de Quervains Disease Named after a Swiss surgeon, Fritz de Quervain,whom first described the problem in 1895. It is a progressive stenosing tenosynovitis whichaffects the tendon sheaths of the 1st dorsalcompartment of the wrist. Characterised by degeneration and thickening ofthe tendon sheath.
1st dorsal compartment contains the tendons andsynovial sheaths of APL and EPB tendons.
EtiologyInflammation of synovial sheaths results from continuousrepetitive use of EPB and APL muscle.↓Scarring and thickening of tendon sheaths.Stenosing, increase friction↓Inflammation↓Degeneration RA – affect synovial proliferation and swelling in tendonsheaths
Predisposing Factors Overuse injury Repetitive tasks that involve overexertion of thumb, radial andulnar deviation of the wrist ArthritisActivities such as: Wringing out wet clothes. Hammering. Painting. Skiing. Knitting. Lifting heavy objects such as a jug of milk, taking a frying panoff of the stove, or mother lifting a baby out of a crib (babywrist).
Incidence and Prevalence: Usually a gradual and insidious onset of dull ache over radialaspect of the wrist. Occurs most often in individuals age between 30 and 50 y.o 10 times more common in women. Higher risk for workers / sports that perform repetitive activitiesrequiring sideways movement of the wrist while gripping thethumb (eg. hammering, some assembly line jobs, skiing, golf)
Sign & Symptoms Localised swelling and tenderness inthe region of radial styloid process. Pain while performing ulnar deviation,thumb flexion and adduction.Diagnosis Positive Finkelstein test Increase pain on active contractionagainst resistance on thumb extension Xray to r/o bony pathology (eg.scaphoid #, arthritic changes)
ManagementConservative Mx Rest from activity that increases pain / Thumb Spica Splint for 3~4wk Modification of activity Anti-inflammatory medication Corticosteroid injection PhysiotherapySurgical (tenosynovectomy) Only indicated for surgical if symptoms persists > 3mth / conservativefailed. A 1-2cm incision is made over the first dorsal compartment and theextensor retinaculum is divided to free the tendons.
Rehabilitation -ConservativeGoal : Decrease pain and swelling,Activity modification,Restore mobility and strengthTreatment: Pain Relieve - Physical modalities Soft Tissue Massage (STM) Tendon gliding ex MWM for wrist & manipulation of thumb. As pain decrease, gradual progress to strengthening ex for wrist andhands
Rehabilitation – Post OpDay 0-2- Rest, surgical wound on dressingDay 2-14- Removal of dressing, Thumb splica splint- Gentle active ROM ex- STO on 10 -14th days- Desensitization – Digital massage on the area of incision1-6weeks- Gradual progressing strengthening ex- Scars tissue mobilization- Resisted activity to be avoided till 6wks post-op
1st Ax on 16 March 2011SUBJECTIVE ASSESSMENTName : Mr. AXXAge : 29 y.oGender: MaleOccupation: Lorry DriverPt’s Problem:- Sudden onset of pain at Left lateral wrist for 2/52Pain:- Area: Left lateral wrist proximal to radial styloid process- Nature: Sharp pain- Agg: Ulnar deviation, resisted thumb movement- Ease: Rest- 24 hrs: Not specific- Irritability: Low
Hx of Current Condition:Pt. noticed pain at left lateral wrist in the morning, suspect compressingthe thumb during sleep. Did not seek treatment. Pain get worst graduallywith activity.Past Medical Hx.: Had wrist fracture 3 years ago.General health: GoodMedication: NilInvestigation: NilDominant Hand: RightFunctional Status / ADL: Patient experience pain in activity thatinvolve grasping and driving.Vital Sign: B/P: 120/80 mmHg
OBJECTIVE ASSESSMENTLocal Observation- Mild swelling at left lateral wrist as compare toright side.- No open wound / haematomaPalpation- Tenderness at base of left thumb and radialstyloid process.
Movement Active ROM of left wrist, with end-range-pain on ulnar andradial deviation Active ROM of thumb, with end-range-pain on thumbextension and abduction. Active ROM of elbow and neck motions were full and painfree.Muscle Power (Oxford grading) Muscle grading were deferred d/t resisted movementinvolving thumb and wrist were painful. All other fingers tested normal.Special Test Finkelstein’s test – Positive
Analysis- Impaired motor function and ROM associated withinflammation of EPB and APL tendons and tendon sheathssuggesting de Quervain’s disease.Short Term Goal-To control pain to tolerable level with activity in 1/52- To reduce swelling in 1/52- To preserve ROM, muscle length and strengthLong Term Goal- Pain free thumb and wrist motions in 2/12- Strengthen muscle power of left wrist and thumb to 5/5- Prevent complication and recurrent pain
Plan WAX Soft Tissue Massage (STM) Tendon gliding ex MWM for wrist & manipulation of thumb. Strengthening ex for wrist and hands Patient education on activity modificationIntervention1) Hot cold test √2) WAX bath3) Transverse friction massage on EPB & APL tendon4) Tendon gliding ex for EPB & APL5) MWM for wrist flexion & extension6) Thumb manips7) Ultrasound at lateral wrist (1MHz, 1.0W/cm2, 3mins)8) Home exercise programme – STM, tendon gliding ex, pain free ROM ex9) Patient was told to rest left thumb and avoid aggravating motions andactivities.
EVALUATION- Pt. able to perform wrist and thumb motions with lesser pain.Motions felt less restricted.REVIEW- To review patient’s pain scale and joint motions. KIV muscle powertest when pain reduce. Gradually increase ex intensity and progressto strengthening ex.
ConclusionMost individuals does not require surgery and will recover with rest orinjections within 6wk times. Surgical cases may require up to 3-6months to regain pre-operative strength.Recurrence of the symptoms is very rare. ComplicationsPossible problems after the surgery can include irritation of the smallnerves which give feeling of numbness or tingling sensation to thearea of skin on the wrist and back of the hand.Previous injury that altered the anatomy of the wrist would maketreatment more difficult.
References Brotzman, S. and Wilk, K. (2003) ClinicalOrthopaedic Rehabilitation, 2nd ed.Philadelphia: Mobsy, p.72-75. Dutton, M. (2008) OrthopaedicExamination, Evaluation, and Intervention,2nd ed. USA: The Mc-Graw Hill, p.810-828. Website:http://www.ajronline.org/cgi/content/full/182/3/719