De Quervains Tenosynovitis

By : dr. Hermilawaty

Definition

Stenosing tenosynovitis of the thumb abductors at the radiostyloid process

Rene Cailliet, Hand & ImpairmentPhiladelphia 1975

 The Tendons of the abductor pollicis longus and extensor pollicis brevis move in the same synovial sheath that passes in a bony groove over the radiostyloid process and forms a sharp angle of as much as 105.

Rene Cailliet, Hand & ImpairmentPhiladelphia 1975

www.ars.usda.gov/Services/docs

Pathophysiology
Synovitis result from friction between the tendon, the sheath and the bony process occurs during pinching with the thumb and simultaneous motion of the wrist. Vascularity of the outer sheath that, coupled with edema, thickens the sheath and constricts the enclosed tendon.
The synovial fluid of the sheath increases and turns a yellowish color. Fine hair-like adhesions may be found between the sheath and the tendon and the sheath may be thickened to two or four times its normal size.

Sex :
the female to male ratio is 8 : 1

Age :
most common in adult

Clinical
Pain at the dorsolateral aspect of the wrist (over the styloid process) with referral pain toward

the thumb and/or the lateral forearm.

The history includes chronic repetitive activities using the involved hand or thumb. Examples include work activities (eg, computer use, materials handling) or recreational activities (eg, knitting, golf, racket sports).

Patrick M Foye, MD, Professor of Physical Medicine and Rehabilitation University of Medicine and Dentistry of New Jersey, New Jersey Medical School (e-medicine)

 The pain is aggravated by movement on the wrist and thumb. Characteristic symptoms can be reproduced by flexing the thumb and cupping it under the fingers, then flexing the wrist in an ulnar deviation which stretches the thumb tendons
There may be tenderness over the tendon.
Rene Cailliet, Hand & Impairment Philadelphia 1975

 The Finkelstein test draws the tendons of the first dorsal compartment distally and causes sharp, local pain when tendon entrapment has occurred and inflammation is present.

De Quervain Tenosynovitis Author: Roy A Meals, MD, Clinical Professor, Department of Orthopedic Surgery, University of California at Los Angeles

Differential Diagnosis :
Carpal Tunnel Syndrome Tigger Fingers Rheumatoid Arthritis

Treatment :
Rehabilitation Program Rest, Splinting, heat modalities, stretching of the first dorsal compartment muscles, and ice may offer relief of symptoms. Medical Corticosteroid injection Surgical Intervention

Rene Cailliet, Hand & Impairment,Philadelphia 1975 & Patrick M Foye, MD, Professor of Physical Medicine and Rehabilitation University of Medicine and Dentistry of New Jersey, New Jersey

Medical School (e-medicine)

prognosis
The patients can generally return to full function after the inflamation quiet down with treatment. Sometimes bracing is used during future activities that involve repetitive wrist motion.
www.medicinenet.com/de_quervains_tenosynovitis

Case Report Patient identify, date 14 September 2009 Name : Mrs. MI Age : 60 years old Address : Surabaya Occupational : housewife Religion : Moslem

Referred from neurology outpatient clinic with De Quervains syndrome

Chief complain : sakit pada pergelangan tangan diatas ibu jari kiri. Present illness : - She feel pain in the wrist upper the thumb sinistra since 1 month ago. - She felt the pain when she abducting her thumb sinistra. - She went to neurology outpatient clinic and get medicine natrium diklofenac. - The pain disturb her activity as washing clothes, and carrying her grandson (5 yo). - The pain is not radiated, no numbness and no tingling sensation.

 History of Past Illness : No Hipertension, no diabetes and no trauma Physical Examination (14 September 2009) General Status Composmentis, Independent ambulation, gait normal, right handed BP : 130/80 mmHg , HR : 76 x/minutes Body Weight : 54 kg, body high: 150cm, BMI : 24

Head and neck : no anemia, icterus, cyanosis & dyspneu Thorax : cor : S1-S2 sound, murmur pulmo : Vesiculer, wheezing-/-, ronchi -/: meteorismus -, unpalpable hepar & lien : warm acral +/+

Abdomen

Extremities

Physiatric Examination

Musculoskeletal Examination ROM

Cervical Flexion Extension Lateral Flexion Rotation

MMT
5 5 5/5 5/5

F (0 45) F (0 45) F/F (0 45) F/F (0 60)

Trunk Flexion Extension Lateral Flexion Rotation

F/F (0 80) F/F (0 30) F/F (0 35) F/F (0 45)

5/5 5/5 5/5 5/5

Shoulder Flexion Extension Abduction Adduction Ext. Rotation Int. Rotation

F/F (0 180) F/F (0 80) F/F (0 180) F/F (0 45) F/F (0 45) F/F (0 55)

5/5 5/5 5/5 5/5 5/5 5/5

Elbow Flexion extension F/F (0 -150) Forearm supination F/F (0 80) Forearm pronation F/F (0 80)
Wrist Flexion Extension Radial Deviation Ulnar Deviation

5/5 5/5 5/5

F/F (0 80) F/F (0 70) F/F (0 20) F/F (0 30)

5/5 5/5 5/5 5/5(pain)

Finger Flexion MCP PIP DIP Extension Abduction Adduction

F/F (0 90) F/F (0 100) F/F (0 90) F/F (0 15) F/F (0 20) F/F (20 0)

5/5 5/5 5/5 5/5 5/5 5/5

Thumb Flexion extension MCP IP Abduction adduction

F/F (0-60) F/F (0-65) F/F (0 50)

5/5 5/5 5/5 (pain)

Hip Flexion Extension Abduction Adduction Ext. Rotation Int. Rotation F/F (0 125) F/F (0 30) F/F (0 45) F/F (0 20) F/F (0 45) F/F (0 45) 5/5 5/5 5/5 5/5 5/5 5/5

Knee flexion Extension Ankle Plantar Flexion Dorsi flexion Inversion Exversion

F/F (0 135)

5/5

F/F (0 45) F/F (0 35) F/F (0 35) F/F (0 25)

5/5 5/5 5/5 5/5

Toes Flexion MTP IP Extension Big Toe Flexion MTP IP Extension

F/F (0 30) F/F (0 50) F/F (0 80)

5/5 5/5 5/5

F/F (0 25) F/F (0 25) F/F (0 80)

5/5 5/5 5/5

Neurological Examination Cranial Nerves DTRS : Normal : BPR ++/++ KPR ++/++ TPR ++/++ APR ++/++ Pathological Reflexs : Babinsky -/-, Chaddock -/, HT -/Sensory Deficit : (-) VAS : 4

Local Status : Area thumb, manus sinistra I : Inflamation (-), swelling (-), redness (-), deformity (-), difficulty in abduction the thumb sinistra P : Tender point at abductor tendon thumb sinistra

Hand Function : Cylindrical : Normal / Normal Spherical : Normal / normal Hook : Normal / Normal Pinch : Normal / Normal but pain Opposition : Normal / Normal Grips : Normal / Normal but pain Diagnosis : De Quervains tenosynovitis sinistra

Functional Diagnosis : Impaired : she feel pain in abductor tendon thumb sinistra. disability : disturb her daily activivity such as washing clothes and carrying her grandson. Handicap : -

Problem List : Surgical : Medical : De Quervains tenosynovitis sinistra

Rehabilitation Medicine : R1 (Ambulation) : R2 (ADL) : disturb her daily activity such as washing clothes and carrying her grandson R3 (Communication): -

R4 (Sociological)

:-

R5 (Psychological) : she worries about her illness R6 (Vocational) R7 (others) :: - pain when she abduct her thumb sinistra.

 Planning : Surgical : Medical : continue the medicine from neurology outpatient clinic (na diclofenac) Rehabilitation medicine : P. Dx : P. Tx : - USD at abductor tendon thumb sinistra - ROM exercise manus sinistra - Splint Thumb manus sinistra P. Mx : Klinis P. Ed : Health Education & Home Exercise Program - avoid repetitive movement - warm compression at home - ROM exercise at home

Summary
It has been reported that woman 60 y.o. Referred from neurology outpatient clinic with de Quervains syndrome. Her chief complain : sakit pada pergelangan tangan diatas ibu jari kiri. She feel pain in the wrist upper the thumb sinistra since 1 month ago. She felt the pain if she abducting her thumb sinistra. She went to neurology outpatient clinic and get medicine na diklofenac. The pain disturb her activity as washing clothes, and carrying her grandson (5 yo). The pain is not radiated, no numbness and no tingling sensation.

Physical examination : Abduction adduction thumb F/F (0 50) 5/5(pain) Ulnar Deviation F/F (0 30) 5/5(pain) VAS 4 Tender point at abductor tendon thumb sinistra. He can grips and pinch but feel pain. Diagnose : De Quervains Tenosynovitis sinistra, with planning therapy : USD at abductor tendon thumb sinistra, ROM execise manus sinistra and Splint Thumb manus sinistra. Health Education and Home Exercise Program such as avoid repetitive movement, warm compress and exercise.

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