De Quervain Disease
De Quervain syndrome (French pronunciation: [də kɛʁvɛ̃]; 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.
The management of De Quervain’s disease is determined more by convention than scientific data. From the original description of the illness in 1895 until the first description of corticosteroid injection by Christie in 1955, it appears that the only treatment offered was surgery. Since approximately 1972 the prevailing opinion has been that of McKenzie (1972) who suggested that corticosteroid injection was the first line of treatment and surgery should be reserved for unsuccessful injections. However, data regarding the efficacy of corticosteroid injection is sparse and uncontrolled (Oxford Level of Evidence 4) and it is not clear that there is a benefit over the natural history of the illness. A structured review published in 2003 identified only 35 publications that addressed De Quervain’s on Medline, only 7 of which presented data regarding corticosteroid injection, and none of which were controlled studies.
Retrospective studies all report success rates for corticosteroid injection greater than 70%, but the one prospective cohort study noted a success rate of only 58% and many of those patients took 12 to 18 months until symptom resolution.While the authors of that study ascribed the failure of corticosteroid injection to anatomical variations, it has not been clearly established that corticosteroid injection is better than placebo or that a symptom course of 12 to 18 months is any better than the natural course of the illness.
Another commonly used criterion for failure of non-operative treatment is election of operative treatment, but the decision to operate is complex and biased by the beliefs and emotions of the surgeon and the patient. Use of an elective event such as surgery to define success makes data regarding nonoperative treatment difficult to interpret. For instance, in one of the two investigations in which a substantial number of patients were treated without injection (splints and anti-inflammatory medication alone were used), a remarkable 45 of 93 (48%) of patients in all non-operative treatment groups had surgery. This may simply reflect frustration on the part of both the patient and the surgeon with the prolonged symptom course associated with the disease. It may appear to both patient and surgeon that, after many months of symptoms, the illness will never resolve. The data of Lane and colleagues indicating that non-operative treatment is successful only in mild cases is similarly marred by the lack of patients randomly assigned to alternative treatments and the use in many patients of a decision for surgery as a failure criterion.
Most tendinoses are self-limiting and the same is likely to be true of de Quervain’s although further study is needed.
Palliative treatments include a splint that immobilized the wrist and the thumb to the interphalangeal joint and anti-inflammatory medication or acetaminophen.
Surgery (in which the sheath of the first dorsal compartment is opened longitudinally) is documented to provide relief in most patients. The most important risk is to the radial sensory nerve.