de quervains tenosynovitis cover

treatment options for de quervain's tenosynovitis

De Quervain’s tenosynovitis (DQTS), also known as chronic stenotic tenosynovitis and de Quervain’s disease (DQD), is a condition affecting the thumb extensor tendons and has many non surgical and operative treatments. It is a disorder characterized by pain of varying degrees of severity in the radial side of the wrist due to restricted gliding of the tendons of abductor pollicis longus and extensor pollicis brevis in the fibro-osseous canal of the first dorsal compartment of the wrist. Around 75 percent of cases occur in women.  

Case Introduction

A 36 year old first time mother presents to your clinic with right wrist pain. Her baby is now 3 months old. She states she was gripping very tightly on the bed while delivering and has had some wrist pain since then. She has pain with thumb extension and exquisite pain with Finkelstein test. What is the most effective nonsurgical monotherapy treatment option?

A) Corticosteroid injection into first dorsal compartment
B) Thumb spica splint for 3-6 weeks
C) Occupational therapy paired with ultrasound
D) Short arm cast for 3-6 weeks

There is debate in regards to the etiology of DQTS with one report indicating degenerative changes that narrow the fibro-osseous canal and thicken the tendon sheath [1]. A more recent report by Kuo et al. immunohistochemically demonstrated the presence of inflammatory cells and higher levels of infiltration factors in de Quervain’s disease retinaculum, and that tissue inflammation and angiogenesis occurred and increased with progression of the disease [2]. The general consensus is that it is not an inflammatory condition. The prevalence rate of de Quervain’s disease in the general population is 0.5% for males and 1.3% for females. Other reports show the risk of de Quervain’s disease is relatively higher in the black race and in occupations involving repetitive use of hand [3-4].

NON-surgical management

Nonsurgical treatment is the primary treatment of choice for DQTS and many options exist.  The goal of treatment is pain relief and restoration of a fully functioning hand and wrist.  Nonsurgical options previously discussed in the literature include corticosteroid injection (CSI), nonsteroidal antiinflammatory drugs, thumb spica casting or bracing, and physical therapy.  

Several prospective and retrospective studies have found anywhere between 67% and 93% success rate of CSI, which are widely considered the most effective conservative monotherapy in management of de Quervain tenosynovitis. One other recent randomized trial compared ketorolac and betamethasone with betamethasone having significantly lower pain scores, better patient-reported outcomes and less likely need for a second injection [19].
There are conflicting studies on whether casting or bracing after injections is beneficial. More recent research has shown that the addition of immobilisation splinting post–corticosteroid injection improved outcomes versus injection alone. [7-9] The addition of exercises has also been shown to improve longevity of pain relief versus steroid injection plus splinting [10].
corticosteroid injections for de quervains tenosynovitis

Figure 1:  Studies from 2004 and prior showing a success rate of 67 to 93 percent

There are studies suggesting ultrasound-guided steroid injections have shown better results than blind techniques in patients with de Quervain’s disease, as medication can be delivered precisely into the tendon sheath [5-6].  Correct needle placement with US guidance avoids intratendinous injection and local complications such as fat atrophy and depigmentation [6].  

The abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons are usually in the same compartment, but some patients have separate subcompartments for the APL and EPB tendons within the first extensor compartment. This results in sub compartmentalization of the first extensor compartment and makes it difficult for the medication to reach inside each tendon sheath effectively and can lead to failure. Three anatomical variants have been described with ultrasound. Complete sub compartmentalization has a septum throughout separating the APL and EPB tendons. With distal incomplete sub-compartmentalization, the APL and EPB run in the same sheath at the level of the distal radius until the crossover with the second dorsal compartment. The last variant has no sub-compartmentalization [18]. Kume et. al proposed type I De Quervain’s disease that describes no sub-compartilization or septum and type II that has complete sub-compartilization. Both studies using an ultrasound-guided anatomical approach have shown to be beneficial and superior to palpation guided injections [5,18].
Ultrasound Complete subcompartmentalization of first dorsal compartment de quervains

Figure 2.  Complete subcompartmentalization with ultrasound guided technique approaching each side. Adopted from [18].

ultrasound distal incomplete subcompartmentalization of thumb extensor tendons de quervains

Figure 3.  Ultrasound images of distal incomplete subcompartmentalization of APL and EPB.  Injection technique would include targeting more proximally or injection in two areas more distally.  Adopted from  [18].

Despite successful outcomes with corticosteroid monotherapy, there is a lack of consensus on the role of immobilization with thumb spica casting or splinting. Splinting for De Quervain’s tenosynovitis has been found to decrease pain while increasing patients’ ability to continue to participate in activities of daily living [8].  The splint must immobilize the wrist and thumb, excluding the thumb interphalangeal joint, in order to offload the APL and EPB tendons. Splints can either be rigid thermoplastic types or over the counter types made of semi-stiff fabric with metal bars for support. 

There is no definitive consensus on how long or often splints should be worn. Menendez et al. showed that full-time splint wear versus as desired splint wear had no effect on disability, grip strength, pain intensity, or patient satisfaction, concluding that strict rest by immobilization is not disease modifying [11]. In a 3-armed study, Weiss et al. studied use of corticosteroid injections and splinting together and separately to determine their clinical effect. They observed a 67% improvement with injection alone, 57% improvement with both injection and splinting, and 19% improvement with splinting alone. Lane et al. separated their study population into minimal, moderate, and severe illness based on clinical symptoms [12]. They identified a success rate of 88% with use of NSAIDs and splints in patients with “minimal” symptoms but only a 32% success rate with “moderate to severe” symptoms [13].

Kinesiology tape, like thumb splinting, has been shown to offer short-term benefit in the conservative management of de Quervain disease [14]. Other modalities that have been investigated include acupuncture, therapeutic ultrasound and hyaluronic acid [20-21].

Two separate studies describe treatment with platelet rich plasma or PRP.  One study with 30 patients showed decreased pain scores on the visual analog scale at 6 months.  Another study with 40 treatments showed corticosteroids to have better pain relief and hand function at 1 month.  However, the PRP group had better pain relief and hand function testing at 6 months.  No side effects were reported with PRP in either study [25-26].

Determining the efficacy of non-steroidal anti-inflammatory medications (NSAIDs) is difficult because they are often combined with other treatment modalities in most series examining their use for de Quervain’s tenosynovitis. Jirarattanaphochai et al. found no benefit to adding nimesulide, a selective cyclooxygenase-2 inhibitor, to corticosteroid injection in a randomized, double-blinded prospective study [15-16].  A case series of four de Quervain patients reported on complete symptom resolution in 75 percent of patients with only physical therapy [17].  A more recent study with 98 patients had a success rate of 82.71% with corticosteroid injection and 65.31% with splinting, heat and ice compression and NSAID gel.  The results showed a significant difference for both groups with respect to pain score and cure rate [18].

Treatment algorithm for De Quervains tenosynovitis

Figure 4: Treatment algorithm proposed for De Quervain’s tenosynovitis.  Adopted from [27].

Surgical treatment

Surgery should be considered for recalcitrant cases that have shown no improvement with conservative measures over a 3–6-month time frame. The cure rate has been shown to be around 90 percent [24].  The presence of a septum and multiple tendon slips are known to contribute to failure of non-operative treatment [22].  There are many different surgical techniques reported and all require decompression.  This usually involves a transverse incision with release on the dorsal side of 1st compartment to prevent volar subluxation of the tendon.  Other incisions have also been described including longitudinal, lazy “s” or even specific angle technique [23].  Close attention must be paid to the anatomy of the APL and EPB and tendon slips and compartments (as mentioned earlier). 

Close attention must be paid to the anatomy of the APL and EPB and tendon slips and compartments (as mentioned earlier). This can lead to recurrence or poor outcome. Close attention must also be paid to the superficial radial sensory nerve. A recent long-term report of 80 cases assessed at 9.5 years had resolution of 85 % and 97.5 % satisfaction without any cases of recurrence. However, no consensus has been established on a “golden standard” for the incision type used for surgical treatment of DQTS. The ideal incision should provide the best exposure with minimal scar tissue formation, a low recurrence rate and a minimal chance of iatrogenic damage to anatomical structures.

summary

In conclusion, the current evidence suggests a multimodal approach to conservative measures for the management of de Quervain’s tenosynovitis.  Corticosteroids seem to be the most effective measure for long term relief and ultrasound is a valuable tool to identify and visualize septation or sub-compartmentalization of the APB and EPL.  Ultrasound guided injections can improve accuracy and clinical cure rates with a more anatomical approach, although success rate with palpation guided injections ranges from 67 to 93 percent.  Surgery is reserved for recalcitrant cases after 3-6 months and has shown to have very good outcomes around 90 percent.

– More Wrist Pain from Sports Medicine Review: https://www.sportsmedreview.com/by-joint/wrist/

– Read More: https://wikism.org/De_Quervains_Tenosynovitis

Case conclusion

Answer A. Nonsurgical options previously discussed in the literature include corticosteroid injection (CSI), nonsteroidal antiinflammatory drugs, thumb spica casting or bracing, and physical therapy. Several prospective and retrospective studies have found anywhere between 67% and 93% success rate of corticosteroid injection, which are widely considered the most effective conservative monotherapy in management of de Quervain tenosynovitis. In a 3-armed study, Weiss et al. studied use of corticosteroid injections and splinting together and separately to determine their clinical effect. They observed a 67% improvement with injection alone, 57% improvement with both injection and splinting, and 19% improvement with splinting alone. Lane et al. separated their study population into minimal, moderate, and severe illness based on clinical symptoms. They identified a success rate of 88% with use of NSAIDs and splints in patients with “minimal” symptoms but only a 32% success rate with “moderate to severe” symptoms.
Weiss AP, Akelman E, Tabatabai M. Treatment of de Quervain’s disease. J Hand Surg 1994;19A:595–598.
Lane LB, Boretz RS, Stuchin SA. Treatment of de Quervain’s disease: role of conservative management. J Hand Surg 2001;26B: 258–260

References

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  2. Kuo YL, Hsu CC, Kuo LC, Wu PT, Shao CJ, Wu KC, et al. Inflammation is present in De Quervain’s disease – Correlation study between biochemical and histopathological evaluation. Ann Plast Surg. 2015;74(Suppl 2):S146–51
  3. Walker-Bone K, Palmer KT, Reading I, Coggon D, Cooper C. Prevalence and impact of musculoskeletal disorders of the upper limb in the general population. Arthritis Rheum. 2004;51:642–51.
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  5. Kume K, Amano K, Yamada S, Amano K, Kuwaba N, Ohta H. In de Quervain’s with a separate EPB compartment, ultrasoundguided steroid injection is more effective than a clinical injection technique: a prospective open-label study. J Hand Surg Eur Vol. 2012;37(6):523–7.
  6. Di Sante L, Martino M, Manganiello I, Manganiello I, Santilli V. Ultrasound-guided corticosteroid injection for the treatment of de Quervain’s tenosynovitis. Am J Phys Med Rehabil. 2014;93(3): 278.
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  12. Weiss AP, Akelman E, Tabatabai M. Treatment of de Quervain’s disease. J Hand Surg 1994;19A:595–598. 
  13.  Lane LB, Boretz RS, Stuchin SA. Treatment of de Quervain’s disease: role of conservative management. J Hand Surg 2001;26B: 258–260
  14. D’Angelo K, Sutton D, Côté P, Dion S, Wong JJ, Yu H, Randhawa K, Southerst D, Varatharajan S, Cox Dresser J, Brown C, Menta R, Nordin M, Shearer HM, Ameis A, Stupar M, Carroll LJ, Taylor-Vaisey A. The effectiveness of passive physical modalities for the management of soft tissue injuries and neuropathies of the wrist and hand: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration. J Manipulative Physiol Ther. 2015 Sep;38(7):493-506. doi: 10.1016/j.jmpt.2015.06.006. Epub 2015 Aug 21. 
  15. Lane LB, Boretz RS, Stuchin SA. Treatment of de Quervain’s disease: role of conservative management. J Hand Surg 2001;26B: 258–260. 
  16. Jirarattanaphochai K, Saengnipanthkul S, Vipulakorn K, Jianmongkol S, Chatuparisute P, Jung S. Treatment of de Quervain disease with triamcinolone injection with or without nimesulide. A randomized, double-blind, placebo-controlled trial. J Bone Joint Surg 2004; 86A:2700–2706.
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  18. Bing JH, Choi SJ, Jung SM, Ryu DS, Ahn JH, Kang CH, Shin DR. Ultrasound-guided steroid injection for the treatment of de Quervain’s disease: an anatomy-based approach. Skeletal Radiol. 2018 Nov;47(11):1483-1490.
  19. Chadderdon, Chris, et al. “Betamethasone Versus Ketorolac Injection for the Treatment of De Quervain’s Tenosynovitis: A Double-Blind Randomized Clinical Trial: Level 1 Evidence.” Journal of Hand Surgery 42.9 (2017): S45-S46.
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  21. Orlandi, D., Corazza, A., Fabbro, E. et al. Ultrasound-guided percutaneous injection to treat de Quervain’s disease using three different techniques: a randomized controlled trial. Eur Radiol 25, 1512–1519 (2015).
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  23. Poublon AR, Kleinrensink GJ, Kerver A, Coert JH, Walbeehm ET. Optimal surgical approach for the treatment of Quervains disease: A surgical-anatomical study. World J Orthop. 2018;9(2):7-13. Published 2018 Feb 18. doi:10.5312/wjo.v9.i2.7
  24. Ta KT, Eidelman D, Thomson JG. Patient satisfaction and outcomes of surgery for de Quervain’s tenosynovitis. J Hand Surg Am. 1999 Sep;24(5):1071-7.
  25. AL-Ardi, Iskandar Mahdi. “Platelet-rich plasma as a treatment for DE Quervain’s Disease.” Al-Qadisiyah Medical Journal 13.23 (2017): 197-201.
  26. SOBHIA, A. MAHMOUD, A. EMAN, and M. ABD EL-RAHIM. “The Role of Platelet Rich Plasma in Comparison with Corticosteroids in the Treatment of De Quervain Tenosynovitis.” The Medical Journal of Cairo University 88.March (2020): 141-148.
  27. Abi-Rafeh, Jad, et al. “Conservative Management of de Quervain Stenosing Tenosynovitis: Review and Presentation of Treatment Algorithm.” Plastic and reconstructive surgery 146.1 (2020): 105-126.