DeQuervain's syndrome

de Quervain syndrome (also known as washerwoman's sprain, Radial styloid tenosynovitis, de Quervain disease or mother's wrist), named for Swiss surgeon Fritz de Quervain who first identified it in 1885, is an inflammation of the sheath or tunnel that surrounds two tendons that control movement of the thumb.

It should not be confused with "de Quervain thyroiditis" (E06.1).

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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 abductionin (as opposed to movement of the hand 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 tenosynovitis, evaluation of histological specimens shows no inflammatory changes--rather a thickening and myxoid degeneration consistent with a chronic degenerative process are seen. (Clarke MT, Lyall HA, Grant JW, Matthewson MH. The histopathology of de Quervain disease. J Hand Surg [Br]. 1998 Dec;23(6):732-4.) The pathology is identical in de Quervain seen in new mothers. (Read HS, Hooper G, Davie R. Histological appearances in post-partum de Quervain disease. J Hand Surg [Br]. 2000 Feb;25(1):70-2.) de Quervain syndrome is more common in women as they have a greater styloid process angle of the radius, which the problematic tendons run over.

(de Quervain, not De Quervain's)

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. ^{[1] [2]}.

Given that the illness remains idiopathic, any reference to "overuse" or "repetive use" is speculative at best. At worst such a negative illness concept risks blaming innocent bystanders. For instance, the occurrence of de Quervain in new mothers led some in the past to blame the wringing of cloth diapers. The fact that the illness did not disappear as the use of cloth diapers waned did not lead "overuse" proponents to question their theory--rather, the blame is now often placed on the way the baby is held. This type of speculation should be discouraged without better scientific support, because negative illness concepts increase suffering and feelings of guilt and loss of control at a time when most new mothers can least afford it. The majority of de Quervain does not occur in new mothers. The fact that de Quervain remains idiopathic means that its sufferers are blameless victims of an incompletely understood illness.

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. 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 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 physiotherapists and occupational therapists) can provide very effective treatment, which will eventually allow the individual to return to pain free movement. Splinting (for about 2 weeks) to immobilise the wrist and place the thumb into extension provides time for the injured tendons to rest and heal. Activity modification is also recommended to avoid repetitive eccentric lowering of the wrist into ulna deviation. 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.

References

1. ^ Weiss Orthopaedics - Common Injuries - Wrist/Hand - de Quervain Stenosing Tenosynovitis.
2. ^ OSH Answers: De Quervain's Disease.