- Email: [email protected]
Ultrasonographic examination of de Quervain’s disease
J Orthop Sci (2000) 5:96–99
Ultrasonographic examination of de Quervain’s disease Masahiro Nagaoka, Hiromi Matsuzaki, and Takahiro Suzuki Orthopaedic Department, Surugadai Nihon University Hospital, 1-8-13 Kanda Surugadai, Chiyoda-ku, Tokyo 101-8309, Japan
Abstract: In order to assess the usefulness of ultrasonography in the preoperative evaluation of de Quervain’s disease, we retrospectively analyzed the ultrasonographic findings in 32 patients, and compared these findings with operative findings. Ultrasonography identified a septum between the abductor pollicis longus and extensor pollicis brevis tendons in 26 patients and showed absence of the septum in 6 patients. During surgery, the presence of the septum was confirmed in 27 patients, and was absent in 5. Our results demonstrated the usefulness of preoperative ultrasonography in correctly detecting anatomic abnormalities in patients with de Quervain’s disease. Key words: ultrasound examination, de Quervain’s disease, tenosynovitis
Introduction The diagnosis of de Quervain’s disease is based on characteristic physical signs, such as tenderness and swelling of the first extensor compartment of the wrist and a positive Finkelstein test, and is usually not difficult. Although the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons are contained in the compartment, a septum is present between the two tendons in some patients. It has been reported that the septum is present more frequently among patients with de Quervain’s disease than has been noted in cadavers.1,4–6,15 Ultrasonographic examination of the wrist can detect the septum between APL and EPB using dynamic images. In order to determine whether the septum could be detected before surgery, we examined patients with de Quervain’s disease by ultrasonography of the wrist, and compared the Offprint requests to: M. Nagaoka Received for publication on April 15, 1999; accepted on Sept. 27, 1999
preoperative ultrasonographic findings with operative findings.
Patients and methods A total of 32 wrists of 32 patients with de Quervain’s disease were surgically treated between 1993 and 1997 because the disease failed to respond to conservative therapy. Ultrasonographic examination was performed before operation in all patients. Both the surgery and the ultrasonographic examination were performed by the authors. The right wrist was affected in 12 patients, and the left wrist in 20. The patients, 7 men and 25 women, ranged in age from 19 to 68 years (mean, 47 years), with a predominance of women in the their thirties. For ultrasonographic examination, we used an Aloka SSD-1200 model (Aloka, Tokyo, Japan) with a 10-MHz mechanical sector transducer. A medium that facilitates the transmission of ultrasound was applied to the radial aspect of the wrist, as the probe poorly fitted the anatomical area. With the probe placed on the styloid process of the radius, the area was transversely scanned. Ultrasonographic examination was performed to identify the APL and EPB. The APL could be clearly identified when the thumb was abducted with the metacarpophalangeal (MP) joint stationary, and the EPB could be identified by flexion and extension of the MP joint. These findings on the affected side were compared with those on the contralateral normal side in each patient.
Results The radius forming the base of the first extensor compartment appeared as a hyperechoic line on ultrasonography, with a hyperechoic mass of tendons
M. Nagaoka et al.: Ultrasound in de Quervain’s disease
above it. In affected wrists, the mass was surrounded by hypoechoic areas. When there was no septum between the two tendons, the APL and EPB tendons appeared as a single mass. The two tendons could be distinguished from each other only when they were moved individually. In the presence of a septum between the two tendons, a hypoechoic area was imaged between them. In addition, these two tendons themselves were often larger than the contralateral normal tendons. Based on the above ultrasonographic findings, we were able to determine the presence or absence of the septum between the two tendons in each wrist affected by de Quervain’s disease. The septum was identified in 26 patients, and no septum was recognised in 6. During surgery, the presence of the septum was confirmed in 27 wrists and was absent in 5. The single septum that could not be detected on ultrasonography but was present during surgery was thin, incomplete, and present only in the distal part of the tendons. Case 1 A 68-year-old woman presented with a 2-year history of pain in the right wrist. Because the pain was resistant to conservative treatment, surgical treatment was indicated. When the first extensor compartment of the wrist was examined by ultrasonography, the tendons appeared as a round hyperechoic area with a hypoechoic zone around them. When the tendons were moved individually, the APL was distinguished from the EPB, but the two tendons were imaged as a mass without a septum between them (Fig. 1a). In the
a
97
contralateral normal wrist, the tendons showed lower echogenecity and were thinner than the affected counterparts of the opposite wrist (Fig. 1b). During operation, there was actually no septum between the two tendons as shown by ultrasonography. Case 2 A 57-year-old woman presented with a 1-year history of pain along the radial aspect of the right wrist. Ultrasonographic examination showed an APL with a diameter greater than that of the EPB, with a hypoechoic belt between them, on the affected side (Fig. 2a). The hypoechoic areas were less clearly seen around the tendons on the normal side (Fig. 2b). During operation, a septum was present between these two tendons. The EPB was particularly thin, with clear signs of tenosynovitis. Case 3 A 22-year-old woman presented with a 6-month history of pain in the left wrist. When the left wrist was examined by ultrasonography, the APL and EPB, which were of equal diameters, were imaged separately in the first extensor compartment, with a hypoechoic area suggestive of a septum between them (Fig. 3a). On the normal side, although both tendons could be distinguished from each other, the findings were apparently different from those on the affected side (Fig. 3b). During operation, it was confirmed that, in the affected wrist, both tendons were completely separated from each other by a septum.
b
Fig. 1. a Ultrasonogram showing a single compartment in the affected wrist of a 68-year-old woman. b Ultrasonogram of the unaffected wrist showing smaller tendon area than that of the affected side. APL, Abductor pollicis longus; EPB, extensor pollicis brevis
b
Fig. 2. a Ultrasonogram showing double compartment in the affected wrist of a 57-year-old woman. Note that the diameter of the EPB is smaller than that of the APL. b Ultrasonogram of the unaffected wrist showing the hypoechoic area less clearly
b
Fig. 3. a Ultrasonogram showing double compartment in the affected wrist of a 22-year-old woman. The diameters of the EPB and APL are almost the same. b Ultrasonogram of the unaffected wrist. The diameters of the EPB and APL are smaller than those on the affected side
a
a
Table 1. Review of the literature indicating type of study (cadaver dissection or clinical), number of wrists examined, and the number and percentage of wrists in which a septum was identified between the two tendons Authors
Year
Method
Wrists
No.
Percentage
Keon-Cohen7 Leão8 Giles2 Jackson et al.6
1951 1958 1960 1986
Horiuchi et al.5
1989
Harvey et al.4 Leslie et al.9 Minamikawa et al.11
1990 1990 1991
Witt et al.15 Weiss et al.14 Bahm et al.1
1991 1994 1995
CWD CWD CWD CWD CS CWD CS CS CWD CWD CS CS CS CS
66 50 50 300 40 100 60 11 100 71 70 30 45 70
22 12 10 120 27 57 50 10 34 53 33 22 20 42
33 24 20 40 67 57 83 91 34 75 47 73 44 60
CWD, Cadaver wrist dissection; CS, clinical study
M. Nagaoka et al.: Ultrasound in de Quervain’s disease
Discussion De Quervain’s disease is a stenosing tenosynovitis of the first dorsal compartment of the wrist. Many anatomical studies have been reported to date.2,5–9,11,12 The frequency of cases in which a septum is detected between the APL and EPB tendons varies widely among studies. In cadaveric studies, Keon-Cohen identified the septum in 33% of cases, Jackson et al.6 in 40%, and Leslie et al.9 in 34%, with the septum being identified in fewer than 50% of cases in most other studies (Table 1). In contrast, in clinical studies, the septum was detected more frequently than in cadavers. Thus, the proportions of cases with the septum was 67% as reported by Jackson et al.,6 83% by Horiuchi et al.,5 and 60% by Bahm et al.1 In the present study, we identified the septum in 27 of 32 patients (84% of cases). Since the report of Loomis,10 this difference has been considered to be more or less related to the etiology of de Quervain’s disease.5,6,14,15 In this form of tenosynovitis, the EPB is frequently more severely involved than the APL. Surgical treatment would be unsuccessful if only the tendon sheath of the APL were released while that of the EPB in another canal were left unreleased.2,5,9,11 In patients treated with steroid injections, the septum may serve as a barrier, leading to failure of therapy.1,4,9,15 It is therefore important to identify the presence of the septum before surgery or before the injection of steroids. There are only a few reports on the ultrasonographic examination of de Quervain’s disease; however, although the ultrasonographic characteristics of this disease were described, there was no surgical exploration for the presence of the septum between the two tendons.3,13 The diagnosis of de Quervain’s disease, based on characteristic clinical symptoms and a positive Finkelstein test, is usually not difficult. However, the addition of ultrasonographic examination can further confirm the diagnosis. In addition, as described above, it can provide information on the presence of a septum between the two tendons and on changes in the size of the two tendons. All patients in the present series underwent ultrasonographic examination before opera-
99
tion. Therefore, we were assured that the tendon sheath of the EPB would be released during the operation. Consequently, no pain persisted postoperatively in any patient. As a rule, ultrasonographic examination was performed as an outpatient procedure at our hospital. The procedure is simple and can image the tendons while they are in motion, providing advantages of this examination over others. The examination failed to identify the septum in one patient, however. Further improvements in ultrasonography could further improve the results.
References 1. Bahm J, Szabo Z, Foucher G. The anatomy of de Quervain’s disease. Int Orthop 1995;19:209–11. 2. Giles KW. Anatomical variations affecting the surgery of de Quervain’s disease. J Bone Joint Surg Br 1960;42:352–5. 3. Giovagnorio F, Andreoli C, De Cicco ML. Ultrasonographic evaluation of de Quervain disease. J Ultrasound Med 1997;16: 685–9. 4. Harvey FJ, Harvey PM, Horsley MW. de Quervain’s disease: surgical or nonsurgical treatment. J Hand Surg Am 1990;15:83–7. 5. Horiuchi Y, Itoh Y, Nemoto T, et al. Analysis of operative findings of de Quervain’s disease. Seikeigeka (Orthopaed Surg) 1989;40:199–203 (in Japanese). 6. Jackson WT, Viegas SF, Coon TM, et al. Anatomical variations in the first extensor compartment of the wrist. J Bone Joint Surg Am 1986;68:923–6. 7. Keon-Cohen B. de Quervain’s disease. J Bone Joint Surg Br 1951;33:96–9. 8. Leão L. de Quervain’s disease. A clinical and anatomical study. J Bone Joint Surg Am 1958;40:1063–70. 9. Leslie BM, Ericson WB Jr, Morehead JR. Incidence of a septum within the first dorsal compartment of the wrist. J Hand Surg Am 1990;15:88–91. 10. Loomis LK. Variations of stenosing tendovaginitis at the radial styloid process. J Bone Joint Surg Am 1951;33:340–6. 11. Minamikawa Y, Peimer CA, Cox WL, Sherwin FS. De Quervain’s syndrome: Surgical and anatomical studies of the fibroosseous canal. Orthop 1991;14:545–9. 12. Muckart RD. Stenosing tenosynovitis of abductor pollicis longus and extensor pollicis brevis at the radial styloid (de Quervain’s disease). Clin Orthop 1964;33:201–8. 13. Read JW, Conolly WB, Lanzetta M, et al. Diagnostic ultrasound of the hand and wrist. J Hand Surg Am 1996;21:1004–10. 14. Weiss APC, Akelman E, Tabatabai M. Treatment of de Quervain’s disease. J Hand Surg Am 1994;19:595–8. 15. Witt J, Pess G, Gelberman RH. Treatment of de Quervain tenosynovitis. J Bone Joint Surg Am 1991;73:219–22.
Ultrasonographic examination of de Quervain’s disease Masahiro Nagaoka, Hiromi Matsuzaki, and Takahiro Suzuki Orthopaedic Department, Surugadai Nihon University Hospital, 1-8-13 Kanda Surugadai, Chiyoda-ku, Tokyo 101-8309, Japan
Abstract: In order to assess the usefulness of ultrasonography in the preoperative evaluation of de Quervain’s disease, we retrospectively analyzed the ultrasonographic findings in 32 patients, and compared these findings with operative findings. Ultrasonography identified a septum between the abductor pollicis longus and extensor pollicis brevis tendons in 26 patients and showed absence of the septum in 6 patients. During surgery, the presence of the septum was confirmed in 27 patients, and was absent in 5. Our results demonstrated the usefulness of preoperative ultrasonography in correctly detecting anatomic abnormalities in patients with de Quervain’s disease. Key words: ultrasound examination, de Quervain’s disease, tenosynovitis
Introduction The diagnosis of de Quervain’s disease is based on characteristic physical signs, such as tenderness and swelling of the first extensor compartment of the wrist and a positive Finkelstein test, and is usually not difficult. Although the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons are contained in the compartment, a septum is present between the two tendons in some patients. It has been reported that the septum is present more frequently among patients with de Quervain’s disease than has been noted in cadavers.1,4–6,15 Ultrasonographic examination of the wrist can detect the septum between APL and EPB using dynamic images. In order to determine whether the septum could be detected before surgery, we examined patients with de Quervain’s disease by ultrasonography of the wrist, and compared the Offprint requests to: M. Nagaoka Received for publication on April 15, 1999; accepted on Sept. 27, 1999
preoperative ultrasonographic findings with operative findings.
Patients and methods A total of 32 wrists of 32 patients with de Quervain’s disease were surgically treated between 1993 and 1997 because the disease failed to respond to conservative therapy. Ultrasonographic examination was performed before operation in all patients. Both the surgery and the ultrasonographic examination were performed by the authors. The right wrist was affected in 12 patients, and the left wrist in 20. The patients, 7 men and 25 women, ranged in age from 19 to 68 years (mean, 47 years), with a predominance of women in the their thirties. For ultrasonographic examination, we used an Aloka SSD-1200 model (Aloka, Tokyo, Japan) with a 10-MHz mechanical sector transducer. A medium that facilitates the transmission of ultrasound was applied to the radial aspect of the wrist, as the probe poorly fitted the anatomical area. With the probe placed on the styloid process of the radius, the area was transversely scanned. Ultrasonographic examination was performed to identify the APL and EPB. The APL could be clearly identified when the thumb was abducted with the metacarpophalangeal (MP) joint stationary, and the EPB could be identified by flexion and extension of the MP joint. These findings on the affected side were compared with those on the contralateral normal side in each patient.
Results The radius forming the base of the first extensor compartment appeared as a hyperechoic line on ultrasonography, with a hyperechoic mass of tendons
M. Nagaoka et al.: Ultrasound in de Quervain’s disease
above it. In affected wrists, the mass was surrounded by hypoechoic areas. When there was no septum between the two tendons, the APL and EPB tendons appeared as a single mass. The two tendons could be distinguished from each other only when they were moved individually. In the presence of a septum between the two tendons, a hypoechoic area was imaged between them. In addition, these two tendons themselves were often larger than the contralateral normal tendons. Based on the above ultrasonographic findings, we were able to determine the presence or absence of the septum between the two tendons in each wrist affected by de Quervain’s disease. The septum was identified in 26 patients, and no septum was recognised in 6. During surgery, the presence of the septum was confirmed in 27 wrists and was absent in 5. The single septum that could not be detected on ultrasonography but was present during surgery was thin, incomplete, and present only in the distal part of the tendons. Case 1 A 68-year-old woman presented with a 2-year history of pain in the right wrist. Because the pain was resistant to conservative treatment, surgical treatment was indicated. When the first extensor compartment of the wrist was examined by ultrasonography, the tendons appeared as a round hyperechoic area with a hypoechoic zone around them. When the tendons were moved individually, the APL was distinguished from the EPB, but the two tendons were imaged as a mass without a septum between them (Fig. 1a). In the
a
97
contralateral normal wrist, the tendons showed lower echogenecity and were thinner than the affected counterparts of the opposite wrist (Fig. 1b). During operation, there was actually no septum between the two tendons as shown by ultrasonography. Case 2 A 57-year-old woman presented with a 1-year history of pain along the radial aspect of the right wrist. Ultrasonographic examination showed an APL with a diameter greater than that of the EPB, with a hypoechoic belt between them, on the affected side (Fig. 2a). The hypoechoic areas were less clearly seen around the tendons on the normal side (Fig. 2b). During operation, a septum was present between these two tendons. The EPB was particularly thin, with clear signs of tenosynovitis. Case 3 A 22-year-old woman presented with a 6-month history of pain in the left wrist. When the left wrist was examined by ultrasonography, the APL and EPB, which were of equal diameters, were imaged separately in the first extensor compartment, with a hypoechoic area suggestive of a septum between them (Fig. 3a). On the normal side, although both tendons could be distinguished from each other, the findings were apparently different from those on the affected side (Fig. 3b). During operation, it was confirmed that, in the affected wrist, both tendons were completely separated from each other by a septum.
b
Fig. 1. a Ultrasonogram showing a single compartment in the affected wrist of a 68-year-old woman. b Ultrasonogram of the unaffected wrist showing smaller tendon area than that of the affected side. APL, Abductor pollicis longus; EPB, extensor pollicis brevis
b
Fig. 2. a Ultrasonogram showing double compartment in the affected wrist of a 57-year-old woman. Note that the diameter of the EPB is smaller than that of the APL. b Ultrasonogram of the unaffected wrist showing the hypoechoic area less clearly
b
Fig. 3. a Ultrasonogram showing double compartment in the affected wrist of a 22-year-old woman. The diameters of the EPB and APL are almost the same. b Ultrasonogram of the unaffected wrist. The diameters of the EPB and APL are smaller than those on the affected side
a
a
Table 1. Review of the literature indicating type of study (cadaver dissection or clinical), number of wrists examined, and the number and percentage of wrists in which a septum was identified between the two tendons Authors
Year
Method
Wrists
No.
Percentage
Keon-Cohen7 Leão8 Giles2 Jackson et al.6
1951 1958 1960 1986
Horiuchi et al.5
1989
Harvey et al.4 Leslie et al.9 Minamikawa et al.11
1990 1990 1991
Witt et al.15 Weiss et al.14 Bahm et al.1
1991 1994 1995
CWD CWD CWD CWD CS CWD CS CS CWD CWD CS CS CS CS
66 50 50 300 40 100 60 11 100 71 70 30 45 70
22 12 10 120 27 57 50 10 34 53 33 22 20 42
33 24 20 40 67 57 83 91 34 75 47 73 44 60
CWD, Cadaver wrist dissection; CS, clinical study
M. Nagaoka et al.: Ultrasound in de Quervain’s disease
Discussion De Quervain’s disease is a stenosing tenosynovitis of the first dorsal compartment of the wrist. Many anatomical studies have been reported to date.2,5–9,11,12 The frequency of cases in which a septum is detected between the APL and EPB tendons varies widely among studies. In cadaveric studies, Keon-Cohen identified the septum in 33% of cases, Jackson et al.6 in 40%, and Leslie et al.9 in 34%, with the septum being identified in fewer than 50% of cases in most other studies (Table 1). In contrast, in clinical studies, the septum was detected more frequently than in cadavers. Thus, the proportions of cases with the septum was 67% as reported by Jackson et al.,6 83% by Horiuchi et al.,5 and 60% by Bahm et al.1 In the present study, we identified the septum in 27 of 32 patients (84% of cases). Since the report of Loomis,10 this difference has been considered to be more or less related to the etiology of de Quervain’s disease.5,6,14,15 In this form of tenosynovitis, the EPB is frequently more severely involved than the APL. Surgical treatment would be unsuccessful if only the tendon sheath of the APL were released while that of the EPB in another canal were left unreleased.2,5,9,11 In patients treated with steroid injections, the septum may serve as a barrier, leading to failure of therapy.1,4,9,15 It is therefore important to identify the presence of the septum before surgery or before the injection of steroids. There are only a few reports on the ultrasonographic examination of de Quervain’s disease; however, although the ultrasonographic characteristics of this disease were described, there was no surgical exploration for the presence of the septum between the two tendons.3,13 The diagnosis of de Quervain’s disease, based on characteristic clinical symptoms and a positive Finkelstein test, is usually not difficult. However, the addition of ultrasonographic examination can further confirm the diagnosis. In addition, as described above, it can provide information on the presence of a septum between the two tendons and on changes in the size of the two tendons. All patients in the present series underwent ultrasonographic examination before opera-
99
tion. Therefore, we were assured that the tendon sheath of the EPB would be released during the operation. Consequently, no pain persisted postoperatively in any patient. As a rule, ultrasonographic examination was performed as an outpatient procedure at our hospital. The procedure is simple and can image the tendons while they are in motion, providing advantages of this examination over others. The examination failed to identify the septum in one patient, however. Further improvements in ultrasonography could further improve the results.
References 1. Bahm J, Szabo Z, Foucher G. The anatomy of de Quervain’s disease. Int Orthop 1995;19:209–11. 2. Giles KW. Anatomical variations affecting the surgery of de Quervain’s disease. J Bone Joint Surg Br 1960;42:352–5. 3. Giovagnorio F, Andreoli C, De Cicco ML. Ultrasonographic evaluation of de Quervain disease. J Ultrasound Med 1997;16: 685–9. 4. Harvey FJ, Harvey PM, Horsley MW. de Quervain’s disease: surgical or nonsurgical treatment. J Hand Surg Am 1990;15:83–7. 5. Horiuchi Y, Itoh Y, Nemoto T, et al. Analysis of operative findings of de Quervain’s disease. Seikeigeka (Orthopaed Surg) 1989;40:199–203 (in Japanese). 6. Jackson WT, Viegas SF, Coon TM, et al. Anatomical variations in the first extensor compartment of the wrist. J Bone Joint Surg Am 1986;68:923–6. 7. Keon-Cohen B. de Quervain’s disease. J Bone Joint Surg Br 1951;33:96–9. 8. Leão L. de Quervain’s disease. A clinical and anatomical study. J Bone Joint Surg Am 1958;40:1063–70. 9. Leslie BM, Ericson WB Jr, Morehead JR. Incidence of a septum within the first dorsal compartment of the wrist. J Hand Surg Am 1990;15:88–91. 10. Loomis LK. Variations of stenosing tendovaginitis at the radial styloid process. J Bone Joint Surg Am 1951;33:340–6. 11. Minamikawa Y, Peimer CA, Cox WL, Sherwin FS. De Quervain’s syndrome: Surgical and anatomical studies of the fibroosseous canal. Orthop 1991;14:545–9. 12. Muckart RD. Stenosing tenosynovitis of abductor pollicis longus and extensor pollicis brevis at the radial styloid (de Quervain’s disease). Clin Orthop 1964;33:201–8. 13. Read JW, Conolly WB, Lanzetta M, et al. Diagnostic ultrasound of the hand and wrist. J Hand Surg Am 1996;21:1004–10. 14. Weiss APC, Akelman E, Tabatabai M. Treatment of de Quervain’s disease. J Hand Surg Am 1994;19:595–8. 15. Witt J, Pess G, Gelberman RH. Treatment of de Quervain tenosynovitis. J Bone Joint Surg Am 1991;73:219–22.