Styloid stenosis tenosynovitis is an aseptic inflammation caused by pain and swelling of the abductor pollicis longus and extensor pollicis brevis tendons at the dorsal carpal sheath at the radial styloid process. Symptoms worsen with thumb extension and calimor deviation. The disease was first reported by the Switzerland surgeon de Quervain in 1895, so radial styloid stenosis tenosynovitis is also known as de Quervain’s disease.
The disease is more common in people who engage in frequent wrist and palmar finger activities, and is also known as “mother’s hand” and “game finger”. With the development of the Internet, the number of people affected by the disease is increasing and younger. So how to diagnose and treat this disease? The following will give you a brief introduction from three aspects: anatomical structure, clinical diagnosis and treatment methods!
I.Anatomy
The styloid process of the radius has a narrow, shallow sulcus covered by a dorsal carpal ligament that forms a fibrous sheath of bony. The abductor pollicis longus tendon and extensor pollicis brevis tendon pass through this sheath and fold at an angle and terminate at the base of the first metacarpal bone and the base of the proximal phalanx of the thumb, respectively (Figure 1). When the tendon slides, there is a large friction force, especially when the wrist ulnar deviation or thumb movement, the fold angle increases, increasing the friction between the tendon and the sheath wall. After long-term repeated chronic stimulation, the synovium presents inflammatory changes such as edema and hyperplasia, causing thickening, adhesion or narrowing of the tendon and sheath wall, resulting in the clinical manifestations of stenosis tenosynovitis.
Fig.1 Anatomical diagram of the styloid process of the radius
II.Clinical diagnosis
1.The medical history is more common in middle-aged, manual operators, and more common in women; Onset is slow, but symptoms can occur suddenly.
2.Signs: localized pain in the styloid process of the radius, which can radiate to the hand and forearm, thumb weakness, limited thumb extension, aggravation of symptoms when thumb extension and wrist ulnar deviation; Palpable nodules may be palpable at the styloid process of the radius, resembling a bony eminence, with marked tenderness.
3.Finkelstein’s test (i.e., fist ulnar deviation test) is positive (as shown in Figure 2), the thumb is flexed and held in the palm, the ulnar wrist is deviated, and the pain at the radius styloid process is aggravated.
4.Auxiliary examination: X-ray or color ultrasound examination can be performed if necessary to confirm whether there is bone abnormality or synovitis. The Guidelines for the Multidisciplinary Treatment of Styloid Stenosis Tenosynovitis of the Radius Note that other physical examinations are required to distinguish between osteoarthritis, disorders of the superficial branch of the radial nerve, and forearm cruciate syndrome at the time of diagnosis.
III.Treatment
Conservative therapyLocal immobilization therapy: In the early stage, patients can use an external fixation brace to immobilize the affected limb to reduce local activities and relieve the friction of the tendon in the tendon sheath to achieve the goal of treatment. However, immobilization may not ensure that the affected limb is in place, and prolonged immobilization may result in long-term motion stiffness. Although immobilization-assisted other treatments are empirically used in clinical practice, the efficacy of treatment remains controversial.
Local occlusion therapy: As the preferred conservative therapy for clinical treatment, local occlusion therapy refers to intrathecal injection at the local pain site to achieve the purpose of local anti-inflammatory. Occlusive therapy can inject drugs into the painful area, joint sheath sac, nerve trunk and other parts, which can reduce swelling and relieve pain and relieve spasms in a short period of time, and play the greatest role in the treatment of local lesions. The therapy consists mainly of triamcinolone acetonide and lidocaine hydrochloride. Sodium hyaluronate injections can also be used. However, hormones may have complications such as post-injection pain, local skin pigmentation, local subcutaneous tissue atrophy, symptomatic radial nerve injury, and elevated blood glucose. The main contraindications are hormone allergy, pregnant and lactating patients. Sodium hyaluronate may be safer and can prevent scarring of adhesions around the tendon and promote tendon healing. The clinical effect of occlusive therapy is obvious, but there are clinical reports of finger necrosis caused by improper local injection (Figure 3).
Fig.3 Partial occlusion leads to necrosis of the fingertips of the index fingers: A. The skin of the hand is patchy, and B, C. The middle segment of the index finger is distantly distant, and the fingertips are necrosis
Precautions for occlusive therapy in the treatment of radius styloid stenosis tenosynovitis: 1) The position is accurate, and the syringe must be withdrawn before injecting the drug to ensure that the injection needle does not penetrate the blood vessel; 2) Appropriate immobilization of the affected limb to avoid premature exertion; 3) After hormone occlusion injection, there are often different degrees of pain, swelling, and even aggravation of pain, generally disappearing in 2~3 days, if finger pain and pallor appear, antispasmodic and anticoagulant therapy should be given quickly, and angiography should be performed to make a clear diagnosis if possible, and vascular exploration should be carried out as soon as possible if necessary, so as not to delay the condition; 4) Hormonal contraindications such as hypertension, diabetes, heart disease, etc., should not be treated with local occlusion.
Shockwave: is a conservative, non-invasive treatment that has the advantage of generating energy outside the body and producing results in targeted areas deep within the body without damaging the surrounding tissues. It has the effect of promoting metabolism, strengthening blood and lymphatic circulation, improving tissue nutrition, dredging blocked capillaries, and loosening joint soft tissue adhesions. However, it started late in the treatment of styloid stenosis tenosynovitis of the radius, and its research reports are relatively few, and large-scale randomized controlled studies are still needed to provide more evidence-based medical evidence to promote its use in the treatment of styloid stenosis tenosynovitis disease of the radius.
Acupuncture treatment: small acupuncture treatment is a closed release method between surgical treatment and non-surgical treatment, through the dredging and peeling of local lesions, the adhesions are released, and the entrapment of the vascular nerve bundle is more effectively relieved, and the blood circulation of the surrounding tissues is improved through the benign stimulation of the acupuncture, reducing inflammatory exudation, and achieving the purpose of anti-inflammatory and analgesic.
Traditional Chinese medicine: Radial styloid stenosis tenosynovitis belongs to the category of “paralysis syndrome” in the medicine of the motherland, and the disease is based on the deficiency and the standard. Due to the long-term activity of the wrist joint, excessive strain, resulting in local qi and blood deficiency, this is called the original deficiency; Due to the local qi and blood deficiency, the muscles and veins are lost in nourishment and slippery, and because of the feeling of wind, cold and dampness, which aggravates the blockage of qi and blood operation, it is seen that local swelling and pain and activity are restricted, and the accumulation of qi and blood is more serious and the local spasm is more serious, so it is found that the pain of the movable wrist joint and the first metacarpophalangeal joint is aggravated in the clinic, which is a standard. It was clinically found that moxibustion therapy, massage therapy, external treatment of traditional Chinese medicine and acupuncture treatment have certain clinical effects.
Surgical treatment: Surgical incision of the dorsal carpal ligament of the radius and limited excision is one of the treatments for stenosis tenosynovitis in the styloid process of the radius. It is suitable for patients with recurrent tenosynovitis of radius styloid stenosis, which has been ineffective after multiple local occlusions and other conservative treatments, and the symptoms are severe. Especially in patients with stenotic advanced tenosynovitis, it relieves severe and refractory pain.
Direct open surgery: The conventional surgical method is to make a direct incision at the tender area, expose the first dorsal muscle septum, cut the thickened tendon sheath, and release the tendon sheath so that the tendon can slide freely within the tendon sheath. Direct open surgery is quick to achieve, but it carries a series of surgical risks such as infection, and due to the direct removal of the dorsal support band during surgery, tendon dislocation and damage to the radial nerve and vein may occur.
1st septolysis: This surgical method does not cut the thickened tendon sheath, but removes the ganglion cyst found in the 1st extensor septum or cuts the septum between the abductor pollicis longus and extensor pollicis brevis to release the 1st dorsal extensor septum. This method is similar to direct open surgery, with the main difference being that after cutting the extensor support band, the tendon sheath is released and the tendon sheath is removed instead of by incision of the thickened tendon sheath. Although tendon subluxation may be present in this method, it protects the 1st dorsal extensor septum and has a higher long-term efficacy for tendon stability than direct resection of the tendon sheath. The disadvantage of this method is mainly due to the fact that the thickened tendon sheath is not removed, and the thickened tendon sheath may still be inflammatory, edema, and friction with the tendon will lead to recurrence of the disease.
Arthroscopic osteofibrous duct augmentation: arthroscopic treatment has the advantages of less trauma, short treatment cycle, high safety, fewer complications and faster recovery, and the biggest advantage is that the extensor support belt is not incised, and there will be no tendon dislocation. However, there is still controversy, and some scholars believe that arthroscopic surgery is expensive and time-consuming, and its advantages over direct open surgery are not obvious enough. Therefore, arthroscopic treatment is generally not chosen by the majority of doctors and patients.
Post time: Oct-29-2024
