De Quervain syndrome

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de Quervain Syndrome
Originaler Finkelstein-Test.jpg
Finkelstein's test for DeQuervain's tenosynovitis
Classification and external resources
SpecialtyPlastic surgery
Young people using their smartphones with their thumbs (2014).

De Quervain syndrome (French pronunciation: ​[də kɛʁvɛ̃]; also known as BlackBerry thumb, texting thumb, gamer's thumb, washerwoman's sprain, radial styloid tenosynovitis, de Quervain disease, de Quervain's tenosynovitis, de Quervain's stenosing tenosynovitis, mother's wrist, or mommy thumb), is a tenosynovitis of the sheath or tunnel that surrounds two tendons that control movement of the thumb.[1]

Signs and symptoms[edit | edit source]

Symptoms are pain at the radial side of the wrist, spasms, tenderness, occasional burning sensation in the hand, and swelling over the thumb side of the wrist, and difficulty gripping with the affected side of the hand. The onset is often gradual.[1] Pain is made worse by movement of the thumb and wrist, and may radiate to the thumb or the forearm.[1]

Causes[edit | edit source]

The cause of de Quervain's disease is not established. Evidence regarding a possible relation with occupational risk factors is debated.[2][3] A systematic review of potential risk factors discussed in the literature did not find any evidence of a causal relationship with occupational factors.[4] However, researchers in France found personal and work-related factors were associated with de Quervain's disease in the working population; wrist bending and movements associated with the twisting or driving of screws were the most significant of the work-related factors.[5] Proponents of the view that De Quervain syndrome is a repetitive strain injury[6] consider postures where the thumb is held in abduction and extension to be predisposing factors.[2] Workers who perform rapid repetitive activities involving pinching, grasping, pulling or pushing have been considered at increased risk.[3] Specific activities that have been postulated as potential risk factors include intensive mouse/trackball use[2] and typing, as well as some pastimes, including bowling, golf and fly-fishing, piano-playing, and sewing and knitting.[3]

Women are affected more often than men.[3] The syndrome commonly occurs during and after pregnancy.[7] Contributory factors may include hormonal changes, fluid retention and—more debatably—lifting.[7][8]

Pathophysiology[edit | edit source]

The mucous sheaths of the tendons on the back of the wrist.

De Quervain syndrome involves noninflammatory thickening of the tendons and the synovial sheaths that the tendons run through. The two tendons concerned are those of the extensor pollicis brevis and abductor pollicis longus muscles. These two muscles run side by side and function to bring the thumb away from the hand; the extensor pollicis brevis brings the thumb outwards radially, and the abductor pollicis longus brings the thumb forward away from the palm. De Quervain tendinopathy affects the tendons of these muscles as they pass from the forearm into the hand via a fibro-osseous tunnel (the first dorsal compartment). Evaluation of histopathological specimens shows a thickening and myxoid degeneration consistent with a chronic degenerative process, as opposed to inflammation.[9] The pathology is identical in de Quervain seen in new mothers.[10]

Diagnosis[edit | edit source]

De Quervain syndrome is diagnosed clinically, based on history and physical examination, though diagnostic imaging such as x-ray may be used to rule out fracture, arthritis, or other causes, based on the patient's history and presentation. Finkelstein's test is a physical exam maneuver used to diagnose de Quervain syndrome. To perform the test, the examiner grasps the thumb and sharply deviates the hand toward the ulnar side. If sharp pain occurs along the distal radius (top of forearm, about an inch below the wrist), de Quervain's syndrome is likely. While a positive Finkelstein's test is often considered pathognomonic for de Quervain syndrome, the maneuver can also cause pain in those with osteoarthritis at the base of the thumb.[1]

Differential diagnoses[11] include:

  1. Osteoarthritis of the first carpo-metacarpal joint
  2. Intersection syndrome—pain will be more towards the middle of the back of the forearm and about 2–3 inches below the wrist
  3. Wartenberg's syndrome

Treatment[edit | edit source]

As with many musculoskeletal conditions, the management of de Quervain's disease is determined more by convention than scientific data. From the original description of the illness in 1895 until the first description of corticosteroid injection by Jarrod Ismond in 1955,[12] it appears that the only treatment offered was surgery.[12][13][14] Since approximately 1972, the prevailing opinion has been that of McKenzie (1972) who suggested that corticosteroid injection was the first line of treatment and surgery should be reserved for unsuccessful injections.[15] A systematic review and meta-analysis published in 2013 found that corticosteroid injection seems to be an effective form of conservative management of de Quervain's syndrome in approximately 50% of patients, although more research is needed regarding the extent of any clinical benefits.[16] Efficacy data are relatively sparse and it is not clear whether benefits affect the overall natural history of the illness.[medical citation needed]

Most tendinoses are self-limiting and the same is likely to be true of de Quervain's although further study is needed.[medical citation needed]

Palliative treatments include a splint that immobilized the wrist and the thumb to the interphalangeal joint and anti-inflammatory medication or acetaminophen. Systematic review and meta-analysis do not support the use of splinting over steroid injections.[17][18]

Surgery (in which the sheath of the first dorsal compartment is opened longitudinally) is documented to provide relief in most patients.[19] The most important risk is to the radial sensory nerve.

Some physical and occupational therapists suggest alternative lifting mechanics based on the debatable theory that the condition is due to repetitive use of the thumbs during lifting such as seen in new mothers picking up their child. Physical/Occupational therapy can suggest activities to avoid based on the theory that certain activities might exacerbate one's condition, as well as instruct on strengthening exercises based on the theory that this will contribute to better form and use of other muscle groups, which might limit irritation of the tendons. This approach may risk reinforcing catastrophic thinking (pain catastrophizing) and kinesiophobia.[20][medical citation needed]

Some physical and occupational therapists use other treatments based on the rationale that they reduce inflammation and pain and promote healing: UST, SWD, or other deep heat treatments, as well as TENS, dry needling, or infrared light therapy, and cold laser treatments. However, the pathology of the condition is not inflammatory changes to the synovial sheath and inflammation is secondary to the condition from friction.[21] Teaching patients to reduce their secondary inflammation does not treat the underlying condition but may reduce their pain.

Eponym[edit | edit source]

It is named after the Swiss surgeon Fritz de Quervain who first identified it in 1895.[22] It should not be confused with de Quervain's thyroiditis, another condition named after the same person.

Society and culture[edit | edit source]

De Quervain syndrome

BlackBerry thumb is a neologism that refers to a form of repetitive strain injury (RSI) caused by the frequent use of the thumbs to press buttons on PDAs, smartphones, or other mobile devices. The name of the condition comes from the BlackBerry, a brand of smartphone that debuted in 1999,[23] although there are numerous other similar eponymous conditions that exist such as "Wiiitis",[24] "Nintendinitis",[25] "Playstation thumb", "texting thumb",[26] "cellphone thumb",[27] "smartphone thumb", "Android thumb", and "iPhone thumb". The medical name for the condition is De Quervain syndrome and is associated with the tendons connected to the thumb through the wrist. Causes for the condition extend beyond smartphones and gaming consoles to include activities like golf, racket sports, and lifting.[28]

Symptoms of BlackBerry thumb include aching and throbbing pain in the thumb and wrist.[29] In severe cases, it can lead to temporary disability of the affected hand, particularly the ability to grip objects.[30]

One hypothesis is that the thumb does not have the dexterity the other four fingers have and is therefore not well-suited to high speed touch typing.[31]

See also[edit | edit source]

References[edit | edit source]

  1. 1.0 1.1 1.2 1.3 "De quervain tenosynovitis of the wrist". J Am Acad Orthop Surg 15 (12): 757–64. 2007. PMID 18063716. 
  2. 2.0 2.1 2.2 "Hand pain other than carpal tunnel syndrome (CTS): the role of occupational factors". Best Pract Res Clin Rheumatol 25 (1): 31–42. February 2011. doi:10.1016/j.berh.2010.12.001. PMID 21663848. 
  3. 3.0 3.1 3.2 3.3 O'Neill, Carina J (2008). "de Quervain Tenosynovitis". In Frontera, Walter R. Essentials of Physical Medicine and Rehabilitation: Musculoskeletal Disorders, Pain, and Rehabilitation. Elsevier Health Sciences. pp. 129–132. ISBN 978-1-4160-4007-1. Retrieved 9 August 2013. 
  4. Stahl, Stéphane; Vida, Daniel; Meisner, Christoph; Lotter, Oliver; Rothenberger, Jens; Schaller, Hans-Eberhard; Stahl, Adelana Santos (December 2013). "Systematic Review and Meta-Analysis on the Work-Related Cause of de Quervain Tenosynovitis". Plastic and Reconstructive Surgery 132 (6): 1479–1491. doi:10.1097/01.prs.0000434409.32594.1b. PMID 24005369. 
  5. "Risk factors for de Quervain's disease in a French working population". Scand J Work Environ Health 37 (5): 394–401. Sep 2011. doi:10.5271/sjweh.3160. 
  6. "Repetitive strain injury". Lancet 369 (9575): 1815–22. May 2007. doi:10.1016/S0140-6736(07)60820-4. PMID 17531890. 
  7. 7.0 7.1 Allen, Scott D; Katarincic, Julia A; Weiss, Arnold-Peter C (2004). "Common Disorders of the Hand and Wrist". In Leppert, Phyllis Carolyn. Primary Care for Women. Lippincott Williams & Wilkins. p. 664. ISBN 978-0-7817-3790-6. Retrieved 9 August 2013. 
  9. "The histopathology of de Quervain's disease". J Hand Surg [Br] 23 (6): 732–4. December 1998. PMID 9888670. 
  10. "Histological appearances in post-partum de Quervain's disease". J Hand Surg [Br] 25 (1): 70–2. February 2000. doi:10.1054/jhsb.1999.0308. PMID 10763729. 
  11. Mayo Clinic. "Arm pain: Causes". 
  12. 12.0 12.1 "Local hydrocortisone in de Quervain's disease". Br Med J 1 (4929): 1501–3. Jun 1955. doi:10.1136/bmj.1.4929.1501. 
  13. "De Quervain's tendovaginitis". Am J Surg 83 (5): 691–4. Mar 1952. doi:10.1016/0002-9610(52)90304-8. 
  14. "De Quervain's disease: an analysis of 52 cases". Ann Surg 138 (6): 832–41. Dec 1953. 
  15. McKenzie JM (Dec 1972). "Conservative treatment of de Quervain's disease". Br Med J 4 (5841): 659–60. doi:10.1136/bmj.4.5841.659. 
  16. Ashraf, MO; Devadoss, VG (22 January 2013). "Systematic review and meta-analysis on steroid injection therapy for de Quervain's tenosynovitis in adults". European journal of orthopaedic surgery & traumatology: orthopedie traumatologie 24 (2): 149–57. doi:10.1007/s00590-012-1164-z. PMID 23412309. 
  17. Peters-Veluthamaningal, C; van der Windt, DA; Winters, JC; Meyboom-de Jong, B (8 July 2009). "Corticosteroid injection for de Quervain's tenosynovitis". The Cochrane database of systematic reviews (3): CD005616. doi:10.1002/14651858.CD005616.pub2. PMID 19588376. 
  18. Coldham, F (2006). "The use of splinting in the non-surgical treatment of De Quervains disease: a review of the literature". British Journal of Hand Therapy 11 (2): 48–55. Retrieved 8 December 2013. 
  19. Weiss AP, Akelman E, Tabatabai M. Treatment of de Quervain's disease. J Hand Surg [Am] 1994 Jul;19(4):595–8.
  20. De, Soumen Das; Vranceanu, Ana-Maria; Ring, David C. (2 January 2013). "Contribution of Kinesophobia and Catastrophic Thinking to Upper-Extremity-Specific Disability". The Journal of Bone and Joint Surgery (American) 95 (1): 76. doi:10.2106/JBJS.L.00064. 
  21. Eplasty. 2013; 13: ic52.
  22. "Fritz de Quervain, MD (1868-1940): stenosing tendovaginitis at the radial styloid process". J Hand Surg [Am] 29 (6): 1164–70. 2004. doi:10.1016/j.jhsa.2004.05.019. PMID 15576233. 
  23. [1] Archived 21 August 2008 at the Wayback Machine.
  24. "Magnetic resonance imaging of acute "wiiitis" of the upper extremity". Skeletal Radiology 37 (5): 481–83. 2008. doi:10.1007/s00256-008-0456-1. PMID 18259743. 
  25. Koh TH (December 2000). "Ulcerative "nintendinitis": a new kind of repetitive strain injury". The Medical Journal of Australia 173 (11–12): 671. PMID 11379534. 
  26. Rush University Medical Center (1 August 2012). "'Texting thumb' and other tech-related pain, explained". Rush University Medical Center. Retrieved 2015-04-11. 
  27. Karim SA (March 2009). "From 'playstation thumb' to 'cellphone thumb': the new epidemic in teenagers". South African Medical Journal 99 (3): 161–2. PMID 19563092. 
  28. Mayo Clinic Staff (1 August 2012). "De Quervain's Tenosynovitis". Mayo Clinic. Retrieved 2012-12-05. 
  29. Joyce, Amy (23 April 2005). "For Some, Thumb Pain Is BlackBerry's Stain". The Washington Post. Retrieved 2010-04-03. 
  30. "The Agony of 'BlackBerry Thumb'". 21 October 2005. Retrieved 2010-05-18. 
  31. "BlackBerry Thumb: Real Illness or Just Dumb?". 26 January 2005. Retrieved 2010-05-18. 

External links[edit | edit source]