Goldstein SA, et al: Ergonomic considerations in hand and wrist tendinitis. J Hand Surg (Am) ;12(5 pt 2):830-837, 1987.

3. Armstrong TJ: Ergonomics and cumulative trauma disorders, in Kasdan M (ed): Hand Clinics. Philadelphia, WB Saunders Co, 2(3):553-565, 1986..

4. Armstrong TJ, Radwin RG, Hansen DJ, et al: Repetitive trauma disorders: job evaluation and design. Hum Factors 28(3):325-336, 1986.

5. Shea KG, Shumsky IB, Shea OF: Shifting into wrist pain: de Quervain's disease and off-road mountain biking. Physician Sportsmed. 19(9):59-63, 1991.

6. Finklestein, H: Stenosing tendovaginitis at the radial styloid process. J Bone Joint Surg 1930;12:509-540.

7. Kirkpatrick WH: de Quervain's disease, in Hunter JM, Schneider LH, Mackin EJ, et al (eds): Rehabilitation of the Hand: Surgery and Therapy, ed 3. St. Louis, CV Mosby Co, 1990, pp 304-307.

8. Lister G: The Hand: Diagnosis and Indications. Edinburgh, Churchill Livingstone, 1977, pp 128-129.

9. Harvey FJ, Harvey PM, Horsley MW: De Quervain's disease: surgical or nonsurgical treatment. J. Hand Surg. ;15A(1):83-87, 1990.

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