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Locking of the thumb in a patient with de Quervain’s disease: a case report
J Orthop Sci (2003) 8:607–609 DOI 10.1007/s00776-003-0659-1
Locking of the thumb in a patient with de Quervain’s disease: a case report Yasuhiro Yoshikawa, Masao Nishiwaki, and Tsuneyo Matsubayashi Department of Orthopaedic Surgery, Hiratsuka Municipal Hospital, 1-19-1 Minamihara, Hiratsuka 254-0065, Japan
Abstract We report a patient with a locked left thumb in association with de Quervain’s disease. While bathing her baby 1 month after giving birth a 32-year-old woman suddenly noticed that she could not radially abduct her left thumb. Magnetic resonance imaging showed thickening of the abductor pollicis longus tendon with a heterogeneous signal intensity on T2-weighted images. Bandage fixation for 4 weeks did not improve her thumb movement, and she was subsequently treated by surgery. Operative findings revealed inhibition of the tendon gliding proximally as a result of nodule formation in the abductor pollicis longus tendon distal to the first dorsal compartment. This condition, locking of the thumb, was improved by excising the extensor retinaculum of the first dorsal compartment and tenosynovium around the abductor pollicis longus and extensor pollicis brevis tendon. At the 1-year follow-up examination the patient had no limitations or pain during active radial abduction of the left thumb. Key words de Quervain’s disease · Locking · Nodule · Abductor pollicis longus · Tenosynovitis
Introduction De Quervain’s disease is characterized by stenosing tenovaginitis of the extensor pollicis brevis (EPB) tendon mainly and the abductor pollicis longus (APL) tendon secondarily in the first dorsal compartment of the wrist, and it is sometimes associated with tenosynovitis of these two tendons. In 1895 de Quervain reported five cases of this condition1 with nodular thickening; many authors have subsequently reported symptoms and treatment strategies for this disease7,9 along with the pathology3 and anatomy of the first
Offprint requests to: Y. Yoshikawa Received: November 7, 2002 / Accepted: February 1, 2003
dorsal compartment.4 This disease is five to eight times more common in women than in men, with the peak incidence during periods of pregnancy and menopause.5 An abnormal nodule may form on the APL or EPB tendon, possibly resulting in the thumb locking in the abduction or extension position.8 We report the case of a woman whose left thumb became locked in the adduction position in association with de Quervain’s disease.
Case report After giving birth a 32-year-old woman became aware of a pain around the styloid process of the left radius on motion of her left thumb. One month later she suddenly found it impossible to abduct her thumb radially and experienced a feeling of tendon avulsion while bathing her baby. Her condition did not improve over the next month. An initial medical examination revealed a small concavity (Fig. 1) just distal to the first dorsal compartment of the left hand with mild tenderness and swelling. Radial abduction of the left thumb was impossible, although palmar abduction of the thumb and extension/flexion of the interphalangeal and metacarpophalangeal joints were possible. Continuity of the APL tendon at the concavity could be ascertained manually, although the normal tension of the APL tendon was lost distal to the first dorsal compartment. Both Finkelstein’s test and Nozue-Iwahara’s sign (pain upon full extension of the thumb with the wrist maximally flexed) were negative, and triggering of the thumb was absent. Radiographs of the left hand showed no abnormalities in the radius or carpal bones. Magnetic resonance imaging (MRI) revealed thickening of the APL tendon with a signal intensity that was higher than that of normal tendons on T1-weighted images and heterogeneous increased signal intensity on T2-weighted
608
Y. Yoshikawa et al.: Thumb locking in de Quervain’s disease
Fig. 1. Small concavity (arrow) just distal to the first dorsal compartment in the left hand was observed. Active radial abduction of the left thumb was impossible
A
B
sequences (Fig. 2). Because radial abduction movements of the left thumb were not restored after bandage fixation for 4 weeks, surgery was performed under general anesthesia, considering the possibility of tendon graft. The APL tendon and the first dorsal compartment were explored, and constriction in the APL tendon was revealed after reflecting the extensor retinaculum of the first dorsal compartment, characterized by diffuse thickening of the wall (Fig. 3). No septum between the APL and EPB tendons was identified, and one of the three APL tendon slips with the largest diameter
Fig. 2. Magnetic resonance images of the thickening abductor pollicis longus tendon (arrow) on T1weighted (A) and T2-weighted (B) coronal sequence
formed a nodule distal to the first dorsal compartment. Excision of the extensor retinaculum and an additional tenosynovectomy of the adjacent APL and EPB tendons allowed smooth gliding of both tendons. Histological examination of the excised extensor retinaculum showed dense fibrous changes with increased vascularity and myxoid degeneration of the connective tissue but no presence of inflammatory cells. Active radial abduction of the left thumb became possible immediately after the operation. One year later the patient can readily use her thumb without pain or movement limitations.
Y. Yoshikawa et al.: Thumb locking in de Quervain’s disease
Fig. 3. Exploration of the extensor retinaculum of the first dorsal compartment (asterisk) showing nodule formation (arrow) in the abductor pollicis longus tendon
Discussion Triggering of the thumb in de Quervain’s disease is uncommon; there have been only four such reports since Chow2 described the case of a child with an anomalous EPB muscle belly in 1979. Alberton et al.1 stated that the prevalence of clinical triggering in de Quervain’s disease was 1.3% based on a retrospective case review of 827 patients. Witczak et al.8 implied that triggering in the first dorsal compartment was much more common than previously recognized judging from their case review of nine patients with triggering. Locking of the thumb in de Quervain’s disease, which is associated with triggering, may be more infrequent than triggering. Viegas6 reported a case of de Quervain’s disease with occasional locking of the thumb in the extension or abduction positions due to a nodule in the EPB tendon. Alberton et al.1 described locking of the thumb in the extension position as a manifestation of triggering due to tenosynovitis of the APL and EPB tendons separated by a septum. We observed complete locking of the thumb with a nodule and tenosynovitis in the APL tendon distal to the first dorsal compartment, with no septal subdivision between it and the EPB tendon; this is the first case of this type to be reported. The histopathological appearance of the thickening of the extensor retinaculum in de Quervain’s disease is characterized by intrinsic degenerative change, myxoid degeneration, rather than extrinsic inflammatory changes, an increase in inflammatory cells.3 These fea-
609
tures are consistent with our case, but other anomalous changes in the extensor retinaculum resulting in locking of the APL tendon were not observed. We propose the following causal mechanism for this case: the nodule in the APL tendon, which resulted from severe constriction of the extensor retinaculum, moved from the proximal end to the distal end through the first dorsal compartment by strong traction of the tendon distally, probably as a result of strong flexion of the thumb with ulnar flexion of the wrist while the patient was bathing her baby. Consequently, the APL tendon was prevented from gliding proximally without triggering, and the thumb became locked. Previous reports have indicated that a primary factor in the etiology of de Quervain’s disease is tenovaginitis or tenosynovitis of the EPB tendon in the subcompartment in the first dorsal compartment.5,6 Yuasa and Kiyoshige9 advocated decompression of only the EPB subcompartment as a surgical treatment for de Quervain’s disease. This surgical procedure may be expedient, especially in cases where a septum exists between the EPB and APL tendons, as in 50%–80% of reported cases that were surgically treated.4 However, decompression of the APL compartment in addition to that of the EPB subcompartment of the first dorsal compartment (i.e., total excision of the retinaculum) may be important in cases with triggering or locking of the thumb in which tenosynovitis or nodule formation in the APL or EPB tendon is suspected preoperatively.
References 1. Alberton GM, High WA, Shin AY, et al. Extensor triggering in de Quervain’s stenosing tenosynovitis. J Hand Surg [Am] 1999;24: 1311–4. 2. Chow SP. Triggering due to de Quervain’s disease. Hand 1979;11: 93–4. 3. Clarke MT, Lyall HA, Grant JW, et al. The histology of de Quervain’s disease. J Hand Surg [Br] 1998;23:732–4. 4. Horiuchi Y, Takayama S. Surgical treatment of de Quervain’s disease. J Joint Surg 1998;17:639–43 (in Japanese). 5. Kay NRM. De Quervain’s disease: changing pathology or changing perception? J Hand Surg [Br] 2000;25:65–9. 6. Viegas SF. Trigger thumb of de Quervain’s disease. J Hand Surg [Am] 1986;11:235–7. 7. Weiss APC, Akelman E, Tabatabai M, et al. Treatment of de Quervain’s disease. J Hand Surg [Am] 1994;19:595–8. 8. Witczak JW, Masear VR, Meyer RD. Triggering of the thumb with de Quervain’s stenosing tendovaginitis. J Hand Surg [Am] 1990; 15:265–8. 9. Yuasa K, Kiyoshige Y. Limited surgical treatment of de Quervain’s disease: decompression of only the extensor pollicis brevis subcompartment. J Hand Surg [Am] 1998;23:840–3.
Locking of the thumb in a patient with de Quervain’s disease: a case report Yasuhiro Yoshikawa, Masao Nishiwaki, and Tsuneyo Matsubayashi Department of Orthopaedic Surgery, Hiratsuka Municipal Hospital, 1-19-1 Minamihara, Hiratsuka 254-0065, Japan
Abstract We report a patient with a locked left thumb in association with de Quervain’s disease. While bathing her baby 1 month after giving birth a 32-year-old woman suddenly noticed that she could not radially abduct her left thumb. Magnetic resonance imaging showed thickening of the abductor pollicis longus tendon with a heterogeneous signal intensity on T2-weighted images. Bandage fixation for 4 weeks did not improve her thumb movement, and she was subsequently treated by surgery. Operative findings revealed inhibition of the tendon gliding proximally as a result of nodule formation in the abductor pollicis longus tendon distal to the first dorsal compartment. This condition, locking of the thumb, was improved by excising the extensor retinaculum of the first dorsal compartment and tenosynovium around the abductor pollicis longus and extensor pollicis brevis tendon. At the 1-year follow-up examination the patient had no limitations or pain during active radial abduction of the left thumb. Key words de Quervain’s disease · Locking · Nodule · Abductor pollicis longus · Tenosynovitis
Introduction De Quervain’s disease is characterized by stenosing tenovaginitis of the extensor pollicis brevis (EPB) tendon mainly and the abductor pollicis longus (APL) tendon secondarily in the first dorsal compartment of the wrist, and it is sometimes associated with tenosynovitis of these two tendons. In 1895 de Quervain reported five cases of this condition1 with nodular thickening; many authors have subsequently reported symptoms and treatment strategies for this disease7,9 along with the pathology3 and anatomy of the first
Offprint requests to: Y. Yoshikawa Received: November 7, 2002 / Accepted: February 1, 2003
dorsal compartment.4 This disease is five to eight times more common in women than in men, with the peak incidence during periods of pregnancy and menopause.5 An abnormal nodule may form on the APL or EPB tendon, possibly resulting in the thumb locking in the abduction or extension position.8 We report the case of a woman whose left thumb became locked in the adduction position in association with de Quervain’s disease.
Case report After giving birth a 32-year-old woman became aware of a pain around the styloid process of the left radius on motion of her left thumb. One month later she suddenly found it impossible to abduct her thumb radially and experienced a feeling of tendon avulsion while bathing her baby. Her condition did not improve over the next month. An initial medical examination revealed a small concavity (Fig. 1) just distal to the first dorsal compartment of the left hand with mild tenderness and swelling. Radial abduction of the left thumb was impossible, although palmar abduction of the thumb and extension/flexion of the interphalangeal and metacarpophalangeal joints were possible. Continuity of the APL tendon at the concavity could be ascertained manually, although the normal tension of the APL tendon was lost distal to the first dorsal compartment. Both Finkelstein’s test and Nozue-Iwahara’s sign (pain upon full extension of the thumb with the wrist maximally flexed) were negative, and triggering of the thumb was absent. Radiographs of the left hand showed no abnormalities in the radius or carpal bones. Magnetic resonance imaging (MRI) revealed thickening of the APL tendon with a signal intensity that was higher than that of normal tendons on T1-weighted images and heterogeneous increased signal intensity on T2-weighted
608
Y. Yoshikawa et al.: Thumb locking in de Quervain’s disease
Fig. 1. Small concavity (arrow) just distal to the first dorsal compartment in the left hand was observed. Active radial abduction of the left thumb was impossible
A
B
sequences (Fig. 2). Because radial abduction movements of the left thumb were not restored after bandage fixation for 4 weeks, surgery was performed under general anesthesia, considering the possibility of tendon graft. The APL tendon and the first dorsal compartment were explored, and constriction in the APL tendon was revealed after reflecting the extensor retinaculum of the first dorsal compartment, characterized by diffuse thickening of the wall (Fig. 3). No septum between the APL and EPB tendons was identified, and one of the three APL tendon slips with the largest diameter
Fig. 2. Magnetic resonance images of the thickening abductor pollicis longus tendon (arrow) on T1weighted (A) and T2-weighted (B) coronal sequence
formed a nodule distal to the first dorsal compartment. Excision of the extensor retinaculum and an additional tenosynovectomy of the adjacent APL and EPB tendons allowed smooth gliding of both tendons. Histological examination of the excised extensor retinaculum showed dense fibrous changes with increased vascularity and myxoid degeneration of the connective tissue but no presence of inflammatory cells. Active radial abduction of the left thumb became possible immediately after the operation. One year later the patient can readily use her thumb without pain or movement limitations.
Y. Yoshikawa et al.: Thumb locking in de Quervain’s disease
Fig. 3. Exploration of the extensor retinaculum of the first dorsal compartment (asterisk) showing nodule formation (arrow) in the abductor pollicis longus tendon
Discussion Triggering of the thumb in de Quervain’s disease is uncommon; there have been only four such reports since Chow2 described the case of a child with an anomalous EPB muscle belly in 1979. Alberton et al.1 stated that the prevalence of clinical triggering in de Quervain’s disease was 1.3% based on a retrospective case review of 827 patients. Witczak et al.8 implied that triggering in the first dorsal compartment was much more common than previously recognized judging from their case review of nine patients with triggering. Locking of the thumb in de Quervain’s disease, which is associated with triggering, may be more infrequent than triggering. Viegas6 reported a case of de Quervain’s disease with occasional locking of the thumb in the extension or abduction positions due to a nodule in the EPB tendon. Alberton et al.1 described locking of the thumb in the extension position as a manifestation of triggering due to tenosynovitis of the APL and EPB tendons separated by a septum. We observed complete locking of the thumb with a nodule and tenosynovitis in the APL tendon distal to the first dorsal compartment, with no septal subdivision between it and the EPB tendon; this is the first case of this type to be reported. The histopathological appearance of the thickening of the extensor retinaculum in de Quervain’s disease is characterized by intrinsic degenerative change, myxoid degeneration, rather than extrinsic inflammatory changes, an increase in inflammatory cells.3 These fea-
609
tures are consistent with our case, but other anomalous changes in the extensor retinaculum resulting in locking of the APL tendon were not observed. We propose the following causal mechanism for this case: the nodule in the APL tendon, which resulted from severe constriction of the extensor retinaculum, moved from the proximal end to the distal end through the first dorsal compartment by strong traction of the tendon distally, probably as a result of strong flexion of the thumb with ulnar flexion of the wrist while the patient was bathing her baby. Consequently, the APL tendon was prevented from gliding proximally without triggering, and the thumb became locked. Previous reports have indicated that a primary factor in the etiology of de Quervain’s disease is tenovaginitis or tenosynovitis of the EPB tendon in the subcompartment in the first dorsal compartment.5,6 Yuasa and Kiyoshige9 advocated decompression of only the EPB subcompartment as a surgical treatment for de Quervain’s disease. This surgical procedure may be expedient, especially in cases where a septum exists between the EPB and APL tendons, as in 50%–80% of reported cases that were surgically treated.4 However, decompression of the APL compartment in addition to that of the EPB subcompartment of the first dorsal compartment (i.e., total excision of the retinaculum) may be important in cases with triggering or locking of the thumb in which tenosynovitis or nodule formation in the APL or EPB tendon is suspected preoperatively.
References 1. Alberton GM, High WA, Shin AY, et al. Extensor triggering in de Quervain’s stenosing tenosynovitis. J Hand Surg [Am] 1999;24: 1311–4. 2. Chow SP. Triggering due to de Quervain’s disease. Hand 1979;11: 93–4. 3. Clarke MT, Lyall HA, Grant JW, et al. The histology of de Quervain’s disease. J Hand Surg [Br] 1998;23:732–4. 4. Horiuchi Y, Takayama S. Surgical treatment of de Quervain’s disease. J Joint Surg 1998;17:639–43 (in Japanese). 5. Kay NRM. De Quervain’s disease: changing pathology or changing perception? J Hand Surg [Br] 2000;25:65–9. 6. Viegas SF. Trigger thumb of de Quervain’s disease. J Hand Surg [Am] 1986;11:235–7. 7. Weiss APC, Akelman E, Tabatabai M, et al. Treatment of de Quervain’s disease. J Hand Surg [Am] 1994;19:595–8. 8. Witczak JW, Masear VR, Meyer RD. Triggering of the thumb with de Quervain’s stenosing tendovaginitis. J Hand Surg [Am] 1990; 15:265–8. 9. Yuasa K, Kiyoshige Y. Limited surgical treatment of de Quervain’s disease: decompression of only the extensor pollicis brevis subcompartment. J Hand Surg [Am] 1998;23:840–3.