De Quervain's tenosynovitis is a painful inflammation of the tendons at the base of the thumb. This process involves the tendons of the extensor pollicis brevis and abductor pollicis longus muscles. These muscles are located on the dorsal surface of the forearm and pass to the lateral side of the thumb through the fibro-osseous tunnel formed by the styloid process of the radius and the extensor retinaculum. Pain, which is the main complaint in this disease, occurs with abduction of the thumb, grasping movements and ulnar deviation of the hand. Swelling and hardening of the tissue may also be present.
Clinically Relevant Anatomy
Clinically Relevant Anatomy
Extensor pollicis brevis
- Beginning: ½ of the posterior surface of the body of the radius, interosseous septum of the forearm.
- Attachment: base of the proximal phalanx of the thumb.
- Functions: wrist joint: radial abduction;
- thumb: extension.
Abductor pollicis longus muscle
- Beginning: posterior surface of the radius and ulna, interosseous septum of the forearm.
- Attachment: base of the first metacarpal bone.
- Functions: wrist joint: radial abduction;
- thumb: abduction.
Etiology
- Currently, the cause of the disease is associated with myxoid degeneration (a process in which connective tissue is replaced by a gelatinous substance) rather than with acute inflammation of the synovium. In myxoid degeneration, there is excessive deposition of fibrous tissue and increased vascularization, which causes a thickening of the tendon sheath. This causes the extensor pollicis brevis and abductor pollicis longus muscles to become pinched.
- The main cause of the disease is repetitive movements in the wrist joint, especially those in which radial abduction of the thumb occurs with simultaneous extension and radial deviation of the wrist.
- The classic contingent of patients are mothers of newborns who constantly lift babies with a radially abducted thumb and wrist, moving from ulnar to radial deviation.
- The most common cause is chronic cumulative trauma.
- Cumulative injuries can occur from golfing, playing the piano, fly fishing, carpentry, or carrying a child for long periods of time. Also at risk are office workers and musicians.
- Repeated squeezing, grasping, clenching, squeezing or squeezing (when washing, for example) movements can cause inflammation of the tendons or their sheaths. This may lead to narrowing of the first dorsal compartment, resulting in a limitation in range of motion. If left untreated, inflammation and progressive narrowing (stenosis) can lead to scarring and subsequent restriction of movement of the thumb.
- In women, this disease occurs approximately 10 times more often than in men. Most often it occurs after the birth of a child and mainly occurs in women 30-50 years old. With the advent of new technologies and the proliferation of gadgets, it became known as “Blackberry Thumb Syndrome.”
Symptoms and diagnosis
Knott's disease or stenosing ligamentitis. ICD-10 code: M65.3
The danger of the pathology is that the primary symptoms may seem harmless: a slight clicking sound, after which the finger freely assumes a given position, usually does not cause concern. It is for this reason that there is a risk of missing the first stage, which is most susceptible to therapy, when the chances of complete healing with conservative methods are highest.
In subsequent phases, the symptoms become much more distinct: obstacles are felt more strongly, movement of the finger is accompanied by pain, a click is heard with every bend or extension.
trigger finger syndrome symptoms
To diagnose a disease, a specialist only needs to interview the patient, conduct an examination and palpation. If diagnosis is difficult, an x-ray examination is performed. An X-ray is advisable when several fingers are affected: such a sign indicates other diseases with similar symptoms. Stenosing ligamentitis is diagnosed at the earliest stages, so it makes sense to consult a doctor at the first suspicion.
Clinical picture
Clinical picture of de Quervain's tenosynovitis
The main complaint of patients is pain in the wrist on the side of the radius, which radiates to the forearm when trying to grab something with the thumb or straighten it. The pain is described as “constantly aching, burning, twitching.” Often the pain is aggravated when performing grasping, squeezing or twisting movements. Examination may reveal swelling in the area of the anatomical snuffbox, tenderness in the area of the styloid process of the radius, decreased range of motion in the first metacarpal joint, palpable thickening of the first dorsal compartment, and tendon crepitus. Other symptoms include weakness and paresthesia of the hand. These symptoms appear with a positive Finkelstein diagnostic test.
Survey
Inspection
Evaluation of a patient with signs and symptoms of de Quervain's tenosynovitis should begin with a thorough history followed by a physical examination.
History taking
- Overuse injury or acute injury.
- Have symptoms appeared before?
- Repetitive hand movements during work or daily activities.
- The pain is localized above the base of the thumb and in the dorsolateral region of the wrist near the styloid process of the radius.
- One hand dominance.
- Pregnancy or postpartum period.
Physical examination
Vital Signs
- Height.
- Weight.
- HELL.
- Pulse.
- NPV.
- Temperature (if required).
In a sitting position
- Resting hand/thumb position.
- Inflammation around the base of the finger on the dorsal side and/or near the styloid process of the radius.
Neurological examination
If you have symptoms such as numbness and tingling, as well as pain, it is necessary to conduct a neurological examination and check whether the symptoms are associated with pathology in the cervical spine. It is important to determine whether the central nervous system is involved in the process, whether the sensitivity of the skin at the base of the thumb and index finger is reduced (this area is innervated by the superficial branches of the radial nerve). Pay attention to a symptom such as hand weakness and determine whether it is due to pain or a neurological problem.
Dermatomes (C4-T1)
- Myotomes (C4-T1).
- Reflexes (C5, C6, C7).
- Pathological Hoffman reflex.
Palpation
During palpation, the most significant will be the detection of such a deviation as painful sensitivity over the base of the thumb and/or the 1st compartment of the wrist extensors above the styloid process of the radius. It is also possible to palpate the thickening of the synovial vagina. It is very important to rule out arthritis or a fracture of the scaphoid by palpating the first carpometacarpal joint to determine whether there is tenderness or deformity there.
- Dorsoradial region.
- Styloid process of the radius.
- “Anatomical snuffbox” - scaphoid, trapezius, extensor digitorum longus, extensor pollicis brevis, abductor pollicis longus and first carpometacarpal joint.
- Soft tissue surrounding the affected area.
Range of motion
Range of motion can also be used as a screening tool to rule out involvement of the cervical spine, proximal joints, and anatomical structures. Note any deviations in range of motion and be aware that when testing the thumb, there may be a clicking sound and a feeling of “sticking” in the thumb. All this is associated with reduced tendon mobility.
- Range of motion in the cervical spine.
- Flexion, extension, adduction and abduction of the shoulder (right and left).
- Flexion and extension in the elbow joint (right and left).
- Pronation and supination of the forearm (right and left).
- Wrist: Flexion, extension, ulnar and radial deviation.
- Fingers two to five:
- Abduction and adduction in the metacarpophalangeal joints.
- Flexion and extension (in the metacarpal, metacarpophalangeal and interphalangeal joints).
- Abduction and adduction (in the metacarpal-carpal, metacarpophalangeal joints).
- Opposition.
Muscle tests with resistance
In the presence of pain, strength naturally decreases. Note the maximum force possible in the absence of pain. This data will be useful in tracking the patient's progress during treatment.
- Grip strength.
- Pinch strength (finger squeezing force).
Muscle length
Watch for signs of hyper/hypomobility. Treatment will be prescribed based on dysfunction. Keep in mind that areas of hypomobility are often areas of referred pain.
- Congenital flexibility (clawed hand symptom).
- Extensors and flexors of the wrist.
Joint mobility
- Distal radioulnar joint.
- Wrist joint.
- Midcarpal joint.
- Thumb.
- Metacarpal, metacarpophalangeal and interphalangeal joints.
- Brush.
- Intercarpal joints.
Specific tests
Finkelstein test
- To confirm - Finkelstein test.
- To exclude: test for osteoarthritis of the first metacarpal joint (Grind Test);
- palpation to identify a scaphoid fracture;
- Upper Limb Tension Test, or ULTT B - to determine neuritis of the superficial sensory branch of the radial nerve;
- assessing the clinical likelihood of cervical radiculopathy;
- intercarpal instability.
Neurological tests
- Upper Limb Tension Test, or ULTT B.
- Test to detect damage to the radial nerve.
- Test to detect damage to the superficial sensory branch of the radial nerve.
- Tinel's sign.
Be careful with the position of your thumb while performing tests.
Circulation
- Pallor/Capillary refill.
- It is important to use the capsule-ligamentous apparatus in the acute phase of traumatic injury.
- Stress test of the collateral ligaments of the fingers (varus/valgus).
How to protect yourself from predicted disaster
In the future, it is worth taking measures in advance to protect yourself from negative predictions. Amulets and amulets are well suited for this purpose. They must be illuminated and carried with you without taking them off.
If you don’t want to wear the talisman around your neck, you can put it in your bag or pocket. Children are allowed to put amulets in their school backpack.
A good mood will set you up for a positive course of events. Don't let yourself get discouraged. The main power of human energy lies not in talismans, but in himself. Charms only provide additional protection to protect against unexpected problems when people are most vulnerable. Self-confidence and fortitude are bestowed not by stones and amulets, but by the person himself.
It turns out that fingers can itch for many reasons. Since ancient times, special interpretations have been attributed to this phenomenon. The location of the itch, the time of day and day of the week are also of great importance, because from this the interpretation can acquire absolutely polar meanings.
Differential diagnosis
- Intercarpal instability. The wrist is a complex anatomical area consisting of a large number of small bones and ligaments. Degenerative processes or direct trauma can lead to instability between the articulating bones, which in turn leads to pathological changes in the biomechanics of the hand and the appearance of pain. Scapholunate dissociation, scaphotrapeziotrapezial joint degeneration, and lunate-triquetral dissociation can all be associated with radial wrist pain.
- Fracture of the scaphoid bone.
- Most often, a scaphoid fracture occurs as a result of a fall on an outstretched arm with an extended wrist. In this case, pain occurs on the side of the radius, there is also swelling in the area of the anatomical snuffbox, limited range of motion, pain when performing a movement, especially at the end of the amplitude. If the patient has been injured and subsequently experiences pain in the wrist from the side of the radius, then it is first necessary to exclude a fracture of the scaphoid bone.
- Damage to the superficial branches of the radial nerve (Wartenberg syndrome). The superficial branches of the radial nerve innervate the dorsal surface of the first and second fingers and the first interdigital space. Nerve fibers can become compressed between the extensor carpi radialis brevis and brachioradialis tendons due to scar tissue formation after injury or from wearing tight jewelry. As a result of compression, ischemia develops and, as a result, numbness and tingling in the area of innervation.
- Radiculopathy of the cervical spine at the C6 level. Compression of the spinal nerve roots can cause sensory disturbances, muscle weakness, and weakened reflexes. The key dermatomes of the C6 segment are the radius of the second metacarpal and the index finger, which is approximately the same area where pain occurs in de Quervain's syndrome. It is precisely because of the similarity of symptoms that it is important to exclude cervical radiculopathy and carefully check the C6 segment.
- Osteoarthritis of the first metacarpal joint. Osteoarthritis of the first metacarpal joint usually occurs in people over 50 years of age and usually manifests itself as stiffness of the joint in the morning, decreased range of motion, and tenderness in the area. With this disease, the squeeze test will be positive.
- Crossover syndrome. With this syndrome, pain will occur closer to the back of the forearm, mainly in the middle and about 5 cm below the wrist.
Person's character by thumb
From the point of view of many palmists, the thumb is almost as important for reading as all the others combined.
The thumb is not named after any god (although it is sometimes associated with the first house of the horoscope), but it is a key indicator of the level of vitality and vital energy.
Some Hindus are known to limit fortune telling to just the thumb, ignoring the whole hand! Each part (phalanx) of the thumb has traditional associations: the first (where the nail is) with will, the second with logic.
The thumb, like all the others, has three phalanges, the third being the pad of flesh that forms the side of the palm. It is traditionally combined with other pads, all of which are called “hills”.
The larger the thumb, the greater the vitality and power of a person, especially when combined with a strong index finger.
A very large and strong thumb on a mixed type hand is a sign of selfishness, independence, pride, arrogance and even an exaggerated opinion of one’s own talents and merits.
People with a long and highly developed thumb are immersed in the world of ideas and their own thoughts; as a rule, they are closed, self-sufficient, soberly assess their capabilities and have no illusions about their place in this world.
A long and powerful thumb on a miniature hand indicates an insightful mind, vivid imagination, and the ability to analyze and introspect.
- Long thumb: Good leader, clear mind, willpower coupled with judgment.
- Very long: A tyrant, a despot, always does things his own way.
- A short thumb is a sign of a nature that is more emotional than rational.
- A weak and underdeveloped thumb on a hand with smooth fingers indicates its owner’s love for poetry and the fine arts.
- Short: Impressionable, indecisive, heart rules head.
- Big: Gifted, strong.
- Short and Thick: Stubborn, persistent.
- Small and weak: Lack of energy and will.
- Direct and tough: Reserved, loyal, reliable, cautious, stubborn.
- Flexible: Flexible nature, good-natured, generous, tolerant, prone to extravagance.
- Smooth joints: Fullness of life.
- Knotty joints: Energy comes during violent disputes.
- High location: Acquisitiveness, stinginess, meanness.
- Low placement: (1) Courage, versatility.
- Closely attached to the palm: (2) Not entirely honest.
- Tendency, hiding under other fingers: Unhappy and self-destructive.
- Forming a right angle with the palm when drawn: Strong sense of justice.
- Formative angle greater than straight: Too soft-hearted.
Phalanges of the thumb
- Equal Length(s): A balanced person.
- The entire finger—the first and second phalanx—is the same width (b): Rough, straight.
- Wide and strong first phalanx: Large reserve of vitality, well-directed energy.
- The first is longer than the second: Energy is not controlled by logic.
- Strongly pointed first: Lack of stamina and vitality.
- Thickened upper phalanx (c): Violent, full of uncontrollable energy. Considered the "killer's finger".
- Broad and strong second: Logical, reflective, thinks before doing.
- The second is longer than the first: Constricted, feels restricted.
- Narrowed second (d): Witty, tactful, impulsive, can be evasive.
Treatment
The goal of treatment for de Quervain's tendonitis is to reduce pain caused by irritation and swelling.
Conservative treatment
The goal of nonsurgical treatment is to reduce pain and swelling. At the initial stage the following can be used:
- Immobilize the thumb or wrist joint with a splint or splint to rest the tendons. So far, clinicians have not reached a consensus on the duration of wearing orthoses: a number of experts recommend wearing them for 4-6 weeks, others recommend wearing them only during periods of pain.
- Avoiding repetitive movements and movements that aggravate the condition.
- Applying ice.
- Taking NSAIDs.
- Injections of corticosteroids into the synovial membranes.
- Physical therapy.
Patients may also be required to be immobilized for up to 6 weeks. To do this, use a bandage on the thumb. It was found that when wearing an orthosis, improvements occurred in 19% of cases. However, with simultaneous use of NSAIDs, this figure was even higher and amounted to 57%.
Ultrasound examination, according to some estimates, can have a positive effect on treatment results. In addition, it can act as a diagnostic tool. Injections administered under ultrasound guidance were more effective. In addition, there were no side effects. Ultrasound-guided injections performed into the extensor pollicis brevis area with septation are more effective than manual injection.
Another effective conservative treatment option is steroid injection, but more research is needed to establish its full benefits.
Direct injection of a small dose of cortisone into both tendons has worked well. For primary disease, the effectiveness of this measure is about 60-70%.
Affairs of love, family and religion
Orthodox Christians traditionally wear rings associated with marital status on the ring fingers of their right hands. Catholics and Protestants wear wedding bands in the same way, but on their left hands.
However, wedding and engagement rings can also be seen on the thumbs. As a rule, the reason for this phenomenon is quite utilitarian: the person lost weight, the ring began to fall off the ring finger, and it was necessary to move it to the thickest one, that is, the big one.
There is no particular crime in this, especially since a ring made of noble metal without a stone (namely, these are the classic “engagement rings”), put on the thumb, does not look too provocative. And from the point of view of esotericists, this usually only benefits the wearer.
Sometimes grieving widows wear the rings of their deceased husbands this way. This is natural: usually men's fingers are thicker than women's, and husbands' rings fit exactly the size of wives' thumbs.
However, if you think that a wedding, wedding or engagement ring does not belong on your thumb, you can do otherwise: go to a workshop, secure the jewelry with another ring, or move the jewelry to your neck.
Gold wedding ring in the SUNLIGHT catalog
But the Christian ring “Save and Preserve” would be quite appropriate on the thumb. Moreover, it is advisable to wear it on the active hand (the right hand for right-handed people, vice versa for left-handed people): nevertheless, the choice of a religious symbol and life path is an act of will, therefore such jewelry belongs on the right hand.
Physical therapy
Friends, on July 17 in Moscow, as part of the #RehabTeam project, Anna Ovsyannikova’s seminar “Rehabilitation of the hand after a fracture of the distal radius (fracture of the “radius in a typical place”)” will take place.” Find out more... In addition, on July 18, she will conduct a seminar “Rehabilitation of the hand after fractures of the metacarpal bones (Boxer fracture).” Find out more...
Applying Ice/Heat
Heat can help relax tight muscles, and ice can help reduce inflammation of the extensor sheath.
Massage
Deep tissue massage in the area of the big toe can also help relax tight muscles, leading to less pain.
Stretching
You can also relax the tight muscles of the thumb eminence by stretching. This is facilitated by extension and abduction of the thumb.
Increased strength
- Finger extension with resistance.
- The position of the palm up is extension and abduction of the thumb.
- Thumb up - extension and abduction of the thumb.
- Radial deviation with resistance.
- Thumb up – supination with resistance.
- Thumb up – Opposing the thumb with resistance.
Increased range of motion
As mentioned above, stretching can help increase your range of motion. Applying ice/heat helps relax tight muscles, which also leads to increased range of motion.
Reduced swelling
The following measures may help reduce swelling:
- Thumb splinting.
- Corticosteroid injections.
- NSAIDs.
- Cold/warm.
- Massage.
- Stretching.
Massage of the thumb - for normal functioning of the spleen, stomach, cardiovascular system
According to Chinese medicine, the thumbs are responsible for the functioning of the lungs, and the normal functioning of the heart depends on the health of the respiratory organs. For arrhythmia and a pressing sensation in the chest, it is useful to intensively massage the entire thumb. Problems with the lungs negatively affect the functioning of the spleen and stomach, and massage of the thumbs will also come to the rescue here. The following exercise is also useful: bend your thumbs outward as much as possible.
Exercises at home
Any of the stretching or strength-building exercises listed above can be incorporated into a home recovery program. At home, patients can also use ice packs or apply heat. After completing the training, patients can also perform self-massage at home.
To date, there have been no high-quality studies examining the effects of conservative treatment as a stand-alone intervention. The literature primarily describes the effects of corticosteroids and other injections compared with placebo. Studies that showed injections were better than splinting did not examine long-term results.
A Cochrane review states that there is “silver-level” evidence that corticosteroid injections are superior to splinting for pain relief. The authors, however, acknowledge that "the evidence is based on a short-term, very small, controlled clinical trial of low methodological quality that included only pregnant and breastfeeding women."
Walker presented a case study that examined the use of manual techniques in a patient with radial wrist pain. Although de Quervain's disease was immediately ruled out, the report advocated an approach using manual techniques. Particularly for the relief of pain and dysfunction in radial, radiocarpal, intercarpal and first metacarpal joint pain.
Ashurst described a case in which a patient diagnosed with de Quervain's disease was prescribed oral anti-inflammatory drugs, a brace, and relative rest. The patient wore the orthosis at night and was instructed to text as little as possible (a series of messages always preceded the onset of pain). This case supports the prescription of relative rest, in which the patient avoids aggravating movements but remains active.
Viikari-Juntura presented a literature review and found that wearing an orthosis is an essential component of the treatment of tenosynovitis. It was found that the use of an orthosis that allowed some movement was preferable to complete immobilization of the thumb. Rest from work, according to the survey, is neither necessary nor desirable. It was also found that heat, massage, and electrotherapy were not effective in improving the patient's physical capabilities.