journal club

1. Dr.sunil ms ortho
Assistant professor
Birrd hospital

2. Dequervains tenosynovitis
 Stenosing
tenosynovitis of the
abductor pollicis
longus and extensor
pollicis brevis
tendons occurs
typically in adults 30
to 50 years old.
 Women are affected
six to 10 times more
frequently than men.

3.  The cause is almost always related to overuse,
either in the home or at work, or is associated
with rheumatoid arthritis,malunited distal end
radius fracture and radial styloid fracture and
other inflammatory disorders

4. Clinical features
 The presenting symptoms usually are pain and
tenderness at the radial styloid.
 Sometimes a thickening of the fibrous sheath is
palpable

5.  The Finkelstein test
usually is positive: on
grasping the patient's
thumb and quickly
abducting the hand
ulnarward, the pain
over the styloid tip is
excruciating.

6. Differential diagnosis
 Arthritis in the trapeziometacarpal,
scaphotrapeziotrapezoid, and radiocarpal joints
 superficial radial nerve entrapment or neuroma
 Tenosynovitis at the crossing of the extensor
pollicis brevis and abductor pollicis longus over
the extensor carpi radialis longus and brevis
(intersection syndrome) also can cause similar
symptoms

7.  Conservative treatment:-
 consisting of rest on a
splint
 Anti inflammatory
medications
 Local infiltration of
steroid preparation to para
tenon, is most successful
within the first 6 weeks
after onset

8. Low level laser therapy
 It is also known as low level light therapy or
photobiomodulation
 Uses:-it reduces inflammation and edema and induce
analgesia and promote healing in various
musculoskeletal pathologies
 It will treat nocieceptive and neuropathic pain

9. Therapeutic uses
 Acute orthopedic conditions such as sprains , strains,
post-surgical pain,muscular back pain and cervical
and lumbar radiculopathy
 chronic conditions such as osteoarthritis ,rheumatoid
arthritis, frozen shoulder , neck and back pain ,
epicondylitis , carpal tunnel syndrome , tendinopathy ,
fibromyalgia , plantar fasciitis , post tibial fracture
surgery .

10. MECHANISM OF LLLT
 Long convex pad is used to compress the
superficial tissues and displace excess fluid
and then laser penetrates the deep tissues
 As light enters the tissue photons will be
scaterred and absorbed
 Wave length of 660 to 1300 nm is absorbed
by hb, oxy hb
 Cyto c is activated and is found in the inner
cell membrane of mitochondria
 Cyto c causes activation of ATP(molecule
which facilitates energy),nitrous oxide and
ROS(reactive oxygen species)
 These signaling molecules causes growth
factor production
 Outside the cell NO causes vasodilatation
which increases micro circulation in
damaged tissues,delivering o2 and vital
sugars ,nutrients and proteins and salts and
removes wastes

11. EFFECTS OF LLLT

12. ULTRASONIC THERAPY

13.  Surgical Treatment :-
• Use a local anesthetic and a tourniquet.
• After sterile skin preparation and draping, use a
tourniquet as needed, and infiltrate the skin in the
area of the first dorsal compartment with sufficient
local anesthetic.
• Make a skin incision that runs from dorsal to volar in
a transverse-to-oblique direction, parallel with the
skin creases over the area of tenderness in the first
dorsal compartment .

14. • Carry sharp dissection just through the dermis
and not into the subcutaneous fat, avoiding the
branches of the superficial radial nerve.
• After retracting the skin edges, use blunt
dissection in the subcutaneous fat. Find and
protect the sensory branches of the superficial
radial nerve, usually located deep to the
superficial veins

15. • Identify the tendons proximal to the stenosing
dorsal ligament and sheath, and open the first
dorsal compartment on its dorsoulnar side.
• With the thumb abducted and the wrist flexed,
lift the abductor pollicis longus and the extensor
pollicis brevis tendons from their groove.
• Close the skin incision only, and apply a small
pressure dressing

17. INDIAN JOURNAL OF
ORTHOPAEDICS
 Outcome of low level lasers versus
ultrasonic therapy in de Quervain’s
tenosynovitis
Renu Sharma, Aditya N Aggarwal, Shuchi
Bhatt1, Sudhir Kumar, SK Bhargava1
Publishes on Tuesday, August 02, 2016, IP:
14.99.24.187]

18.  Aim of study:-to evaluate the outcome ultrasound
therapy vs low level laser therapy in de quervains
disease
 Materials and methods:-
 Study design:-prospective study
 Sample size:-30 cases
 The patients included in the study were randomly
dividedin two groups, one group (n = 15) received US
Th and the other group (n = 15) received LLLT.

19.  The following outcome measures were used namely
Finkelstein’s test, tenderness over radial styloid , grip
strength, pain as assessed by visual analog scale (VAS)
and ultrasonographic assessment of change in
thickness of APL and EPB tendon sheaths. All the
outcome measures were done before commencement
and after the end of seven sessions of therapy.

20.  Tenderness on pressure over the radial styloid was
graded by Ritchie’s tenderness scale.
 The grades were
 Grade I - Tolerable pain,
 Grade II - Patient winces on
pressure
Grade III - Patient winces and withdraws hand.

21.  Grip strength was measured by a standard mercury
sphygmomanometer with the arm cuff inflated to
30 mm Hg. The elbow and arm were supported on a table
and the elbow flexed to 90°. The cuff was then pressed in the
cylindrical grasp. The elevation of the mercury column was
recorded 3 times. The average of three readings was taken.
Clinically, the improvement was assessed subjectively by the
patient, using a 11-point (0 = no pain, 10 = severepain).
 The clinical tests were repeated before reducing
the dosage of laser/ultrasound therapy if improvement
was observed.

22.  Inclusion criteria:-Patients with no prior history of any
treatment for de Quervain’s tenosynovitis (operative or
nonoperative)for at least 3 months were included in
the study.
 Exclusion criteria:-
 Patients who had a history of cervical spondylosis with
or without radiating pain, hypertension, diabetes
mellitus,fractures of upper extremity or any other
chronic condition like rheumatoid arthritis were
excluded from study.

23. Results
 Thirty patients taken up for the study, the left side was
involved in 19 (59%), and the rightside (dominant
extremity) was involved only in 13 patients.
Bilateral involvement was seen in two patients. However
only the more affected extremity was included in the
study.
The tenderness (Ritchie’s Tenderness Scale) was found
significantly improved in the US Th.

24.  Finkelstein’s test conducted before and after
treatment was not statistically significant in both the
groups, that is LLLT and US Th.

25.  Grip strength for both the groups as compared with
mann-whitney u-test, before and after the treatment
shows no significant difference though with in groups
it was found significant
 Visual analog scale when compared between groups,
the change was not found statistically significant
though within groups it was found significant

26.  In the study, one subject (case no. 18) gave a VAS and
Ritchie’s tenderness scale reading of zero after
treatment.
 Finkelsteins Test was found to be negative. She was
given US Th. The ultrasonographic measurement
showed decrease of 0.07 cm in the AP and 0.04 cm in
the ML diameter of the tendons.

27.  Six subjects had grade 1 (minimalpain) on VAS scale
after treatment. Four of them belonged to LLLT group,
and the remaining 2 were from the USTh. group.
 In the study, there were six subjects who had a
post-treatment VAS of 10 or 9, indicating no
improvement

28.  On ultrasonographic measurements of tendon sheath
diameters, the difference in AP and ML diameters before
and after treatment was not found to be statistically
significant within groups as well as on comparison
between groups except one patient

29. CONCLUSION
 He concluded that grip strength and VAS showed
better improvement in US Th group as compared to
laser therapy group

30. Merits of study
 It is a prospective study
 Single observer and single surgeon (less bias)

31. Limitations of study
 sample size is small and case control study
 Further study with differential ultrasonographic
measurements of the extensor retinaculum and
tendonsheath thickness in de Quervains tenosynovitis
and its relation to the response to treatment should be
conducted.
 Followup is for short period

32. References
 CAMPBELL TEXT BOOK OF ORTHOPAEDICS
 Outcome of low level lasers versus ultrasonic
therapy in de Quervain’s tenosynovitis
Renu Sharma, Aditya N Aggarwal, Shuchi Bhatt1,
Sudhir Kumar, SK Bhargava1

33. Thank you