​Kembara Xtra - Medicine - De Quervain Tenosynovitis

​Kembara Xtra - Medicine - De Quervain Tenosynovitis 
In the year 1895, Fritz De Quervain was the first person to identify the painful condition known as de Quervain tenosynovitis. This condition is characterized by stenosis of the tendon sheath in the first dorsal compartment of the radial aspect of the wrist.
This condition is brought on by repeated motion of the extensor pollicis brevis (EPB) and abductor pollicis longus (APL) over the radial styloid, which ultimately leads to metaplastic alterations in the tendon sheath that surrounds the affected area.


Epidemiology (Incidence and Prevalence) 

Those between the ages of 30 and 50 are more likely to be afflicted, and women are more likely to be affected than men.

This illness is becoming more common as a result of evolving occupational and professional expectations, and its prevalence is gradually growing.
Incidence
The incidence of de Quervain tenosynovitis is calculated to be 0.9 per 1,000 person-years on average.
The incidence is 1.4/1,000 person-years for patients older than 40 years old, but it is only 0.6/1,000 person-years for patients younger than 20 years old.
The incidence rate ratio for women is 2.8/1,000 person-years, while the incidence rate ratio for males is 0.6/1,000 person-years. The incidence rate ratio for de Quervain tenosynovitis in blacks is 1.3/1,000 person-years, while the incidence rate ratio for whites is 0.8/1,000 person-years.
Prevalence

At this time, it is believed that 1.3% of females and 0.5% of males suffer from it.

Causes and effects: etiology and pathophysiology 

Microtrauma, a metaplastic thickening of the tendons (EPB, APL), and a constriction of the surrounding tendon sheath can be caused by repetitive motions of the wrist and/or thumb.
Movement of the EPB and APL is resisted as they glide over the radial styloid, which causes discomfort with motions of the thumb and wrist.
Cadaveric analyses have identified an additional septum within the 1st dorsal compartment in 34–44% of individuals, and subcompartmentalization has been reported in 86–94% of patients with de Quervain tenosynovitis.

factors of danger 
African American women between the ages of 30 and 50 who are pregnant (especially in their third trimester and after giving birth)
Systemic diseases such as rheumatoid arthritis Participation in activities that involve repetitive motion or forceful grasping with the thumb and wrist deviation such as golf, fly fishing, racquet sports, rowing, or bicycling, video gaming, and more recently text messaging Repetitive movements with the hand or thumb that require forceful grasping with the wrist involving ulnar/radial deviation; dental hygienists, musicians, carpenters, assembly


Preventative Steps and Precautions 

It is important to refrain from overusing or performing repetitive movements of the wrist and/or thumb, as these are often connected with strong gripping and ulnar/radial deviation.

History of the Presenting Symptoms Repetitive motion activities; overuse of the wrist or thumb Gradual worsening of discomfort along the radial aspect of the thumb and wrist with certain motions, particularly ulnar deviation of the wrist Pregnancy Sports, leisure, and employment history Trauma (rare) History of the condition

The Patient's Clinical Examination 
● Pain over the radial styloid exacerbated when patients
move the thumb or make a fist
● Crepitus with movement of the thumb
● Swelling over the radial styloid and base of the thumb
● Decreased range of motion of the thumb

● Pain over the 1st dorsal compartment on resisted thumb
abduction or extension
● Tenderness may extend proximally or distally along the
tendons with palpation or stress.
Finkelstein test: The patient is asked to aggressively ulnar deviate off the edge of a table, and the examiner grasps the affected thumb and continues to passively deviate the hand in the ulnar direction as the patient performs the test. When there is discomfort along the distal radius, this indicates that the test was successful.
The Finkelstein test is more sensitive for diagnosing tenosynovitis of the APL and EPB tendons than the Eichhoff test, in which the patient grasps a flexed thumb and the examiner deviates the wrist in an ulnar direction.


A differential diagnosis may include a scaphoid fracture, a tear in the scapholunate ligament, a dorsal wrist ganglion, osteoarthritis of the 1st carpometacarpal (CMC) joint, flexor carpi radialis tendonitis, infectious tenosynovitis, tendonitis of the wrist extensors, intersection syndrome, or trigger thumb.

Findings from the Laboratory Initial tests (laboratory, imaging) Primarily a clinical diagnosis Radiographs of the wrist to rule out other pathology, such as CMC arthritis, if the diagnosis is in question MRI is the imaging test of choice to rule out coexisting soft tissue injury or wrist joint pathology.

Additional Assessments, as well as Other Important Factors
Using ultrasound, one can identify anatomical differences in the first dorsal extensor compartment of the wrist, which is helpful for targeting corticosteroid injections.

It has been stated that ultrasound imaging has a sensitivity of one hundred percent for the diagnosis of pathology.
The Interpretation of Tests
Inflammation as well as a thickening of the tendon's retinacular sheath

The majority of cases of de Quervain tenosynovitis heal on their own without medical intervention.
Rest and nonsteroidal anti-inflammatory drugs (NSAIDs) Icing the area for 15 to 20 minutes, five to six times a day Immobilization using a thumb spica splint Occupational therapy Acupuncture Corticosteroid injection (ideally ultrasound guided) Consider surgical intervention if conservative therapies fail for more than six months.

Preventative Steps and Precautions 

If the pain is not completely relieved, it may be possible to alleviate the symptoms with a corticosteroid injection into the tendon sheath.
Anatomical variation, such as the subcompartmentalization of the first dorsal compartment or the EPB tendon traveling in a distinct compartment, has the potential to make treatment more difficult.
These variants can be differentiated with ultrasound, which also helps enhance the anatomic precision of injections. If symptoms continue to be a problem after 3 to 6 months of conservative treatment, it may be necessary to perform surgical release. Surgery has a good success rate and is associated with a low risk of complications on average.

The First Line Of Defense Is Medication
NSAIDs, immobilization in splints, and rest are all recommended.

Two-Thirds Line
Injections of corticosteroids into the tendon sheath have demonstrated a high level of success in curing the condition. It is sometimes necessary to administer further shots.
It has been found that immobilization on its alone is not as beneficial as when combined with corticosteroid injection.

Newer treatments for de Quervain tenosynovitis, such as ultrasound-guided percutaneous tenotomy, retinaculum release, and/or injection of platelet-rich plasma, have the potential to be effective.


Questions to be Submitted for Referral 

If there is no progress with conservative therapy, it is recommended that the patient be referred to a hand surgeon.

Extra Medical Interventions

Hand therapy, in combination with iontophoresis and phonophoresis, might be helpful in improving outcomes in instances that are chronic.
Patients may benefit from doing activities that extend their thumbs as part of their recovery.

Endoscopic release may provide speedier relief, fewer problems to the superficial radial nerve, and more patient satisfaction with the ensuing scar compared to open release, which is indicated for patients who have failed conservative treatment. Open release is indicated for individuals who have failed conservative treatment.

Admission into a hospital for the purpose of receiving care related with operative treatment

In the event that symptoms continue to manifest themselves after 4 to 6 weeks, a follow-up corticosteroid injection may be administered. Use extreme caution when administering multiple steroid injections.
Attempt to steer clear of activities and motions that have a painful recurrent pattern.

Patient education regarding activity modification: try to avoid activities that involve forceful grabbing or repetitive movements of the wrist or thumb.

Complete resolution may take up to one year. 95% success rates have been observed with conservative therapy that lasts longer than one year. Prognosis: Extremely favorable with conservative treatment; complete resolution may take up to one year.
 Up to one-third of people may experience symptoms that may not go away.

Complications 

The majority of problems arise as a result of the treatment. Injuries to the gastrointestinal tract, renal system, and liver can result from taking NSAIDs.
During surgery, there is a risk of sustaining nerve damage.
Corticosteroid injection has been linked to a number of potential side outcomes, including hypopigmentation, fat atrophy, hemorrhage, infection, and tendon rupture. The risk of complications is decreased by using ultrasound guidance, and thumb flexibility may be lost owing to fibrosis if the condition is not properly treated in a timely manner.

---