DeQuervain's syndrome

de Quervain syndrome (also known as washerwoman's sprain, Radial styloid tenosynovitis, de Quervain disease, de Quervain's tenosynovitis, de Quervain's stenosing tenosynovitis or mother's wrist), is an inflammation or a tendinosis of the sheath or tunnel that surrounds two tendons that control movement of the thumb.

Eponym

It is named after the Swiss surgeon Fritz de Quervain who first identified it in 1895. It should not be confused with "de Quervain's thyroiditis", another condition named for the same person.

Pathology

The two tendons concerned are the tendons of the extensor pollicis brevis and abductor pollicis longus muscles. These two muscles, which run side by side, have almost the same function: the movement of the thumb away from the hand in the plane of the hand--so called radial abduction (as opposed to movement of the thumb away from the hand, out of the plane of the hand (palmar abduction)). The tendons run, as do all of the tendons passing the wrist, in synovial sheaths, which contain them and allow them to exercise their function whatever the position of the wrist. While de Quervain syndrome is commonly believed to be an inflammatory condition or tendosynovitis, evaluation of histological specimens shows no inflammatory changes--rather a thickening and myxoid degeneration consistent with a chronic degenerative process are seen. The pathology is identical in de Quervain seen in new mothers.

de Quervain syndrome is more common in women. A speculative rationale for this is that women have a greater styloid process angle of the radius, but scientific support for this theory is lacking.

Cause

The cause of de Quervain is not known. In medical terms, it remains idiopathic.

Some claim that this diagnosis should be included among overuse injuries and that repetitive movements of the thumb are a contributing factor. More specifically, repetitive eccentric lowering of the wrist into ulnar deviation especially with a load in the hand such as a child or even a stack of dishes. .

Symptoms

Symptoms are pain, tenderness, and swelling over the thumb side of the wrist, and difficulty gripping.

Finkelstein's test is used to diagnose de Quervain syndrome in people who have wrist pain. To perform the test, the thumb is placed in the closed fist and the hand is tilted towards the little finger - ulna deviation (as in the picture) in order to test for pain at the wrist below the thumb. Pain can occur in the normal individual, but if severe, DeQuervain's syndrome is likely. Pain will be located on the thumb side of the forearm about an in inch below the wrist.

Differential diagnosis includes ruling out: 1. Osteoarthritis of the first carpo-metacarpal joint 2. intersection syndrome - pain will be more towards the middle of the back of the forearm and about 2-3 inches below the wrist 3. Wartenberg's syndrome

Treatment

The natural history of de Quervain is not well documented. Nonetheless, there is enough observational experience to be fairly certain that it is a self-limited illness with no long-term consequence. Once resolved it rarely recurs. The illness tends to last about 1 year on average. There are no treatments that have been scientifically demonstrated to shorten the duration of symptoms, principally because there are no controlled scientific studies. Things that are tried, without support, and with inconsistent results include immobilization, round the clock anti-inflammatory medications, iontophoresis, and corticosteroid injections. Case series of patients receiving one of the most popular treatments (corticosteroid injection) have claimed effectiveness even when the illness did not resolve for months--clearly more study is needed. Operative release is the only known way for predictably shortening the duration of symptoms, but is elective. Surgery consists of opening the tunnels, or sheaths, that the tendons pass through. The pain usually resolves in the time it takes the wound to heal.

While patients await disease resolution, the symptoms of de Quervain can be managed with a spica splint that immobilises the wrist and thumb, anti-inflammatory pain medications (or other non-narcotic pain medications), and ice. While avoiding activities that cause pain will certainly decrease the overall amount of pain experienced, there is no evidence that this will speed recovery, or that continuing to engage in these activities will lead to any harm -- the illness is in general a harmless nuisance. Therefore, patients can safely choose their activity and pain level. It is not dangerous or neglectful to remain active in spite of the pain. The splint can be used as desired to improve function and quality of life during the illness.

Specialised hand therapists (both physical therapists and occupational therapists) provide treatment in the form of splinting to immobilise and rest the wrist and thumb.

Therapists may recommend activity modification to avoid repetitive eccentric lowering of the wrist into ulna deviation, but this is done in spite of the debate regarding the role of hand use in etiology and risks "blaming the patient". Some therapists also advocate that--once pain free--therapeutic exercise (focusing on eccentric control) are encouraged to strengthen muscles and progressively overload the tendons so that future episodes are avoided. This is also a highly debatable theory. Recurrence of deQuervain's is very uncommon. Once it runs its course it rarely returns.

While splinting and activity modification are clearly Palliative, there is little scientific support for the efficicacy of these treatments in shortening the duration of the illness.

References

External links

• Hand University: A Patient's Guide to de Quervain Tenosynovitis
• Alexandra Hospital: DeQuervain's Syndrome - illustration and text
• DeQuervain's Syndrome: Medical Imagery - Medical Art and Illustration
• Computer related diseases and prevention methods