De Quervain syndrome
|de Quervain Syndrome|
|Classification and external resources|
Finkelstein's test for DeQuervain's tenosynovitis
De Quervain syndrome (French pronunciation: [də kɛʁvɛ̃]; also known as BlackBerry thumb, gamer's thumb, washerwoman's sprain, radial styloid tenosynovitis, de Quervain disease, de Quervain's tenosynovitis, de Quervain's stenosing tenosynovitis, mother's wrist, or mommy thumb), is a tenosynovitis of the sheath or tunnel that surrounds two tendons that control movement of the thumb.
Symptoms are pain, tenderness, and swelling over the thumb side of the wrist, and difficulty gripping.
The cause of de Quervain's disease is not established. Among those that believe De Quervain syndrome is a repetitive strain injury, postures where the thumb is held in abduction and extension are thought to be predisposing factors. Evidence regarding its relation with occupational risk factors is debated. Workers who perform rapid repetitive activities involving pinching, grasping, pulling or pushing are thought to be at increased risk. Activities that have been implicated include intensive mouse/trackball use and typing, as well as some pastimes, including bowling, golf and fly-fishing, piano-playing, and sewing and knitting.
Women are affected more often than men. The syndrome commonly occurs during and after pregnancy. Contributory factors may include hormonal changes, fluid retention and — more debatably — lifting.
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. Evaluation of histological specimens shows a thickening and myxoid degeneration consistent with a chronic degenerative process. The pathology is identical in de Quervain seen in new mothers.
Finkelstein's test is used to diagnose de Quervain syndrome in people who have wrist pain. To perform the test, the examining physician grasps the thumb and the hand is ulnar deviated sharply, as shown in the image. If sharp pain occurs along the distal radius (top of forearm, about an inch below the wrist; see image), de Quervain's syndrome is likely.
Differential diagnoses include:
- Osteoarthritis of the first carpo-metacarpal joint
- Intersection syndrome—pain will be more towards the middle of the back of the forearm and about 2–3 inches below the wrist
- Wartenberg's syndrome
The management of de Quervain’s disease is determined more by convention than scientific data. From the original description of the illness in 1895 until the first description of corticosteroid injection by Jarrod Ismond in 1955, it appears that the only treatment offered was surgery. Since approximately 1972 the prevailing opinion has been that of McKenzie (1972) who suggested that corticosteroid injection was the first line of treatment and surgery should be reserved for unsuccessful injections. However, data regarding the efficacy of corticosteroid injection is sparse and uncontrolled (Oxford Level of Evidence 4) and it is not clear that there is a benefit over the natural history of the illness. A structured review published in 2003 identified only 35 publications that addressed de Quervain’s on Medline, only 7 of which presented data regarding corticosteroid injection, and none of which were controlled studies.
Retrospective studies all report success rates for corticosteroid injection greater than 70%, but the one prospective cohort study noted a success rate of only 58% and many of those patients took 12 to 18 months until symptom resolution. While the authors of that study ascribed the failure of corticosteroid injection to anatomical variations, it has not been clearly established that corticosteroid injection is better than placebo or that a symptom course of 12 to 18 months is any better than the natural course of the illness.
Another commonly used criterion for failure of non-operative treatment is election of operative treatment, but the decision to operate is complex and biased by the beliefs and emotions of the surgeon and the patient. Use of an elective event such as surgery to define success makes data regarding nonoperative treatment difficult to interpret. For instance, in one of the two investigations in which a substantial number of patients were treated without injection (splints and anti-inflammatory medication alone were used), a remarkable 45 of 93 (48%) of patients in all non-operative treatment groups had surgery. This may simply reflect frustration on the part of both the patient and the surgeon with the prolonged symptom course associated with the disease. It may appear to both patient and surgeon that, after many months of symptoms, the illness will never resolve. The data of Lane and colleagues indicating that non-operative treatment is successful only in mild cases is similarly marred by the lack of patients randomly assigned to alternative treatments and the use in many patients of a decision for surgery as a failure criterion.
Most tendinoses are self-limiting and the same is likely to be true of de Quervain's although further study is needed. One retrospective series documented resolution in 90% of patients within 1 year 
Palliative treatments include a splint that immobilized the wrist and the thumb to the interphalangeal joint and anti-inflammatory medication or acetaminophen.
Surgery (in which the sheath of the first dorsal compartment is opened longitudinally) is documented to provide relief in most patients. The most important risk is to the radial sensory nerve.
Some physical and occupational therapists suggest alternative lifting mechanics based on the debatable theory that the condition is due to repetitive use of the thumbs during lifting such as seen in new mothers picking up their child. Physical/Occupational therapy can suggest activities to avoid base on the theory that certain activities might exacerbate one's condition, as well as instruct on strengthening exercises based on the theory that this will contribute to better form and use of other muscle groups, which might limit irritation of the tendons. It's important to realize that this approach risks reinforcing catastrophic thinking (Pain catastrophizing) and kinesiophobia--the most important determinants of pain intensity and disability with this condition.  One can argue that the idea that a mother can harm her hand by lifting her child is so troublesome that it should be proved definitively before it is promoted.
Some physical and occupational therapists use other treatments based on the rationale that they reduce inflammation and pain and promote healing: UST, SWD, or other deep heat treatments, as well as TENS, dry needling, or infrared light therapy, and cold laser treatments. However, the pathology of the condition is not inflammatory (see above) and these treatment are unproved and best considered experimental.
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- DeQuervain's Syndrome: Medical Imagery - Medical Art and Illustration
- The Sports Medicine Patient Advisor: De Quervain's Tenosynovitis Rehabilitation Exercises
- -1744437193 at GPnotebook