Duke Orthopaedics
presents
Wheeless' Textbook of Orthopaedics

DeQuervain's Disease 


- See:
      - Anatomic Snuff Box
      - First Compartment

- Discussion:
    - a stenosing tenosynovitis of APL & EPB tendons (first compartment) at the styloid process of the radius;
    - inflammation causes thickening & stenosis of synovial sheath of first compartment & pain w/ tendon movement;
    - most common in women between 30 and 50 years;
    - pts develop pain over radial styloid process (& sometimes forearm & thumb);

- Exam:
    - swelling & palpable thickening of fibrous sheath;
    - sharp tenderness over styloid process of radius;
    - Finkelstein's test:
           - pt makes fist over thumb, and ulnarly deviating wrist;
           - ulnar deviation stress is applied to index metacarpal;
           - positive test is indicated by exquisite pain in region of radial styloid this test may also be positive in pts w/ CMC DJD;
           - sharp pain at this site is also produced by active extension & abduction of the thumb against resistance;

- Differential diagnosis:
    - Diff Dx of Radial Wrist Pain
    - DJD of CMC joint
         - grind test will be negative in DeQuervain's but positive in DJD;
                - performed by forcefully pushing thumb against CMC joint, while also rotating it slightly, to cause a grinding motion;
         - typically, the pain will be located on volar side of the wrist;
    - Intersection Syndrome:
         - tendons of first compartment may cross over the tendons of the second compartment (ECRL/B), just proximal to the extensor retinaculum;
         - caused by irritation at the intersection of the outrigger muscles, ie. between (APL, EPB) and the (ECRL/ECRB), about 4 cm proximal to wrist joint;
           - resultant tenosynovitis occurs mainly in the second compartment, and steroid injections into this compartment relieve most symptoms;
    - Wartenberg's Syndrome:
         - isolated neuritis of the superficial radial nerve;
         - may have positive Tinel sign;
         - may be caused by tight jewelry;

- Radiographs:
    - if diagnosis is in doubt, consider obtaining a Roberts view, inorder to profile the CMC joint (see CMC arthrosis);

- Non Operative Treatment:
    - thumb spica splint;
          - this needs to be applied to maximize function (ie allows pinch);
    - steroid injection:
          - symptoms are relieved by injecting steroids into sheath or placing thumb spica in cast for about 1 mo, or both;
          - some surgeons advocate repeated steroid injections, noting that the results of surgical release can be unpredictable;
          - dexamethasone (clear cortisone preparation) can be used to minimize depigmenation and subcutaneous fat atrophy, which is common w/thin skin & pigmented skin;
                  - 1.5 inch no 27 needle is used instead of 5/8 inch needle, & fluid is injected from distal to proximal thru 1st dorsal compartment;
                  - injection must be beneath the retinaculum and not subcutaneous;

- Surgical Treatment:
    - surgical anatomy:
    - may use local anesthesia;
    - incision: may use either transverse or longitudinal incision;
         - longitudinal incision: - fewer complications related to iatrogenic radial sensory neuropathy;
         - oblique incision: allows for extended distal exposure, if needed;
         - transverse: higher risk of injury to superficial radial nerve;
    - superficial branches of the radial nerve are identified and should be rerouted away from first compartment tendon sheath (if necessary);
               - leaving them adjacent to the tendon sheath may allow them to become entrapped in scar tissue postoperatively;
    - decompression of first dorsal compartment:
         - directly visualize the distal edge of the first compartment sheath;
         - thickened sheath is opened w/ longitudinal incision thru the central aspect of compartment roof, thus freeing the involved tendons;
               - it is important to leave equal halves of the tendon sheath (on either side of the tendons) inorder to avoid postoperative instability;
               - preserving retinacular flaps will help to prevent prolapse w/ wrist flexion or extension;
         - search for anatomic abnormalities, and release more tendon sheath if necessary;
               - must have positive identification of the EPB (5% absent)
               - note possibility of separate fibroosseous canal for EPB tendon;
               - multiple slips of APL tendon are also common;
    - determine if there is any instabilty:
         - flex and extend the wrist, and note if there is a tendency for subluxation;
         - if subluxation is present, then loosely oppose the edges of the tendon sheath w/ a horizontal matress stitch;
               - it is permissible for these flaps to gap open, if tendon stability has been restored;                
   - rongeur bony prominences;
   - start early ROM of thumb, but w/ wrist splinted in 10 deg of extension for 2 weeks to prevent volar tendon prolapse;

- Complications:
     - nerve entrapement and/or neuroma formation:
           - ulnar branch of the of superficial radial nerve parallels the first compartment tendons and becomes adherent to the opened tendon compartment roof;
           - positive Tinels, hypesthesia;
     - inadequate decompression of involved tendons: (EPB tendon & APL);
           - often there are multiple slips of the APL and complete compartmentalization of the EPB;
           - inadequate release of the EPB is tested for by placing thumb in maximum abduction and by then asking the patient to extend the proximal phalanx against resistance (tenderness indicates persistent stenosis);
     - tendon instability
           - subluxation may result from extreme radial release of extensor retinaculum;
           - tendons may subluxate volarly during wrist flexion, causing a painful snapping sensation;
           - this condition may be avoided by incising the tendon sheath more dorsally, and by splinting the wrist in extension for about 10 days;
     - tendon adherence:
           - w/ inadequate early mobilization, the APL and EPB will become adherent, which will limit thumb IP flexion and MCP extension;
     - adherence of surgical scar



Anatomical variations in the first extensor compartment of the wrist. A clinical and anatomical study.

Treatment of de Quervain tenosynovitis. A prospective study of the results of injection of steroids and immobilization in a splint.

Atypical mycobacterium soft-tissue infection of the dorsal radial wrist: a possible complication of steroid injection for de Quervain's disease..

Common variations of the radial wrist extensors.  



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Thursday, October 4, 2012 1:01 pm

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