Work related etiology of de Quervain's tenosynovitis: a case-control study with prospectively collected data

Fascial Lengthening at the Time of Surgical Release for de Quervain's Tenosynovitis to Prevent Postsurgical Tendon Subluxation

BACKGROUND

De Quervain's tenosynovitis is a relatively common, painful condition. Although commonly managed nonoperatively, some patients have recalcitrant disease, necessitating surgical release. Traditional surgical release for de Quervain's tenosynovitis with simple retinacular release can leave patients susceptible to first dorsal extensor compartment tendon subluxation. We present a stair-step flap technique that releases the first dorsal compartment while simultaneously preventing postoperative tendon subluxation via fascial lengthening.

METHODS

All patients over the past decade who underwent surgical release with this technique were collected. Preoperative characteristics, surgical details, and postoperative outcomes were reviewed and aggregated as summary statistics.

RESULTS

A total of 101 patients were found. Of these, 35 patients had isolated first dorsal compartment release. Tourniquet time for the total group was 1 hour and that for the isolated first dorsal compartment release subgroup was 20 minutes. The average follow-up was 590 days for the total group and only 440 days for the isolated first dorsal compartment release subgroup. No patients who underwent our novel technique experienced subluxation of the tendons postoperatively. One patient required oral antibiotics for a superficial cellulitis, and 1 patient had recurrent symptoms due to excessive scarring that resolved with scar massage and steroid injection. No patient required repeat operations.

CONCLUSION

Our study demonstrates that first dorsal compartment release with a stair-step incision allows for closure of the compartment with a very loose sheath without subluxation and simultaneously provides satisfactory decompression. This procedure is safe and efficacious and can be considered a useful modification to traditional retinacular release alone.

LEVEL OF EVIDENCE

Level III.

Smartphone usage behaviors and their association with De Quervain's Tenosynovitis (DQT)among college students: a cross-sectional study in Guangxi, China

BACKGROUND

The growing prevalence of smartphone use among college students in China has led to health concerns, including De Quervain's Tenosynovitis (DQT). However, the specific smartphone usage behaviors contributing to DQT remain poorly understood. This study aimed to explore the relationship between smartphone usage behaviors and DQT in college students.

METHODS

A cross-sectional study was conducted with 937 students from various majors in Guangxi between September 2021 and April 2022. Participants completed an online questionnaire assessing smartphone usage behaviors and their association with DQT. The Finkelstein test was employed to diagnose DQT.

RESULTS

Over half of the college students (52%) tested positive for DQT via Finkelstein's test. Higher levels of smartphone usage time (6-8 h/day: OR = 4.454, 95%CI:1.662-12.229; ≥8 h/day: OR = 4.521, 95%CI:1.596-12.811), phone games (OR = 1.997, 95%CI:1.312-3.040), social media (OR = 2.263, 95%CI:1.795-3.833), and leisure activities (OR = 1.679, 95%CI:1.140-2.475) were significantly associated with an increased risk of DQT. Two specific gestures (Bilateral thumbs, BT: OR = 1.900, 95%CI:1.281-2.817; Bilateral thumbs-horizontal screen, BT-HS: OR = 1.872, 95%CI:1.244-2.818) and two screen sizes (5.0-5.5inch: OR = 2.064, 95%CI:1.108-3.846; 6.0-6.5inch: OR = 2.413, 95%CI:1.125-4.083) also exhibited a higher risk of DQT. Bilateral DQT was observed, with Gesture-BT identified as the primary risk factor.

CONCLUSION

Our findings suggest that increased smartphone usage time, phone games, social media, and leisure activities elevate the risk of DQT among college students. Furthermore, two specific gestures and two screen sizes were also linked to a heightened DQT risk. To mitigate DQT development, college students should reduce smartphone usage time and adopt appropriate gestures.

Reintervention, PROMs, and Factors Influencing PROMs Following Surgery for de Quervain's Tenosynovitis

Objective  The aims of this study are to describe and identify the factors that influence patient reported outcomes following surgery of de Quervain's tenosynovitis. The secondary objective is to report the rate of reintervention following surgery of de Quervain's tenosynovitis. Patients and Methods  Outcomes using the numerical rating scale (NRS) for pain, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), Patient-Rated Wrist Evaluation (PRWE), the Patients Reported Outcome Measurement Information System Pain Interference (PROMIS PI), and a custom de Quervain's questionnaire were obtained. A multivariable linear regression analysis was performed to identify independent factors associated with patient-reported outcomes. Results  Seventy-six patients who underwent de Quervain's release participated. The average age was 52.8 years (95% confidence interval: 49.6-56.1) and median follow-up age was 7.0 years (interquartile range [IQR]: 4.3-12.0). Outcomes were: NRS of pain was 0 (IQR: 0.0-3.0), the median QuickDASH was 6.82 (IQR: 0.00-28.41), the median PRWE score was 4.0 (IQR: 0.00-18.50), and the median PROMIS PI score was 43.90 (IQR: 38.70-53.90). Eighteen (23.7%) of the patients reported pain with thumb activities, four of whom had a reintervention. Additionally, 21 (26.9%) patients reported decreased strength in the thumb compared to the contralateral side, of which two underwent a reintervention. In total, eight patients underwent reintervention of which seven had a second surgery and one had a cortisone injection. Conclusion  Roughly 1 in 20 patients following de Quervain's release undergoes reintervention. Patients with high PROMIS PI scores report poor surgical outcomes more frequently. Patients with high PROMIS PI scores report higher NRS pain scores ( p  < 0.05), higher QuickDASH scores ( p  < 0.05), and higher PRWE scores ( p  < 0.05). In practice, careful consideration of PROMIS PI scores and psychosocial factors are recommended before considering reintervention.

Work-Related De Quervain's Tensosynovitis (DQT): The Diagnosis Dilemma

A female presented with right wrist pain for nine months. The diagnosis was De Quervain's tenosynovitis; her condition was initially managed conservatively, but later she needed surgery due to the lack of improvement. No workplace intervention had been implemented because her hand surgeons did not consider her occupational exposures. It was later discovered that there was significant exposure to ergonomic hazards at her workplace. She received accommodations in her workplace that led to reduction of exposure to ergonomic hazards and the subsequent dramatic improvement in her condition. This case report indicates that some orthopedists do not appreciate the role of occupational exposure to ergonomic hazards in the pathogenesis of similar conditions. Occupational medicine specialists and orthopedists should, therefore, communicate with each other to reach a consensus regarding the association between occupational exposures to ergonomic hazards and work-related upper limb disorders (WRULDs).

Enhanced Recovery After Aesthetic Breast Surgery Under Sedation, Intercostal Block and Tumescent Anaesthesia: A Prospective Cohort Study of the Early Postoperative Phase

BACKGROUND

Comfort and recovery are major concerns of patients seeking aesthetic surgery. This study aimed to assess postoperative pain and recovery after outpatient breast surgery under sedation, intercostal block, and local anaesthesia.

METHODS

This prospective cohort study included all consecutive patients who underwent aesthetic breast surgery between April 2021 and August 2022. Epidemiological data, anaesthesia, pain, and patients' satisfaction were systematically assessed with standardized self-assessment questionnaires.

RESULTS

Altogether, 48 patients [median (IQR) age: 30 (36-25)] were included. The most frequent surgery was mastopexy. 69% of surgeries involved additional procedures. The mean intercostal block and local anaesthesia time was 15 min. Patients received a median (IQR) of 19 (34-2) mg/kg lidocaine and 2.3 (2.5-2.0) mg/kg ropivacaine. The median (IQR) consumption of propofol and alfentanil was, respectively, 4.89 (5.48-4.26) mg/kg/h and 0.27 (0.39-0.19) µg/kg/min. No conversion to general anaesthesia or unplanned hospital admission occurred. Patients were discharged after a median (IQR) of 2:40 (3:43-1:58) hours. Within the first 24 postoperative hours, 17% required once an antiemetic medication and 38% an opioid. Patients were very satisfied with the anaesthesia and 90% of the patients had not wished more analgesia in the first 24 h.

CONCLUSIONS

Aesthetic breast surgery under sedation, intercostal block, and tumescent anaesthesia can safely be performed as an ambulatory procedure and is associated with minimal intra- and postoperative opioid consumption and high patient satisfaction. These data may be used to inform patients and clinicians and improve the overall quality of care.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Time to Reconsider Occupation Induced De Quervain's Tenosynovitis: An Updated Review of Risk Factors

De Quervain's tenosynovitis (DQT) is described to be an attritional and degenerative process, triggered by stenosing inflammation of the tendon sheath in the first dorsal compartment of the wrist. Understanding and targeting the risk factors associated with DQT will help clinicians and patients to reduce its prevalence. This review aims to evaluate the current literature surrounding the risk factors which were divided into the anatomical, patient, and occupational factors associated with the condition. The two main anatomical variations associated with DQT are subcomparmentalization and multiple tendon slips of the abductor pollicus longus (APL) and extensor pollicus brevis (EPB) tendons. DQT is more common in females and is often noted in pregnancy and the postpartum period. When considering occupational factors, work-related activity has not been shown to be a direct cause of DQT, despite leading organisations supporting the converse.

Workplace-based rehabilitation with garment workers: A multiple case study

BACKGROUND: Garment workers are at risk of developing work-related upper limb disorders (WRULD) due to the highly repetitive nature of their work. Workplace-based rehabilitation (WBR) facilitates improvement in work performance by providing intervention at the worker’s place of work. OBJECTIVE: This study aims to determine the documented outcomes of workplace-based occupational therapy rehabilitation of garment workers with upper limb conditions. METHODS: A multiple case study design was used through a retrospective record review. All garment workers with upper limb conditions who were treated at a student occupational therapy practice in Cape Town, South Africa, with pre- and post-intervention outcome assessment, were included in the study (n = 7). Data were extracted from occupational therapy and medical files. RESULTS: 70% of the cases (n = 5) improved after WBR while 30% of cases showed no improvement or deterioration. Participants received 3– 5 individual WBR sessions of approximately 30 minutes each, over a period of 4 to 6 weeks. Interventions included workstation adaptations, job rotation, psychoeducation, work task modification, assistive technology and exercise programmes. Outcome measures most commonly used were the RULA, DASH, Boston Carpal Tunnel Questionnaire and pain intensity using the VAS. CONCLUSION: Workplace-based occupational therapy can be effective at improving upper limb function, pain and ergonomic risk amongst garment workers with upper limb conditions.

Diagnostic accuracy of imaging modalities in the detection of clinically diagnosed de Quervain's syndrome: a systematic review

OBJECTIVES

To collate and synthesise the literature to provide estimates of the diagnostic accuracy of imaging modalities, and summarise the reported imaging findings associated with de Quervain's syndrome.

MATERIALS AND METHODS

A systematic search was performed in seven databases (MEDLINE, EMBASE, CINAHL, Cochrane Library, PROSPERO, Web of Science, and ProQuest Dissertations & Theses Global). Two reviewers independently performed screening, data extraction and quality assessment using a modified Quality Assessment of Diagnostic Accuracy Studies-2. Measures of diagnostic accuracy were summarised for different modalities and imaging findings.

RESULTS

Twenty-two studies were included, reporting ultrasound, magnetic resonance imaging, X-ray and scintigraphy findings. Reported imaging findings included sheath effusion, retinaculum thickening, subcutaneous oedema, tenosynovitis, hypervascularity, increased tendon size, bony erosion, apposition, calcific lesions and increased uptake on scintigraphy. The most commonly reported imaging findings related to the tendon sheath, with a sensitivity ranging from 0.45 to 1.00 for thickening, and 0.29 to 1.00 for effusions. The risk of bias of studies is largely unclear owing to a lack of reported detail.

CONCLUSIONS

The accuracy of imaging in the diagnosis of de Quervain's syndrome is unable to be determined because of the quality of the studies included. Ultrasound is the most frequently studied imaging modality and may be the modality of choice in clinical practice. Further research involving both symptomatic and asymptomatic participants and clear definitions of abnormal findings are required to better evaluate the effectiveness of imaging in identifying de Quervain's syndrome.

Work-break schedules for preventing musculoskeletal symptoms and disorders in healthy workers

BACKGROUND

Work-related musculoskeletal disorders are a group of musculoskeletal disorders that comprise one of the most common disorders related to occupational sick leave worldwide. Musculoskeletal disorders accounted for 21% to 28% of work absenteeism days in 2017/2018 in the Netherlands, Germany and the UK. There are several interventions that may be effective in tackling the high prevalence of work-related musculoskeletal disorders among workers, such as physical, cognitive and organisational interventions. In this review, we will focus on work breaks as a measure of primary prevention, which are a type of organisational intervention.

OBJECTIVES

To compare the effectiveness of different work-break schedules for preventing work-related musculoskeletal symptoms and disorders in healthy workers, when compared to conventional or alternate work-break schedules.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, PsycINFO, SCOPUS, Web of Science, ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform, to April/May 2019. In addition, we searched references of the included studies and of relevant literature reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of work-break interventions for preventing work-related musculoskeletal symptoms and disorders among workers. The studies were eligible for inclusion when intervening on work-break frequency, duration and/or type, compared to conventional or an alternate work-break intervention. We included only those studies in which the investigated population included healthy, adult workers, who were free of musculoskeletal complaints during study enrolment, without restrictions to sex or occupation. The primary outcomes were newly diagnosed musculoskeletal disorders, self-reported musculoskeletal pain, discomfort or fatigue, and productivity or work performance. We considered workload changes as secondary outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles, abstracts and full texts for study eligibility, extracted data and assessed risk of bias. We contacted authors for additional study data where required. We performed meta-analyses, where possible, and we assessed the overall quality of the evidence for each outcome of each comparison using the five GRADE considerations.

MAIN RESULTS

We included six studies (373 workers), four parallel RCTs, one cross-over RCT, and one combined parallel plus cross-over RCT. At least 295 of the employees were female and at least 39 male; for the remaining 39 employees, the sex was not specified in the study trial. The studies investigated different work-break frequencies (five studies) and different work-break types (two studies). None of the studies investigated different work-break durations. We judged all studies to have a high risk of bias. The quality of the evidence for the primary outcomes of self-reported musculoskeletal pain, discomfort and fatigue was low; the quality of the evidence for the primary outcomes of productivity and work performance was very low. The studies were executed in Europe or Northern America, with none from low- to middle-income countries. One study could not be included in the data analyses, because no detailed results have been reported.Changes in the frequency of work breaksThere is low-quality evidence that additional work breaks may not have a considerable effect on musculoskeletal pain, discomfort or fatigue, when compared with no additional work breaks (standardised mean difference (SMD) -0.08; 95% CI -0.35 to 0.18; three studies; 225 participants). Additional breaks may not have a positive effect on productivity or work performance, when compared with no additional work breaks (SMD -0.07; 95% CI -0.33 to 0.19; three studies; 225 participants; very low-quality evidence).We found low-quality evidence that additional work breaks may not have a considerable effect on participant-reported musculoskeletal pain, discomfort or fatigue (MD 1.80 on a 100-mm VAS scale; 95% CI -41.07 to 64.37; one study; 15 participants), when compared to work breaks as needed (i.e. microbreaks taken at own discretion). There is very low-quality evidence that additional work breaks may have a positive effect on productivity or work performance, when compared to work breaks as needed (MD 542.5 number of words typed per 3-hour recording session; 95% CI 177.22 to 907.78; one study; 15 participants).Additional higher frequency work breaks may not have a considerable effect on participant-reported musculoskeletal pain, discomfort or fatigue (MD 11.65 on a 100-mm VAS scale; 95% CI -41.07 to 64.37; one study; 10 participants; low-quality evidence), when compared to additional lower frequency work breaks. We found very low-quality evidence that additional higher frequency work breaks may not have a considerable effect on productivity or work performance (MD -83.00 number of words typed per 3-hour recording session; 95% CI -305.27 to 139.27; one study; 10 participants), when compared to additional lower frequency work breaks.Changes in the duration of work breaksNo trials were identified that assessed the effect of different durations of work breaks.Changes in the type of work breakWe found low-quality evidence that active breaks may not have a considerable positive effect on participant-reported musculoskeletal pain, discomfort and fatigue (MD -0.17 on a 1-7 NRS scale; 95% CI -0.71 to 0.37; one study; 153 participants), when compared to passive work breaks.Relaxation work breaks may not have a considerable effect on participant-reported musculoskeletal pain, discomfort or fatigue, when compared to physical work breaks (MD 0.20 on a 1-7 NRS scale; 95% CI -0.43 to 0.82; one study; 97 participants; low-quality evidence).

AUTHORS' CONCLUSIONS

We found low-quality evidence that different work-break frequencies may have no effect on participant-reported musculoskeletal pain, discomfort and fatigue. For productivity and work performance, evidence was of very low-quality that different work-break frequencies may have a positive effect. For different types of break, there may be no effect on participant-reported musculoskeletal pain, discomfort and fatigue according to low-quality evidence. Further high-quality studies are needed to determine the effectiveness of frequency, duration and type of work-break interventions among workers, if possible, with much higher sample sizes than the studies included in the current review. Furthermore, work-break interventions should be reconsidered, taking into account worker populations other than office workers, and taking into account the possibility of combining work-break intervention with other interventions such as ergonomic training or counselling, which may may possibly have an effect on musculoskeletal outcomes and work performance.

Dispelling the Myth of Work-Related de Quervain's Tenosynovitis

De Quervain's Tenosynovitis (DQT) is a common condition characterized by pain about the dorsal-radial aspect of the wrist, just proximal to the radial styloid. The condition is precipitated by a thickened first dorsal compartment and its tendons. The impression that DQT is caused from work-related injury is misdirected, as no study has established an association between hand usage at work or trauma with DQT. Physicians should exercise caution when discussing the causes and natural history of DQT with symptomatic patients.

Ultrasound-guided methotrexate injection for De Quervain disease of the wrist: what lies beyond the horizon?

De Quervain disease (DQVD) is one of the most common causes of lateral wrist pain and can lead to significant disability. The current case involves a right-handed, middle-aged, female patient with severe lateral wrist pain due to DQVD. Her pain was not responsive to oral non-steroidal anti-inflammatory drugs, rehabilitation, and repeated corticosteroid injections. Because she refused surgical intervention, we performed ultrasound-guided methotrexate injections (four times). After the injections, dramatic pain relief, functional improvement, and reduction of the thickness of the retinaculum and tendons in the first dorsal extensor compartment of the wrist were noted. This case report highlights the potential usefulness of ultrasound-guided methotrexate injection for recalcitrant DQVD of the wrist.

Effects of metabolic syndrome on the functional outcomes of corticosteroid injection for De Quervain tenosynovitis

Metabolic syndrome is a constellation of medical conditions that arise from insulin resistance and abnormal adipose deposition and function. In patients with metabolic syndrome and De Quervain tenosynovitis this might affect the outcome of treatment by local corticosteroid injection. A total of 64 consecutive patients with De Quervain tenosynovitis and metabolic syndrome treated with corticosteroid injection were age- and sex-matched with 64 control patients without metabolic syndrome. The response to treatment, including visual analogue scale score for pain, objective findings consistent with De Quervain tenosynovitis (tenderness at first dorsal compartment, Finkelstein test result), and Disability of the Arm, Shoulder, and Hand score were assessed at 6, 12, and 24 weeks follow-up. Treatment failure was defined as persistence of symptoms or surgical intervention. Prior to treatment, patients with metabolic syndrome had mean initial pain visual analogue scale and Disability of the Arm, Shoulder, and Hand scores similar to those in the control group. The proportion of treatment failure in the metabolic syndrome group (43%) was significantly higher than that in the control group (20%) at 6 months follow-up. The pain visual analogue scale scores in the metabolic syndrome group were higher than the scores in the control group at the 12- and 24-week follow-ups. The Disability of the Arm, Shoulder, and Hand scores of the metabolic syndrome group were higher (more severe symptoms) than those of the control group at the 12- and 24-week follow-ups. Although considerable improvements in symptom severity and hand function will likely occur in patients with metabolic syndrome, corticosteroid injection for De Quervain tenosynovitis is not as effective in these patients compared with age- and sex-matched controls in terms of functional outcomes and treatment failure.

LEVEL OF EVIDENCE

III.

Sex differences in the radial grooves in the first extensor compartment

OBJECTIVE

De Quervain tenosynovitis affects the first extensor compartment of the wrist and occurs more frequently in females. This high prevalence could not be explained by soft tissue. As the osseous anatomy has been mostly neglected, we aimed to compare the distal radius between the sexes.

MATERIALS AND METHODS

We evaluated the presence of a bony ridge on the floor of the first extensor compartment on CT images with multiplanar imaging.

RESULTS

We included 244 wrists (72 females, 172 males) in the study. A bony ridge was present in 58 (23.8 %) and absent in 186 (76.2 %) wrists. A ridge was present in 24 (33.3 %) wrists among females and 34 (19.8 %) wrists among males. A groove with a bony ridge was statistically associated with females.

CONCLUSION

We observed two tendon groove morphologies for the first extensor compartment. A groove with a bony ridge occurs more frequently in females. Further research is needed to clarify the relationship between the high frequency of a bony ridge and increased prevalence of de Quervain tenosynovitis in females.