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JariArokoski

De Quervain's Disease and other Tendinitides of the Wrist and Forearm

Essentials

  • Tendon pain states in the wrist and forearm are caused by one-sided, repetitive and prolonged strain or an imbalance between strain and rest.
  • Most tendon and muscle pain states can be treated conservatively with strain reduction and drug therapy.
  • Surgical treatment may come into question in chronic stenosing tenosynovitis.

Definitions and aetiology

  • The terminology for tendon pain states is inconsistent in literature (table T1).
  • Tendinopathies usually occur as a result of one-sided strain or overstrain. The use of force, poor working positions and exposure to cold contribute to the development of tendinopathies.
  • Tendon diseases may be caused by local trauma to the tendon.
  • Tendon diseases occur in so-called seronegative spondyloarthritis associated with the HLA-B27 antigen (ankylosing spondylitis, reactive arthritis, arthritis associated with chronic inflammatory bowel diseases and psoriasis).
  • The normal anatomical space of the tendon can be restricted by e.g. joint swelling and osteophytes as well as bone fractures and subsequent malalignment.
  • Tendinitides of the wrist region occur especially in occupations that include repetitive straining of the hands, e.g. food processing and assembly work.
    • Risk factors include high amount of repetitive movements at work, use of great force, and wrist positions that deviate from the neutral mid-position.
  • Tendinitides are more common in women than in men.

Terminology for tendon problems

Tendinitis (inflammation of the tendon)
Tendinosis (degenerative changes without histological signs of active inflammation)
Tendinopathy (symptomatic tendon disease)
Insertional tendinitis (inflammation of the tendon insertion)
Tenosynovitis (inflammation of the tendon sheath)
Stenosing tenovaginitis (stenosing inflammation of the tendon sheath)
Peritendinitis (inflammation surrounding the tendon in an area without tendon sheath)
Tear in the tendon

Symptoms

  • In the acute phase, there is locally limited pain, swelling, redness and sometimes crepitation.
  • In the chronic phase, there is thickening of the tendon and its surrounding tissue, palpable moving nodules, snapping (trigger finger Trigger Finger) and locking at the entrapment point.
  • If the inflammation becomes chronic, the tendon may become ruptured.
  • Wrist movement is limited or the wrist is completely locked.
  • Movement of the wrist and hand makes the pain worse.
  • The symptoms are most severe in the morning and alleviate with the daily activities.
  • The strength of the hand may become reduced.

Diagnosis

  • Based on symptoms and clinical examination:
    • periodic pain or ache in the tendon areas of the wrist or forearm and
    • provocation of symptoms in forced muscle movements in the area and
    • the affected tendon is tender on palpation or a crepitation is felt on palpation or there is oedema on the wrist-forearm area.

de Quervain's disease

  • Stenosing tenosynovitis of the common tendon sheath of the m. abductor pollicis longus and m. extensor pollicis brevis
  • Pain provocation test
    • Finkelstein's test is positive when pain is provoked around the radial styloid process as the wrist is deviated in the ulnar direction and the thumb is flexed within the closed fist http://en.wikipedia.org/wiki/File:Finkelstein%27s_test.JPG. The test is performed simultaneously in both hands and differences are registered.
  • Tenderness on palpation at the radial styloid process (may be fairly minor).
  • Sometimes (at the acute phase), crepitation and oedema may be found.

Other tenosynovitides of the extensor muscles

  • In the intersection syndrome, pain and oedema localize more proximally and dorsally, 4-8 cm from the radial styloid process at the point where the tendons of the short extensor and the long abductor of the thumb intersect with the radial extensor tendons of the wrist.
  • Tendinitis of the m. extensor carpi ulnaris is very rare.

Tenosynovitides of the carpal flexors

  • Tenosynovitides of the deep and superficial flexors of the fingers that run in the carpal tunnel may also cause the carpal tunnel syndrome Carpal Tunnel Syndrome (CTS).
  • Tenosynovitis of m. flexor carpi radialis and, more rarely, m. flexor carpi ulnaris are also encountered.

Differential diagnosis

  • Diseases in the wrist and hand region to be considered in differential diagnosis are listed in table T2.

Non-tendon diseases of the wrist and hand

Osteoarthritis
Neurogenic causes (entrapments and injuries of n. medianus and n. ulnaris)
Nerve root pain states related to the plexus and cervical spine
Bone fractures, articular capsule damage and ligament damage
Rheumatoid arthritis and other inflammatory joint diseases
Tumours
Infections
Dupuytren's contracture Dupuytren's Contracture or postinjury contracture
Thoracic outlet syndrome (TOS) Thoracic Outlet Syndrome

Treatment and prevention

  • Assess the straining of the hand, avoid and reduce provoking tendon strain (ergonomics).
  • In cases of tenosynovitis caused by overstrain, avoidance of provocative exertion for a sufficiently long period and, as necessary, sick leave in the acute phase (up to 2-6 weeks)
  • Anti-inflammatory drug orally or topically as a course - not for long-term use
  • Cold therapy reduces pain and inflammatory reaction during the acute phase.
  • Splint therapy 1-2 weeks in the acute phase - not for long-term use
  • In systemic inflammation, good treatment of underlying disease
  • If these measures fail, a glucocorticoid injection may be tried mainly in stenosing tenosynovitis.
    • In De Quervain's tenosynovitis, pain symptoms may be relieved for a short time (1-2 weeks after the procedure). The glucocorticoid injection may be repeated 1-2 times if necessary.
    • A glucocorticoid injection combined with thumb splint may be more effective than either treatment form alone (short to medium-length follow-up time).
  • In some chronic cases, surgical treatment may be considered (splitting of the stenosed tendon sheath).
  • Tendon diseases are prevented by keeping the frequency of work movements, use of hand force and other risk factors within reasonable limits.

Injection technique (de Quervain's disease)

  • Inject long-acting glucocorticoid that is diluted with lidocaine or some other anaesthetic.
  • Insert the needle (1.5 cm, 25 G) in a 45° angle about 1 cm proximally from the radial styloid process towards it until bone contact is reached. The tendon is more easily felt on palpation if the patient resists the extension of the thumb isometrically with the index finger.
  • Insert the needle tangentially to the tendon sheath. If you suspect that the needle is in the tendon, remove the syringe and ask the patient to move his/her thumb: the needle will sway if it is in the tendon. Do not inject against a resistance (into the tendon).
  • Avoid hitting the radial nerve: if the patient feels something like a mild electric shock, draw the needle gently backwards. Injecting into the radial nerve may lead to a troublesome neuralgia.
  • The injection may be repeated, if necessary, after 4-6 weeks.

    References

    • Strain injuries of the hand and forearm. Current Care Guideline. Working group appointed by the Finnish Medical Society Duodecim and the Finnish Association of Occupational Health Physicians. Helsinki: Finnish Medical Society Duodecim, 2022 (accessed 20 Sep 2022). Available in Finnish http://www.kaypahoito.fi/hoi50055.