ARTICLE IN PRESS
Translated Article
ON THE NATURE AND TREATMENT OF STENOSING
TENDOVAGINITIS ON THE STYLOID PROCESS
OF THE RADIUS
DR F DE QUERVAIN OF BASEL
First published: Muenchener Medizinische Wochenschrift 1912, 59, 5–6
In 1895, on the basis of five observations of my own, I
described a painful disorder in the area of the abductor
pollicis longus and the extensor pollicis brevis, which I
characterized as follows:
On moving the thumb, the patients experience more
or less severe pain that radiates from the area of the
wrist towards the thumb and the forearm, so that
they are often no longer able to hold an object that
they have grasped. Palpation yields either a negative
result, or some thickening of the tendovaginal
chamber that rests against the distal radius end.
The tendovaginal chamber is in all cases markedly
sensitive to pressure, whilst the remaining tendon
sheath is much less so, or not at all. The progression
of the condition is chronic.
As a main cause, I cite trauma in the wider sense; the
action of over-work (friction), and direct damage to the
tendovaginal chamber, which is particularly exposed
due to its anatomical position. By way of treatment, for
those cases in which cold, heat, stimulating ointments,
immobilization and massage are of no use, I recommend
the complete or partial removal of the tendovaginal
chamber under local anaesthetic, which has yielded
good results for me in two cases. At the personal
suggestion of Kocher, I described the condition as
fibrous, stenosing tendovaginitis. It follows from my
description that the illness must not be confused with
the so-called tendovaginitis crepitans, even if in one of
my observations it has followed on from one such case.
In my specific surgical diagnosis, I also gave a short
description of the condition (Quervain, 1895,1911).
In 1896, Welti reported on a case of the same type,
which in view of my report was likewise treated by
removal of the entire tendovaginal chamber, and in
which the condition was attributed to over-exertion
(Welti, 1896).
In 1903, Marion – without knowing of my report –
submitted a description of the same condition. He
emphasizes that it is not a disease of the bone, but a
synovitis that is restricted to the tendovaginal chamber
of the abductor pollicis longus. He infers a serous
effusion from the swelling and from the lack of
crepitation. In five cases out of six, the patients were
women, and, in particular, were kitchen maids and
servants. The sole aetiology he assumes is over-work. In
392
all cases, he achieved a cure within 8–10 days through
blistering plasters and compression bandages (Marion,
1903).
In January 1911, Poulsen, likewise unaware of my
work, again described the same condition. He however
takes the explanation to lie mainly in an irritation of the
periosteum as a result of straining through the
tendovaginal chamber (traction periostitis, which he
places alongside other periosteal irritations through
tendon traction, e.g. in the tibia on the part of the
soleus). He has observed ten such cases, almost
exclusively in women. He was unable to show that any
particular occupation or influence of physical work
stood out. In one case, syphilis was present. In most
cases, the malady was already long-standing and very
intractable. What proved best for him in respect of
treatment was revulsion and immobilization of the
thumb (Poulsen, 1911).
The reports from Welti, Marion and Poulsen show
that my original description was based not only on a
rarity fortuitously observed in several examples, but a
not so uncommon picture, even if it has not yet been
mentioned in the textbooks and manuals of surgery.
Since my first report, I have seen a number of cases, and
treated eight of them surgically.
The observations I have made in these cases are,
briefly, as follows:
AETIOLOGY
In exceptional cases, I found gout or gouty heredity or
chronic joint rheumatism. The triggering factor in most
cases was over-exertion – usually housework, in one case
playing the piano. In a few cases, no such aetiology was
to be found. Tuberculosis and syphilis did not come into
consideration in any of the cases. With one exception,
they were all females, aged 18–65 years.
SYMPTOMS
The symptoms mostly began gradually; exceptionally –
as in the second case of my earlier report – they followed
a more acute phase. At the point in time at which I saw
the patient, they had already lasted for some months at
least. They consisted of pain, partly in the area of the
 ARTICLE IN PRESS
NATURE AND TREATMENT OF STENOSING TENDOVAGINITIS
tendovaginal chamber on the processus styloides radii,
partly radiating towards the thumb and forearm, and
occurred most particularly in the case of abduction and
extension movements of the thumb, but occasionally
also in the case of gripping movements. Grating,
infiltration of the superficial soft parts, reddening of
the skin and oedema were never present, nor was there
any demonstrable tendovaginal effusion at the time at
which I saw the patient. The second case in my first
report is the only one in which the disease had started
through tendovaginitis crepitans. On the other hand, I
always found marked sensitivity to pressure over the
respective tendovaginal chamber, and usually a slight
but clear swelling of the same.
DIAGNOSIS
Once one is familiar with the clinical picture, the
diagnosis cannot be missed. As Marion remarks, if
one is not familiar with it, one may be slightly inclined
to think of the start of tubercular disease in the radius.
Apart from the fact that such a location for tuberculosis
is at the very least extraordinarily rare, accurate
palpation will exclude this error, in that the bone, hard
next to the tendovaginal chamber, is shown not to be
sensitive to pressure. Finally, one could also obtain the
assistance of an X-ray image.
NATURE OF THE DISEASE
The histological examinations which I have carried out
in all cases of excision since my first report show a
certain thickening of the taut fibrous connective tissue
compared with normal tendovaginal chambers, but no
signs of fresh inflammation, in other words neither
round cell infiltration nor a strikingly increased quantity
of cells. On the other hand, during the operation the
tendovaginal chamber regularly seemed to be too
narrow for both tendons, i.e. the latter appeared as
strangled therein. Thus, according to the macroscopic
findings, it appears to be a case of an abnormal
narrowness of the chamber, due to the thickening and
unyielding nature of its wall. Nothing abnormal was
ever found in the tendons themselves. What causes the
pain is not, for example, adhesions in the area of the
tendon sheath, nor fibrin deposits or anything of that
nature, but solely the increased friction caused by the
narrowing of the chamber. The correctness of this view
was confirmed to me by the success of the simple linear
longitudinal slitting of the wall. Thus the assumption by
Poulsen that it is an irritation of the periosteum fails,
since symptoms caused by a periostitic irritation would
not suddenly disappear after simple splitting of the outer
wall. Regarding the cause of the constriction, even after
undertaking the histological examinations, I am still
unable to say any more than in 1895. The chamber in
393
question is simply particularly exposed to external
trauma on account of its position. Then, given the
importance of the thumb, considerable demands are
made of it in functional terms. Finally, in the case of
pronounced abduction of the thumb it is exposed to
heavier stresses perpendicular to the longitudinal direc-
tion of the tendons than most other tendovaginal
chambers. These various circumstances predispose it
both to acute states of irritation and to chronic
irritation, and finally a vicious circle can arise in that
with the increased friction, irritation and thickening of
the wall, the resulting constriction and unyielding nature
in turn causes increased friction again. Naturally, a
rheumatic predisposition can encourage this.
TREATMENT
If it is a very acute case, e.g. immediately after severe
over-exertion, then the application of cold, immobiliza-
tion and – in some circumstances – compression
bandages will eliminate the most severe problems in a
short time. In the case of a more drawn-out progression,
an attempt at treatment with a revulsant would be
appropriate (blistering plasters, iodine tincture, stimu-
lating ointments). Heat treatment too (the best being a
hot-air bath for 1–2 hours a day) could be considered at
this stage.
If all this yields no result, or if the case is a chronic
one from the start, then in my experience only surgical
treatment is indicated.
The small intervention is, of course, carried out under
local anaesthetic. The tendovaginal chamber in ques-
tion, is exposed by an incision at the level of the
processus styloideus, taking care to protect the branch of
the radial nerve that runs somewhat to the rear of this
site, towards the back of the hand. As a rule one sees
very clearly how the tendons of the abductor pollicis
longus and of the extensor brevis are constricted in the
chamber. The chamber is opened by a cut parallel to the
tendons, which practically bulge out of it. As I have
already mentioned, initially I excised the entire chamber;
then, with the same success, in five cases I cut away the
outer wall of the same, and in one case left it at
straightforward splitting. Finally, in two cases I made
do with the subcutaneous splitting of the wall of the
chamber. With some care, this carries no danger of
nerve damage. Even in the case of an abnormal
progression, the radial artery is easily felt through the
skin. The cutaneous veins running in this area can also
be easily seen. The nerve ramus running to the rear of
the puncture site, towards the back of the hand, can
easily be felt in people who are not too fat. One
introduces a narrow, sickle-shaped tenotomy knife, with
its back directed against the tendons, proximally into
their chamber, leads it parallel to the tendons through
the chamber towards the thumb, and on drawing the
instrument back one severs the outer wall of the
 ARTICLE IN PRESS
394
chamber. In this way, injury to the tendons is easily
avoided. In the case of the two subcutaneous divisions,
the success was just as good as in the cases of open
division or resection of the chamber. After the tendons
have been freed, the patient immediately experiences a
marked sensation of relief. Movement of the thumb
should be resumed as soon as possible after any of these
surgical methods, so that no unnecessary adhesions
form between the tendon and its surroundings.
I have obtained information about the end results
from eight patients (my two first cases included). In all
cases, the cure proved permanent, whatever the type of
division carried out. No detrimental consequences were
shown, and the patients were to some extent able to use
their thumbs for very fine work just as well as before.
Only one patient writes that her wrist has become
somewhat weaker, although it was already weak before.
She is, incidentally, very satisfied with the result of the
minor operation, since her problems have disappeared
permanently.
SUMMARY
1. In females in particular, sometimes for no apparent
reason, sometimes under the influence of over-work,
there can occur a relative constriction of the
tendovaginal chamber of the extensor pollicis brevis
and of the abductor pollicis longus, which leads to
more or less severe pain that radiates out towards the
elbow and the thumb. These problems sometimes
THE JOURNAL OF HAND SURGERY VOL. 30B No. 4 AUGUST 2005
take the form of acute phases, sometimes a more
chronic progression from the start.
2. Histologically, all that can be shown is a thickening
of the wall of the tendovaginal chamber, without any
inflammatory changes.
3. In fresh cases, treatment consists of the application of
cold, immobilization, compression bandages; revul-
sion or heat treatment in longer-lasting cases; and
open or subcutaneous division of the tendovaginal
chamber in very intractable cases. In all the cases that
were operated on to date, and for which a report was
obtainable, the cure was permanent.
References
de Quervain F (1895). Ueber eine is Form von chronischer
Tendovaginitis. Korrespondenzblatt für Schweizer Aerzte, 13.
de Quervain F. Spezielle chirurgische Diagnostik, 3rd ed. Leipzig,
F.C.W. Vogel, 1911.
Welti E (1896). Ein Fall von sog. Chronischer Tendovaginitis.
Korrespondenzblatt für Schweizer Aerzte, 10.
Marion (1903). D’une affection fréquente, presque toujours méconnue,
la synovite de la gaine du long abducteur du pouce. Arch. Gén. de
Médecine, II: 192.
Poulsen Kr. Tenosynitis i 1ste Kulisse paa Antibrachium, lei saget af
Traktionsperiostitis paa Processus styloides radii. Hospitalstitende,
18th January 1911 (detailed paper in Sem. Médicale 1911, no. 29,
p. 345).
r 2005 Muenchener Medizinische Wochenschrift. Published by Elsevier Ltd. The British
Society for Surgery of the Hand.
doi:10.1016/j.jhsb.2005.01.010 available online at http://www.sciencedirect.com