De Quervain's Stenosing Tenosynovitis

I.     Background

This condition results from first dorsal compartment narrowing and irritation of the abductor pollicis longus and extensor pollicis brevis tendons as they course through this tunnel. The disease commonly occurs between the ages of 30 and 50 years and af­fects women ten times more frequently than men. It can be caused by repetitive wrist extension and radial deviation, trauma, synovial proliferative diseases, anomalous tendons or thyroid disease. It may be seen in association with osteoarthritis of the thumb carpometacarpal joint. The presenting complaints are usu­ally pain, tenderness, and occasionally swelling, triggering and crepitus at the radial styloid region aggravated by wrist or thumb use. The majority of patients with DeQuervain's disease respond to a nonoperative treatment program.

II.  Diagnostic Criteria

A. Pertinent Historical and Physical Findings

Onset of this condition may be associated with:

1.         Direct trauma to the radial styloid;

2.         Overuse of the thumb and wrist;

3.         Spontaneous onset;

4.         Recent infant care (new mother's disease);

5.         Thyroid disease or collagen disease

Physical findings include tenderness to palpation over the ra­dial styloid, swelling over the radial styloid, crepitation with motion of the abductor pollicis longus or extensor pollicis brevis tendons through the first dorsal compartment, and pos­itive Finklestein's test. This is the most consistent diagnostic maneuver for DeQuervain's disease. The thumb is placed in the palm and the wrist is forcefully ulnarly deviated, recreat­ing the patient's pain.

B. Appropriate Diagnostic Tests and Examinations

1.                Wrist and/or thumb x-ray will not verify diagnosis but maybe needed to rule out other conditions.

2.                Studies to rule out systemic disease are sometimes indicated.

C. Inappropriate Diagnostic Tests and Examinations

1.         EMG, nerve conduction tests

2.         Arteriogram

3.         CT scan

4.         EKG for left arm pain

5.         Radioactive scans

D. Exceptions to Above Criteria

1.                  Concurrent neurologic, cardiac, neoplastic or other disease may require CT scan, radionuclide   imaging, arteriogram, or neurodiagnostic studies

2.                  Possible use of electrodiagnostic studies in patients with radial nerve injury who may present with pain on the radial side of the wrist and hand or suspected carpal tunnel syndrome

E. Evolving Diagnostic Tests and Examinations

1.                  MRI

2.                  High resolution ultrasound (for ganglions)

III. Treatment

A. Outpatient Treatment

1. Nonoperative Treatment

            a. Indications: pain and functional disability

            b. Treatment Options

         1)         Splinting

                        2)         Nonsteroidal anti-inflammatory medication

         3)         Steroid injections into the tendon sheath

                        4)         Thermal modalities (e.g., ultrasound, moist heat, ice pack)

            c. Home Health Care: none

2. Ambulatory Surgery

a.         Indications: no response or incomplete response to nonoperative treatment for approxi­mately                 6 to 12 weeks

            b.         Treatment Options: operative release of the first dorsal compartment under regional, local, or                 general anesthesia followed by postoperative splinting.

            c.         Home Health Care: none

            d.         Rehabilitation: physical or occupational hand therapy may be needed if patient has stiffness of the wrist or hand.

B. Inpatient Treatment

1.                  Nonoperative Treatment: none

2.                  Operative Treatment

            a. Indications for Admission

         1)         Unstable medical condition requiring hospital monitoring

                        2)         Concurrent systemic disease

            b. Treatment Options: operative release of the first dorsal compartment under regional, local, or                         general anesthesia followed by postoperative splinting.

            c. Indications for Discharge

                        1)         Patient comfort

                        2)         Stable medical condition

            d. Home Health Care: none

            e. Rehabilitation: physical or occupational hand therapy would be indicated for a stiff wrist or                 hand for residual weakness, or for symptoms related to superficial radial neuropathy.

C. Inappropriate Treatment

1.                  Multiple (more than 3 to 4) steroid injections

2.                  Prolonged joint immobilization

3.                  Whirlpool or wrist manipulation

4.                  Failure to adequately release accessory tendon sheaths

5.                  Excessive tendon sheath removal

D. Estimated Duration of Care

1.                  Nonoperative Treatment—6 to 12 weeks

2.                  Operative Treatment—8 to 12 weeks

E. Anticipated Outcomes

1.                  Complete or partial relief of symptoms

2.                  Improved motion of the thumb and wrist

F. Evolving therapeutic procedures: none

G. Modifiers (age, sex, etiology and co-morbidity)

1.                  There is an etiologic linkage between DeQuervain's disease, carpal tunnel syndrome and trigger finger

2.                  Occupations associated with repetitive wrist motion

3.                  Arthritis of carpometacarpal joint

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