Pellegrini - Stied disease (m. Pellegrini - Stied), peritendinitis of the knee joint, shadow or Stied fracture, Stied - Pellegrini disease, post-traumatic paracondylar ossification of the thigh, paraosseous accompanying shadow of Pellegrini, Keller - Pellegrini - Stied disease. It was first described in 1905 by the Italian physician Pellegrini A., and in 1907 by the German surgeon Stied A. Ossification, located in the soft tissues in the area of the internal femoral condyle. What is it, what are the causes and symptoms, as well as treatment methods, we will consider further.
Features and general description
Pellegrini-Stied disease is a pathological bone growth characterized by a latent clinical picture. In scientific terms, we are talking about ossification of paraaticular tissues in the area of the epicondyle of the knee. The disease occurs most often due to injury or regular microtrauma against the background of significant loads on the joint.
The development of the pathological process begins with the formation of tendon ruptures and necrotic lesions in the muscle tissue. Progression may be complicated by reactive periarthritis. First, the tendon is involved in the pathological process, and then the synovial tissue. Periarthritis leads to tendobursitis. As a result, the soft tissues in the knee structure swell. At the same time, the patient already experiences difficulties with movement and is tormented by constant severe pain. Properly selected therapy leads to the disappearance of symptoms. Otherwise, residual manifestations of Pellegrini-Stied disease are revealed, which leads to its transformation into a chronic pathology.
Causes of the syndrome
The triggering mechanism is usually a direct blow to the area of the medial epicondyle of the femur, forced abduction of the tibia, or a sharp uncoordinated contraction of the adductor magnus muscle of the thigh. As a result, hemorrhages occur at the site of attachment of the tibial collateral ligament and the tendon of the adductor magnus muscle of the thigh to the epicondyle and aseptic necrosis of tissue in the damaged area.
Factors that increase the risk of periarthritis:
- injuries in sports and at work;
- heart attacks;
- arthrosis;
- mental disorders;
- endocrine dysfunction;
- neuroreflex dysfunctions;
- long exposure to dampness;
- age over 40 years.
Exposure to one or more of these factors provokes increased ossification in the area of the medial epicondyles of the knee. Heredity and the presence of the disease in one of the closest relatives play a huge role in the development of the disease. This is due to the genetically determined characteristics of bone growth. But even in this case, the development of Pellegrini-Stied disease will require severe trauma or prolonged microtrauma.
Main reasons
Men aged 25 to 45 years, whose daily work is directly related to sports or physical activity, are predisposed to the disease. Provoking factors are direct mechanical injury to the thigh and sudden abduction of the lower leg. In addition, the following factors may accompany Pellegrini-Stied disease:
- bleeding in the knee;
- necrotic processes in periarticular tissues;
- hormonal imbalances;
- the presence of varicose veins;
- arthritis;
- trophic disorders;
- prolonged swelling in the knee area.
Doctors also warn about a hereditary predisposition to the pathology. This is due to the genetic characteristics of bone growth. The presence of close relatives with its manifestations sharply increases the likelihood of a repetition of the diagnosis in the family. However, even in this case, a trigger in the form of injury will be needed.
What kind of disease is this?
Pellegrini-Stida disease is a post-traumatic ossification of paraarticular tissues in the area of the medial epicondyle of the femur. Most authors consider it a disease of traumatic origin. When the internal ligament is torn from the femoral condyle at the site of its attachment, the periosteum rises and a subperiosteal hematoma is formed, which undergoes ossification. The disease develops more often in men aged 25-45 years, mainly among those involved in physical labor or sports.
Most patients are asymptomatic or with minor pain in the medial part of the knee joint.
In cases of timely contact with specialists and the correct prescription of therapy, the prognosis in most cases is favorable and the patient’s complete recovery is observed.
- ICD-10 code: in classes M70-M79, combining “Other soft tissue diseases”, Pellegrini-Stida disease is designated by code M76.4 under the name “Tibial collateral bursitis”.
Clinical picture
For a long time, Pellegrini-Stied disease of the knee joint can be asymptomatic. At the same time, patients often complain of discomfort in this area, which only intensifies after physical activity or sports. As the disease progresses, the clinical picture is supplemented by swelling, pain, redness of the skin around the affected joint, and increased temperature in this area. In addition, difficulties with movement may occur, gait changes and lameness appears. In the case of a prolonged pathological process, the volume of motor activity is reduced. In the final stages of the disease, a person loses the ability to make full movements in the knee joint, and ankylosis occurs.
Symptoms of Pellegrini-Stied disease
The onset of pathological changes is characterized by the formation of tendon ruptures and foci of necrosis in the periosteal muscle tissue. There are no external manifestations yet, so Pellegrini-Stida disease on the knee joints often remains untreated.
The progression of the disease is manifested by severe symptoms and reactive periarthritis. First, the tendon is affected, then the pathology affects the synovial tissue.
Characteristic signs of knee joint disease:
- pain in the area of ossification formation;
- irradiation of pain to the front of the leg;
- severity of torment at night;
- dysfunction of active flexion and extension of the knee;
- swelling of soft periarticular structures;
- local increase in skin temperature;
- increased or decreased sensitivity;
- atrophy of the muscular frame of the affected lower limb.
Pellegrini Stida disease may have similar symptoms and signs to other knee diseases, so see your doctor for an accurate diagnosis.
Diagnostic methods
A doctor may suspect Pellegrini-Stied disease of the knee joint after a physical examination and palpation of the affected area. To confirm the diagnosis, the patient is prescribed an X-ray examination in several projections simultaneously. In case of a pronounced pathological process, the image clearly visualizes excess bone growths in the area of the diseased knee joint. To determine the extent of the lesion, MRI and CT are required. A blood test is also required to determine the amount of calcium in the body.
Symptoms of calcifying periarthritis
Redness of the skin in the knee area is one of the symptoms of the disease.
Important manifestations of the pathology are tissue damage, compactions and nodules in the muscle tissue, painful on palpation or during movement. The muscles themselves become tense. Signs of pathology depend on its location.
Pellegrini-Stida syndrome in the knee joint is characterized by pathology of the muscle tendons and is localized in the soft tissues surrounding the joint.
Symptoms of periarthritis:
- pain at the site of inflammation;
- swelling and redness of the skin;
- pain on palpation;
- restriction of motor volume
- decreased tactile sensations.
The disease significantly worsens the quality of life: it brings discomfort, sleep disturbance due to pain, suffering. In the absence of timely treatment, working capacity and the possibility of free movement are limited.
Conservative therapy
Pellegrini-Stied disease can be treated in two ways. One of them is conservative, the other is operational. The first option is resorted to in the initial stages of the disease. Non-steroidal anti-inflammatory drugs are usually prescribed. In case of disease progression, exposure to novocaine blockades and hormonal agents is required. The doctor selects all medications, as well as their dosage, on an individual basis.
Simultaneously with taking medications, physiotherapeutic treatment is recommended to improve blood circulation in the affected area. The following procedures are particularly effective: electromassage, mud applications, magnetic laser procedures, ultrasound, electrophoresis.
Diagnostics
To confirm and clarify the diagnosis, instrumental studies are required.
X-ray – performed in anteroposterior and lateral projections. Although x-rays are the most common test for suspected Koenig's disease, they are not always informative. Even full-thickness hyaline cartilage defects may not be visible on imaging. However, the femur is usually well displayed. With osteochondritis dissecans, the doctor sees an area of clearing near the knee joint. At the same time, the trabecular structure of the bone is preserved. A necrotic area in the form of a thin strip is often visualized. In the initial stage of the disease, the contour of the femoral condyle is preserved, but as the pathology progresses, defects may appear.
X-ray stages of osteochondritis dissecans:
- 1 – focus of necrosis;
- 2 – delamination;
- 3 – incomplete separation of the necrotic fragment;
- 4 – complete separation of the fragment.
MRI
– the most accurate non-invasive study. The technique allows you to visualize hyaline cartilage and assess the condition of the subchondral bone and soft tissues. The most reliable results are obtained when performing MRI with contrast.
Arthroscopy
- an even more accurate, but invasive diagnostic method, therefore it is rarely used. The doctor makes an incision in the knee and inserts a tube with a video camera to examine the inside of the joint. For diagnostic purposes, arthroscopy is performed only when MRI is insufficiently informative or immediately before treatment of the pathology.
According to the International Cartilage Repair Society classification, there are 4 arthroscopic stages of the disease:
- 1 – softening of hyaline cartilage;
- 2 – partial separation of cartilage;
- 3 – violation of the continuity of cartilage;
- 4 – formation of free fragments.
The need for surgery
Treatment of Pellegrini-Stied disease of the knee joint by surgery is indicated when the volume of motor activity in the affected limb is reduced. During the operation, the doctor removes the overgrown bone and altered cartilage. The latter is replaced by the patient’s own similar elements taken from other parts of the body.
After surgery, a long period of rehabilitation is required to avoid relapse. The patient is prescribed hemostasis, electrophoresis with Lidaza, hydrokinesitherapy and a course of exercise therapy.
Treatment of pathology
Therapy for Pellegrini-Stida disease should be comprehensive and include therapeutic techniques that are used in the early stages of the development of the process. In severe cases, surgery is used. Traditional methods of treatment are used as an additional method before the main therapy. At the initial stages of the disease, non-steroidal anti-inflammatory drugs are used, which relieve signs of inflammation and reduce pain. Muscle relaxants, chondroprotectors and vitamin complexes are also indicated.
Herbal medicine using decoctions of anti-inflammatory herbs will be useful.
If the volume of motor activity of the limb decreases, surgery is performed. During its course, the overgrown bone is removed, and the altered cartilage is removed and replaced with its own cartilage tissue taken from other parts of the body. After surgery, the patient requires a long period of rehabilitation. For this purpose, a complex of physiotherapeutic measures is carried out, therapeutic massage and restorative gymnastics are prescribed.
Prognosis for recovery
With timely and competent treatment, as well as the patient’s compliance with therapeutic recommendations, the prognosis for recovery is favorable. After a rehabilitation period, the affected limb eventually regains its function. However, the possibility of the disease returning cannot be ruled out.
Prevention of relapse cases comes down to preventing knee injuries, eliminating intense sports and physical activity. Only with this approach can a recurrence of the disease or its transformation into a chronic stage be avoided.
De Quervain's disease is an inflammatory disease of the tendons of the abductor longus muscle of the first finger ( m
.
abductor pollicis longus
) and its short extensor muscle (
m
.
extensor pollicis brevis
), characterized by a narrowing of the lumen of the first dorsal osteofibrous canal in which they pass.
The disease was first described in 1895 by the Swiss surgeon Fritz de Quervain as an occupational disease of laundresses [1]. In his work “Ueber eine form von chronischer tendovaginitis” he presented data on 5 patients with this pathology. It should be noted that a similar description of the disease is found in the classic anatomy textbook published in 1893, authored by Henry Gray. However, de Quervain's work went unnoticed and the disease he described was subsequently “discovered” anew. Thus, in 1903, C. Marion, in the article “A frequent, not yet recognized disease - synovitis of the vagina of the abductor pollicis longus muscle,” based on several observations of patients suffering from pain in the area of the styloid process of the radius, describes the same disease as de Quervain [29].
Among the domestic scientists who dealt with the problem of de Quervain's disease, it should be noted A.Ya. Schnee, V.P. Gorbunova, M.A. Elkina, I.Ya. Slonima, V.K. Selutina.
Monograph by V.P. Gorbunov “Stenotic ligamentitis of the dorsal ligament of the wrist and annular ligaments of the fingers” and the repeatedly republished monograph by M.A. Elkin “Occupational surgical diseases of the hands”, where one of the sections is devoted to stenosing ligamentitis of the dorsal ligament of the wrist, became classic works devoted to this problem.
Currently, in the literature and Internet resources there are many synonyms for de Quervain's disease: tenosynovitis of the styloid process of the radius, de Quervain's syndrome, stenosing de Quervain's tenosynovitis, stenosing de Quervain's tenosynovitis, stenosing ligamentitis of the dorsal carpal ligament, mother's wrist, child's wrist, mother's finger , gamer's finger, laundress syndrome, "Washer Woman's Sprain", "Washer Woman's syndrome", Gamer's Thumb, "smartphone finger". In ICD-10 (code M65.4) the disease is recorded as “tenosynovitis of the styloid process of the radius (de Quervain syndrome).”
Among the working population, the prevalence of de Quervain's disease is 2.8 cases per 1000 in women and 0.6 in men. This pathology accounts for 0.5% in men and 1.0% in women of all musculoskeletal diseases of the upper limb [2].
According to E.V. Usoltseva and K.I. Mashkar [3], patients suffering from stenotic processes of fibrous canals constitute the largest group (36.2%) among diseases of the “auxiliary connecting devices of the tendons of the hand,” of which 12% are accounted for by de Quervain’s disease.
Among all stenosing tenosynovitis in the dorsum of the wrist joint, this pathology occurs in 80–85% of cases or 7–8 times more often than other localizations of canal syndromes [4].
Patients suffering from de Quervain's disease account for up to 40% of all visits to orthopedists, surgeons, and rehabilitation doctors. It has been established that de Quervain's disease is diagnosed in approximately 1% of patients who contact rehabilitation medicine doctors with complaints of problems with the neck or arm.
The disease most often occurs on the dominant hand at the age of 30–55 years, and de Quervain's tenosynovitis occurs 8–10 times more often in women than in men. In most women, the pathology develops during pregnancy or in the first months after childbirth, which is associated with a sharp increase in household workload [5]. This disease is often observed in grandmothers who “very diligently” help mothers with newborns. Often the onset of the disease in women coincides with the onset of menopause.
No correlation was found between the incidence of the disease and race.
The disease is accompanied by pain, sometimes quite severe, dysfunction and decreased strength of the hand, including pinch grip [6]. Such manifestations lead to a significant deterioration in the patient’s quality of life, disruption of his work and daily activities, forcing him to seek medical help sooner or later.
Individual structural features of the first dorsal canal, formed during the process of phylogenesis, determine the complexity of the pathogenesis, diagnosis and treatment of de Quervain's disease.
I. Features of the anatomy of the first dorsal osteofibrous canal
The tendons of the abductor longus muscle of the first finger pass through the first dorsal osteofibrous canal ( m
.
abductor pollicis longus
) and its short extensor muscle (
m
.
extensor pollicis brevis
). The tendons lie in a groove on the dorsolateral surface of the radius and pass over the convexity of its styloid process, which causes frequent injuries (Fig. 1).
Rice.
1. Anatomical structure of the first dorsal osteofibrous canal (according to [8]). Extensor digitorum brevis ( m
.
extensor pollicis brevis
) starts from the interosseous septum of the forearm and the middle of the dorsal surface of the radius.
It is attached in 75% of cases to the base of the dorsal surface of the proximal phalanx or to both phalanges of the thumb. Rarely - to the first metacarpal bone. M. extensor pollicis brevis
is a phylogenetically relatively young muscle; in 2% of cases it may be completely absent or double [7].
Function m
.
extensor pollicis brevis
- radial abduction of the hand, extension of the first finger, the muscle is innervated by the radial nerve, supplied with blood
a
.
interossea posterior
.
Abductor longus muscle of the first finger ( m
.
abductor pollicis longus
) originates from the dorsum of the radius and ulna bones and from the interosseous septum of the forearm, moving obliquely downwards, bends around the radius with its tendon and attaches to the base of the first metacarpal bone. Only in 16% of cases this muscle has one tendon, in more than 80% of cases there are two or more [7].
In cases where the tendon m
.
The abductor pollicis longus
is divided into several bundles, one of them is attached at the base of the first metacarpal bone, and the others can be attached to the large polyhedral bone, trapezium bone, woven into the palmar carpal ligament, thenar fascia,
abductor pollicis brevis
or
opponens pollicis
.
Function m
.
abductor pollicis longus
- radial abduction of the hand and first finger, the muscle is innervated by the radial nerve, supplied with blood
a
.
interossea posterior
.
Between tendons m
.
abductor pollicis longus
and
m
.
extensor pollicis brevis
, on the one hand, and
m
.
extensor pollicis longus
- on the other there is a gap called the “anatomical snuffbox”. Outside, the “snuffbox” is covered with its own fascia, and its bottom is the scaphoid bone and the capsule of the wrist joint with its ligaments. The “anatomical snuffbox” is clearly contoured when the extended first finger is abducted (Fig. 2).
Rice. 2. “Anatomical snuff box.” Within the “snuffbox” there are the radial artery, veins and starting from the radial artery a
.
ramus carpeus dorsalis
.
Branches of the superficial branch of the radial nerve pass over the dorsal carpal ligament. On the back of the forearm, this branch emerges from under the tendon m
.
brachioradialis
at the border of the lower and middle third of the forearm approximately 8.31 cm proximal to the styloid process of the radius. Then it goes to the hand, located at a radial distance of an average of 1.49 cm from the styloid process [9]. In the area of the ligament, the nerve is divided, as a rule, into four terminal branches. The main branch going to the dorsum of the first finger passes 50±13 mm (min - 26 mm, max - 72 mm) proximal to the styloid process [10] (Fig. 3).
Rice.
3. Terminal branches of the superficial branch of the radial nerve (according to [8]). The location of these branches must be taken into account when performing surgery to avoid injury to them.
Many authors note significant variability in the anatomy in the region of the first dorsal canal in de Quervain's disease. The variations in its structure are due to the fact that very often there is an additional channel inside the main canal; therefore, the tendon of the abductor pollicis longus muscle can be represented by not one, but several additional tendons. Stenosis can be either the main or additional canal.
Separate channel for tendon m
.
extensor pollicis brevis
; this is a congenital anatomical feature of humans that occurs equally in both men and women [11].
T. Kulthanan and B. Chareonwat [12] note in 89% of cases the presence of additional trunks in the abductor pollicis tendon, doubling of the extensor digitorum brevis in 2%, and the presence of a septum in 37% of cases.
M.A. Elkin [13] identifies 4 variants of the structure of the first dorsal osteofibrous canal:
1. The tendons of the abductor digitorum longus muscle and the extensor brevis muscle can occupy separate osteofibrous canals.
2. The tendons of the abductor digitorum longus muscle and its extensor brevis muscle may be located in a common osteofibrous canal.
3. In addition to the extensor and abductor tendons, the first canal contains an accessory tendon that does not have a separate canal.
4. The accessory tendon (one or more) is located in a separate fibrous-osseous canal, which is usually located dorsal to the main fibrous-osseous canal.
According to the author, in accordance with the variants of the structure of the first canal and the tendons passing through it, stenosis can occur in the following forms:
- stenosis of the tendons of the abductor digitorum longus muscle and its extensor brevis muscle when they pass together through the first canal;
- stenosis of the same tendons and the accessory tendon when they pass together through the first canal;
- stenosis of the accessory tendon, which has a separate channel;
- isolated stenosis of the tendon of the short extensor or long abductor muscle, which have their own separate channels;
- stenosis of the tendon of the abductor longus muscle with an accessory tendon or the short extensor muscle with an accessory tendon;
- stenosis of the tendons of the abductor longus and extensor brevis, lying in one canal, and the accessory tendon, which has its own canal.
The structural features of the first carpal canal and the tendons passing through it are of great practical importance. The success of surgery depends on how completely the obstacles to the free sliding of the tendons are removed. During surgery, the accessory tendon of the extensor pollicis longus may be mistaken for the extensor pollicis brevis tendon. While in fact the tendon of the short extensor pollicis is often located in an additional stenotic canal. Dissection of only the wall of the main canal without dissection of the wall of the additional stenotic canal may not lead to a complete cure of the patient.
II. Etiopathogenesis of de Quervain's disease
Despite the close attention of many specialists to this pathology for many years, the reasons for its occurrence remain unclear. Some authors consider the root cause of the disease to be the peculiarities of the anatomical structure of the tendons, in particular the presence in some cases of 2–3 additional tendons emanating from the abdomen of the m
.
abductor pollicis longus
, which are attached in various places [12, 14–16].
A.I. Ashkenazi [4] emphasizes the role of constitutional factors in the development of pathology: patients are often short, squat and stocky.
There is an assumption that the cause of the disease may be an acute injury to the wrist or first finger, the consequences of a fracture of the radius in a typical place, although no convincing evidence for this has been found [17, 18].
De Quervain's disease often occurs in patients with rheumatoid arthritis. The disease can be observed in the second half of life and in patients with hypermobility syndrome. Cases of de Quervain's disease have been observed in patients with lymphedema of the upper extremities due to breast cancer [19].
Often, de Quervain's disease develops in young mothers who often lift the child by the armpits - the thumb is deviated and is under severe tension; a case of bilateral hand lesions in a young mother is described [20]. In older women, a similar phenomenon is called “granny ligamentitis.” They perform the same movements when playing with and caring for their grandchildren.
It is believed that the occurrence of the disease in women during menopause is due to hormonal changes in the body, which affects the condition of connective tissue. A decrease in the inhibitory effect of sex hormones on the secretion of growth hormone from the pituitary gland leads to its excessive secretion and, as a consequence, swelling of the soft tissues inside the canal. During these periods of life, de Quervain's disease is often observed on both sides, but with varying degrees of severity.
However, most authors associate the occurrence of the disease with chronic microtrauma to the hand and wrist, which occurs due to monotonous repetitive movements, or prolonged static load on the hand [21–24]. It has been proven that the risk of developing wrist tendonitis is 29 times higher in workers with such working conditions [25]. It is especially great where work involves the need for constant flexion and extension of the wrist and performing twisting movements [26]. It is not for nothing that Henry Gray called this pathology “the disease of the laundresses,” in whom it arose due to the constant twisting of the linen when wrung out.
The disease is becoming more common among workers in the meat industry and automotive industry. De Quervain's disease often occurs in secretaries, assembly line workers, masons, and professionals who use scissors (gardeners, tailors). Pianists, knitters, and fishermen suffer from this pathology.
Among athletes, de Quervain's disease can occur in skiers, tennis players, golfers, and hammer throwers. It has been proven that in volleyball players the likelihood of developing the disease is directly proportional to the duration of training and sports experience [27].
Long-term use of game consoles and smartphones (typing text, sending SMS messages) can also cause the disease. However, an analysis of literature sources conducted using the Ovid MedLine, EMBASE and Cochrane Library databases did not reveal sufficient scientific publications to confirm the cause-and-effect relationship between the occurrence of de Quervain's disease and occupational risk factors [17].
All this once again confirms that the true cause of de Quervain’s tenosynovitis is unknown and in most cases we have to talk about the idiopathic cause of the disease. Environmental factors, trauma, etc. serve only as triggers for the development of a pathological process, the pathogenesis of which is also not completely clear.
When performing various grips involving the thumb, the first osteofibrous canal essentially acts as a block, guiding the tendons m
.
abductor pollicis longus
and
m
.
extensor pollicis brevis
to the phalanges of the finger. Normally, these tendons slide smoothly and smoothly in the tendon sheath, where the synovial fluid is located. Prolonged, repeated load on the first finger or constant monotonous movements in the form of flexion-extension, abduction of the finger cause high differences in intracanal pressure.
In some people, such overload of the ligament leads to negative consequences - the development of pathological macroscopic changes in it in the form of its hypertrophy. Degeneration, cyst formation and plasma cell infiltration are detected microscopically. The number of chondrocytes and extracellular matrix increases, and type II collagen proliferation is observed. Fibrocartilaginous metaplasia of the ligament develops as an adaptation to prolonged or repeated stress on the hand.
Reducing the lumen of the canal leads to increased friction of the tendons passing through it against its inner wall. Chronic trauma to the tendon as it moves through a narrowed canal can be compared to the abrasion of a thread repeatedly passing through the eye of a needle.
As a result of constant irritation of the tendon sheaths m
.
abductor pollicis longus
and
m
.
extensor pollicis brevis
swelling and inflammation occur, which are especially often localized in the area of the styloid process of the radius. However, histological studies showed no signs of inflammation in the tendon tissue. There were only degenerative changes, thickening of the tendon sheaths associated with the accumulation of mucopolysaccharides [28]. For this reason, the authors consider the term "stenosing tenovaginitis" to be incorrect, since the pathology is the result of degenerative rather than inflammatory changes.
Thus, the pathogenesis of de Quervain's disease is based on a conflict between the tendons passing in the first canal and the dorsal carpal ligament. In this case, a vicious circle is formed - the mechanical mutual irritation of these structures leads to an increase in edema, which further impedes the movement of the tendons (Fig. 4).
Rice. 4. Simplified diagram of the pathogenesis of de Quervain's disease.
III. Clinic and diagnosis of de Quervain's disease
Making a diagnosis, as a rule, does not cause any particular difficulties and is based on medical history and the results of a clinical examination. When collecting anamnesis, you should pay attention to the patient’s work characteristics - the presence of monotonous, repetitive movements involving the hand and first finger in labor operations. It is also possible for the patient to perform specific movements of the hand that provoked the symptoms (long-term work on the computer, knitting, playing tennis, badminton). Some patients indicate a history of hand trauma. Taking into account ergonomic and provoking factors allows you to make a correct diagnosis and subsequently give appropriate recommendations.
The onset of the disease is usually gradual. A typical complaint is the appearance of paroxysmal pain, which intensifies with movements of the affected hand, especially when squeezing the fingers and performing twisting movements. The patient may report a gradual increase in pain in recent weeks or months, but it can often occur unexpectedly. The intensity of the pain varies and can be very severe, causing the patient to wake up at night. The typical localization of pain is along the radial edge of the wrist 1.5–2.0 cm below the base of the first finger (“anatomical snuffbox”), in the first dorsal osteofibrous canal, the region of the styloid process of the radius. As the process progresses, pain can radiate to the first finger, forearm, and shoulder. Because of the pain, the function of the hand is impaired: its strength decreases, it becomes almost impossible to perform power and pinch grips, or to abduct the hand to the ulnar side. The patient experiences difficulty opening doors, turning the key, or performing a cylindrical grip. The pain can be so severe that it makes the brush completely useless.
In the area of the first dorsal canal, slight swelling and redness may sometimes be observed. The phenomenon of “clicking” in this disease is very rare, however, upon palpation of the area of the first dorsal canal, pain, small nodules and thickened tendons of the extensor muscles of the first finger are determined, and sometimes a “creaking” of the tendons is felt. In advanced cases, the distal phalanx of the first finger may become blocked in the flexion position.
To clarify the diagnosis, provocative tests are used: active and passive circular movements of the first finger and the Finkelstein test, which is specific for this disease. The test is based on passive tension of the extensor tendons of the first finger. Test technique (Fig. 5):
Rice. 5. Technique for performing the Finkelstein test. the patient brings the first finger to the palm, bending it at the distal and metacarpophalangeal joints. The other fingers are clenched into a fist, clasping the first finger. After this, the doctor performs passive abduction of the wrist to the ulnar side (towards the little finger). Increased pain at the base of the first finger and along the radial edge of the wrist confirms the diagnosis. The test results are compared with the contralateral hand. This sign differentiates the disease from rhizarthrosis.
M.A. Elkin and A.D. Lee [29] proposed to determine the “finger test” symptom to diagnose de Quervain’s disease. This test consists of bringing together the tips of the first finger and the other four fingers equally freely and painlessly on a healthy hand. With stenosis of the first canal, the patient is able to freely and painlessly bring together the tips of the I–II and I–III fingers, and the bringing together of the tips of the I–IV and especially the I–V fingers always causes pain in the area of the styloid process of the radius, and many patients cannot bring them together tips of fingers I–V.
Laboratory tests do not confirm the diagnosis of the disease, although some patients may have positive serologic tests consistent with rheumatoid arthritis.
Ultrasonography, which allows visualization of the tendon itself and surrounding tissue, can confirm the clinical diagnosis of de Quervain's disease. Ultrasound examination reveals thickening of the affected tendon with its hypervascularization, thickening of the vagina and changes in echogenicity; decreased tendon gliding due to fibrous adhesions and vaginal compression.
Magnetic resonance imaging is also informative for diagnosing this pathology. With this method, it is possible to see the presence of free fluid along the thickened tendons m
.
abductor pollicis longus
and
m
.
extensor pollicis brevis
, swelling of the soft tissues in the immediate vicinity of the radius.
An X-ray examination, as a rule, is not required and is performed in cases where there is a suspicion of a fracture or deforming arthrosis of the joints of the first finger. If, despite a negative X-ray picture, the suspicion of a fracture or other bone pathology persists, a computed tomography scan is performed to clarify the diagnosis. No other diagnostic procedures are necessary.
Despite the apparent simplicity of diagnosing de Quervain's tenosynovitis, one must remember that under the mask of this disease there may be other pathologies that require fundamentally different treatment tactics. Differential diagnosis of de Quervain's disease should include a scaphoid fracture, carpal instability, Kienböck's disease, deforming arthrosis of the carpometacarpal joint of the thumb, styloiditis of the radial styloid, tenosynovitis of the extensor carpi radialis, intersection syndrome, neuropathy of the superficial branch of the radial nerve. (Wartenberg syndrome). Radiculopathy of the CVI root may masquerade as de Quervain's disease. The main diagnostic criteria for these pathologies are presented in the table.
The main diagnostic differences between some pathologies and de Quervain's disease It should be remembered that the cause of pain along the radial edge of the hand can be the dorsal ganglion of the wrist, as well as rheumatoid arthritis with damage to the joints of the hand, however, with this disease there is a typical deformation of the fingers and hand. A case is described in which osteoid osteoma of the styloid process of the radius in a 37-year-old man manifested itself as de Quervain’s disease [30]. The correct diagnosis was made only after a computed tomography scan. Impaired sensitivity of the first finger, pain in the area of the first interdigital space can occur with damage to the median and radial nerves, carpal tunnel syndrome. The cause of pain on the dorsal-lateral surface of the forearm may be epicondylitis, so it is necessary to examine the tendon attachment points in the area of the lateral epicondyle of the humerus.
The general scheme of examination of a patient with de Quervain's disease is presented in Fig. 6.
Rice. 6. General scheme of examination of a patient with de Quervain's disease.
Information about authors
For contacts:
Novikov A.V. — e-mail: [email protected] mail.ru
Medical Encyclopedia - the meaning of the word Pellegrini - Shtidy Disease
I (A. Pellegrini, Italian surgeon; A. Stieda, German surgeon, 1869-1945; synonym: Pellegrini-Stied syndrome, calcifying periarthritis of the knee joint area) a disease characterized by foci of heterotopic bone formation in the periarticular tissues of the medial epicondyle of the femur due to previous trauma.
For the first time, the clinical, radiological and pathomorphological picture of the disease was described by A. Pellegrini (1905), believing that it was characterized by calcification of the tibial collateral ligament of the knee joint. A.
Stida (1907) considered the formation of ossification to be a consequence of an avulsion fracture of the epicondyle of the femur, resulting from direct trauma or a sharp contraction of the adductor magnus muscle of the femur. Modern morphological and histochemical studies have shown that the disease is based on a perverted regeneration reaction in response to damage.
It is believed that in the occurrence of this metaplasia, in addition to trauma, hemorrhage, necrosis, and prolonged tissue edema, the individual predisposition of the body plays a large role. The disease develops more often in men aged 25-45 years, mainly among those involved in physical labor or sports.
The triggering mechanism is usually a direct blow to the area of the medial epicondyle of the femur, forced abduction of the tibia, or a sharp uncoordinated contraction of the adductor magnus muscle of the thigh.
As a result, hemorrhages occur at the site of attachment of the tibial collateral ligament and the tendon of the adductor magnus muscle of the thigh to the epicondyle and aseptic necrosis of tissue in the damaged area.
The main symptom of Pellegrini-Stied disease is pain, which always corresponds to the location of the ossification and can spread along the obturator nerve or the infrapatellar branch of the saphenous nerve to the anterior surface of the leg. In 1/3 of patients, the pain intensifies at night and is of a burning, boring nature.
In addition, there is a limitation of movements in the knee joint, both flexion and extension, which are usually combined with swelling of the soft tissues of the knee joint, local hyperthermia, hyperesthesia or hypoesthesia in the area of edema, as well as atrophy of the muscles of the thigh and lower leg.
In the early period after an injury, when the clinical picture is identical to a bruise or distortion of the knee joint, as well as when combined with internal injuries, its diagnosis is difficult. 3-4 weeks after the injury, ossification is detected on radiographs of the knee joint (Fig.
), having the shape of a bracket, sickle or irregular shape, which is separated from the epicondyle of the femur by a strip of lucency. In case of negative radiological data, but in the presence of palpable ossification, it is necessary to take X-rays with internal or external rotation of the limb by 20° to eliminate the layering of ossification on the contour of the femoral condyle.
Radionuclide testing can provide information about the degree of maturity of the ossificate. The differential diagnosis is made with an avulsion fracture of the medial epicondyle of the femur, which is revealed on an x-ray immediately after the injury. In addition, the marginal defect of the epicondyle corresponds in shape and size to the torn bone fragment.
A similar x-ray picture can be observed with a restructured process in the epicondyle of traction origin, resulting from repeated forced strains of the adductor magnus muscle of the thigh, for example in football players. However, the gradual development of this disease, younger age, and association with sports help clarify the diagnosis.
Treatment is often conservative. Physiotherapeutic methods are often ineffective, because provide only temporary improvement. The use of ultrasound therapy in combination with electrophoresis of a novocaine solution or 10% sodium chloride solution is effective only in the first 3 months after injury.
A lasting positive effect is usually achieved by injections of hydrocortisone with novocaine into the focus of ossification. Surgical interventions are performed if there is no effect from conservative measures, but not earlier than 3 months after the injury if there are signs of ossification maturity.
To do this, the density, structure of the ossification, and the clarity of the sclerotic border are determined on radiographs. Radionuclide data are also used. When combining P. - Sh. b. with internal injuries of the knee joint, especially if the ossification is located near the nerve trunks or when it is introduced into the joint cavity, treatment is only surgical.
To prevent recurrence of ossification after surgery, the scars surrounding the ossification are carefully removed, because they retain the potential for metaplasia into bone tissue. Be sure to eliminate the cavity in the soft tissues after excision of the ossification (suturing the tissue or filling it with part of the medial head of the quadriceps femoris muscle). The operation is completed with careful hemostasis. In the postoperative period, lidase electrophoresis is prescribed in the first 2 weeks. For 11/2 months, patients take indomethacin, do therapeutic exercises and hydrokinesotherapy. The prognosis is favorable, because With timely treatment, limb function is fully restored. Prevention consists of preventing injuries to the knee joint and their timely treatment. X-ray of the knee joint (direct projection) in Pellegrini-Stied disease: ossification in the area of attachment of the adductor magnus muscle of the thigh and the medial collateral ligament of the knee joint to the medial femoral condyle, as well as along the course of the ligament. IIPellegrini - Stida's disease (A. Pellegrini, modern Italian surgeon: A. Slieda, 1869-1945, German surgeon)
see Pellegrini - Stied syndrome.
See the meaning of Pellegrini - Shtidy Disease in other dictionaries
Disease _
Synonym dictionary
Illness - to be sick, etc. see pain. Dahl's Explanatory Dictionary
Illness - About the nature, strength, duration of the illness. Sudden, long-standing, long-term, inveterate, neglected, inveterate, protracted, protracted, curable, debilitating,……..
Dictionary of epithets
Zh.'s disease - 1. Disruption of the normal functioning of the body, a health disorder (about a person). // Disruption of the normal functioning of the animal’s body. // Deviation…….. Efremova’s Explanatory Dictionary
Disease - -and; g.1. A specific disease that disrupts the activity of the body (or its individual organs); health disorder. Diseases of bees and livestock. Potato diseases……..
Kuznetsov's Explanatory Dictionary
A disease is a disruption of the normal functioning of the body caused by functional or morphological changes. B. arises from exposure to harmful factors on the body…….. Economic Dictionary
Dutch disease is the deindustrialization of the economy due to the emergence of new sources of natural resources. The name is associated with Holland, where such a process began, after they were........ Economic Dictionary
Mental illness (mental illness) is a disease manifested in a disruption of normal mental activity, which significantly affects a person’s ability to correctly understand the surrounding reality..... Economic Dictionary
Mental illness - see MENTAL ILLNESS. Economic dictionary
Mental illness (mental illness) is a disease manifested in a disruption of normal mental activity, which significantly affects a person’s ability to correctly understand the surrounding reality..... Legal Dictionary
Abta-Letterer-Siwe Disease - (A. Abt, 1867-1955, American pediatrician; E. Letterer, born in 1895, German pathologist; S. Siwe, born in 1897, Swedish pediatrician) see Letterer-Siwe disease. Large medical dictionary
Addison's Disease - (Th. Addison, 1793-1860, English doctor) see Addison's disease. Large medical dictionary
Addison-Biermer Disease - (Th. Addison, 1793-1860, English physician; A. Biermer, 1827-1892, Swiss physician) see Pernicious anemia. Large medical dictionary
Addison's Disease - (morbus Addisoni; Th. Addison; synonym: Addison's disease, bronze disease, chronic adrenal insufficiency) endocrine disease caused by bilateral lesions...... Big medical dictionary
Alexander's Disease - 1) (V. Alexander, modern American doctor) - see Hypoproconvertinemia; 2) (WS Alexander, modern English neurologist; synonym Rosenthal leukodystrophy) – hereditary disease c. n. p., characterized by…….. Big medical dictionary
Alibert's Disease - (JL Alibert, 1768-1837, French doctor) see Mycosis fungoides. Large medical dictionary
Albers-Schonberg Disease - (N. E. Albers-Schonberg, 1865-1921, German radiologist) see Marble disease. Large medical dictionary
Almeida-Lutz-Splendore Disease - (FP de Almeida, modern Brazilian doctor; A. Lutz, 1855-1940, Brazilian bacteriologist; A. Splendore, modern Brazilian doctor) see Paracoccidioidosis. Large medical dictionary
Alzheimer's disease - (A. Alzheimer, 1864-1915, German doctor) a type of presenile dementia, manifested, along with the progressive development of amnestic dementia, aphasic, apraxic...... Big medical dictionary
Andersen Disease - (D. N. Andersen, 1901-1964, American pathologist) see Glycogenosis type IV. Large medical dictionary
Mental illness - see MENTAL ILLNESS. Legal dictionary
Adjuvant Disease is a complication caused by the use of adjuvants. Manifested by the development of proliferative processes in joints, periarticular tissue, and other organs and tissues. Pathogenesis…….. Dictionary of microbiology
Botkin's disease - Botkin's diseaseSee. Hepatitis A Dictionary of Microbiology
Infectious disease - a disruption of the normal functioning of the body, caused by functional and (or) morphological changes resulting from penetration into…….. Dictionary of Microbiology
Creutzfeldt-Jakob disease - Creutzfeldt-Jakob disease is a subacute spongy encephalopathy of humans. It proceeds according to the type of precynic dementia. Refers to slow infections (see). Called a prion. Dictionary of microbiology
Sleepy disease - see African trypanosomiasis. Dictionary of microbiology
Chagas disease - see American trypanosomiasis. Dictionary of microbiology
Brill - Zinsser disease - Brill - Zinsser disease see. Typhus. Dictionary of microbiology
Vasilyeva Weyl's disease - Vasilyev Weyl's disease is one of the forms of leptospirosis (see). Dictionary of microbiology
Aujeszky's Disease - (A. Aujeszky, 1869-1933, Hungarian pathologist; synonym: Aujeszky's disease nrk. false rabies, infectious bulbar paralysis) - an acute infectious disease of domestic and agricultural........ Big medical dictionary