De Quervain's disease is a stenosing tenosynovitis of the first dorsal compartment of the wrist caused by inflammation of the tendon sheaths of the abductor pollicis longus and extensor pollicis brevis tendons. It often affects women ages 30-50 and is caused by repetitive motions of the thumb like gripping. Symptoms include pain on the radial side of the wrist worsened by ulnar deviation and thumb movement. Diagnosis is based on tenderness over the tendon sheaths and a positive Finkelstein's test. Most cases are treated conservatively with splinting, activity modification and anti-inflammatories while surgery is reserved for persistent cases.

2. de Quervain's Disease
 Named after a Swiss surgeon, Fritz de Quervain,
whom first described the problem in 1895.
 It is a progressive stenosing tenosynovitis which
affects the tendon sheaths of the 1st dorsal
compartment of the wrist.
 Characterised by degeneration and thickening of
the tendon sheath.

3.  1st dorsal compartment contains the tendons and
synovial sheaths of APL and EPB tendons.

4. Etiology
Inflammation of synovial sheaths results from continuous
repetitive use of EPB and APL muscle.
↓
Scarring and thickening of tendon sheaths.
Stenosing, increase friction
↓
Inflammation
↓
Degeneration
 RA – affect synovial proliferation and swelling in tendon
sheaths

5. Predisposing Factors
 Overuse injury
 Repetitive tasks that involve overexertion of thumb, radial and
ulnar deviation of the wrist
 Arthritis
Activities such as:
 Wringing out wet clothes.
 Hammering.
 Painting.
 Skiing.
 Knitting.
 Lifting heavy objects such as a jug of milk, taking a frying pan
off of the stove, or mother lifting a baby out of a crib (baby
wrist).

6. Incidence and Prevalence:
 Usually a gradual and insidious onset of dull ache over radial
aspect 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 activities
requiring sideways movement of the wrist while gripping the
thumb (eg. hammering, some assembly line jobs, skiing, golf)

7. Sign & Symptoms
 Localised swelling and tenderness in
the region of radial styloid process.
 Pain while performing ulnar deviation,
thumb flexion and adduction.
Diagnosis
 Positive Finkelstein test
 Increase pain on active contraction
against resistance on thumb extension
 Xray to r/o bony pathology (eg.
scaphoid #, arthritic changes)

8. Management
Conservative Mx
 Rest from activity that increases pain / Thumb Spica Splint for 3~4wk
 Modification of activity
 Anti-inflammatory medication
 Corticosteroid injection
 Physiotherapy
Surgical (tenosynovectomy)
 Only indicated for surgical if symptoms persists > 3mth / conservative
failed.
 A 1-2cm incision is made over the first dorsal compartment and the
extensor retinaculum is divided to free the tendons.

9. Rehabilitation -
ConservativeGoal : Decrease pain and swelling,
Activity modification,
Restore mobility and strength
Treatment:
 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 and
hands

10. Rehabilitation – Post Op
Day 0-2
- Rest, surgical wound on dressing
Day 2-14
- Removal of dressing, Thumb splica splint
- Gentle active ROM ex
- STO on 10 -14th days
- Desensitization – Digital massage on the area of incision
1-6weeks
- Gradual progressing strengthening ex
- Scars tissue mobilization
- Resisted activity to be avoided till 6wks post-op

12. Case Presentation

13. 1st Ax on 16 March 2011
SUBJECTIVE ASSESSMENT
Name : Mr. AXX
Age : 29 y.o
Gender: Male
Occupation: Lorry Driver
Pt’s Problem:
- Sudden onset of pain at Left lateral wrist for 2/52
Pain:
- 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

14. Hx of Current Condition:
Pt. noticed pain at left lateral wrist in the morning, suspect compressing
the thumb during sleep. Did not seek treatment. Pain get worst gradually
with activity.
Past Medical Hx.: Had wrist fracture 3 years ago.
General health: Good
Medication: Nil
Investigation: Nil
Dominant Hand: Right
Functional Status / ADL: Patient experience pain in activity that
involve grasping and driving.
Vital Sign: B/P: 120/80 mmHg

15. OBJECTIVE ASSESSMENT
Local Observation
- Mild swelling at left lateral wrist as compare to
right side.
- No open wound / haematoma
Palpation
- Tenderness at base of left thumb and radial
styloid process.

16. Movement
 Active ROM of left wrist, with end-range-pain on ulnar and
radial deviation
 Active ROM of thumb, with end-range-pain on thumb
extension and abduction.
 Active ROM of elbow and neck motions were full and pain
free.
Muscle Power (Oxford grading)
 Muscle grading were deferred d/t resisted movement
involving thumb and wrist were painful.
 All other fingers tested normal.
Special Test
 Finkelstein’s test – Positive

17. Analysis
- Impaired motor function and ROM associated with
inflammation of EPB and APL tendons and tendon sheaths
suggesting 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 strength
Long 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

18. 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 modification
Intervention
1) Hot cold test √
2) WAX bath
3) Transverse friction massage on EPB & APL tendon
4) Tendon gliding ex for EPB & APL
5) MWM for wrist flexion & extension
6) Thumb manips
7) Ultrasound at lateral wrist (1MHz, 1.0W/cm2, 3mins)
8) Home exercise programme – STM, tendon gliding ex, pain free ROM ex
9) Patient was told to rest left thumb and avoid aggravating motions and
activities.

19. 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 power
test when pain reduce. Gradually increase ex intensity and progress
to strengthening ex.

20.  Conclusion
Most individuals does not require surgery and will recover with rest or
injections within 6wk times. Surgical cases may require up to 3-6
months to regain pre-operative strength.
Recurrence of the symptoms is very rare.
 Complications
Possible problems after the surgery can include irritation of the small
nerves which give feeling of numbness or tingling sensation to the
area of skin on the wrist and back of the hand.
Previous injury that altered the anatomy of the wrist would make
treatment more difficult.

22. References
 Brotzman, S. and Wilk, K. (2003) Clinical
Orthopaedic Rehabilitation, 2nd ed.
Philadelphia: Mobsy, p.72-75.
 Dutton, M. (2008) Orthopaedic
Examination, Evaluation, and Intervention,
2nd ed. USA: The Mc-Graw Hill, p.810-828.
 Website:
http://www.ajronline.org/cgi/content/full/182
/3/719