De Quervain’sTenosynovitis

Dr. Akshita(PT) B.P.T D.C.PT Yoga Instructor Nutritionist

INTRODUCTION• It is named after Swiss surgeon, FRITZ DE

QUERVAIN who first described the condition in 1895.

• It is a stenosing tenosynovitis which affects the tendon sheaths of the 1st dorsal compartment of the wrist.

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

Incidence• 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

AnantomyThe dorsal aspect of the wrist contains six compartments that transmit the tendons to the

hand.

• 1-Abd. Pollicis longus Ext. pollicis brevis• 2- Ext.carpi radialis longus Ext. carpi radialis brevis• 3- Ext. pollicis longus• 4-Ext. digitorum Ext. indicis• 5- Ext. digiti minimi• 6- Ext. carpi ulnaris

First Dorsal Compartment

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

Abductor pollicis longus

• Originates from-posterior shaft of ulna and radius

• Inserts at-base of 1st meta carpal

• Supplied by-radial nerve• Action- abduction

+extension of thumb

Extensor pollicis bevis

• Originates from-posterior shaft of radius

• Inserts at-base of proximal phalanx

• Supplied by-radial nerve

• Action- extension of thhumb.

Predisposing Factors• Overuse injury• Repetitive tasks that involve overexertion of

thumb, radial and ulnar deviation of the wrist• Arthritis• pregnancy

Activities such as

• Wringing out wet clothes.• Long use of computer

mouse.• Use of scissors, surgical

tongs.• Texting • Hammering.• Knitting.• Lifting heavy objects such as

a jug of milk, taking a frying pan off of the stove, or mother lifting a baby out of a crib (babywrist).

EtiologyThe tendons of the abductor pollicis longus and

the extensor pollicis brevis are tightly secured against the radial styloid by the overlying extensor retinaculum.

Acute or repetitive trauma restrains gliding of the tendons results in inflammation of synovial sheath

Increases friction

Reactive fibrosis and thickening of the sheath.

Degeneration.

Clinical Features• Patient may complain

pain on the radial side of the wrist that is worsened by moving the wrist or thumb.

• Sometimes there is a visible swelling over the radial styloid.

• The tendon sheath may feels thick and hard.

• Tenderness is mostly acute at the tip of the radial styloid.

• Pain aggravates on grasping and raising objects with the wrist

• Wet leather sign • The Finkelstein test is positive.

Finkelstein test• It is a provocative test used in diagnostic for de Quervain's

tenosynovitis.• Makes a fist with the

thumb inside.• Now ask the patient to bend the wrist toward little finger

Differential Diagnosis• CMC arthritis of the thumb: pain and crepitus

present with the thumb "crank and grind test .• Scaphoid fracture: in this tenderness will be in the

anatomic snuff box. • Chauffeur's fracture • Intersection syndrome-tenosynovitis of the second

dorsalcompartment involving the tendons of extensor carpi radialis brevis (ECRB) and extensor carpi radialis longus (more proximal pain)

• Extensor pollicis longus (EPL) tendonitis of the third dorsalcompartment: common in patients with rheumatoid arthritisor with direct injury and distal radius fracture .

TREATMENT GOALS

I. Restoration of normal,painless use of the involved hand. II. Resolution of the inflammatory process.

III. Prevention of recurrence of the through education.

IV. Restoration of pain-free movements and strength .

CONSERVATIVE MANAGEMENT

Medical management• Corticosteroid injection: can be

given to patient with morderate to marked pain with symptoms lasting for more than 3 weeks.

• NSAIDS : it is precribed initially for 6 to 8 weeks to reduce pain and inflammation.

PHYSIOTHERAPY MANAGEMENT• Immoblisation : A thumb

spica splint is used to restrict thumb movement so that the first dorsal compartment tendons are at rest.

• Cold compression : for 10 to 12 minutes over the inflammed area.

• Ultrasonic therapy: pulsed mode, 3 mhz, time-5min.

• Phonophorersis :with 10% hydrocortisone.

• Gentle active and passive motion of thumb and wrist encouraged for 5 minutes every hour to prevent joint contractures and adhesions.

• Strenghtening and stretching exercises after the initial pain subsides.

Indication for decompression surgery

• Unsatisfactory symptom reduction• Persistence of symptoms after conservative

interventions.• Limitations in A.D.Ls due to pain.

After Decompression Surgery

0-2 Days Immobilization within castActive movement of IP joint: Flexion andExtension.After 48 hours of surgery dressings are removed.After this begin with gentle active motion ofthe wrist and thumb.

2-14 Days• Presurgical splint is worn for comfort and

active exercises are continued for Ipjoint, elbow and shoulder joint .

• By 10- 14 days: sutures are removed.

2-6 Weeks • Grip and pinch strengthening exercises may

begin at approximately 3 weeks and can be progressed gradually.

• By the end of 6 week the patient usually is able to resume full activities.

Ergonomics1) Ergonomic mouse: It

feature a molded thumb rest support will help reduce the amount of gripping force your thumb needs to apply to hold the mouse.

2) Use the power grip (all fingers in a loose grip) instead of using a pinch.

3) Minimize repetition and rest arm occasionally during a repetitive activity or slow down activity.

4) Use a light grip on tools, pens, the mouse.

5) Alternate hands during activities if possible

Case Study • Name - Hemlata• Age - 45• Gender- female• Occupation – housewife• Dominance-right

• Chief complaint-pain at left thumb and area below thumb from 20 days which has increased from last few days.

Pain history

• Mechanism of injury- can’t be recalled by pateint.• Duration of pain-20 days• Vas score-6• Type-sharp pain with movement• Aggravating factor –doing house hold work like washing

clothes ,brooming etc.• Relieving factor – pain relieving ointment(balm,painkiller

given by physician)• Severity-level 4 i.e pain during and after specific activity

that does affect performance

• Past history-The patient reported no past history of elbow, forearm or wrist pain. No history of systemic disease.

• No family history of major systemic diseases

On examination

• Swelling –minimal swelling seen on comparing right wrist ( non pitting).

• Tenderness-present grade :2 i.e patient allows to touch but it gives pain.

• RIM Wrist extensor and flexor –strong and painless Radial deviation ulnar deviation –strong and

painfull

• THUMB Flexion Extension STRONG PAINFULL Abduction Adduction• Roms shown no variations.

TREATMENT

Ultrasonic therapy 3mhz pulsed 1:4 time: 5 minutes Intensity:8Cold compression/ Ice massage- for 10 to 12

minutes.Advice for rest.