1

General Considerations

Introduction And Terminology De Quervains tenosynovitis or tendinitis was first described in 1895 by Fritz De Quervain, a Swiss surgeon. Prior to this, the first use of the terms tenosynovitis and crepitating peritendinitis to describe injuries to the tendons and surrounding tissues was by Velpeau in 1825. This condition is a wrist tendinitis with inflammation of the tendon sheaths of the abductor pollicis longus and extensor pollicis brevis. Epidemiology De Quervains tenosynovitis is the most common tenosynovitis affecting the dorsal tendons of the wrist. It is usually diagnosed in individuals between 30 and 50 years of age and is ten times more prev alent among women than men (Dupuis, 1986). American and Scandinavian studies examining the relation between work activities and De Quervains tenosynovitis have rarely distinguished between this condition and other type of tendinitis of the wrist and hands. Epidemiological studies have demon strated that workers in the meat processing and man u facturing industries run a higher risk of de vel oping tendinitis of the hand and wrist: perform ing highly repetitive work increases the relative risk of developing De Quervains tenosynovitis to 3.3, while performing work requiring the exertion of great force increases it to 6.1. Among individuals performing work that is both highly repetitive and forceful, the relative risk is 29 (Hagberg et al., 1995).

Anatomical Review The tendons of the forearm are relatively long, extending beyond the wrist to cover the dorsal aspect of the hand and thumb. The tendons of the abductor pollicis longus and extensor pollicis brevis both run through the groove of the radial styloid process in the first of the six dorsal com partments of the wrist and have their insertion at the base of the first metacarpal and the proximal phalanx of the thumb (Figure 1.1). These muscles, individually and jointly, extend and abduct the trapezometacarpal joint and extend the metacarpophalangeal joint. They are also active during radial deviation and, to a lesser extent, flexion of the wrist (Kendall et al., 1988). Both are innervated by the posterior interosseous branch of the radial nerve, which originates mostly in the C6, C7, and C8 roots. pathoPhysiology De Quervains tenosynovitis is a stenosing tenosyno vitis involving inflammation of the tendon sheath of the extensor pollicis brevis and abductor pollicis longus (Dupuis, 1986; Hagberg et al., 1995). The rigidity of the structures and limited space within the wrist compartment favour the de velopment of tenosynovitis.

Guide to the Diagnosis of Work-Related Muskuloskeletal Disorders

Figure 1.1

Insertion and Action of the Tendons of the Extensor Pollicis Brevis and Abductor Pollicis Longus

Extensor pollicis brevis

Abductor pollicis longus

Tenosynovitis may result from trauma or from excessive friction between the tendon and sur rounding tissues during movements of the thumb and wrist. The thickness of the synovial membranes is an indication of the stage of the tendinitis. As the inflammation progresses, the tendon tends to thin out and become more friable,

and stenosis increases. In the final stages, the sheath of the first dorsal compartment thickens, becomes fibrous, and impinges on the space of the fibro-osseous groove. This may result in trigger finger, a chronic form of De Quervains tenosynovitis.

Etiology

General Considerations Tendinitis and tenosynovitis may occur when muscle and tendon structures are subjected to: regular biomechanical strain which, over the long term, exceeds the limits of the tendons and synovial membranes intense or unusual biomechanical strain (re sumption of working activities after an absence, increase in production rates, modification of tasks, intense practice of a sport or musical ins trument) local trauma Tendinitis and tenosynovitis of the upper limb may also be related to: metabolic diseases (diabetes mellitus, hypo thy roidism, gout, ankylosing spondylitis, various collagenoses) infection such tuberculosis or a bacterial in fection specific conditions such as pregnancy De Quervains tenosynovitis may coexist with carpal tunnel syndrome and trigger finger. Tenosynovitis affecting the dorsal tendons of the wrist may be of two types: Tenosynovitisis with effusion is of infectious or rheumatoid origin. In the latter case, it is indica tive of rheumatoid arthritis and may pres age polyarthritis (Dupuis, 1986). De Quervains tenosynovitis is one of the most common forms of the stenosing tenosynovitises,

inflammatory conditions whose most common cause is microtrauma. The palmar aspect of the flexor digitorum profundus tendons may be involved, and the condition may be congenital or secondary to rheumatoid arthritis (Dupuis, 1986). work-relatedness of Musculoskeletal Strain Excluding accidents, the primary patho physiological cause of De Quervains tenosynovitis is biome chan ical strain on the tendons of the abductor pollicis longus and extensor pollicis brevis in the groove of the radial styloid process as a result of physical activity. As noted in the section on epidemiology, musculoskeletal strain associated with actions that are highly repetitive or forceful or both is an im portant cause of hand and wrist tendinitises, including De Quervains tenosynovitis (Hagberg et al., 1995). De Quervains tenosynovitis is also associated with grasping objects with the fingers spread, rotation of the wrist, and pronationsupination of the forearm (Kuorinka and Koskinen, 1979; Kurppa et al., 1991; Kroemer, 1989). Wrist movements requiring a pinch grip and frequent hand movements with the wrist flexed and thumb abducted generate great strain on the tendons of the abductor pollicis longus and extensor pollicis brevis. Finally, factors such as the use of gloves and ex posure to cold or vibration increase the risk of de vel oping this condition. Box 2.1 illustrates the move ments frequently associated with De Quervains tenosynovitis.

Guide to the Diagnosis of Work-Related Muskuloskeletal Disorders

Box 2.1

Most Common Stressful Movements of the Abductor Pollicis Longus and Extensor Pollicis Brevis

Repeated application of pressure while flexing the distal phalanx of the thumb

Loaded abduction or extension of the thumb

Wrist movements during normal or pinch prehension

Loaded flexion-extension of the wrist

Application of thumb pressure with the wrist deviated Cofactors Strain on the thumb: during wrist movements while maintaining pressure on the palm or the hand use of gloves

exposure to cold or vibration