De quervains tenosynovitis

De quervains tenosynovitisJoaquin L. Guillermo Jr. MD Post-Grad InternPhilippine National Police General HospitalDepartment of Orthopedic Surgery

1CASE55 y/o FemaleNUP- Desk jobsNon-smokerNon-alcohol beverages drinker

c/c: Wrist pain, left x 4 weeksROS: UnremarkablePE: Extremities: (+) Palpable mass on the radial aspect of the wrist L, movable, non tender(+) Pain on the thumb upon motion(+) Crepitus

c/c: aggravated by moving the thumb as described by the patient, no medications, no consultPE: flex the thumb across the palm, make a fist, and then ulnarly deviate the wristFinkelstein- pathognomonic

2managementWas referred to PMRS Conservative management was doneThumb Spica splintCold ModalitiesAROM exercisesTransverse FrictionGalvanic ESIontophoresis

NSAIDThumb Spica- rest3rehab for how long?meds for iontophoresisOn follow-upAfter 6th therapy sessions, pain decreased but was persistent.Corticosteroids was given for 2 sessions with one month interval4Failure= Surgical InterventionSurgical release of the 1st compartmentDiscussionFritz de Quervain 1895Stenosing tenosynovitis of the 1st dorsal compartment of the wristMost common- entrapment tendinitis of the hand and wrist- trigger digit2nd MC is de Quervains

Swiss surgeonAPL and EPB2nd mc 1/20 of the population of the trigger digit6Risk FactorsPregnancy/ Post PartumWork- related washer womans hands/p Mastectomy30th-60th decade of life6x more common in Females

Pregnancy- not clearPost partum- carrying childrens/p mastectomy- lymphedema- 30-40% chance of developing but unclear

7Anatomy

UlnaRadius1st 2nd 3rd 4th 5th 6th Extensor Retinaculum1st DCAPL, EPB

2nd DCECRL/B3rd DCExtensor pollicis longus4th DCextensor digitorum communis and extensor indicis proprius5th DCextensor digiti minimi6th DC extensor carpi ulnarisRadial- ulnar1st dorsal compartment- APL, EPB2nd dorsal compartment- ECRL/B3rd dorsal compartment- Extensor pollicis longus4th dorsal compartment- extensor digitorum communis and extensor indicis proprius5th dorsal compartment- extensor digiti minimi6th dorsal compartment- extensor carpi ulnaris8PresentationPain on the wrist weeks- months, along the radial aspect of the wristAggravated by thumb motionLump/mass 1-2 cm proximal to the styloid processNo tenderness proximal to the 1st compartmentNo tenderness proximal to the 1st compartment- Arthritis!9DDxGanglion of the extensor retinaculumOA of the thumb CMC joint Carpal Tunnel SyndromeScaphoid fractureIntersection SyndromeTuberculous TenosynovitisOA of the thumb- (+) axial grid testIntersection syndrome- 2nd compartment crosses with the 1st compartment

Tuberculous Tenosynovitis- diffuse granulomatous and purulent involvement of the tendon sheath, contains particles of fibrin known as rice bodies. Mx excision and immobilization + anti TB drugs10how to perform axial grid test?Diagnostics

Finkelsteins TestPE: flex the thumb across the palm, make a fist, and then ulnarly deviate the wristFinkelstein- pathognomonic

11managementConservativeSurgicalRelease of the 1st dorsal compartmentRehabilitationThumb Spica splintCorticosteroidsTransverse Friction

Hand- based spica splint lifted from Braddom

Corticosteroids- 1994 Weiss et al corti + lido is better than splinting alone Corticosteroids- 0.5 ml of lido + 0.5 corticesteroids (prednisone)2 sessions with 1 mo interval 50%- 45%12

13SurgicalAdd video14Thank you!!!