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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 tendons of second compartment (ECRL/B), just proximal to 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;
           - tenosynovitis occurs mainly in 2nd 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 & 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 radial nerve are identified and 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 central aspect of compartment roof, thus freeing the involved tendons;
               - it is important to leave equal halves of tendon sheath (on either side of 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
                     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 tendon sheath more dorsally, and by splinting wrist in extension for about 10 days;
     - tendon adherence:
           - w/ inadequate early mobilization, APL and EPB will become adherent, which will limit thumb IP flexion and MCP extension;
     - adherence of surgical scar

- References:

Receptor-β Expression in De Quervain's Disease.

 

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.