De Quervain Syndrome

Definition

 

Stenosing tenosynovitis of the first dorsal compartment of wrist

 

Epidemiology

 

Most are middle aged women

 

Aetiology

 

Repetitive thumb movements

- abduction & extension

- combined with RD & UD movements

 

Any mechanical irritation

- foreign body

- prominent bony surface

- restricted fascial compartment

- abnormal muscle to epitenon

 

Anatomy

 

1st dorsal compartment

- over styloid process

- in osseoligamentous tunnel 

- shallow groove in styloid 

- roofed by dorsal ligament 

- attached by fibrous septa to bone

- tunnel ~1cm long

- 20% have 2 compartments

 

EPB

- phylogenetically young muscle

- found only in humans & gorillas as separate from APL

- EPB absent 5-7% 

- inserts base of P1

 

APL

- larger

- 75% of population has 2 or 3 or more tendinous slips

- varous insertions

- base of 1st MC / trapezium / volar carpal ligament /  opponens pollicis / APB

 

Associations

 

RA

Pseudogout / Gout

Hypothyroidism

TB

DM

Vascular Disease

OA

Post Trauma

Gout

Pregnancy

 

Clinical Features

 

Pain & swelling over styloid

 

Positive Finkelstein's test

- grasp the patient's thumb  / ulna deviation of wrist

 

Finkelstein Test

 

Eichoff maneuver

- patient grasps own thumb in fist, ulna deviation of wrist

 

Eichoff Test

 

Crepitus

 

X-ray

 

Exclude base of thumb OA

Look for bony spur that may need resection

 

DDx

 

Wartenberg's Syndrome 

- compression superficial branch radial nerve

 

CMC OA

 

Ganglion

 

Intersection syndrome

- ECRL/B crossed by APL & EPB 

 

Management

 

Non-operative

 

Rest

 

Thumb spica splint

 

HCLA

 

Prolonged conservative treatment

- pregnancy, DM etc

 

Operative

 

Technique

 

Transverse / Longitudinal incision

- longitudinal protects nerve

- transverse gives better scar

 

Identify and protect SRN

 

Divide Annular Ligament 

- ensure all compartments are decompressed

- may be more than one

- make incision ulna side to prevent radial instability

 

Assess floor of compartment for pathology

 

Asses for instability

- Z lengthen and repair fascial roof if present

 

Complications

 

Very common

- radial nerve neuroma / division

- hypertrophic scar from longitudinal incision

- volar subluxation of tendon if remove too much sheath

- insufficient release