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How Do I Distinguish Between Carpal Tunnel Syndrome and
De Quervain’s Disease?
Krista Paulson, BSc, BMR-PT, MSc
Acupuncture Provider
Physiotherapist
Certified Hand Therapist
Co-owner of EastCity Physiotherapy: A Hand to Shoulder Clinic
May indirectly benefit from increased referrals to our clinic, although no specific referrals will be solicited.
Relationships with Commercial Interests:
Objectives
✦ Review anatomy, patient history, exam,
diagnostic imaging findings
✦ Review evidence-based conservative and surgical
management
✦ Review when / where to refer (Winnipeg)
Carpal Tunnel Syndrome (CTS)Carpal Tunnel
Syndrome (CTS)
CTS - Anatomy
(Source: http://noelhenley.com/noelhenley-new2/wp-content/uploads/2012/01/carpal-tunnel-cross-section.jpg)
(Source: Author)
APB
T
S
H
P
CTS - Anatomy
(Source: http://ars.els.cdn.com/content/image/1-s2.0-S0025712508001326-gr1.jpg)
(Source: http://upload.wikimedia.org/wikipedia/commons/
7/77/Musculusabductorpollicusbrevis.png)
CTS - History
✦Most common focal neuropathy
✦Women > Men (especially ages 40-60)
✦Diabetes, RA, Obesity, Smoking
✦Pregnancy, menopause, estrogen use
✦Vibrating tools, repeated forceful gripping
(Calandruccio & Thompson, 2018; D’Arcy & McGee, 2000; Leblanc & Cestia, 2011)
CTS - Examination
✦ Variety of clinical tests with varying sensitivity
and specificity
✦ Multiple positives = more compelling
CTS - Examination (Motor)
(Source:
http://www.onmedica.comgetresourceid=658c7oce-b169-
42a4-8087-665497f9affd)
*
(D’Arcy & McGee, 2000)
“The Abductor Pollicus Brevis (APB) Test” Abductor Pollicus Brevis Wasting
CTS Examination - Durkan’s
✦Apply pressure over
carpal tunnel for 30
seconds
✦Positive:
Numbness/tingling
in median
distribution
✦Sensitivity 87%
✦Specificity 90%
(Calandruccio & Thompson, 2018)
(Source: Author)
CTS Examination - Tinel’s
(Source: Skirven, T. Clinical Examination of the Wrist. J Hand Ther. 1996 Apr-Jun;9(2);96-107)
✦Percuss median
nerve just distal to
wrist crease
✦Positive:
Numbness/tingling
in median
distribution
✦Sensitivity 62%
✦Specificity 93%(Skirven, 1996)
CTS Examination - Phalen’s✦Passive wrist flexion
30-60 seconds
✦Positive:
Numbness/tingling
in median
distribution
✦Sensitivity 68-70%
✦Specificity 73-83%
(Source: Skirven, T. Clinical Examination of the Wrist. J Hand Ther. 1996 Apr-Jun;9(2);96-107)
(Calandruccio & Thompson, 2018; D’Arcy &
McGee, 2000)
X
(Source: Author)
CTS - Electrodiagnostic Testing
✦ Often required by third party payers
✦ Nerve Conduction*: impaired conduction of median
nerve across carpal tunnel
✦ Electromyography (EMG): usually assesses
pathologic changes in Abductor Pollicus Brevis,
more used if other neuropathy/radiculopathy
suspected
✦ Sensitivity 49-84%, specificity 95-99%(Calandruccio & Thompson, 2018)
CTS - Management
✦ Mild to Moderate: consider 3-6 months of
conservative management (splinting, injection)
✦ Severe: consider surgical evaluation
(Leblanc & Cestia, 2011; Wiperman & Goerl, 2016)
(Source: Author)
CTS Management - Splinting
(Hall et al., 2013; So, Chung, Cheung & Yip, 2018)
✦ Mild to moderate CTS
✦ 8-12 weeks of nightly splint use
✦ Unclear if custom more effective
than off-the-shelf
✦ Sweating
✦ Comfort
✦ Insurance coverage
(Source: Author)
~$60
~$95
✦ Only one RCT comparing splinting vs
methylprednisolone acetate premixed with
lidnocaine (mild to moderate CTS)
✦ Equally effective on Boston Carpal Tunnel
Questionnaire
✦ But injection yielded better hand function scores
CTS - Injection
(So, Chung, Cheung & Yip, 2018)
CTS - Injection
(Source: specialistphysio.com)
✦As effective as
splinting
✦Repeat injection
after 6 months
✦Delay surgery up to
1 year
Wiperman & Goerl, 2016)
CTS - Surgical Intervention
✦Results favorable up to 9 years post-op even in severe
cases
✦Two portal endoscopic vs open release:
✦ Endoscopic: less post op pain
✦ Both equivalent for scar pain, patient satisfaction
and recurrence rate at 5-yrs post op
(Atroshi et al, 2009; So, Chung, Cheung & Yip, 2018; Tang, Lai & Tay, 2017)
De Quervain’s DiseaseDe Quervain’s Disease
“New Mom Thumb”
“Baby Wrist”
“Washerwoman’s Syndrome”?
First Dorsal Compartment Tendinopathy
De Quervain’s DiseaseDe Quervain’s Disease
(Source: Author)
(Source: http://3.bp.blogspot.com/-Y76uWzfJ2uQ/T2tAkZmZgPI/AAAAAAAAA4A/o0dmhmZdDhA/s1600/asb2.jpg)
De Quervain’s History
Three Groups of Patients:
✦ Anatomical
✦ Pregnancy/lactation
✦ Mechanical
✦Anatomical variations:
✦ Septum between APL and EPB (30%-60%)
✦ Multiple tendon slips of APL
✦? More prone to De Quervain’s
(Mirzanli et. al., 2012; Orlandi et. al., 2014 Scheller, 2009; Vuillemin et. al., 2012)
(Source:
http://www.sciencedirect.com/science/articla/pii/S197134951
2000069)
De Quervain’s History
✦Pregnancy / Lactation
✦? d/t fluid retention, hormones
✦Mechanical stress of infant care
✦Self limiting with cessation of lactation (Avci et.
al., 2002; Orlandi et. al., 2014; Peters-Veluthamaningal et al., 2009; Scheller, 2009)
De Quervain’s History
✦Degenerative:
✦ Intrinsic, degenerative mechanism rather than
extrinsic inflammatory
✦Thickened sheath
✦ Increased ground substance (Scheller, 2009)
De Quervain’s - Examination
✦Finkelstein’s Test
✦Eichoff’s Test
✦WHAT Test
(Avci et. al., 2002; Peters-Veluthamaningal et al., 2009; Scheller, 2009)
Finkelstein’s Test
✦Often described
incorrectly!
✦Ulnar deviation with
longitudinal traction
✦Sensitivity: ?
✦Specificity: ?
(Goubau et al., 2014)
(Source: Goubau et al., 2014)
Eichoff’s Test
✦Often mislabeled as
Finkelstein’s Test
✦Passive Thumb
Opposition with Ulnar
Deviation
✦Sensitivity: 89%
✦Specificity: 14%(Source: Goubau et al., 2014)
(Goubau et al., 2014)
WHAT Test
✦Wrist in flexion
✦Resist thumb palmar
abduction
✦Sensitivity: 99%
✦Specificity: 29%
(Source: Goubau et al., 2014)
(Goubau et al., 2014)
(Source: Jbara, Patnana, Kazmi & Beltran; 2014)
De Quervain’s - MRI
✦De Quervain’s is primarily a clinical
diagnosis
✦Fluid in tendon sheath
✦+/- tendon sheath thickening
✦Low-signal intensity within tendon
sheath = fibrosis = poorer prognosis
(Source: Jbara, Patnana, Kazmi & Beltran; 2014)
De Quervain’s - Splinting
✦Best for more mild cases
✦ Short to midterm benefit demonstrated (moderate evidence)
✦ Contradictory evidence re: combining with steroid injection
✦ No studies comparing custom vs off-the-shelf splints
(Huisstede, Gladdines, Randsdorp & Koes, 2017; Richie & Briner, 2003Weiss et. al.; 1994)
De Quervain’s Management - Splinting
(Source: Author) (Source: Author)
(Source: dme-direct.com)
~$60
~$95
~$95
De Quervain’s Management - Injection
✦ Short to midterm benefit demonstrated (moderate evidence)
✦Superior to splinting alone
✦ Contradictory evidence re: combining with splinting injection
✦ Not as beneficial in females, obesity
✦ Suggestion that US guided is superior, particularly if septum is present
(Huisstede, Gladdines, Randsdorp & Koes, 2017; Oh, Messing, Hyrien & Hammert, 2017; Orlandi et. al., 2014; Richie & Briner, 2003; Weiss et. al.; 1994)
✦Before considering Sx:
✦4-6 months of conservative tx
✦1-3 cortisone injections (in both APL, EPB*)
✦Last resort treatment (Scheller et al., 2009)
De Quervain’s Management - Surgery
De Quervain’s Surgical Release
✦ If septum present, both APL EPB released
✦ Favorable outcomes in the long-term (16 years)
✦ High patient satisfaction
✦ Dorsal radial sensory nerve lesion more common
in open procedure vs. endoscopic
(Kang, Hahn, Kim & Choi, 2011; Scheller, 2009)
Hand TherapyHand Therapy
Hand Therapy
✦ Public (*Splinting = OT): HSC
✦ Private: EastCity Physiotherapy, Green Hand to
Shoulder Physiotherapy, Foundation
Rehabilitation Services, Centric Health
✦ “Splinting as required” on referral, please
Injections/Surgery
✦ Sports Medicine:
✦ Pan Am (* US guided - Dr. H. Peters)
✦ Legacy
✦ Plastic Sx (Hands)
✦ Ortho Sx (Hands)
Electrodiagnostic Testing
✦ Riverview Health Centre
✦ Health Sciences Centre
✦ St. Boniface Hospital
✦ Deer Lodge
✦ Private Neurologist
✦ Private Physiatrist
ReferencesAtroshi, I., Hofer, M., Larsson, G. U., Ornstein, E., Johnsson, R., & Ranstam, J. (2009). Open compared with 2-portal endoscopiccarpal tunnel release: a 5-year follow-up of a randomized controlled trial. J Hand Surg Am, 34(2), 266-272. doi:10.1016/j.jhsa.2008.10.026
Brunelli, G. (2003). [Finkelstein's versus Brunelli's test in De Quervain tenosynovitis]. Chir Main, 22(1), 43-45.
Calandruccio, J. H., & Thompson, N. B. (2018). Carpal Tunnel Syndrome: Making Evidence-Based Treatment Decisions. Orthop Clin
North Am, 49(2), 223-229. doi:10.1016/j.ocl.2017.11.009
D'Arcy, C. A., & McGee, S. (2000). The rational clinical examination. Does this patient have carpal tunnel syndrome? Jama, 283(23), 3110-3117.
Goubau, J. F., Goubau, L., Van Tongel, A., Van Hoonacker, P., Kerckhove, D., & Berghs, B. (2014). The wrist hyperflexion and abduction of the thumb (WHAT) test: a more specific and sensitive test to diagnose de Quervain tenosynovitis than the Eichhoff'sTest. J Hand Surg Eur Vol, 39(3), 286-292. doi:10.1177/1753193412475043
Hall, B., Lee, H. C., Fitzgerald, H., Byrne, B., Barton, A., & Lee, A. H. (2013). Investigating the effectiveness of full-time wrist splinting and education in the treatment of carpal tunnel syndrome: a randomized controlled trial. Am J Occup Ther, 67(4), 448-459. doi:10.5014/ajot. 2013.006031
Huisstede, B. M., Gladdines, S., Randsdorp, M. S., & Koes, B. W. (2017). Effectiveness of Conservative, Surgical, and Postsurgical Interventions for Trigger Finger, Dupuytren Disease, and De Quervain Disease: A Systematic Review. Arch Phys Med Rehabil. doi:10.1016/j.apmr. 2017.07.014
Jbara, M., Patnana, M., Kazmi, F., & Beltran, J. (2006). MR imaging: Arthropathies and infectious conditions of the elbow, wrist, and hand. Radiol Clin North Am, 44(4), 625-642, ix. doi:10.1016/ j.rcl.2006.04.009
Kang, H. J., Hahn, S. B., Kim, S. H., & Choi, Y. R. (2011). Does endoscopic release of the first extensor compartment have benefits over open release in de Quervain's disease? J Plast Reconstr Aesthet Surg, 64(10), 1306-1311. doi:10.1016/j.bjps.2011.05.015
LeBlanc, K. E., & Cestia, W. (2011). Carpal tunnel syndrome. Am Fam Physician, 83(8), 952-958.
ReferencesOh, J. K., Messing, S., Hyrien, O., & Hammert, W. C. (2017). Effectiveness of Corticosteroid Injections for Treatment of de Quervain's Tenosynovitis. Hand (N Y), 12(4), 357-361. doi: 10.1177/1558944716681976
Orlandi, D., Corazza, A., Silvestri, E., Serafini, G., Savarino, E. V., Garlaschi, G., . . . Sconfienza, L. M. (2014). Ultrasound-guided procedures around the wrist and hand: how to do. Eur J Radiol, 83(7), 1231-1238. doi:10.1016/j.ejrad.2014.03.029
Richie, C. A., 3rd, & Briner, W. W., Jr. (2003). Corticosteroid injection for treatment of de Quervain's tenosynovitis: a pooledquantitative literature evaluation. J Am Board Fam Pract, 16(2), 102-106.
Scheller, A., Schuh, R., Honle, W., & Schuh, A. (2009). Long-term results of surgical release of de Quervain's stenosing tenosynovitis. Int Orthop, 33(5), 1301-1303. doi:10.1007/ s00264-008-0667-z
Skirven, T. (1996). Clinical examination of the wrist. J Hand Ther, 9(2), 96-107.
So, H., Chung, V. C. H., Cheng, J. C. K., & Yip, R. M. L. (2018). Local steroid injection versus wrist splinting for carpal tunnel syndrome: A randomized clinical trial. Int J Rheum Dis, 21(1), 102-107. doi:10.1111/1756-185x.13162.
Tang, C. Q. Y., Lai, S. W. H., & Tay, S. C. (2017). Long-term outcome of carpal tunnel release surgery in patients with severe carpal tunnel syndrome. Bone Joint J, 99-b(10), 1348-1353. doi: 10.1302/0301-620x.99b10.Bjj-2016-0587.R2
Weiss, A. P., Akelman, E., & Tabatabai, M. (1994). Treatment of de Quervain's disease. J Hand Surg Am, 19(4), 595-598. doi:10.1016/0363-5023(94)90262-3
Wipperman, J., & Goerl, K. (2016). Carpal Tunnel Syndrome: Diagnosis and Management. Am Fam Physician, 94(12), 993-999.
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