DeQuervains syndrome

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Synonyms and keywords: Washerwoman's sprain; radial styloid tenosynovitis; DeQuervain's disease; mother's wrist

Overview

DeQuervain's syndrome (also known as washerwoman's sprain, Radial styloid tenosynovitis or De Quervain's disease or mother's wrist), named for Swiss surgeon Fritz de Quervain who first identified it in 1885, is an inflammation of the sheath or tunnel that surrounds two tendons that control movement of the thumb.

It should not be confused with "De Quervain's thyroiditis" (E06.1).

Pathophysiology

The two tendons concerned are the tendons of the extensor pollicis brevis and abductor pollicis longus muscles. These two muscles, which run side by side, have almost the same function: the movement of the thumb away from the hand in the plane of the hand--so called radial abductionin (as opposed to movement of the hand away from the hand, out of the plane of the hand (palmar abduction). The tendons run, as do all of the tendons passing the wrist, in synovial sheaths, which contain them and allow them to exercise their function whatever the position of the wrist. While de Quervain's syndrome is commonly believed to be an inflammatory condition or tenosynovitis, evaluation of histological specimens shows no inflammatory changes--rather a thickening and myxoid degeneration consistent with a chronic degenerative process are seen. (Clarke MT, Lyall HA, Grant JW, Matthewson MH. The histopathology of de Quervain's disease. J Hand Surg [Br]. 1998 Dec;23(6):732-4.) The pathology is identical in de Quervain's seen in new mothers. (Read HS, Hooper G, Davie R. Histological appearances in post-partum de Quervain's disease. J Hand Surg [Br]. 2000 Feb;25(1):70-2.)

Causes

The cause of de Quervain's is not known. In medical terms, it remains idiopathic.

Some claim that this diagnosis should be included among overuse injuries and that repetitive movements of the thumb are a contributing factor.

Given that the illness remains idiopathic, any reference to "overuse" or "repetive use" is speculative at best. At worst such a negative illness concept risks blaming innocent bystanders. For instance, the occurrence of de Quervain's in new mothers led some in the past to blame the wringing of cloth diapers. The fact that the illness did not disappear as the use of cloth diapers waned did not lead "overuse" proponents to question their theory--rather, the blame is now often placed on the way the baby is held. This type of speculation should be discouraged without better scientific support, because negative illness concepts increase suffering and feelings of guilt and loss of control at a time when most new mothers can least afford it. The majority of de Quervain's does not occur in new mothers. The fact that de Quervain's remains idiopathic means that its sufferers are blameless victims of an incompletely understood illness.

Natural History, Complications and Prognosis

The natural history of de Quervain's is not well documented. Nonetheless, there is enough observational experience to be fairly certain that it is a self-limited illness with no long-term consequence. The illness tends to last about 1 year on average.

Diagnosis

History and Symptoms

Symptoms are pain, tenderness, and swelling over the thumb side of the wrist, and difficulty gripping.

Finkelstein's test is used to diagnose DeQuervain's syndrome in people who have wrist pain. To perform the test, the thumb is placed in the closed fist and the hand is tilted towards the little finger (as in the picture) in order to test for pain at the wrist below the thumb. Pain can occur in the normal individual, but if severe, DeQuervain's syndrome is likely.

Treatment

There are no treatments that have been scientifically demonstrated to shorten the duration of symptoms, principally because there are no controlled scientific studies. Things that are tried, without support, and with inconsistent results include immobilization, round the clock anti-inlammatory medications, iontophoresis, and corticosteroid injections. Case series of patients receiving one of the most popular treatments (corticosteroid injection) have claimed effectiveness even when the illness did not resolve for months--clearly more study is needed. Operative release is the only known way for predictably shortening the duration of symptoms, but is elective. Surgery consists of opening the tunnels, or sheaths, that the tendons pass through. The pain usually resolves in the time it takes the wound to heal.

While patients await disease resolution, the symptoms of deQuervain's can be managed with a splint that immobilizes the wrist and thumb, anti-inflammatory pain medications (or other non-narcotic pain medications), and ice. While avoiding activities that cause pain will certainly decrease the overall amount of pain experienced, there is no evidence that this will speed recovery, or that continuing to engage in these activities will lead to any harm -- the illness is in general a harmless nuisance. Therefore, patients can safely choose their activity and pain level. It is not dangerous or neglectful to remain active in spite of the pain. The splint can be used as desired to improve function and quality of life during the illness.

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