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de Quervain's tenosynovitis (stenosing tenosynovitis)
Overuse syndrome involving the extensor & abductor tendons of the thumb.
Etiology:
1) repetitive use or overuse of the hands
2) association with rheumatoid arthritis
3) association with pregnancy
Epidemiology:
1) more common in women, M:F ratio = 1:10
2) generally occurs age 30-50
- especially in women in postpartum period [5]
3) seen in occupations: clerical, assembly
Pathology:
- stenosing tenosynovitis of the 1st dorsal retinacular compartment of the wrist involving tendons of the:
1) extensor pollicis brevis
2) abductor pollicis longus
Clinical manifestations:
1) pain over the styloid process of the radius
2) pain in the anatomical snuff box or radial aspect of wrist
3) pain may radiate down the thumb & up the lateral forearm
4) pain occurs with use of the thumb
5) pain intensified by ulnar flexion of the wrist with thumb folded into the palm & fingers flexed over thumb (Finkelstein's sign)*
6) pain on the radial side of the wrist during pinch grasping [2]
7) pain with extreme extension of the extensor tendon of the thumb [2]
8) swelling
9) crepitation
* alternatively described as patient opens hand loosely, then grasps her thumb & uses it to deviate her hand in the ulnar direction towards the 5th finger [5]
Laboratory:
1) ESR is generally normal
- elevated ESR suggests other etiology
2) joint aspiration
a) examination under polarized light for uric acid crytals
b) gram stain & culture to rule out infection etiology
Radiology:
- X-ray of hand
- look for osteoarthritis of the 1st carpometacarpal joint
Differential diagnosis:
1) scaphoid fracture
2) osteoarthritis of the 1st carpometacarpal joint
3) carpal tunnel syndrome
4) gout
5) infiltrative tenosynovitis
6) radiculopathy
7) compression neuropathy involving superficial branch of the radial nerve ('bracelet syndrome')
8) infection
Management:
1) rest, splinting
2) physical therapy
3) NSAIDs
4) glucocorticoid/local anesthetic injections
a) use 20-40 mg of triamcinolone (or equivalent)
b) avoid damage to tendon
c) refereral to rheumatology or orthopedics for injection
2) surgical repair in cases recalcitrant to medical treatment
Related
abductor pollicis longus
extensor pollicis brevis
Finkelstein's sign
Useful
joint/bursa injection (knee injection, subacromial bursa injection)
General
tenosynovitis
repetitive strain disorder; repetitive motion disorder; cumulative trauma disorder; overuse syndrome
References
- Saunders Manual of Medical Practice, Rakel (ed),
WB Saunders, Philadelphia, 1996, pg 742
- Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 16,
American College of Physicians, Philadelphia 1998, 2006, 2012
- Moore JS.
De Quervain's tenosynovitis. Stenosing tenosynovitis of the
first dorsal compartment.
J Occup Environ Med. 1997 Oct;39(10):990-1002.
PMID: 9343764
- Clyman B, in: UCLA Intensive Course in Geriatric Medicine &
Board Review, Marina Del Ray, CA, Sept 12-15, 2001
- Ferri's Clinical Advisor, Instant Diagnosis and Treatment,
Ferri FF (ed), Mosby, Philadelphia, 2003, page 253
- NEJM Knowledge+ Rheumatology
- Avci S, Yilmaz C, Sayli U.
Comparison of nonsurgical treatment measures for de Quervain's disease of
pregnancy and lactation.
J Hand Surg Am. 2002 Mar;27(2):322-4.
PMID: 11901392 Clinical Trial.
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