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De Quervain's Tenosynovitis

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Topic updated on 08/01/16 8:58pm
Introduction
  • A stenosing tenosynovial inflammation of the 1st dorsal compartment which includes
    • abductor pollicis longus (APL) 
    • extensor pollicis brevis (EPB) 
  • Epidemiology
    • demographics
      • woman > men
      • 30 - 50 years old
    • body location
      • most commonly in the dominant wrist
    • risk factors
      • overuse
        • golfers and racquet sports
      • post-traumatic
      • postpartum 
  • Pathophysiology
    • pathoanatomy
      • thickening and swelling of extensor retinaculum causes increased tendon friction
      • NOT considered an inflammatory process
        • may be related to accumulation of mucopolysaccharides
  • Prognosis
    • most cases resolve with non-operative management 
    • high recurrence rate
Anatomy
  • Extensor tendon compartments  
    • Compartment 1 (De Quervain's Tenosynovitis)
      •  APL
      •  EPB
    • Compartment 2 (Intersection syndrome )
      •  ECRL 
      •  ECRB 
    • Compartment 3
      •  EPL 
    • Compartment 4
      •  EIP 
      •  EDC 
    • Compartment 5 (Vaughn-Jackson Syndrome )
      •  EDM
    • Compartment 6 (Snapping ECU )
      •  ECU
Presentation
  • Symptoms
    • gradual onset 
    • radial sided wrist pain
    • pain exacerbated by gripping and raising objects with wrist in neutral
  • Physical exam 
    • inspection
      • tenderness over 1st dorsal compartment at level of radial styloid
    • motion
      • usually normal wrist motion
      • pain with resisted radial deviation
    • neurovascular exam
      • normal
    • provocative tests
      • Finkelstein maneuver
        • On grasping the patient’s thumb and quickly abducting the hand ulnarward, the pain over the styloid tip is painful
        • more indicative of EPB > APL tendon pathology
      • Eichhoff maneuver
        • ulnar deviated wrist while patient clenches thumb in fist, followed by relief of pain once the thumb is extended even if the wrist remains ulnar deviated
Imaging
  • Radiographs
    • recommended views
      • AP, lateral views of wrist
    • indications
      • radiographs usually not indicated
    • findings
      • may be used to rule out
        • basilar arthritis of the thumb
        • carpal arthritis
Treatment
  • Nonoperative
    • rest, NSAIDS, thumb spica splint, steroid injection
      • indications
        • first line of treatment
      • technique
        • NSAIDS, rest and immobilisation usually first step
        • steroid injections into first dorsal compartment usually second step  
      • outcomes
        • overall corticosteriods found to be superior to splinting 
        • concomitant splinting and/or NSAIDs after steriods injection does not improve outcomes
  • Operative
    • surgical release of 1st dorsal compartment 
      • indications
        • severe symptoms 
        • usually consider after 6 months of failed nonoperative management 
      • technique
        • radial based incision proximal to the wrist
        • protect the superficial radial sensory nerve
Surgical Techniques
  • Surgical release of 1st dorsal compartment 
    • approach
      • transverse incision with release on dorsal side of 1st compartment to prevent volar subluxation of the tendon
        • has variable anatomy with APL usually having at least 2 tendon slips and its own fibro-osseous compartment
        • a distinct EPB sheath is often encountered dorsally
Complications
  • Sensory branch of radial nerve injury
  • Neuroma formation
  • Failure to decompress with recurrence 
    • may be caused by failure to recognize and decompress EPB or APL lying in separate subsheath/compartment
  • Complex regional pain syndrome

 

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Qbank (2 Questions)

TAG
(OBQ12.253) A 45-year-old patient presents with recurrence of radial sided wrist pain after undergoing a first dorsal compartment release about 3 months ago. The surgery was completed by one of your partners; operative reports indicate that the sheath was incised on the dorsal edge. On physical exam she is found to have normal appearing skin, a negative Tinel’s sign, and a positive Finklestein test. What is the most likely cause of the recurrence of her symptoms? Topic Review Topic

1. Development of neuroma
2. Complex regional pain syndrome
3. Failure to decompress the EPB sub-sheath
4. Failure to decompress the EPL sub-sheath
5. Failure to decompress the APB sub-sheath

PREFERRED RESPONSE ▶
TAG
(OBQ08.9) A 31-year-old mother of a 2-month-old infant complains of radial sided wrist pain. Corticosteroid injections should be directed into what anatomic area? Topic Review Topic

1. First carpometacarpal joint
2. Carpal tunnel
3. First dorsal compartment near the radial styloid
4. A1 pulley of thumb
5. At the crossing of the first and second dorsal compartments

PREFERRED RESPONSE ▶



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