De Quervains’ disease
Overview
de Quervain syndrome (also known as washerwoman's sprain, Radial styloid tenosynovitis, de Quervain disease, de Quervain's tenosynovitis, de Quervain's stenosing tenosynovitis or mother's wrist), is an inflammation or a tendinosis of the sheath or tunnel that surrounds two tendons that control movement of the thumb.
Symptoms
Symptoms are pain, tenderness, and swelling over the thumb side of the wrist, and difficulty gripping. Finkelstein's test is used to diagnose de Quervain 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 - ulna deviation (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. Pain will be located on the thumb side of the forearm about an in inch below the wrist. Differential diagnosis includes ruling out: 1. Osteoarthritis of the first carpo-metacarpal joint 2. Intersection syndrome - pain will be more towards the middle of the back of the forearm and about 2-3 inches below the wrist 3. Wartenberg's syndrome
Causes
The cause of de Quervain 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. More specifically, repetitive eccentric lowering of the wrist into ulnar deviation especially with a load in the hand such as a child or even a stack of dishes.
Treatment
The natural history of de Quervain 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. Once resolved it rarely recurs. The illness tends to last about 1 year on average. 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-inflammatory 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 de Quervain can be managed with a spica splint that immobilises 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. Specialised hand therapists (both physical therapists and occupational therapists) provide treatment in the form of splinting to immobilise and rest the wrist and thumb.