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De Quervain's disease: Surgical or nonsurgical treatment
De Quervain's disease: Surgical or nonsurgical treatment Ninety-one wrists in 82 consecutive patients with de Quervain's disease were treated by the one surgeon between 1978 and 1987. The treatment of 79 wrists in 71 patients who had received their entire treatment from this surgeon is analyzed. Uniformity of injection technique is thus ensured. Initial treatment in 63 wrists was an injection of steroids and local anesthetic into the tendon sheath, which gave complete relief in 45 cases. Seven wrists received two injections before the pain abated. Only 11 of the 63 injected wrists had an operation. In 10 of these the extensor pollicis brevis tendon was in a separate compartment. It is concluded that injection of steroids is the preferred initial treatment in de Quervain's disease, giving complete and lasting relief in 80% of cases. If injection falls, it appears likely that the extensor pollicls brevis tendon lies in a separate compartment. (J HAND SURG 1990;15A:83-7.)
Francis J. Harvey, FRACS, Patricia M. Harvey, MBBS, and Mark W. Horsley, MBBS, Sydney, Australia
In this retrospective study we assessed the results of steroid injection in the treatment of de Quervain's disease as an alternative to the more traditional surgical approach. Accurate injection into the tendon sheath is vital, and this is ensured by including only those patients treated exclusively by one surgeon. Treatment in large clinics, often manned by personnel relatively inexperienced in the technique, may result in deposition of steroids outside the sheath, with unsatisfactory results. We did not use any splints or restrictive bandages in our patients, encouraging instead normal use of the hand. Absence from work and consequent economic loss, which is usual with operation, were avoided. Injection of steroids in de Quervain's disease is a simple, inexpensive procedure, and, if proven satisfactory, it must be preferable to surgery as the initial treatment. From the Hand and Microsurgery Unit, Royal North Shore Hospital, Sydney, Australia. Received for publication July 13, 1988; accepted in revised form Jan. 23, 1989. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Francis J. Harvey, FRACS, 200 Pacific Highway, Crows Nest. N.S.W.2065, Australia.
3/1/11773
MaterialS and methods Between 1978 and 1987 we treated 91 wrists in 82 consecutive patients with de Quervain's disease. The criteria for diagnosis were a history of pain over the radial aspect of the wrist, aggravated by use of the thumb, and sharply localized tenderness over the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons where they cross the radial styloid. Finkelstein's test l was positive in all cases. There were 70 females and 12 males in the series, with a mean age of 45 years (range, 16 to 83 years (Fig. 1). The right hand was unilaterally involved in 45 patients and the left in 28; 9 were bilateral. In 52 patients the dominant hand was affected, and in 23 the nondominant; dominance was not recorded in 7. Occupations were home duties (17), secretarial (17), nursing (7), laboring (l), handyman (1), and hobby farming (1). Occupation was not recorded in 15 patients, and the remainder held a variety of professional and managerial positions. Association with recent childbearing was present in 10 patients, with onset of pain ranging from 2 days to 6 months after delivery. In addition, one woman had a 14-month old infant, and two were minding small children (Table I). The onset of pain was related by the patient to specific events other than the above in 23 patients, namely after strenuous activity (15), fall on the outstretched hand (4), direct trauma to the wrist (2), following contusion
THE JOURNAL OF HAND
SURGERY
83
84
The Journal of HAND SURGERY
Harvey, Harvey, and Horsley
Table I. Association with child care in 13 of 82 patients
30
Patients (No.)
I N C A I G D
Mother of infants less than 6 months of age Mother of 14-month-old infant Minding small children
20
E E N C E
10 I
2
Table II. Treatment of 79 wrists Wrists
Treatment
(No.)
One injection of steroid Two injections of steroid Injection followed by surgery Surgery alone No treatment
45 7 11 9 7
10
o
2
3
4
5
6
7
8
9
DECADE
Table III. Indication for operation
20 wrists Wrists
Fig. 1. Graphic representation of age incidence of 82 patients
(No.)
with de Quervain's disease.
of the wrist from intravenous infusion (1), and dog bite (1). Associated conditions noted were osteoarthritic changes in the carpometacarpal joints (5), trigger thumb on the affected side (2), and on the other side (1), bilateral carpal tunnel syndrome (1), unilateral carpal tunnel syndrome on the same side (3), and on the other side (1), volar wrist ganglion (2), and congenital absence of four fingers of the other hand (I). One patient had a history of bilateral carpal tunnel decompression and trigger thumb release 5 years previously. Treatment involved one of the following: 1. Steroid and local anesthetic into the first extensor compartment 2. Steroid injection followed by surgery 3. Surgery alone Hydrocortisone acetate was initially used for steroid injection, but was later replaced by methylprednisolone acetate, which was more readily available. Local anesthetic was injected from the distal end of the compartment, and only when a visible swelling was produced proximal to the extensor retinaculum was the needle judged to be correctly placed. A small amount of steroid was then injected. Splints or bandages were not used after injection, and, in fact, patients were encouraged to use the wrist and hand normally.
i~
Failed injection Surgery indicated for other pathology Severe disabling pain Not recorded
II 5 3 I
A second injection was given if necessary. Those with persistent pain and positive clinical findings after injection had surgery. At operation a careful search was made for a separate compartment for the tendon of EPB. Results In assessing the results of treatment 11 patients and 1 wrist in a patient with bilateral involvement were excluded from the series, because they had received initial treatment elsewhere. Uniformity of injection technique was considered essential to ensure accurate analysis of results. Thus, treatment of 79 wrists in 71 patients was studied. In 63 of the 79 wrists initial treatment was injection of steroids and local anesthetic. Forty-five wrists had one injection only, and required no other therapy. Seven wrists required a second injection because of persisting pain and positive clinical findings. The mean interval between injections in 6 of these 7 wrists was 4 months (range, 2 months to 8 months), and one was injected again after 1 week. Only II of the 63 injected wrists had surgery. Five of these
Vol. 15A, No.1
Surgical or nonsurgical treatment in de Quervain's disease
January 1990
85
Table IV. Mean duration of symptoms before treatment in 63 wrists treated with injection alone or followed by surgery Wrists Single injection Two injections Injection plus surgery
Mean duration
Range
(No.)
4 rna 3 rno 2.5 rno
3 wk to 12 rno 1 to 5 rna 1 to 14 rna
45 7 11
had one previous injection, and 6 had 2 injections before surgery. The mean interval between injections in these patients was 3 months (range, 1 month to 6 months). Surgery was performed at a mean interval of 5 months after the second injection (range, 3 weeks to 13 months) in these 6 patients. Nine wrists were treated surgically without previous injection. Five of these had other pathologic conditions, such as carpal tunnel syndrome or trigger thumb, which required surgery. Three had disabling pain, and they elected to have surgery as the most certain cure. The reason for operation was not recorded in 1 (Tables II and Ill). Seven wrists were not treated at all, inasmuch as patients considered their symptoms too minor. The mean duration of symptoms before treatment is shown in Table IV. Workmen's compensation claims were involved in 13 patients (14 wrists), and 2 of these wrists had surgery. Response to treatment did not differ significantly from those without claims. All patients were asked to return for review at 2 weeks, or earlier if there was no relief from pain, and it was stressed that operation offered the only certain cure. Those with continuing problems would therefore be expected to report again, and if they did not, were presumed cured. This assumption was verified in the 35 patients who were able to be contacted for longterm review. The mean follow-up period for the 45 wrists treated by the one injection alone was 20 months (range, 1 week to 7 years). Eight of these had a followup of less than 1 month. The seven wrists injected twice had a mean follow-up of 2.5 years (range, 1 month to 4.5 years). Operation confirmed the presence of a separate compartment for the EPB tendon in 10 of the 11 wrists that failed to respond to injection, and in 4 of the 9 wrists treated primarily by surgery. No operative report was available in 2 of the latter cases. These have been retained in the study to preserve the consecutive nature of the series. Complications of injection of steroids and local anesthetic were 2 instances of persistent nontender
Table V. Incidence of separate compartment for EPB in 200 cadaver wrist dissections Author
Wrists
Stein, Ramsey, Key' Keon-Cohen' Leaa'
No.
%
84
9
66
22 12
11 33 24
50
nodules over the affected tendons and 2 of minor skin discoloration. Transitory pain in the first 24 hours after injection was fairly common. Of the 20 wrists treated surgically, there was adherence of the scar to the underlying tendons in 2 wrists, and minor wound infection that responded to oral antibiotics in one. Although great care was taken to avoid branches of the radial nerve in the surgical approach, there was temporary disturbance of sensibility in the distribution of the nerve distal to the scar in three patients.
Discussion In 1895, de Quervain2 described 5 cases of stenosing tenovaginitis at the wrist and considered that the problem arose from a thickening of the common tendon sheath of APL and EPB as it crosses the radial styloid. The presence of the "aberrant tendon" running through the common extensor sheath was noted by Bunnell,3 but variations in anatomy of the first dorsal compartment of the wrist are now known to be the rule rather than the exception, 4 and separate compartments for APL and EPB have been documented in from 11 % to 33% of cadaver dissections. 4•6 By combining statistics from the above authors an incidence of 21 % of separate compartments is obtained (Table V). Loomis? in dissecting 127 forearms reported a frequent occurrence of separate canals, and considered that it may possibly be a pathologic condition as the incidence was so much higher as an operative finding. The incidence at surgery varies widely in reports from 20% to 58%.1.4.8,9 and in our study 10 of the 11 wrists that failed to respond
The Journal of 86
HAND SURGERY
Harvey, Han'l')', and Horsley
to injection were found to have a separate compartment for EPB, This finding is statistically significant, even if the natural incidence of this finding were as high as 45% (p < 0,005). The clinical importance of recognizing and decompressing this separate compartment has been stressed frequently.4, 5, 10-14 Surgery has been recommended as the definitive treatment by many authors. 1, 2,4-6, 9,15,16 Steroid injection was thought to be effective, if at all, only in a minority of cases where the history was short, or where there was a traumatic cause. 4, 9, II, 14 Lea06 first began using steroid injection in this condition in 1953, but he believed that surgery offered a more reliable and rapid cure, although Christie in 1955 17 claimed a 70% cure rate in 20 cases injected with steroids and local anesthetic, It is significant that, in 1972, Lapidus l8 repudiated his earlier recommendation of surgery in de Quervain's disease, and stated that steroid injection was the treatment of choice, with surgery being reserved for refractory cases. In our study steroids and local anesthetic injection has given an 80% cure rate, This compares favorably with the results of Rhoades 19 for a series of trigger fingers and thumbs treated in a similar way, but with the addition of splinting. The use of plaster to immobilize the thumb in conjunction with injection in de Quervain's disease has been advocated by som~ authors ,6, 14 but it was not found necessary in our patients, mobilization of the wrist and thumb being thought more appropriate. The ultimate prognosis for recovery in the condition seems excellent, regardless of the treatment, and spontaneous recovery has been well documented. 5,6, 11,14 Contrary to previous reports 9, 11 the length of history before treatment did not appear relevant in our study. The mean duration of symptoms in those requiring only a single injection was 4 months, which is, in fact, greater than those that did not respond to steroid injection. Only 8 patients described definite trauma precipitating their condition, and an additional 15 related their symptoms to strenuous activity. Patients of all ages, other than the first decades, were represented, with 2 peaks in the fourth and sixth decades, The increased incidence in the third and fourth decades was probably related to child care. As has previously been noted, women looking after small children seem susceptible to de Quervain's disease, possibly because of repeated use of the thumb in either holding the infant2' 4 or in wringing water from clothes. 9 Nineteen percent of the
70 females in our study gave a history of looking after small children.
Conclusions This study shows that a single injection of steroid gives complete and lasting relief in 70% of patients with de Qucrvain's disease, and a further 10% will be cured by a second injection. This is preferrable to the time-honored treatment of surgery, which is costly and not without risk. To ensure a good result the injection must be made accurately into the tendon sheath. This consecutive series of patients, all of whom were treated by the one surgeon, experienced in the technique, has given an excellent cure rate with injection, and this form of treatment is therefore recommended as the initial treatment in de Quervain's disease. It is simple, inexpensive, and without serious complications, Ifused without splintage, the economic advantage to patients, not requiring hospitalization or time off work is obvious, If injection fails it is likely that the tendon of EPB lies in a separate compartment, which should be isolated and decompressed, REFERENCES 1. Finkelstein H. Stenosing tendovaginitis at the radial sty-
loid process, J Bone Joint Surg 1930;12:509·40. 2. De Quervain F, Ueber eine fonn von chronischer tendovaginitis. Cor-BI. f. schweiz. Aerzte 1895;25:389-94, 3. Bunnell S, Surgery of the hand, 2nd ed, Philadelphia: Lippincott, 1944:332-9, 4, Keon-CohenB, De Quervain's disease. J Bone Joint Surg 1951;338:96-9. 5, Stein AB, Ramsey RH, Key JA. Stenosing tendovaginitis at the radial styloid process (de Quervain's disease). AMA Arch Surg 1951;63:216-28, 6. Leao L. De Quervain's disease: a clinical and anatomical study, J Bone Joint Surg 1958;40A:I063-70. 7, Loomis LK, Variations of stenosing tenosynovitis at the radial styloid process, J Bone Joint Surg 1951;33A: 340-6.
8, Strandell G. Variations of the anatomy in stenosing tenosynovitis at the radial styloid process, Acta Chir Scand 1957;113:234-40. 9, Muckart RD, Stenosing tendovaginitis of abductor pollicis longus and extensor pollicis brevis at the radial styloid (de Quervain's disease), Clin Orthop 1964;33: 201-8. 10, Murphy ill, An unusual case of de Quervain's Syndrome: report of two cases, J Bone Ioint Surg 1949; 3IA:858-9, 11, Lipscomb PR, Tenosynovitis of the hand and the wrist:
Vol. 15A, No. I January 1990
12.
13.
l4. IS.
carpal tunnel syndrome, de Quervain's disease, trigger digit. Clin Orthop 1959;13:164-81. Louis DS. Incomplete release of the first dorsal compartment: a diagnostic test. J HAND SURG 1987;12A: 87-8. Burman M. Stenosing tendovaginitis of the dorsal and volar compartments of the wrist. AMA Arch Surg 1952;65:752-62. Faithfull DK, Lamb DW. De Quervain's disease: a clinical review. The Hand 1971;3:23-30. Lamphier TA. De Quervain's disease: an analysis of 52 cases. Ann Surg 1953;138:832-41.
Surgical or nonsurgical treatment in de Quervain's disease
87
16. Woods THE. De Quervain's disease: a plea for early operation: a report on 40 cases. Brit J Surg 1964;51: 358-9. 17. Christie BGB. Local hydrocortisone in de Quervain's disease. B Med J 1955;1:1501-3. 18. Lapidus PW. Stenosing tendovaginitis of the wrist and fingers. Clin Orthop 1972;83:87-90. 19. Rhoades CE, Gelberrnan RH, Manjanis JF. Stenosing tenosynovitis of the fingers and thumb. Clin Orthop 1984; 190:236-8.
Francis J. Harvey, FRACS, Patricia M. Harvey, MBBS, and Mark W. Horsley, MBBS, Sydney, Australia
In this retrospective study we assessed the results of steroid injection in the treatment of de Quervain's disease as an alternative to the more traditional surgical approach. Accurate injection into the tendon sheath is vital, and this is ensured by including only those patients treated exclusively by one surgeon. Treatment in large clinics, often manned by personnel relatively inexperienced in the technique, may result in deposition of steroids outside the sheath, with unsatisfactory results. We did not use any splints or restrictive bandages in our patients, encouraging instead normal use of the hand. Absence from work and consequent economic loss, which is usual with operation, were avoided. Injection of steroids in de Quervain's disease is a simple, inexpensive procedure, and, if proven satisfactory, it must be preferable to surgery as the initial treatment. From the Hand and Microsurgery Unit, Royal North Shore Hospital, Sydney, Australia. Received for publication July 13, 1988; accepted in revised form Jan. 23, 1989. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Francis J. Harvey, FRACS, 200 Pacific Highway, Crows Nest. N.S.W.2065, Australia.
3/1/11773
MaterialS and methods Between 1978 and 1987 we treated 91 wrists in 82 consecutive patients with de Quervain's disease. The criteria for diagnosis were a history of pain over the radial aspect of the wrist, aggravated by use of the thumb, and sharply localized tenderness over the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons where they cross the radial styloid. Finkelstein's test l was positive in all cases. There were 70 females and 12 males in the series, with a mean age of 45 years (range, 16 to 83 years (Fig. 1). The right hand was unilaterally involved in 45 patients and the left in 28; 9 were bilateral. In 52 patients the dominant hand was affected, and in 23 the nondominant; dominance was not recorded in 7. Occupations were home duties (17), secretarial (17), nursing (7), laboring (l), handyman (1), and hobby farming (1). Occupation was not recorded in 15 patients, and the remainder held a variety of professional and managerial positions. Association with recent childbearing was present in 10 patients, with onset of pain ranging from 2 days to 6 months after delivery. In addition, one woman had a 14-month old infant, and two were minding small children (Table I). The onset of pain was related by the patient to specific events other than the above in 23 patients, namely after strenuous activity (15), fall on the outstretched hand (4), direct trauma to the wrist (2), following contusion
THE JOURNAL OF HAND
SURGERY
83
84
The Journal of HAND SURGERY
Harvey, Harvey, and Horsley
Table I. Association with child care in 13 of 82 patients
30
Patients (No.)
I N C A I G D
Mother of infants less than 6 months of age Mother of 14-month-old infant Minding small children
20
E E N C E
10 I
2
Table II. Treatment of 79 wrists Wrists
Treatment
(No.)
One injection of steroid Two injections of steroid Injection followed by surgery Surgery alone No treatment
45 7 11 9 7
10
o
2
3
4
5
6
7
8
9
DECADE
Table III. Indication for operation
20 wrists Wrists
Fig. 1. Graphic representation of age incidence of 82 patients
(No.)
with de Quervain's disease.
of the wrist from intravenous infusion (1), and dog bite (1). Associated conditions noted were osteoarthritic changes in the carpometacarpal joints (5), trigger thumb on the affected side (2), and on the other side (1), bilateral carpal tunnel syndrome (1), unilateral carpal tunnel syndrome on the same side (3), and on the other side (1), volar wrist ganglion (2), and congenital absence of four fingers of the other hand (I). One patient had a history of bilateral carpal tunnel decompression and trigger thumb release 5 years previously. Treatment involved one of the following: 1. Steroid and local anesthetic into the first extensor compartment 2. Steroid injection followed by surgery 3. Surgery alone Hydrocortisone acetate was initially used for steroid injection, but was later replaced by methylprednisolone acetate, which was more readily available. Local anesthetic was injected from the distal end of the compartment, and only when a visible swelling was produced proximal to the extensor retinaculum was the needle judged to be correctly placed. A small amount of steroid was then injected. Splints or bandages were not used after injection, and, in fact, patients were encouraged to use the wrist and hand normally.
i~
Failed injection Surgery indicated for other pathology Severe disabling pain Not recorded
II 5 3 I
A second injection was given if necessary. Those with persistent pain and positive clinical findings after injection had surgery. At operation a careful search was made for a separate compartment for the tendon of EPB. Results In assessing the results of treatment 11 patients and 1 wrist in a patient with bilateral involvement were excluded from the series, because they had received initial treatment elsewhere. Uniformity of injection technique was considered essential to ensure accurate analysis of results. Thus, treatment of 79 wrists in 71 patients was studied. In 63 of the 79 wrists initial treatment was injection of steroids and local anesthetic. Forty-five wrists had one injection only, and required no other therapy. Seven wrists required a second injection because of persisting pain and positive clinical findings. The mean interval between injections in 6 of these 7 wrists was 4 months (range, 2 months to 8 months), and one was injected again after 1 week. Only II of the 63 injected wrists had surgery. Five of these
Vol. 15A, No.1
Surgical or nonsurgical treatment in de Quervain's disease
January 1990
85
Table IV. Mean duration of symptoms before treatment in 63 wrists treated with injection alone or followed by surgery Wrists Single injection Two injections Injection plus surgery
Mean duration
Range
(No.)
4 rna 3 rno 2.5 rno
3 wk to 12 rno 1 to 5 rna 1 to 14 rna
45 7 11
had one previous injection, and 6 had 2 injections before surgery. The mean interval between injections in these patients was 3 months (range, 1 month to 6 months). Surgery was performed at a mean interval of 5 months after the second injection (range, 3 weeks to 13 months) in these 6 patients. Nine wrists were treated surgically without previous injection. Five of these had other pathologic conditions, such as carpal tunnel syndrome or trigger thumb, which required surgery. Three had disabling pain, and they elected to have surgery as the most certain cure. The reason for operation was not recorded in 1 (Tables II and Ill). Seven wrists were not treated at all, inasmuch as patients considered their symptoms too minor. The mean duration of symptoms before treatment is shown in Table IV. Workmen's compensation claims were involved in 13 patients (14 wrists), and 2 of these wrists had surgery. Response to treatment did not differ significantly from those without claims. All patients were asked to return for review at 2 weeks, or earlier if there was no relief from pain, and it was stressed that operation offered the only certain cure. Those with continuing problems would therefore be expected to report again, and if they did not, were presumed cured. This assumption was verified in the 35 patients who were able to be contacted for longterm review. The mean follow-up period for the 45 wrists treated by the one injection alone was 20 months (range, 1 week to 7 years). Eight of these had a followup of less than 1 month. The seven wrists injected twice had a mean follow-up of 2.5 years (range, 1 month to 4.5 years). Operation confirmed the presence of a separate compartment for the EPB tendon in 10 of the 11 wrists that failed to respond to injection, and in 4 of the 9 wrists treated primarily by surgery. No operative report was available in 2 of the latter cases. These have been retained in the study to preserve the consecutive nature of the series. Complications of injection of steroids and local anesthetic were 2 instances of persistent nontender
Table V. Incidence of separate compartment for EPB in 200 cadaver wrist dissections Author
Wrists
Stein, Ramsey, Key' Keon-Cohen' Leaa'
No.
%
84
9
66
22 12
11 33 24
50
nodules over the affected tendons and 2 of minor skin discoloration. Transitory pain in the first 24 hours after injection was fairly common. Of the 20 wrists treated surgically, there was adherence of the scar to the underlying tendons in 2 wrists, and minor wound infection that responded to oral antibiotics in one. Although great care was taken to avoid branches of the radial nerve in the surgical approach, there was temporary disturbance of sensibility in the distribution of the nerve distal to the scar in three patients.
Discussion In 1895, de Quervain2 described 5 cases of stenosing tenovaginitis at the wrist and considered that the problem arose from a thickening of the common tendon sheath of APL and EPB as it crosses the radial styloid. The presence of the "aberrant tendon" running through the common extensor sheath was noted by Bunnell,3 but variations in anatomy of the first dorsal compartment of the wrist are now known to be the rule rather than the exception, 4 and separate compartments for APL and EPB have been documented in from 11 % to 33% of cadaver dissections. 4•6 By combining statistics from the above authors an incidence of 21 % of separate compartments is obtained (Table V). Loomis? in dissecting 127 forearms reported a frequent occurrence of separate canals, and considered that it may possibly be a pathologic condition as the incidence was so much higher as an operative finding. The incidence at surgery varies widely in reports from 20% to 58%.1.4.8,9 and in our study 10 of the 11 wrists that failed to respond
The Journal of 86
HAND SURGERY
Harvey, Han'l')', and Horsley
to injection were found to have a separate compartment for EPB, This finding is statistically significant, even if the natural incidence of this finding were as high as 45% (p < 0,005). The clinical importance of recognizing and decompressing this separate compartment has been stressed frequently.4, 5, 10-14 Surgery has been recommended as the definitive treatment by many authors. 1, 2,4-6, 9,15,16 Steroid injection was thought to be effective, if at all, only in a minority of cases where the history was short, or where there was a traumatic cause. 4, 9, II, 14 Lea06 first began using steroid injection in this condition in 1953, but he believed that surgery offered a more reliable and rapid cure, although Christie in 1955 17 claimed a 70% cure rate in 20 cases injected with steroids and local anesthetic, It is significant that, in 1972, Lapidus l8 repudiated his earlier recommendation of surgery in de Quervain's disease, and stated that steroid injection was the treatment of choice, with surgery being reserved for refractory cases. In our study steroids and local anesthetic injection has given an 80% cure rate, This compares favorably with the results of Rhoades 19 for a series of trigger fingers and thumbs treated in a similar way, but with the addition of splinting. The use of plaster to immobilize the thumb in conjunction with injection in de Quervain's disease has been advocated by som~ authors ,6, 14 but it was not found necessary in our patients, mobilization of the wrist and thumb being thought more appropriate. The ultimate prognosis for recovery in the condition seems excellent, regardless of the treatment, and spontaneous recovery has been well documented. 5,6, 11,14 Contrary to previous reports 9, 11 the length of history before treatment did not appear relevant in our study. The mean duration of symptoms in those requiring only a single injection was 4 months, which is, in fact, greater than those that did not respond to steroid injection. Only 8 patients described definite trauma precipitating their condition, and an additional 15 related their symptoms to strenuous activity. Patients of all ages, other than the first decades, were represented, with 2 peaks in the fourth and sixth decades, The increased incidence in the third and fourth decades was probably related to child care. As has previously been noted, women looking after small children seem susceptible to de Quervain's disease, possibly because of repeated use of the thumb in either holding the infant2' 4 or in wringing water from clothes. 9 Nineteen percent of the
70 females in our study gave a history of looking after small children.
Conclusions This study shows that a single injection of steroid gives complete and lasting relief in 70% of patients with de Qucrvain's disease, and a further 10% will be cured by a second injection. This is preferrable to the time-honored treatment of surgery, which is costly and not without risk. To ensure a good result the injection must be made accurately into the tendon sheath. This consecutive series of patients, all of whom were treated by the one surgeon, experienced in the technique, has given an excellent cure rate with injection, and this form of treatment is therefore recommended as the initial treatment in de Quervain's disease. It is simple, inexpensive, and without serious complications, Ifused without splintage, the economic advantage to patients, not requiring hospitalization or time off work is obvious, If injection fails it is likely that the tendon of EPB lies in a separate compartment, which should be isolated and decompressed, REFERENCES 1. Finkelstein H. Stenosing tendovaginitis at the radial sty-
loid process, J Bone Joint Surg 1930;12:509·40. 2. De Quervain F, Ueber eine fonn von chronischer tendovaginitis. Cor-BI. f. schweiz. Aerzte 1895;25:389-94, 3. Bunnell S, Surgery of the hand, 2nd ed, Philadelphia: Lippincott, 1944:332-9, 4, Keon-CohenB, De Quervain's disease. J Bone Joint Surg 1951;338:96-9. 5, Stein AB, Ramsey RH, Key JA. Stenosing tendovaginitis at the radial styloid process (de Quervain's disease). AMA Arch Surg 1951;63:216-28, 6. Leao L. De Quervain's disease: a clinical and anatomical study, J Bone Joint Surg 1958;40A:I063-70. 7, Loomis LK, Variations of stenosing tenosynovitis at the radial styloid process, J Bone Joint Surg 1951;33A: 340-6.
8, Strandell G. Variations of the anatomy in stenosing tenosynovitis at the radial styloid process, Acta Chir Scand 1957;113:234-40. 9, Muckart RD, Stenosing tendovaginitis of abductor pollicis longus and extensor pollicis brevis at the radial styloid (de Quervain's disease), Clin Orthop 1964;33: 201-8. 10, Murphy ill, An unusual case of de Quervain's Syndrome: report of two cases, J Bone Ioint Surg 1949; 3IA:858-9, 11, Lipscomb PR, Tenosynovitis of the hand and the wrist:
Vol. 15A, No. I January 1990
12.
13.
l4. IS.
carpal tunnel syndrome, de Quervain's disease, trigger digit. Clin Orthop 1959;13:164-81. Louis DS. Incomplete release of the first dorsal compartment: a diagnostic test. J HAND SURG 1987;12A: 87-8. Burman M. Stenosing tendovaginitis of the dorsal and volar compartments of the wrist. AMA Arch Surg 1952;65:752-62. Faithfull DK, Lamb DW. De Quervain's disease: a clinical review. The Hand 1971;3:23-30. Lamphier TA. De Quervain's disease: an analysis of 52 cases. Ann Surg 1953;138:832-41.
Surgical or nonsurgical treatment in de Quervain's disease
87
16. Woods THE. De Quervain's disease: a plea for early operation: a report on 40 cases. Brit J Surg 1964;51: 358-9. 17. Christie BGB. Local hydrocortisone in de Quervain's disease. B Med J 1955;1:1501-3. 18. Lapidus PW. Stenosing tendovaginitis of the wrist and fingers. Clin Orthop 1972;83:87-90. 19. Rhoades CE, Gelberrnan RH, Manjanis JF. Stenosing tenosynovitis of the fingers and thumb. Clin Orthop 1984; 190:236-8.