De Quervain's tenosynovitis

Definition

De Quervain' s tenosynovitis is the thickening of the fibrous sheath enclosing the tendons of the thumb causing their compression and pain.

‍The tendons affected by De Quervain's tenosynovitis

Pathology

De Quervain's tenosynovitis consists in the inflammation of the extensor pollicis brevis and abductor pollicis longus tendons, which are connected to the homonymous muscles. These tendons are enclosed in a fibrous-osseus sheath or synovium on the dorsal side of the forearm that extends along the lateral thumb. The thickening of the synovium is thought to result from repetitive movement of the thumb in combination with radial deviation of the wrist. Over time this action causes the irritation and swelling of the tendons, which are compressed (stenosis) within thicker synovial sheath. This causes pain over the radial styloid process.

Colles' fracture with bone displacement seen before (left) and after closed reduction (right) in a cast

Classification

The fractures of the distal radius are defined with various classification systems including the AO (Arbeitsgemeinschaft fuer Osteosynthese) system. They relate to the mechanisms of injury and bone fracture characteristics and provide a guideline towards suitable treatments. The most frequent types of distal radius fracture are:

No 1.

Colles’ fracture is the most common type of fracture in which the distal bone of the radius tilts upwards following an outer bending of the wrist as it happens when falling on the hand

Smith’s fracture or reversed Colles’ fracture occurs when the distal portion of the radius tilts downwards following the inward bending of the wrist

Barton fracture is an intra-articular fracture of the distal radius with dislocation of the radiocarpal joint

Chauffeur fracture is an intra-articular fracture of the radial styloid process, also known as Hutchinson fracture or backfire fracture.

Left: Distal radius intraarticular, displaced fracture; Middle: Older distal radius fracture with callus formation; Right: Distal radius and ulna fracture, extraarticular and displaced

No 2.

Intra-articular fracture extends to the wrist joint (or articulation)

Extra-articular fracture is located outside of the wrist joint

Open fracture when bone fragments perforate the skin

Comminuted fracture when the bone breaks into multiple fragments

Non-displaced when the anatomical alignment of the bone is maintained or displaced when the bone fragments move apart.

Melone’s classification describes the characteristics of intra-articular fractures of the radius:

i    Stable fracture

ii    Unstable "die-punch"

iii   "Spike" fracture

iv Split fracture

v   Explosion injuries

Acetabular fracture of the pelvis

Acetabular fractures

These fractures are divided into:

Anterior pillar (not weight bearing part of joint)

Posterior pillar (often associated with dislocation of the hip including the weight bearing part of joint)

Transverse

Comminuted involving both column type 

Sacral / coccygeal fractures

The sacrum is a triangular-shaped bone formed by 5 fused vertebrae, which provide a posterior wall to the pelvic ring. At each side of the sacrum, the ala structures articulate with the ilium bones forming the sacro-iliac joints. Sacral fractures are usually parallel to the spine and can involve the ala. Less frequently sacral fractures may display an “H” shape, including a transversal fracture uniting both sides of the sacrum. Three zones are described where sacral fractures can occur that are along vertical lines relative to the alignment of the foramina. Sacral fractures may result in sacral instability and require treatment via sacroplasty (injection of bone glue into the fracture). Surgery is necessary in case of associated neurological symptoms.

Fractures of the coccyx involve the tailbone, the terminal portion of the spine situated below the sacrum formed by 3 to 5 fused vertebrae. Coccyx fractures occur when falling on a seated position. They are more common in elderly women and seldom require surgical treatment.

Golfin is a risk factor for De Quervain's tenosynovitis

Causes

De Quervain's tenosynovitis mostly occurs in women of 30-50 years of age. Overuse of the thumb and wrist seems to be the main cause of this pathology mostly due to manual activities during carpentry work, sport driving and prolonged work with computers. It also occurs with a sudden and direct blow to the dorsal side of thumb/wrist.

Prolonged sewing is a risk factor for De Quevain's tenosynovitis due to repetitive thumb activity

Risk factors

The risk factors to develop De Quervain's tenosynovitis are:

Sport (golf, bowling, tennis, mountain bike, rowing, racquets sports)

Manual work (carpentry, painting, sewing, writing, overuse of hammer/screw driver)

Predisposition to rheumatoid diseases

Use of computers

Lifting children or heavy bags (young mothers)

Presence of narrower synovial sheath of the first extensor tendon of the thumb.

Pain along the thumb line up to the radial side of the wrist is a common symptom of De Quervain's tenosynovitis

Symptoms

De Quervain's tenosynovitis causes pain and tenderness at the radial/thumb side of the wrist below the base of the thumb. These symptoms develop gradually over time. Pain can radiate to the forearm or to the tip of the thumb and is exacerbated during pinching and grasping activities. Other symptoms include:

Catching and snapping sensation during thumb movement

Numbness back of the thumb and index finger

Swelling and redness in the area affected.

Finkelstein manouvre for the diagnosis of De Quervain's tenosynovitis

Diagnosis

De Quervain's tenosynovitis is simply diagnosed with medical examination. It is important to assess the potential causes from life style or professional activities leading or exacerbating the condition to prevent recidivism. 

The Finkelstein manoeuvre is used during medical examination. This test is positive if pain is elicited when the thumb is bent across the palm, the fingers are flexed over the thumb and the hand is moved into ulnar deviation.

Ultrasound image of the extensor pollicis brevis tendon reveals ongoing inflammation and swelling

Ultrasound is an imaging technique used to visualise changes in the structure of the tendons. Occasionally a MRI can be recommended in more severe cases.

Differential diagnosis for arthritis of the first carpo-metacarpal joint of the thumb and other inflammatory conditions of the wrist is recommended.

Treatment

Steroid injection around the extensor pollicis brevis tendon for prolonged symptoms

Nonoperative treatment

Conservative treatment includes the immobilisation for up 2 - 4 weeks with a spica cast to allow minimal movement of the thumb. Additional treatments include:

Rest

Ice pads

Administration of NSAIDs

Painkillers

Local steroid injection

Physiotherapy

‍Surgical decompression of the tendon compartment may lead to radial nerve injury

Surgical treatment

Surgery is required in case of repetitive tenosynovitis or when conservative treatment is ineffective for pain relief. Surgery aims to decompress the first dorsal compartment of the tendons. The thickened sheath is opened surgically with a longitudinal incision to release the extensor pollicis brevis and abductor pollicis longus tendons. A spica cast is applied for 4 weeks after surgery. The efficacy of surgery has been questioned.

Complications

Surgery may lead to the following potential complications:

Injury to the sensory branch of the radial nerve

Insufficient decompression (persisting symptoms)

Excessive decompression (tendon instability and loss of pulley)

Tendon adherence to surgical scar

Gentle stretching of the wrist is useful to recover from De Quervain's tenosynovitis

Rehabilitation

A physical or occupational therapist recommend exercises to restore flexibility and strength of the thumb and wrist (i.e. thumb opposition, extension and flexion) when most symptoms have subsided. Standard rehabilitative therapy also includes:

Massage

Stretches

Electrotherapy

Activity modification advice

Return to activity plan

Taping / bracing

Taping along the thumb avoids strain to the extensor pollicis brevis tendon

Prevention

The main preventative measures aim at reducing the risk of future De Quervain’s tenosynovitis and avoid those repetitive activities that caused the condition. Common preventive strategies are:

Thumb taping

Ergonometric education for proper posture while performing physical activities

Technique correction

Exercise to improve flexibility and strength