De Quervain tenosynovitis is a narrowing of the channel in which the tendons of the thumb pass. Accompanied by inflammation of the tendon sheaths. It occurs due to the constant increased load on the brush, often in connection with the performance of professional duties. Usually develops gradually. The course is chronic. The disease is characterized by pain at the base of the I finger and a small local swelling. Due to pain, the ability to perform a number of movements involving both the first finger and the entire hand is reduced or lost in patients. The diagnosis is made on the basis of complaints and examination of the patient, additional studies are not required. Conservative therapy provides an effect in about 50% of cases. The radical method of treatment is surgery.
ICD 10
M65.4 Tenosynovitis of the styloid process of the radius [de Quervain syndrome]
Meaning
De Quervain tenosynovitis (chronic tendosynovitis, stenosing tendovaginitis, stenosing ligamentitis) is a narrowing (stenosis) of the canal in which the tendons of the first finger of the hand are located. The cause of the disease is the constant traumatization of the canal when tendons move in it. The disease develops gradually and proceeds chronically. Women suffer more often than men, older people – more often than young people. Usually, the connection of the disease with the nature of work or increased load on the brush when performing household duties is revealed.
Causes
In modern traumatology and orthopedics, the prevailing opinion is that de Quervain tenosynovitis is mainly of a professional nature. The disease is usually observed in pianists, housekeepers, milkmaids, laundresses, seamstresses, locksmiths, furriers, stonemasons, field workers, painters, winders, ironers, etc. At the same time, this pathology can also be detected in non-working women. In the latter case, the development of the disease is associated with the performance of household duties and carrying small children in their arms.
Pathogenesis
I finger is the most active. It participates in almost all small movements of the brush and plays an essential role in performing a number of larger operations, for example, fixing objects or tools. With the constant execution of movements associated with prolonged tension of the thumb and the deviation of the hand towards the little finger, the already considerable load on the canal and tendons increases even more. Favorable conditions are created for the development of stenosis and concomitant inflammation. As the disease progresses, due to the narrowing of the canal, tendons begin to rub more and more against its walls, inflammation (tendovaginitis) occurs in the tendon sheaths, and they swell, leading to even greater damage to the canal during movements and stimulating the further development of stenosis.
Symptoms
The disease develops gradually. Usually, patients come to an appointment for the first time a few days or weeks after the onset of symptoms. In about 7% of cases, there is an acute onset associated with a previous hand injury. When collecting anamnesis of the disease, it turns out that at first patients were concerned about pain only with significant extension and withdrawal of the thumb, as well as with a sharp withdrawal of the brush towards the little finger. Subsequently, the pain syndrome progresses and occurs even with minor movements.
Patients complain of pain in the lower part of the forearm and projections of the wrist joint on the side of the thumb. Pain can occur exclusively during movements or be pressing, aching, constant, not disappearing even at rest. With occasional awkward movements, there may also be a sharp pain in sleep. In more than half of the cases, the pain is given down, along the outer surface of the I finger or up, along the forearm, elbow joint and shoulder.
Diagnostics
The examination is necessarily carried out in comparison of both hands – this allows you to accurately identify sometimes not too pronounced, but absolutely characteristic of de Quervain tenosynovitis changes on the part of the diseased hand. In the area of the wrist joint from the side of the I finger, minor or moderate local edema is determined. Anatomical snuffbox is smoothed or not detected due to swelling. The skin over the affected area is not changed, there is no local increase in temperature. Rare cases of peeling, redness and local hyperthermia are caused not by the disease itself, but by independent treatment, which is sometimes carried out by patients before they consult a doctor.
Palpation reveals soreness in the affected area, reaching a maximum in the projection of the awl-shaped process of the radius. Pressing on the area of the tendons of the I finger is painless. Just below the awl–shaped process, a dense and smooth rounded formation is felt – the dorsal ligament, thickened in the canal area. After examining the affected area, the patient is asked to put his hands palms down and deflect the hands alternately towards the little finger and thumb. The patient’s hands deviate almost equally towards the I finger. With a deviation towards the little finger, a limitation of movements by 20-30 degrees is revealed compared to a healthy hand, and the movement is accompanied by pronounced soreness.
In addition, the restriction of thumb withdrawal is determined on the diseased hand. To identify the symptom, the patient is asked to place the hands on the edge with the palms facing each other. With movements, a significant restriction of the lead is noticeable (the difference between the sick and healthy side is from 40 to 80 degrees). The difference in the extension of the I fingers is not so striking, but it is also visible to the naked eye.
Another study that allows you to confirm the diagnosis is the Finkelstein test. The patient presses the thumb to the palm and squeezes it tightly with the other fingers, and then pulls the brush towards the little finger. The movement is accompanied by a sharp pain in the affected area. Also, with this disease, a violation of the ability to hold objects with the help of the I finger is revealed. The patient is asked to simultaneously take some objects (for example, pens or matchboxes) I and II with the fingers of both hands. When pulling on an object, pain and weakness are revealed when holding on the sick side. The diagnosis of de Quervain tenosynovitis is made on the basis of clinical data. No additional research is required.
Treatment
Treatment is carried out by an orthopedist or traumatologist. Conservative therapy is performed on an outpatient basis. A plaster or plastic splint is applied to the patient for a period of 1-1.5 months, ensuring the rest of the affected limb, and subsequently it is recommended to wear a special bandage for the I finger. In addition, the patient is prescribed nonsteroidal anti-inflammatory drugs (ibuprofen, naproxen, etc.). With severe pain syndrome, local blockades are performed.
If conservative therapy is ineffective, surgical treatment is indicated. The operation is carried out in stationary conditions in a planned manner. Local anesthesia is usually used. Before the beginning of anesthesia, the doctor marks the most painful point, and after the introduction of novocaine, performs an oblique or transverse incision over the area of the awl-shaped process passing through this point. Then, with a blunt hook, he gently pulls aside the subcutaneous tissue along with the veins and the superficial branch of the radial nerve and exposes the dorsal ligament. The ligament is dissected and partially excised.
With a prolonged course of the disease, fusion of the tendon with the tendon sheath and the vagina with the periosteum may occur in the affected area. Upon detection, all spikes are carefully excised. The wound is sewn up in layers, after making sure that the tendons move completely freely. The hand is placed on a kerchief bandage. The stitches are removed for 8-10 days. Working capacity is usually restored 14-15 days after surgery. In the postoperative period, numbness and crawling of goosebumps in the area of the I, II and half of the III finger may occur due to anesthesia or compression of the superficial branch of the radial nerve. These symptoms disappear within 2-3 weeks.
Prognosis and prevention
The prognosis is favorable. With conservative treatment, a satisfactory effect is observed in 50% of cases. After operations, there is usually a good recovery. It should be borne in mind that the disease is caused by a chronic pathological process in the area of the annular ligament. If the patient continues to overload the arm after surgery, the disease may recur. Therefore, patients are usually recommended to change the nature of professional activity and reduce the load on the arm when performing household duties.
Literature
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