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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.