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De Quervain Tenosynovitis - NCBI PDF
De Quervain Tenosynovitis - NCBI PDF
DOI 10.1007/s11552-014-9649-3
REVIEW
Abstract de Quervain’s tenosynovitis is an overuse disease (EPB) tendons, which pass through the first dorsal compart-
that involves a thickening of the extensor retinaculum, which ment of the wrist [2, 10, 12, 19]. The etiology of this disease is
covers the first dorsal compartment. A case study approach due to repetitive and continued strain of the APL and EPB
was utilized in this article to demonstrate many of the avail- tendons as they pass under a thickened and swollen extensor
able medical and occupational therapy modalities to treat this retinaculum [2, 10, 12, 19]. Patients present with complaints
condition. A 34-year-old right hand-dominant female who of pain and inflammation in the region of the radial styloid
works in a daycare facility presents with radial side wrist pain [11, 14]. This pain is exacerbated by motion and activity
during lifting activity for the past 4–6 weeks. The patient was requiring ulnar deviation with a clenched fist and thumb
diagnosed with de Quervain’s tenosynovitis and conservative metacarpophalangeal (MP) joint flexion. Specific activities
care was initiated. Conservative care involved anti- that may incite complaints include wringing a washcloth,
inflammatory medication and corticosteroid injections as well gripping a golf club, lifting a child, or hammering a nail.
as occupational therapy to include splinting, activity modifi- Inflammation is increased with continued performance of
cation, modalities, manual treatment, and therapeutic exercise. these or similar functional activities [14]. Physical examina-
Although conservative care assisted the patient with her tion may reveal swelling and tenderness in the region of the
symptoms initially, she returned with increased pain and first dorsal compartment. Finklestein’s test, which involves
discomfort after 2 months time. At that point, surgery was thumb MP joint flexion within a closed fist combined with
discussed and performed to release the first dorsal com- active or passive wrist ulnar deviation, can result in a painful
partment as well as the sub-compartment. The patient was response over the styloid process of the radius [2, 10, 11]. This
provided with a splint postoperatively and initiated occupa- is due to a restricted gliding of the APL and EPB tendons in the
tional therapy for edema and scar management, therapeutic narrowed compartment caused by a thickening of the extensor
exercise, and desensitization. Ultimately, the patient was able retinaculum and the APL and EPB tendons [2, 10, 11].
to return to work pain free. Conservative management of de Quervain’s tenosynovitis
differs based on the severity of the condition. Options include
Keywords Abductor pollicis longus . de Quervain’s . anti-inflammatory medication, corticosteroid injections, and
Extensor pollicis brevis . Finkelstein’s test . Tenosynovitis occupational therapy (OT). If symptoms persist despite a trial
of conservative care, surgical intervention may be warranted.
Surgery consists of a release of the first dorsal compartment,
Introduction including any sub-compartments, followed by immobilization
and OT. Specific components of OT include activity modifi-
de Quervain’s tenosynovitis predominantly impacts the ab- cation with patient education, splinting, manual treatment, use
ductor pollicis longus (APL) and the extensor pollicis brevis of modalities, edema and scar management, as well as desen-
sitization and therapeutic exercises [9–11, 15].
R. Goel : J. M. Abzug (*) The purpose of this paper is to present the most common
Department of Orthopaedics, University of Maryland School of
conservative and postsurgical intervention techniques used by
Medicine, 1 Texas Station Ct., Suite 300, Timonium, MD 21093,
USA occupational therapists in the rehabilitation of patients with de
e-mail: jabzug@umoa.umm.edu Quervain’s tenosynovitis.
2 HAND (2015) 10:1–5
The goal of therapeutic exercises is to enhance gliding of a corticosteroid injection and prescribed anti-inflammatory
the APL and EPB tendons in the first dorsal compartment medication. Additionally, she was referred to OT.
[11]. Pain-free active range of motion (AROM) exercise is Initially, the patient did well with the conservative care and
initiated to the patient’s tolerance, focusing on the wrist and was able to continue to work full time. However, approxi-
thumb joints. Tendon gliding of the APL and EPB tendons is mately 2 months later, her symptoms had worsened and she
gently incorporated into thumb MP flexion combined with returned to the office requesting further treatment. At this
wrist ulnar deviation [11]. Strengthening exercises are then point, the possibility of surgical intervention as a definitive
initiated to assist in return to functional activity [11]. solution was discussed. After discussing the risks, benefits,
The treatment plan used by the authors for patients that and alternatives, the patient opted to undergo operative inter-
present to OT for de Quervain’s tenosynovitis is to splint the vention. A first dorsal compartment release was performed,
joint for immediate support and positioning, initiate range of including release of a sub-compartment for the EPB tendon.
motion therapeutic exercise, and implement modalities for The release was performed on the dorsal ridge of the com-
pain relief such as therapeutic ultrasound and iontophoresis. partment. No subluxation was present following the release,
When pain and edema have decreased, strengthening and and therefore, the retinaculum was not reconstructed. Postop-
functional activity are incorporated into the treatment plan in eratively, the patient was splinted in a thumb spica splint and
preparation for return to normal daily activities. Each patient’s referred to OT. Six weeks following the procedure, the patient
response to pain and treatment are different; therefore, devia- returned to the office with significant improvement in her
tion may be necessary. complaints of pain. She was able to return to work full time
without restrictions.
Case presentation
postoperatively, gentle strengthening is initiated with a focus Desensitization of both nerves and the scar is performed
on simulating the patient’s work and leisure activities [15]. after the procedure if decreased sensation or scar hypersensi-
Resisted eccentric thumb extension and abduction exercises tivity is noted upon evaluation of the patient. In de Quervain’s
are then performed in week 4 [13]. Finally in week 5, resisted tenosynovitis, decreased sensation may be noted along the
eccentric wrist flexion and extension as well as forearm pro- superficial radial nerve following the first dorsal compartment
nation and supination exercises are introduced [13]. release [10]. Vibration is a method of desensitization involv-
Edema noted postoperatively in the thenar eminence, ing a steady movement initiated on the outer edge of the
thumb MP joint, or wrist joint near the radial styloid can be painful area and then travelling toward the center [18]. Other
treated with retrograde massage, which is a manual technique forms of desensitization include exposure of the scar or skin to
in which fluid is guided from a distal location to more prox- a variety of textures including sharp, dull, rough, soft, and wet
imal [16]. This technique is performed with lubricant and objects for sensory re-education.
gentle firm pressure, facilitating movement of fluid from the Our postoperative treatment program following first
fingertips proximal, crossing over the wrist joint, allowing the dorsal compartment release for de Quervain’s tenosynovi-
fluid to re-enter the lymphatic system [16]. However, the tis is to fabricate a thumb spica splint for immediate
result is temporary in its effectiveness; therefore, patients are postoperative use. Two weeks following surgery, OT is
educated on how to perform the technique outside of therapy initiated for ROM, scar management, and edema manage-
[16]. The patient may also be issued compression garments, ment using the abovementioned techniques. Four weeks
such as Isotoner gloves or Tubi-Grip sleeves, in cases of following surgery, gentle strengthening and functional
pitting edema or increased inflammation [17]. The continuous activity performance are incorporated into treatment in
use of a compression garment will minimize the amount of preparation for return to daily activity. Once the patient
fluid retention in the hand, thereby allowing for increased regains full motion and strength, he/she is released to
active motion and decreased pain [17]. Cryotherapy, such as resume all activities at work and for leisure.
cold packs, is used to assist with edema management after
performing therapeutic exercises and scar management tech-
niques that may aggravate the surgical area and cause an Summary
increase in inflammation to the first dorsal compartment [7,
11]. Furthermore, patients are encouraged to perform AROM Although OT treatment in combination with NSAIDs and
exercises, such as hand pumping, to facilitate fluid movement corticosteroid injections has shown relief of symptoms in de
from the hand and digits back into the lymphatic system. Quervain’s tenosynovitis, a first dorsal compartment release
Patients are educated on edema management techniques for may be necessary if continued symptoms present. OT treat-
carryover at home to assist in alleviating the inflammatory ment methods for de Quervain’s tenosynovitis assists with the
response. healing of this disease through activity modification with
The incision after a first dorsal compartment release can be patient education, splinting, manual treatment, use of modal-
longitudinal or transverse in the region of the first dorsal ities, edema, and scar management, as well as desensitization
compartment [10]. Transverse (or cross) friction scar massage and therapeutic exercises.
is initiated once sutures have dissolved or been removed and
the scar has healed. Scar massage assists in decreasing the
development of scar tissue, which can restrict available mo- Conflict of Interest Ritu Goel declares that he has no conflict of
interest.
tion in the wrist and thumb joints [6, 15]. Patients are educated Joshua M. Abzug declares that he has no conflict of interest.
on performing this technique when outside of therapy as part
of their home program to minimize scar tissue development Statement of Human and Animal Rights This article does not contain
and facilitate scar mobilization in between treatment sessions. any studies with human or animal subjects.
Silicone gel sheeting is occasionally issued to patients for
topical scar management over the dorsal scar incision. This Statement of Informed Consent Informed consent was obtained when
necessary.
sheeting is recommended if abnormal scarring occurs such as
increased temperature of the surrounding skin, increased red-
ness, increased pain, increased height of the scar, or increased
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