de quervains tenosynovitis dnbid lecture 2012

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  • 1. DEQUERVAINSTENOSYNOVITISDr. Dibyendunarayan Bid [PT]Saravajanik College of PhysiotherapyRampura, Surat 395009.

2. The most radial of the extensor compartments on thedorsum of the wrist is occupied by the tendons of theextensor pollicis brevis and abductor pollicis longus. The tendons are enveloped in an osseofibrous canallined by synovium, which, when subjected to excessiveor repetitive mechanical stresses, responds in acharacteristic fashion distinguished by pain, swelling,and limitation of motion of the thumb. In 1895,Fritz de Quervain, a Swiss surgeon, was firstcredited with the recognition of this disease and so itbore his name. 3. ANATOMY: Twenty-four extrinsic tendons cross the wrist andprovide power and dexterity in the hand. Each tendon passes through a series of tightfibrous -osseous canals designed to optimize thebalance between motion and force production bymaintaining the tendon in close approximation tothe joint or joints it controls. There are six separate compartments under thedorsal carpal ligament each lined with a separatesynovial sheath membrane. 4. The first one is over the radial styloid and itcontains the abductor pollicis longus and theextensor pollicis brevis tendons. These tendons pass through an unyieldingosteoligamentous tunnel formed by a shallowgroove in the radial styloid process and a toughoverlying roof composed by the transverse fibers ofthe dorsal ligament. 5. This fibrous tunnel is about 2 cm long, whereas thesynovial sheath extends from eachmusculotendinous junction proximal to the tendoninsertions well beyond the tunnel itself. Division or rupture of a critical retinacular ligamentor pulley, will allow the tendon to drift away from thejoints center of rotation and therefore increase themoment arm for force production but alsolengthens the tendon which limits the excursion ofthe joint . 6. CAUSES OF DE QUERVAINS SYNDROME ANDDEMOGRAPHICS: The three most common causes of stenosingtenovaginitis appear to stem from repeated activecontraction of the muscle moving the tendon, anddirect injury. Tenovaginitis is noted to be more common inwomen than men. Lapidus reports female/male ratio of 4:1.Occupational factors may play a role andtendonopathies tend to cluster in some individuals. 7. Often multiple conditions already exist such ascarpal tunnel syndrome, trigger fingers, lateralepicondylitis and rotator cuff disease. Medl echoes these concerns of those with painfulhands outnumber the male patients two to one. Housewives, especially those with small babies,lead in being afflicted by de Quervains syndrome. Workers who use their hands continuously onvarious business machines are also susceptible. 8. Recently, Armstrong et al. stated the risk of handand wrist tendonopathy in persons who performhighly repetitive or forceful jobs is 29 times greateraccording to epidemiologic data. It showed that assemblers, musicians, and meatcutters are often developing the disease. 9. SYMPTOM PRESENTATION: De Quervains syndrome includes pain and swellinglocalized to the area of the radial styloid. Pain is especially aggravated by ulnar deviation ofthe wrist by flexion and adduction of the thumb orby simple adduction of the thumb.1 Pain may also cause weakness with diminishedgrip and pinch strengths. Swelling is often seen especially in chronic cases. 10. MECHANISM OF INJURY, CHIEF COMPLAINT: Cumulative micro-trauma may be caused byforceful, sustained or repetitive thumb abductionand simultaneous wrist ulnar deviation. Opening jars, wringing the hands, cutting withscissors, holding surgical retractors, playing thepiano, and doing needlepoint are a few examples ofactivities that may provoke de Quervains syndrome. The chief complaints usually are pain, weakness,swelling along the radial side of the wrist duringthese activities. 11. EXAMINATION: MedicalHistory: Assessment begins with a thorough history, includingexploration of aggravating activities and associatedconditions that may have predisposed the patient totendonopathies. The pain, which is usually localized, can be provokedwith direct pressure, stretch, or resistance to theaffected tendons.Occupational factors may play a role buttendonopathies tend to cluster in some individuals. 12. If the patient has had surgery to decompress thefirst extensor compartment this op-report needs tobe reviewed. Also any previous surgeries in the area such as atrigger finger release or a carpal tunnel releaseneeds to be discussed and documented. 13. The clinician should carefully review a patientsmedical history questionnaire (on an ambulatoryevaluation), patients medical record, and medicalhistory reported in the hospitals computerizedmedical record. Careful consideration should be made to identifyany traumatic history to the affected extremity,rheumatoid illnesses, diabetes or other metabolicdisorders. Finally, the clinician should review any diagnostictesting and imaging. 14. Upon examination, tenderness is elicited over thefirst dorsal compartment. This tenderness may be worsened in the presenceof inflammation involving the superficial radialnerve. Excruciating pain in the region of the radial styloidis common. Discomfort also may be found with resisted thumbextension at the metacarpalphalangeal joint whichis indicative of a positive hitch-hikers test. 15. Other causes of the pain need to be eliminated. A useful test was proposed by Finklestein in1930and is found to be positive in nearly all patients withde Quervains syndrome. The thumb is held in full flexion -adduction and thewrist is abruptly deviated in an ulnar direction. Excruciating pain in the area of the radial styloidpoints to this diagnosis. 16. Radiographic examination is usually unremarkable. Localizedostopenia in the radial styloid may be noted. Calcifications in the area of the first dorsal compartment may beidentified, especially in chronic cases. Basal joint arthritis may be painful with thumb motion and maydemonstrate a positive Finklestein test. It usually can be distinguished from de Quervains syndrome bya positive axial compression test and the absence of the firstdorsal compartment tenderness to palpation. The two may coexist. 17. HISTORY OF PRESENT ILLNESS: It is important to obtain a detailed history of the paitentsjob requirements and activities to reveal any usefulinformation that may be helpful to the objective clinicalexamination. Specifically, it is important to determine if there areoccupational activities that the patient is performing thatrequire significant grip force and/or prolonged static orrepetitive positioning in elbow extension in conjunctionwith supination or pronation. The clinician should obtain information on the timeline ofonset and development of the symptoms and identifyprovocative vs. relieving activities. 18. MEDICATIONS Any current medications and post-operativemedications need to be identified. Postoperatively patient will be prescribed painmediation by their surgeon. Depending on the dosage these medications mayinterfere with the comprehension of any instructionsso a family member is advised to accompany thepatient to therapy and to be present for the entiresession. 19. SOCIAL HISTORY A review of the patients home, work andrecreational activities will give the therapist insightinto the patients activity level and emotionalsupport at home/work. The support may be needed if the patientexperiences unusual intense pain and swelling andneed assistance with activities of daily livingfollowing surgery. 20. SURGICAL INTERVENTION Surgical release of the first dorsal compartment isindicated after failed conservative management. In general surgery includes the release of constrictingfibrous pulleys, and in some systemic conditions,excision of hypertrophied tenosynovium. The procedure is usually performed with only localinfiltration anesthesia. A pneumatic tourniquet around the forearm is welltolerated for the short duration of the procedure, and is abloodless surgical field is essential for the identificationof radial sensory branches, as well as the anatomicvariations. 21. A 2-cm transverse skin incision is made over thefirst dorsal compartment about 1 cm proximal to thetip of the radial styloid process. Care is taken to identify and gently retract the oneto three radial sensory branches that cross thecompartment obliquely by using gentle, bluntlongitudinal dissection as soon as the deepestdermal layer of skin has been incised. 22. Burton and Littler recommended incising the sheathon its most dorsal margin and leaving a flap ofpalmar sheath to prevent subluxation. Although the particular site of sheath incision isdisputed all authors agree that a thoroughexploration for separate compartments must beperformed, with complete division of all interveningsepta and identification of each tendon slip. 23. Usually thick septa can be excised entirely. If the tenosynovial tissue is thick and opaque,surgical debulking is performed. The tendons are lifted by hook or blunt retractorsout of the tunnel to ensure completedecompression from their musculotendinousjunctions to a point at least 1cm distal to theretinacular sheath. 24. The tendons are replaced and the patient moves thethumb to demonstrate free and independent movementof the long abductor and the short extensor. Hemostasis is established with cautery after tourniquetrelease and the skin is closed with a single intradermalmonofilament pullout suture and adhesive bandages. A soft bulky dressing is applied to minimize motion ofthe thumb during the initial 2 to 3 post-operative days. Thereafter the patient may begin to resume use of thethumb and wrist as tolerated. 25. POTENTIAL COMPLICATIONS: The most serious complication of this operation followsiatrogenic injury to a superficial sensory branch of the radialnerve with the subsequent formation of a painful neuroma. Overly vigorous retraction of a radial nerve branch wi