Slide 1

-Dr. YeshwanthDe Quervains Tenosynovitis

IntroductionNamed after a Swiss surgeon, Fritz de Quervain, who first described the problem in 1895.

De Quervain disease is a stenosing tenosynovitis of the first dorsal compartment of the wrist containing Abductor pollicis longus and Extensor pollicis brevis.

It is characterised by degeneration and fibrosis of the tendon sheath.

Occurs most often in individuals age between 30 and 50 years

It affects women up to six times more often than men

Is commonly associated with dominant hand.

Anatomy Six fibro-osseous tunnels representing the dorsal compartments surround the extensor tendons and function to prevent bowstringing of the extensor tendons

The first dorsal compartment is approximately 2 cm long and is located over the radial styloid proximal to the radio-carpal joint

The abductor pollicis longus and the extensor pollicis brevis tendons pass through this compartment

The APL originates on the distal third of the radius and has multiple slips (2 to 4), with variable insertions on the base of the thumb metacarpal and trapezium.

The primary function of the APL is to abduct the thumb and assist with radial deviation of the wrist

The EPB originates on the dorsal surface of the radius and the interosseous membrane and inserts on the base of the proximal phalanx of the thumb.

The EPB functions to extend the metacarpophalangeal joint and to weakly abduct the thumb

Etiology The etiology is thought to be secondary to repetitive or sustained tension on the tendons of the first dorsal compartmentPossible etiologies include TraumaIncreased frictional forces Anatomic Variations that include septation of the first dorsal compartment and the presence of multiple slips of the APL and, occasionally, of the EPB tendon

Biomechanical compression,Repetitive microtrauma Inflammatory disease, and Increased volume states, such as occurs during pregnancy

Pathophysiology Resisted gliding of the APL and the EPB within the narrowed canal

Fibroblastic response, resulting in thickening and swelling of the compartment

Degeneration

Microanatomic findings of the tendon sheaths and synovium showed thickening of the tendon sheaths to be up to five times because of deposition of dense fibrous tissue, increased vascularity of the tendon sheaths, and accumulation of mucopolysaccharides, which are indicators of myxoid degeneration

Notably, the synovial linings were preserved and were histologically normal.

These changes indicate that de Quervains is a result of an intrinsic degenerative mechanism rather than an inflammatory one.

Clinical featureslocalized pain along the radial side of the wrist -Gradual in onset -Aggravating on grasping and raising objects with the wrist in neutral rotation

Localised swelling may be seen.

Tenderness along the radial styloid

The Finkelstein test is positive: (on grasping the patients thumb and quickly abducting the hand ulnarward produces excruciating pain over the styloid tip)

Differential diagnosisIntersection syndrome Radial styloid fractureScaphoid fractureBasilar arthritis of the thumb andRadial neuritis

InvestigationsDiagnosed is mainly through clinically

Wrist imaging is required only in the presence of associated processes such as previous distal radius or scaphoid fracture, arthritis of the thumb, and instability of the wrist

Conservative Treatment Nonsurgical treatment should be the first course of action for de Quervain disease. The patient presenting with mild to moderate pain that does not limit activities of daily living may be treated with - Rest, Splinting, Nonsteroidal anti-inflammatory drugs orcorticosteroid injection.

Splinting is an effective method for resting the APL and EPB tendons by immobilizing the thumb and wrist in a single position and reducing or preventing the friction

An ideal splint is a radial thumb spica extension splint that holds the wrist in neutral and the thumb in 30 of flexion and 30 of abduction.

Corticosteroid injectionCorticosteroid injection into the first dorsal compartment is perhaps the most common and effective treatment of de Quervain disease.

Failure of response to corticosteroid injection has been attributed to poor technique and anatomic variations within the first dorsal compartment

With the wrist in neutral radioulnar deviation, a rolled-up towel is placed under the wrist to position it in slight ulnar deviation

The course of the APL and EPB tendons along the radial styloid is palpated, and the borders of the first dorsal compartment are straddled with the opposite thumb and index finger.

A 25-gauge needle is introduced into the tendon sheath at the level of the styloid, parallel to the tendons..

The needle is carefully backed out while maintaining pressure on the plunger of the syringe.

The injectable medication should flow smoothly and easily, with both visual and palpable inflation of the compartment.

An additional injection may be offered after a 4- to 8-week interval for the patient who has experienced some improvement with the initial injection

When pain does not resolve after two corticosteroid injections and 6 months of nonsurgical management, then surgical release of the first dorsal compartment is recommended.

Complications Neuritis,Fat necrosis, and Postinjection flareSub dermal atrophy andHypopigmentation

Surgical treatment

Surgical treatment is based on release of the fibro-osseous roof of the first dorsal compartment and decompressing the stenosed APL and EPB tendons

Under local anesthesia, with or without intravenous sedation, and tourniquet control, a transverse or oblique incision is given over radial styloid

The skin is retracted and careful blunt dissection will reveal branches of the radial sensory nerve in the subcutaneous tissueRadial sensory nerve is identified and protected with blunt retractors

Dissection is then carried down to the first dorsal compartment. The retinaculum of the first dorsal compartment is completely incised with in line with the APL and EPB tendons

Any intra-compartmental septae should be released and excised.

Anatomic variations of the compartment are the rule rather than the exception.

Active and free thumb abduction and extension then can be performed on the awake patient

Postoperatively, thumb and hand motion is immediately encouraged except for forceful wrist flexion, which may predispose the tendons toward subluxation during the first 2 weeks after surgery

Complications Radial sensory nerve injury

Incomplete decompression,

Volar subluxation of the tendons