De Quervain's

De Quervain’s syndrome is stenosing tenosynovial inflammation of the 1st dorsal compartment. This impairs gliding of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons, thumb function, and causes pain on the radial (thumb) side of the wrist.

Diagnosis

History: patients suffering from De Quervain's syndrome experience pain and tenderness at the base of the thumb area near the first extensor compartment. Movement of the thumb and/or the wrist can provoke the pain. The pain may appear suddenly or may increase over time. Often, there is also swelling over the first extensor compartment. Its prevalence is 0.5% for men and 1.3% for women among adults of working age in the general population. It is also common in new mothers.

Signs and symptoms

Mild-moderate

• Tenderness over 1st extensor compartment progressing to pain over radial side of wrist
• Discomfort during some ADLs
• No pain at rest
• Swelling over 1st extensor compartment often present

Moderate-severe

• Moderate to severe tenderness
• Pain during most if not all ADLs
• Pain at rest
• Swelling over 1st extensor compartment

Differential diagnosis

• Osteoarthritis of the carpometacarpal (CMC) joint of the thumb may be excluded by using the grind test (See OA thumb section for how to perform)
• Radial nerve compression (to exclude test for a Tinel sign and sensation over the radiodorsal area of the hand)
• Cervical spine/ nerve root
• Scaphoid fracture
• Intersection syndrome; Check whether the complaints are located at the distal 1/3 of the dorsal radius, where the APL/EPB cross over the extensor carpi radialis longus/brevis (ECRL/ECRB) tendons (4-8 cm proximal to the radial styloid), which could suggest intersection syndrome.
• Peritendinitis
• Review previous x-rays

Physical Examination

• Pain and/or weakness on resisted thumb abduction and/or extension
• +ve Finkelstein's test - patient grasps the thumb and ulnar deviate the wrist sharply. Positive response: sharp pain occurs along the distal radius
• Pain on palpation of APL and EPB tendons
• Swelling on the lateral aspect of the wrist
• Crepitus on the lateral aspect of the wrist on thumb movement

Information on the nature of De Quervain’s Syndrome and activity management should be given to the patient:

• National Patient Information Leaflet for De Quervain's

Splinting - thumb spika for 6 weeks:

• To be worn during pain producing activities
• For splint to be beneficial it must be of a good fit

Stretching for 6 weeks:

• Use clinical judgement to determine appropriateness
• In acute stage stretching may aggravate symptoms

Limited evidence for:

Acupuncture, ultrasound, heat, cold, local massage, frictions, NSAIDs.

Second line management

Corticosteroid injection

Ensure patient has followed conservative management advice.  Guidelines suggest a patient can be offered 1-2 steroid injections.

Literature on the effects of corticosteroid during pregnancy and on lactation

Osterman (2012) states that no specific study has been done with regards to the effects of steroid injections to the health of the unborn child, however evidence does show that steroid use aids surfactant production and lung tissue development in premature babies.

There is limited literature on the effects of corticosteroid injection use during breast feeding. Evidence seems to suggest a temporary suppression to lactation after a corticosteroid injection. If considering discuss with local injection therapist.

Guidelines suggest a steroid injection if conservative management has failed, however if a patient declines an injection then specialist splinting from a hand therapist.

Specialist Splinting

If patient has had a trial of a splint, review use and compliance. Consider fabricating a splint for the patient if previous splint is deemed ineffective for that patient's needs.

Review appointment at 6 weeks. 

Escalation

If failure to respond to conservative treatment, consult local service for hand injection provision:

• Injection therapist within MSK
• Hand therapist

Refer for surgical opinion/list for surgery if:

• Failure to respond to conservative treatment
• Severe symptoms
• Unsuitability for CSI

NHSGGC Hand Service Orthopaedic and Therapy Post Operative Guidelines: De Quervain’s Release

Day of Surgery

• Dressing in situ, to be reduced in 48-72hrs by the patient
• Give patient 2 mepore dressings
• Check circulation, sensation and movement
• Instructions on elevation of limb, mobilisation of fingers and the rest of upper limb
• Patient provided with post operative patient information leaflet if they do not already have it
• Specify how and who to contact at clinic if there are any problems
• Fit note provided for the duration of expected absence if required

Review Clinic (10-21 days)

• Remove dressing/ sutures if required
• Check wound
  • Any evidence of infection contact surgical team
• Continue with light finger dressing if required
• Check ROM
  • Stiffness of wrist and hand. Advise on exercises as per patient information leaflet
• Scar Care
  • Once wound has healed gently massage with an emollient hand cream 3-4 times daily
• Returning to work
  • Avoid dirty environments and ensure dressing remains dry
  • Light manual 2-3 weeks
  • Heavy manual 4-6 weeks
• Driving
  • Once feels safe to do so and they feel they are in complete control of the car.  Advise that they may want to check with their insurance company
• Provide post operative patient information leaflet if they don’t already have one
• Specify how and who to contact at clinic, if there are any problems.

Problematic Pain

Consult the Pain Service for information and guidelines on diagnosis and management of Complex Regional Pain Syndrome.

Bionka M.A. Huisstede, J. Henk Coert, Jan Fridén, Peter Hoogvliet, for the European HANDGUIDE Group, Consensus on a Multidisciplinary Treatment Guideline for de Quervain Disease: Results From the European HANDGUIDE Study, Physical Therapy, Volume 94, Issue 8, 1 August 2014, Pages 1095–1110, https://doi.org/10.2522/ptj.20130069

Babwah, T. J., Nunes, P., & Maharaj, R. G. (2013). An unexpected temporary suppression of lactation after a local corticosteroid injection for tenosynovitis. The European Journal of General Practice, 19(4), 248–250. https://doi.org/10.3109/13814788.2013.805198

Jennifer J. Henderson, Peter E. Hartmann, John P. Newnham, Karen Simmer; Effect of Preterm Birth and Antenatal Corticosteroid Treatment on Lactogenesis II in Women. Pediatrics January 2008; 121 (1): e92–e100. 10.1542/peds.2007-1107

McGuire, E. (2012). Sudden loss of milk supply following high-dose triamcinolone (Kenacort) injection. Breastfeeding Review, 20(1), 32–34.

Osterman M, Ilyas AM, Matzon JL. Carpal tunnel syndrome in pregnancy. Orthop Clin North Am. 2012;43(4):515-520. doi:10.1016/j.ocl.2012.07.020