by Arianna Legatie
De Quervain’s disease is also known as washer woman’s strain, or “Blackberry Thumb” in the recent technology age. It is one of the most common causes for wrist pain. Some people believe that de Quervain’s disease is an inflammation of the extensor pollicis brevis and abductor pollicis longus tendons, but newer research suggests that it is a degeneration of the two tendons making the condition a tendinosis. Despite the pathology, de Quervain’s disease causes pain in the first compartment of the extensor retinaculum, including the thumb and radial styloid. Because of thumb overuse and repetitive radial deviation, the extensor pollicis brevis and abductor pollicis longus tendons continuously rub on the radial styloid and cause a friction force that, in turn, causes an inflammatory response to begin. In de Quervain’s disease, these two tendons become swollen and painful, and it is possible for hard and tender nodules to be palpated over the radial side of the forearm in more severe cases.
II. Anatomy 1,4,5,6
Bony Anatomy and Wrist/Thumb Movements
The wrist contains 2 rows of 4 carpal bones each. The proximal row consists of the scaphoid, lunate, triquetrum, and pisiform, and they articulate with the radius and ulna. The distal row consists of the trapezium, trapezoid, capitates, and hamate, and they articulate with the metacarpal bones in the hand. Distal to the metacarpal bones, the thumb has two phalange bones and the four fingers have three phalange bones each.
The wrist allows for 3 degrees of freedom. First of all, the wrist can flex/extend and radial/ulnar deviate at the radiocarpal joint. The forearm can also move the wrist into supination and pronation at the radioulnar joint.
The movements available in the thumb are flexion and extension, abduction and adduction, and opposition. Flexion and extension occurs at the carpo-metacarpal joint, the metacarpo-phalangeal joint, and the interphalangeal joint of the thumb. Abduction and adduction occurs in the carpo-metacarpal and metacarpo-phalangeal joint, and opposition primarily comes from the carpo-metacarpal joint. Opposition is the movement that separates human beings from other species. Opposition moves the thumb across the palm of the hand so that it can come in contact with the other four finger tips. It is important in order to operate some tools and grasp objects of different sizes and shapes.
Ligaments of the Wrist and Hand
Along with bones and muscles, ligaments offer a stabilizing structure for the wrist and hand. The stronger ligaments are in two groups, intrinsic ligaments which are contained among the carpal bones and the extrinsic ligaments which cross between the radius and ulna, the carpal bones, and the metacarpal bones. The scapholunate interosseus ligament is an essential intrinsic ligament of the wrist that connects the scaphoid and lunate carpal bones, and it is one of the most frequently injured wrist ligaments. The extrinsic ligaments starting at the radius help with control the wrist movements, especially ones that include the scaphoid. One of the strongest extrinsic wrist ligaments is the radiolunate. It is important in rotating the scaphoid, and it is tense at the end of each wrist range of motion.
Muscles/Nerves/Arteries associated with de Quervain’s disease
Abductor Pollicis Longus
The abductor pollicis longus (APL) originates at the distal posterior surfaces of the radius, ulna, and interosseus membrane between the radius and ulna. The tendon enters the thumb and inserts on the lateral side of the base of metacarpal The tendon, along with the extensor pollicis brevis tendon, contributes to the lateral border of the anatomical snuffbox The major function of the APL is to abduct the thumb at the carpo-metacarpal joint and radially deviate the wrist. The APL is supplied by the radial nerve and the posterior interosseus artery.
Extensor pollicis brevis
The extensor pollicis brevis (EPB) also originates on the distal posterior surfaces of the radius, ulna, and interosseus membrane between the radius and ulna, but the attachment is distal to the origin of the APL. The EPB tendon enters the thumb, creates the lateral border of the anatomical snuffbox with the APL tendon, and it inserts onto the base of the proximal phalanx of the thumb. The function of the EPB is to extend the thumb at the metacarpophalangeal and carpometacarpal joints. The EPB is also supplied by the radial nerve and the posterior interosseus artery.
III. Indications 7
De Quervain’s disease is always treated conservatively first. Surgery is indicated if conservative management fails for 4-6 months after injury.
IV. Incidence/Prevalence 1
There has not been significant research done regarding incidence and prevalence of de Quervain’s disease, but it has been suggested that it is diagnosed 8-10 times more often in women than men. It is usually an overuse condition, but it can be acute. De Quervain’s disease can be diagnosed in any age, but is more commonly found in patients between 30 and 50 years of age.
V. Clinical Presentation 1,3
Patients will present with moderate to severe pain, swelling, and tenderness on the radial side of the forearm (over the first compartment of extensors, radial styloid, and it can radiate proximally up the forearm and/or distally through the thumb). Aggravating factors include pinching, gripping, radial deviation of the wrist, abduction of the thumb, and resisted thumb extension. There can also be crepitus found with wrist and thumb movements. Patients with de Quervain’s disease will have a positive Finkelstein’s test (explained later). Finally, hard and tender nodules on the radial side of the forearm due to inflammation might be palpated in severe cases.
VI. Etiology 1,3
It was found that the repetitive activities that can cause de Quervain’s disease are continuous thumb postures in abduction (bottom right) and extension (bottom left).
For example, a population that is under a higher risk of developing de Quervain’s disease is nursing mothers. They are at a higher risk because they are responsible for new tasks such as lifting and holding children, and they have to place their hands in awkward positions, such as a flexed ulnarly deviated wrist and extended abducted thumb while breast feeding. Hormonal changes while nursing can also contribute to their risk in developing de Quervain’s disease.
Another example of a high risk population are regular computer users, especially people who frequently use a mouse or trackball. They are at a higher risk for de Quervain’s disease because of the postural requirements associated with mouse and track ball use. Their thumb is maintained in a abducted and extended position while hovering their hand over the equipment.
Other activities/professions that are more prone to de Quervain's disease:
- Mountain biking
- Engine drivers
- Frequent Blackberry users
Diagnostic Tests 3,8
Radiography nor magnetic resonance imaging are used to diagnose de Quervain’s disease. After using the de Quervain’s screening tool explained below, the gold standard for diagnosis requires a local anesthetic injection. If there is a total relief of pain after a precise injection of a small amount of local anesthetics into the first dorsal compartment, the patient can be diagnosed with de Quervain’s disease.
Evaluation/Special Orthopedic Tests 2,3,8
De Quervain’s disease is diagnosed through a thorough patient history and a screening tool which consists of a list of subjective and objective findings. The de Quervain’s screening tool (DQST) includes the following criteria:
- Pain centered over the radial styloid
- Tenderness and swelling of the first extensor compartment
- Painful thumb extension with resistance
- Positive Finkelstein’s test (see below)
The DQST is an easy and reliable list of criteria for diagnosing de Quervain’s because it was found to have good construct validity and it is user friendly. Also, the sensitivity and specificity to differentiate de Quervain’s disease from carpal tunnel syndrome and osteoarthritis of the carpometacarpal joints, two conditions with similar hand pain.
The special orthopedic test used to diagnose de Quervain’s disease, Finkelstein’s test, (shown in the picture and video below). This test is performed by the patient making a fist around their thumb, and then ulnarly deviating their wrist. In this position, the synovial tissue that surrounds the extensor pollicis brevis and abductor pollicis longus tendons is stretched. If they are inflamed and a patient is suffering from de Quervain’s disease, a positive sign will be indicated by pain in the first compartment of the extensor retinaculum. Even unaffected patients can feel an uncomfortable stretch with this pain, so the full DQST is necessary for the valid diagnosis of de Quervain’s disease.
Conservative Treatment 9,10,11
De Quervain’s disease is first treated by a combination of conservative treatments before considering surgery. The following are the most frequently used and successful treatment options for de Quervain’s disease:
The patient will usually be prescribed a splint for thumb immobilization for up to 6 weeks. When compared with corticosteroid injections and NSAIDs, it was found that there was a 19% success rate with splinting alone and a 67% success rate with injection alone. However, there was found to be a 57% success rate with splinting and corticosteroid injection together, and there was an 88% success rate with thumb splinting and NSAIDs (nonsteroidal anti-inflammatory drugs) together.
De Quervain’s disease is very frequently treated with a corticosteroid and/or anesthetic injection into the extensor tendon sheath of the first dorsal compartment. It has been found to have a varying success rate ranging from 62% to as large as 93%.
NSAIDs (Nonsteroidal Anti-inflammatory Drugs)
NSAIDs are often combined with other treatment options in the management of de Quervain’s disease. Taking NSAIDs will help relieve inflammation of the extensor pollicis brevis and the abductor pollicis longus tendons in the extensor sheath.
Ice and/or heat packs
Ice and heat packs are usually used in combination with other treatment options. Heat packs can help relax and loosen tight musculature which can contribute to de Quervain’s disease. Like NSAID use, ice packs can be used to help relieve inflammation of the extensor pollicis brevis and the abductor pollicis longus tendons in the extensor sheath.
Physical Therapy (massage, stretching, strengthening)
Regular physical therapy visits can be helpful for the management of de Quervain’s disease by using the massage techniques, stretching techniques, and exercises shown in the video below.
McKenzie Wrist Management
The patient is instructed to perform ulnar deviation and thumb metaphalangeal flexion with distraction at home 10-20 times at least every 3 hours. The patient is also instructed to avoid radially deviating their wrist. It was found that continulous ulnar deviation with radiocarpal distraction help patients with de Quervain’s disease recover quickly and successfully.
Surgical Treatment 7
When surgery is indicated for de Quervain’s disease patients, operative release of the first dorsal compartment of the extensor sheath has been found to be an effective and successful procedure. After the incision is made and the sensory branches of the radial nerve are protected, the extensor retinaculum is cut along the dorsal margins of the abductor pollicis longus and extensor pollicis brevis. Any extra septations and ganglions are removed and the area is cleaned up. A complete release of the extensor retinaculum can be done, or a partial removal can be done as an alternative in order to avoid potential complications. Complications are rare, but they include wound infection, volar subluxation of the abductor pollicis longus and extensor pollicis brevis, damage to the superficial branch of the radial nerve, incomplete release of the extensor retinaculum, or re-adhesion of the extensor retinaculum. After the surgery, the thumb is splinted, and flexion and extension of the thumb is encouraged immediately. There is limited research on the most effective post-operative rehabilitation program other than the conservative treatment options.
Picture References (from top to bottom)
1. De Quervain's Physio Pedia Website. Available at: http://www.physio-pedia.com/index.php5?title=De_Quervains. Accessed November 20, 2011
2. Kutsumi K, et al. Finkelstein's test: A biomechanical analysis. The Journal of Hand Surgery. 2005;30(1):130-135.
3. Andreu J-L, et al. Hand pain other than carpal tunnel (CTS): The role of occupational factors. Best Practice & Research Clinical Rheumatology. 2011;25:31-42.
4. Jaworski CA, Krause M, and Brown J. Rehabilitation of the wrist and hand following sports injury. Clin Sports Med. 2010;29:61-80.
5. Steinberg BD and Plancher KD. Clinical anatomy of the wrist and elbow. Athletic Elbow and Wrist. 1995;14(2):299-313. J
6. Leversedge FJ. Anatomy and pathomechanics of the thumb. Hand Clin. 2008;24:219-229.
7. Altay MA, Erturk C, and Isikan UE. De Quervain's disease treatment using partial resection of the extensor retinaculum: A short term results survey. Orthopaedics & Traumatology. 2011;97:489-493.
8. Batteson R, Hammond A, Burke F, and Sinha S.The de Quervain's screening tool: Validity and reliability of a measure to support clinical diagnosis and measurement. Musculoskelet. Care. 2008;6(3):168-180.
9. Gonzalez-Iglesias J, Huijbregts P, Gernandez de las Penas C, and Cleland JA. Differential diagnosis and physical therapy management of a patient with radial wrist pain of 6 months' duration: A Case Report. J Ortho and Sports Phys Ther. 2010;40(6):361-368.
10. Ilyas AM. Nonsurgical treatment for de Quervain's tenosynovitis. J Hand Surg. 2009;34(5):928-929.
11. Kaneko S, Takasaki H, and May S. Application of mechanical diagnosis and therapy to a patient diagnosed with de Quervain's disease: A Case Study. J Hand Surg. 2009;22:278-284.