De Quervain S Tenosynovitis

1 General Considerations
Introduction And Terminology Anatomical Review

De Quervains tenosynovitis or tendinitis was first The tendons of the forearm are relatively long, extending
described in 1895 by Fritz De Quervain, a Swiss surgeon. beyond the wrist to cover the dorsal aspect of the hand
Prior to this, the first use of the terms tenosynovitis and thumb. The tendons of the abductor pollicis longus
and crepitating peritendinitis to describe injuries to the and extensor pollicis brevis both run through the groove
tendons and surrounding tissues was by Velpeau in 1825. of the radial styloid process in the first of the six dorsal
This condition is a wrist tendinitis with inflammation of compartments of the wrist and have their insertion at
the tendon sheaths of the abductor pollicis longus and the base of the first metacarpal and the proximal phalanx
extensor pollicis brevis. of the thumb (Figure 1.1).
These muscles, individually and jointly, extend and

Epidemiology
abduct the trapezometacarpal joint and extend the
De Quervains tenosynovitis is the most common metacarpophalangeal joint. They are also active during
tenosynovitis affecting the dorsal tendons of the wrist. radial deviation and, to a lesser extent, flexion of the
It is usually diagnosed in individuals between 30 and 50 wrist (Kendall et al., 1988). Both are innervated by the
years of age and is ten times more prevalent among posterior interosseous branch of the radial nerve, which
women than men (Dupuis, 1986). American and originates mostly in the C6, C7, and C8 roots.
Scandinavian studies examining the relation between
work activities and De Quervains tenosynovitis have
pathoPhysiology
rarely distinguished between this condition and other
type of tendinitis of the wrist and hands. Epidemiological De Quervains tenosynovitis is a stenosing tenosynovitis
studies have demonstrated that workers in the meat involving inflammation of the tendon sheath of the
processing and manufacturing industries run a higher risk extensor pollicis brevis and abductor pollicis longus
Copyright 1998. Editions MultiMondes. All rights reserved.
of developing tendinitis of the hand and wrist: perform (Dupuis, 1986; Hagberg et al., 1995). The rigidity of the
ing highly repetitive work increases the relative risk of structures and limited space within the wrist compartment
developing De Quervains tenosynovitis to 3.3, while favour the development of tenosynovitis.
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).
1
Rossignol, Michel. De Quervain s tenosynovitis [Internet]. Qubec City: Editions MultiMondes; 1998. [cited 2017 August 13]. Available from: ProQuest Ebook Central
Created from uta-ebooks on 2017-08-13 17:18:28.
Tenosynovitis Inter.indd 1 02/04/08 15:44:28

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 and stenosis increases. In the final stages, the sheath of
excessive friction between the tendon and surrounding the first dorsal compartment thickens, becomes fibrous,
tissues during movements of the thumb and wrist. The and impinges on the space of the fibro-osseous groove.
thickness of the synovial membranes is an indication of This may result in trigger finger, a chronic form of De
the stage of the tendinitis. As the inflammation progresses, Quervains tenosynovitis.
the tendon tends to thin out and become more friable,

2 Etiology
General Considerations inflammatory conditions whose most common cause

is microtrauma. The palmar aspect of the flexor
Tendinitis and tenosynovitis may occur when muscle and digitorum profundus tendons may be involved, and
tendon structures are subjected to: the condition may be congenital or secondary to
regular biomechanical strain which, over the long rheumatoid arthritis (Dupuis, 1986).
term, exceeds the limits of the tendons and synovial
membranes work-relatedness of Musculoskeletal
intense or unusual biomechanical strain (resumption Strain
of working activities after an absence, increase in
Excluding accidents, the primary pathophysiological
production rates, modification of tasks, intense
cause of De Quervains tenosynovitis is biomechanical
practice of a sport or musical instrument)
strain on the tendons of the abductor pollicis longus and
local trauma
extensor pollicis brevis in the groove of the radial styloid
process as a result of physical activity.
Tendinitis and tenosynovitis of the upper limb may
also be related to:
As noted in the section on epidemiology,
metabolic diseases (diabetes mellitus, hypothyroidism, musculoskeletal strain associated with actions that are
gout, ankylosing spondylitis, various collagenoses) highly repetitive or forceful or both is an important cause
infection such tuberculosis or a bacterial infection of hand and wrist tendinitises, including De Quervains
specific conditions such as pregnancy tenosynovitis (Hagberg et al., 1995). De Quervains
tenosynovitis is also associated with grasping objects with
De Quervains tenosynovitis may coexist with carpal the fingers spread, rotation of the wrist, and pronation-
tunnel syndrome and trigger finger. supination of the forearm (Kuorinka and Koskinen,
1979; Kurppa et al., 1991; Kroemer, 1989). Wrist
Tenosynovitis affecting the dorsal tendons of the movements requiring a pinch grip and frequent hand
wrist may be of two types: movements with the wrist flexed and thumb abducted
generate great strain on the tendons of the abductor
Tenosynovitisis with effusion is of infectious or pollicis longus and extensor pollicis brevis.
rheumatoid origin. In the latter case, it is indicative
of rheumatoid arthritis and may presage polyarthritis Finally, factors such as the use of gloves and exposure
(Dupuis, 1986). to cold or vibration increase the risk of developing this
De Quervains tenosynovitis is one of the most condition. Box 2.1 illustrates the movements frequently
common forms of the stenosing tenosynovitises, 3
associated with De Quervains tenosynovitis.

Box 2.1
Most Common Stressful Movements of the Abductor Pollicis

Longus and Extensor Pollicis Brevis
Repeated application of pressure while flexing Loaded abduction or extension

the distal phalanx of the thumb of the thumb
Wrist movements during normal Loaded flexion-extension

or pinch prehension 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
4 exposure to cold or vibration

3 Differential Diagnosis
The symptoms of De Quervains tenosynovitis may be Figure 3.1

confused with those of several other pathological Test for Carpometacarpal
conditions, including: Osteoarthrosis of the Thumb
carpometacarpal osteoarthrosis of the thumb
intersection syndrome
Wartenbergs syndrome
brachioradialis insertion tendinitis
tenosynovitis of the extensor digitorum communis
thumb carpometacarpal
osteoArthrosis
Clinical Presentation
Osteoarthrosis of the trapezometacarpal joint and usually
affects women aged 50-70 years (Figure 3.1). It is
accompanied by local deformity, crepitation, and pain of
variable intensity that is unrelated toradiological changes
(Dupuis, 1986).
Probable causes
trauma
age- and sex-related factors
Diagnostic Test
Simultaneous axial compression and rotation of the

thumb will elicit pain at the trapezometacarpal joint.

Figure 3.2 Intersection Syndrome
Test for the Intersection Syndrome
This syndrome is caused by inflammation at the point
where the tendons of the extensor carporadialis longus
and brevis muscles of the second compartment of the
extensors intersect the sheaths of the abductor pollicis
longus and extensor pollicis brevis (Figure 3.2).
Probable Causes
repetitive finger-pinch prehension while flexing and
extending the wrist or supinating the forearm
direct trauma
Diagnostic Test
Palpation will reveal a painful area and crepitation with
swelling on the radial side approximately three
finger-widths above the wrist (Pujol, 1993).
Wartenbergs Syndrome
This syndrome is caused by compression of the distal
Figure 3.3
sensory branch of the radial nerve (Figure 3.3).
Test for Wartenbergs Syndrome Clinical Presentation
pain or numbness over the distal third of the forearm,
increased by ulnar deviation
discomfort while writing
discomfort while grasping objects or using a pinch
grip
Possible Causes of Compression
external trauma, falls, twisting of the forearm
repetitive or forceful pronation
compression by a bracelet or watch
compression by soft-tissue disorders (synovial cyst,
tumour, subcutaneous haematoma)
Diagnostic Tests
Symptoms may be elicited by applying pressure over an
area two finger-widths wide proximal to the radial styloid
process while the patient maintains the forearm pronated
6
and the wrist in ulnar deviation (Figure 3.3). The test is
considered positive if symptoms occur in less than one
minute. Finkelsteins test may also be positive (See
Figure 6.4, page 18).

brachioradialis insertion Tendinitis Figure 3.4
(insertion of the brachioradialis) Test of the Brachioradialis
Resisted elbow flexion* and application of pressure on
the radial styloid process both elicit pain over the radial
styloid process.
Probable Causes
Performing repeated finger-pinch prehensions with
the wrist supinated or extended
Diagnostic Test
Resisted movement of the brachioradialis elicits pain at
its insertion on the radial styloid process (Figure 3.4).
Tendinitis Of The Extensor Digitorum

Communis
Pain is present on the radial side of the dorsal aspect of
the wrist, and may be accompanied by swelling.
Figure 3.5
Probable Causes Test of the Extensor Digitorum Communis
Extension movements
Sustained static pronation associated with grasping of
objects
Diagnostic Test
Resisted extension elicits the symptoms and indicates the
presence of tendinitis of the extensor digitorum
communis (Figure 3.5).
* The term resisted movement refers to a movement made while

force is applied in the opposite direction.
DE QUERVAINS TENOSYNOVITIS


4 Clinical Considerations
Symptoms consultation. Symptoms are usually preceded by a

prepathogenic period during which environmental or
The following questions are essential in establishing the
other pathophysiological factors are assumed to trigger
medical history of patient presenting with symptoms
a pathological condition (Hagberg et al., 1995).
suggestive of De Quervains tenosynovitis:
Where do you feel pain? Characteristics of Onset (How?)
When did the pain start? The onset of symptoms may be sudden or progressive,
What did the pain first feel like and what does it feel and may be caused by accidents or activities involving
like now? the hand or wrist. To facilitate identification of the
underlying causal factors, patients should be asked to
Location of Symptoms (Where?) describe in detail the circumstances surrounding the
De Quervains tenosynovitis presents as pain in the region appearance of their symptoms. Symptoms which intensify
of the apophysis of the radial styloid process. Swelling, during a given activity and disappear at rest or when the
antalgic radial deviation of the hand, and local patient is away from work strongly suggest an extrinsic
inflammation (erythema and warm skin) may be present cause (musculoskeletal strain) (Porter et al., 1992).
in long-standing cases.
A staging scale for evaluating the severity of the
Onset of Symptoms (When?) symptoms associated with hand and wrist activities is
Physicians should determine the time elapsed between proposed in Box 4.2.
the onset of symptoms and the current consultation.
Patients should be asked the precise reason for their
Box 4.1
Symptoms Reported by the Patient

Pain near the apophysis of the radial styloid radiating to the thumb or forearm
Increased pain upon mobilisation of the thumb with the wrist flexed and in ulnar
9
deviation
Weakness and pain during grasping

Box 4.2
Presentation and Clinical Severity of Symptoms

Clinical presentation Severity Symptoms

Symptoms caused by 0 None during these activities
forceful or repetitive
1 slight Only after intense and repetitive activities
movements of the wrist

and the thumb 2 moderate Only after light or occasional activities
3 severe Present even at rest
Source: Adapted from Mahoney et al., 1992
Impact On Activities Of Daily Living

In addition to pain, patients may suffers a diminished living. Box 4.3 lists a series of questions which will help
ability to perform pinching activities with the thumb, patients pinpoint the extent of their disability.
which hinders them from performing certain tasks of daily
Box 4.3
Questions about Activities of Daily Living

Which hand is your dominant hand? Right Left
Never Sometimes Often Always
Do you experience difficulty:
writing with a pencil or pen
buttoning a shirt
turning a key in a lock
picking up and holding objects with your hand

opening a car door
unscrewing the cover of a jar
performing twisting motions (e.g. wringing)
10

5 Recording of Information
on Exposure Factors
Tendinitis of the hand and wristsuch as De Quervains to characterise the occupational, sports-related, and
tenosynovitishas been reported to be associated with household activities that may have contributed to the
forceful or repetitive occupational activities, with the risk development of tendinitis or tenosynovitis.
of developing tendinitis significantly increased when
exposure is to activities that are both forceful and Previous Work
repetitive (Hagberg et al., 1995). Information on The patients occupational history provides information
environmental cofactors such as exposure to cold and on the extent of previous exposure to work-related
vibration should also be gathered. musculoskeletal strain of the upper limb.
Occupational History
To establish that a case of De Quervains tenosynovitis
is caused by biomechanical requirements it is necessary
Box 5.1
Questions about Previous Occupations

Work performed Starting date and duration Hours per day Risk factors or
in months or years cofactors*
* See Box 2.1
11

Current Work
The description of current work should allow the evaluate the contribution of organisational factors
physician to form a good idea of the patients work and (Box 5.4)
the conditions under which it is performed. As it is
There is a wide range of repetitive occupational
generally difficult for physicians to visit the workplace,
activities. Box 5.3 lists common activities which are related
this guide presents series of questions designed to help
to the development of De Quervains tenosynovitis. If
them:
there is little or no correspondence between the patients
obtain accurate information on the general nature of activities and those listed, a useful strategy may be to ask
the work (Box 5.2) her or him to describe working activities or movements
determine the presence of specific biomechanical and evaluate their biomechanical characteristics (duration,
requirements which favour the development of De frequency and force).
Quervains tenosynovitis (Boxes 5.3 and 5.5)
Box 5.2
General Questions on Occupational Activity

and Associated Symptoms
Is your current job full- or part-time?
Which hand do you use the most at work?
Did your pain result from an accident or an abrupt, sudden or unusual
movement?
Did your pain appear progressively?
If so, how long did it take to appear and what did it feel like?
Which activities and movements aggravate your symptoms?
12

Box 5.3
Questions about Activities that Cause Pain in the Hands or Wrist

Activity Hours Frequency of movements Force exerted
per day low medium high low medium high
Applying pressure with the thumb
Maintaining grasping positions
Wrist flexion, extension, or rotation
Manipulation of small objects
with the fingers or hand
Exerting force to hold or grasp
objects
Use of hand tools (screwdrivers,
knives, etc.)
Use of vibrating or percussion tools
(drills, drill presses, sanders, etc.)
Other (describe)
Comments
Cofactors with musculoskeletal load Never Occasionnally Regularly

Wearing gloves at work
Exposure to cold
13

Current Work and organisational

Factors
Certain factors related to the nature and organisation of
work may favour the development of musculoskeletal
disorders (Box 5.4).
Box 5.4
Questions about Organisational Factors at Work

During your work: Never Occasionnally Regularly
Do you feed a machine at
a constant rhythm?
Do you feel time or production

pressure?
Does your work need uninterrupted

attention?
Do you find your work monotonous?
Can you vary your work rhythm?
Do you always work at the same

workstation?
Comments
14

Sports-related, Recreational,
And household Activities
Sports-related, recreational, and household activities may intensity with which these activities are practised and
contribute to the development of De Quervains whether the onset of pain in the hand or wrist has caused
tenosynovitis. It is therefore important to establish the the patient to reduce their practise.
Box 5.5
Questions about Sports, Recreational, and Household

Activities Involving the Hands or Wrist
Activity Hours per week Risk factors or cofactors*
* See Box 2.1

15

De Quervain S Tenosynovitis

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1 General Considerations

Introduction And Terminology Anatomical Review

These muscles, individually and jointly, extend and

Tenosynovitis Inter.indd 1 02/04/08 15:44:28

Extensor pollicis brevis Abductor pollicis longus

Tenosynovitis Inter.indd 2 02/04/08 15:44:29

General Considerations inflammatory conditions whose most common cause

Tenosynovitis Inter.indd 3 02/04/08 15:44:29

Most Common Stressful Movements of the Abductor Pollicis

Repeated application of pressure while flexing Loaded abduction or extension

Wrist movements during normal Loaded flexion-extension

Application of thumb pressure with the wrist deviated

Strain on the thumb:

Tenosynovitis Inter.indd 4 02/04/08 15:44:29

The symptoms of De Quervains tenosynovitis may be Figure 3.1

Simultaneous axial compression and rotation of the

Tenosynovitis Inter.indd 5 02/04/08 15:44:29

tumour, subcutaneous haematoma)

Tenosynovitis Inter.indd 6 02/04/08 15:44:29

Tendinitis Of The Extensor Digitorum

* The term resisted movement refers to a movement made while

Tenosynovitis Inter.indd 7 02/04/08 15:44:30

Tenosynovitis Inter.indd 8 02/04/08 15:44:30

Symptoms consultation. Symptoms are usually preceded by a

Symptoms Reported by the Patient

Tenosynovitis Inter.indd 9 02/04/08 15:44:30

Presentation and Clinical Severity of Symptoms

Impact On Activities Of Daily Living

Questions about Activities of Daily Living

picking up and holding objects with your hand

Tenosynovitis Inter.indd 10 02/04/08 15:44:30

Questions about Previous Occupations

* See Box 2.1

Tenosynovitis Inter.indd 11 02/04/08 15:44:30

General Questions on Occupational Activity

Tenosynovitis Inter.indd 12 02/04/08 15:44:30

Questions about Activities that Cause Pain in the Hands or Wrist

Cofactors with musculoskeletal load Never Occasionnally Regularly

Tenosynovitis Inter.indd 13 02/04/08 15:44:30

Current Work and organisational

Questions about Organisational Factors at Work

Do you feel time or production

Does your work need uninterrupted

Do you find your work monotonous?

Can you vary your work rhythm?

Do you always work at the same

Tenosynovitis Inter.indd 14 02/04/08 15:44:31

Questions about Sports, Recreational, and Household

* See Box 2.1

Tenosynovitis Inter.indd 15 02/04/08 15:44:31

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