De Quervain’

Tenosynovitis
 INTRODUCTION

• It is named after Swiss surgeon, FRITZ DE

QUERVAIN who first described the condition
in 1895.
• It is a stenosing tenosynovitis which affects
the tendon sheaths of the 1st dorsal
compartment of the wrist.
• It is characterised by degeneration and
fibrosis of the tendon sheath.
 Incidence

• Occurs most often in individuals age between

30 and 50 years
• It affects women up to six times more often
than men
• Is commonly associated with dominant hand
 First Dorsal Compartment

• The first dorsal

compartment is
approximately 2
cm long and is
located over the
radial styloid
proximal to the
radio- carpal
joint .
Abductor pollicis longus Extensor pollicis bevis

• Originates from- • Originates from-

posterior shaft of ulna posterior shaft of
and radius radius
• Inserts at-base of 1st • Inserts at-base of
meta carpal proximal phalanx
• Supplied by-radial • Supplied by-radial
nerve nerve
• Action- abduction • Action- extension of
+extension of thumb thhumb.
 Predisposing Factors

• Overuse injury
• Repetitive tasks that involve overexertion of
thumb, radial and ulnar deviation of the wrist
• Arthritis
• pregnancy
 Activities
such as
• Wringing out wet clothes.
• Long use of computer
mouse.
• Use of scissors, surgical
tongs.
• Texting
• Hammering.
• Knitting.
• Lifting heavy objects such
as a jug of milk, taking a
frying pan off of the stove,
or mother lifting a baby out
of a crib (babywrist).
 Etiology
The tendons of the abductor pollicis longus and
the extensor pollicis brevis are tightly secured
against the radial styloid by the overlying
extensor retinaculum.

Acute or repetitive trauma restrains gliding of

the tendons results in inflammation of
synovial sheath

Increases friction
Reactive fibrosis and thickening of the sheath.

Degeneration.
 Clinical Features
• Patient may complain
pain on the radial side
of the wrist that is
worsened by moving
the wrist or thumb.

• Sometimes there is a
visible swelling over the
radial styloid.
• The tendon sheath may feels thick and
hard.
• Tenderness is mostly acute at the tip of
the radial styloid.
• Pain aggravates on grasping and raising
objects with the wrist
• Wet leather sign
• The Finkelstein test is positive.
 Finkelstein test
• It is a provocative test used in diagnostic for de Quervain's
tenosynovitis.
• Makes a fist with the
thumb inside.
• Now ask the patient to bend the wrist toward little finger
 Differential
Diagnosis
• CMC arthritis of the thumb: pain and crepitus
present with the thumb "crank and grind test .
• Scaphoid fracture: in this tenderness will be in the
anatomic snuff box.
• Chauffeur's fracture
• Intersection syndrome-tenosynovitis of the second
dorsalcompartment involving the tendons of
extensor carpi radialis brevis (ECRB) and extensor
carpi radialis longus (more proximal pain)
• Extensor pollicis longus (EPL) tendonitis of the third dorsal
compartment: common in patients with rheumatoid arthritis
or with direct injury and distal radius fracture .
 TREATMENT
GOALS
I. Restoration of normal,painless use of the involved
hand.
II. Resolution of the inflammatory process.
III. Prevention of recurrence of the through
education.
IV. Restoration of pain-free movements
and strength .
 CONSERVATIVE MANAGEMENT
Medical management
• Corticosteroid injection: can be
given to patient with morderate to
marked pain with symptoms
lasting for more than 3 weeks.

• NSAIDS : it is precribed initially

for 6 to 8 weeks to reduce pain
and inflammation.
 PHYSIOTHERAPY MANAGEMENT
• Immoblisation : A thumb
spica splint is used to
restrict thumb movement
so that the first dorsal
compartment tendons are
at rest.

• Cold compression : for 10 to

12 minutes over the
inflammed area.
• Ultrasonic therapy: pulsed mode, 3 mhz, time-
5min.

• Phonophorersis :with 10% hydrocortisone.

• Gentle active and passive motion of thumb and

wrist encouraged for 5 minutes every hour to
prevent joint contractures and adhesions.

• Strenghtening and stretching exercises after the

initial pain subsides.
Indication for decompression surgery
• Unsatisfactory symptom reduction
• Persistence of symptoms after conservative
interventions.
• Limitations in A.D.Ls due to pain.
 After Decompression Surgery
0-2 Days
Immobilization within cast
Active movement of IP joint: Flexion and
Extension.
After 48 hours of surgery dressings are removed.
After this begin with gentle active motion of
the wrist and thumb.
2-14
Days
• Presurgical splint is worn for comfort and
active exercises are continued for Ipjoint,
elbow and shoulder joint .
6 Weeks
• By 10- 14 days: sutures are removed.
• Grip and pinch strengthening exercises
may begin at approximately 3 weeks
and can be progressed gradually.
• By the end of 6 week the patient usually is
able to resume full activities.
 Ergonomics

1) Ergonomic mouse: It
feature a molded
thumb rest support will
help reduce the amount
of gripping force your
thumb needs to apply
to hold the mouse.
2)Use the power grip (all fingers in a loose grip)
instead of using a pinch.

3)Minimize repetition and rest arm occasionally

during a repetitive activity or slow down activity.

4) Use a light grip on tools, pens, the mouse.

5) Alternate hands during activities if possible

 Trigger finger


 Trigger finger is a painful condition that causes the fingers or
thumb to catch or lock when bent. In the thumb its called
trigger thumb.

 Trigger finger happens when tendons in the finger or thumb

become inflamed. Tendons are tough bands of tissue that
connect muscles and bones. Together, the tendons and muscles
in the hands and arms bend and straighten the fingers and
thumbs.
 A tendon usually glides easily through the tissue that covers it
(called a sheath) because of a lubricating membrane
surrounding the joint called the synovium. Sometimes a tendon
may become inflamed and swollen. When this happens,
bending the finger or thumb can pull the inflamed tendon
through a narrowed tendon sheath, making it snap or pop.

 Symptoms


 Symptoms of trigger finger usually start without any
injury, although they may follow a period of heavy hand
use. Symptoms may include:
 A tender lump in palm
 Swelling
 Catching or popping sensation in finger or thumb joints
 Pain when bending or straightening your finger
 Stiffness and catching tend to be worse after inactivity,
such as when wake in the morning. fingers will often
loosen up as move them.
 What Causes Trigger Finger?


• A repeated movement or forceful use of the finger or thumb.
• Rheumatoid arthritis
• Gout
• Diabetes
•  Grasping something, such as a power tool, with a firm grip for a
long time.
 Who Gets Trigger Finger?

 Trigger finger is more common in women than men
and tends to happen most often in people who are 40
to 60 years old.
 Farmers
 Industrial workers
 Musicians often get trigger finger since they repeat
finger and thumb movements a lot
 Smokers can get trigger thumb from repeated use of
a lighter.
 How is trigger finger treated?

In some people, trigger finger may get better without treatment.
However, If treatment is necessary, several different options are
available, including:
 Rest and medication – avoiding certain activities and taking non-
steroidal anti-inflammatory drugs (NSAIDs) may help relieve pain.
 Splinting – this involves strapping the affected finger to a plastic splint
to help ease your symptoms.
 Corticosteroid injections – steroids are medicines that may be used to
reduce swelling.
Surgery on the affected
sheath

surgery involves releasing the

affected sheath to allow the
tendon to move freely again.
This is a relatively minor
procedure generally used when
other treatments have failed. It
can be up to 100% effective,
although may need to take two
to four weeks off work to fully
recover.
 Complications


 Incomplete extension — due to persistent tightness
of the tendon sheath beyond the part that was
released
 Persistent triggering — due to incomplete release of
the first part of the sheath
 Bowstringing — due to excessive release of the
sheath
 Infection
 Recovery

 Most people are able to move their fingers immediately
after surgery.
 It is common to have some soreness in palm. Frequently
raising hand above heart can help reduce swelling and
pain.
 Recovery is usually complete within a few weeks, but it
may take up to 6 months for all swelling and stiffness to
go away.
 If finger was quite stiff before surgery, physical therapy
and finger exercises may help loosen it up.
Mallet finger
Introduction

• Deformity of the finger caused by damaged

extensor tendon distal to DIP.

• Also called baseball finger or hammer finger or

drop finger.

• Disruption may be bony or tendinous.

• Injury at zone 1.
• Common in young to middle-aged males and
older females.
• Most frequently involves long, ring and small
fingers of dominant hand.
Mechanism
• Ball or the object strikes the tip of the finger or
thumb and forcibly bends it.

• A minor force such as tucking in a bed sheet.

• Force tears the tendon or even pull away a piece

of bone.
• Less common mechanism is a sharp or crushing-
type laceration to the dorsal DIP joint.

• Less commonly, a forceful hyperextension injury

of the DIP joint.
Classification (Doyle’s)
Type I Closed injury with or without small dorsal avulsion fracture

Type II Open injury (laceration)

Type III Open injury ( deep soft tissue abrasion involving loss skin and
tendon substance)

Type IV Mallet fracture

A- distal phalanx physeal injury (pediatrics)
B- fracture fragment involving 20% to 50% of articular surface
(adult)
C- fracture fragment >50% of articular surface (adult)
Signs & symptoms
• The fingertip droops. The patient cannot
straighten but passive movement is normal.

• Finger may be painful, swollen and bruised.

• Lack of active DIP extension.

• Swan-neck deformity
Diagnosis
• X-ray : Avulsion of distal phalanx
May be a ligamentous injury with normal
bony anatomy.
Treatment
NONSURGICAL:
• Goal – to keep the fingertip straight until the
tendon heals.

• Extension splints with DIP joint in extension for

6-8 weeks then at night for a 4 additional
weeks.

• Bone avulsion – mallet splint for 6 weeks

• Maintain free movement of the PIP joint.

• Begin progressive flexion exercise at 6 weeks.

Surgical :
Indications-
• volar subluxation of distal phalanx,

• large bone fragments with >50% articular suface

involved,

• non-surgical treatment was not successful.

• >2mm articular gap

• CRPP or ORIF – pin fixation or dorsal/extension
blocking pin.

• ORIF with a pull-out wire.

• Surgical reconstruction of terminal tendon in

chronic injury > 12 weeks with healthy joint –
direct repair, tenodermodesis or retinacular
ligament reconstruction

• Central slip release (Fowler)

• Type 1 and type 2 can be treated closed.

• Type 3 require soft tissue coverage and pinning

of the DIP joint.

• DIP arthrodesis – painful, stiff, arthritic DIP

joint

• Swan neck deformity – lateral band tenodesis,

FDS tenodisis, Fowler central slip tenotomy
Complications
• Extensor lag

• Non union

• Swan neck deformities due to – attenuation of

volar plate and transverse retinacular ligament
at PIP joint, dorsal subluxation of lateral bands,
hyperextension of PIP, contracture of
traiangular ligament.