Randomised controlled trial of local corticosteroid injections for de Quervain's tenosynovitis in general practice

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Publisher: BioMed Central Ltd.
Document Type: Clinical report
Length: 3,747 words

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Authors: Cyriac Peters-Veluthamaningal (corresponding author) [1]; Jan C Winters [1]; Klaas H Groenier [1]; Betty Meyboom-deJong [1]

Background

De Quervain's tenosynovitis is a condition that causes wrist pain and that can lead to disfunction of the affected hand. It is caused by impaired gliding of the tendons of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) muscles[1]. This is most probably caused by thickening of the extensor retinaculum (the thickened part of the general tendon sheath that holds the tendons of the extensor muscles in place) of the wrist.

Fritz de Quervain, a Swiss physician, is given credit for first describing this condition with a report of five cases in 1895 and eight additional cases in 1912[2, 3]. Although the term stenosing tenosynovitis is frequently used, pathophysiology of de Quervain's disease does not involve inflammation since on histopathological examination mainly degenerative changes such as myxoid degeneration, fibrocartilagenous metaplasia and deposition of mucopolysaccharide are seen[4].

The diagnosis is made by history and physical examination. Symptoms consist of pain or tenderness at the radial styloid sometimes radiating to the thumb, forearm or shoulder and on physical examination there might be swelling at the radial styloid with tenderness and crepitations on palpation. Finkelstein's test (deviating the wrist to the ulnar side, while grasping the thumb, results in pain) is in typical cases positive. A positive Finkelstein's test has a between observer repeatability (k) of 0.79[5]. Unfortunately there is no golden diagnostic confirmatory test for de Quervain's tenosynovitis. In the literature a variety of terminology (e.g. tendinitis, peritendinitis, tenosynovitis, tenovaginitis) and case-definitions are used for this condition. In 1998 and 2001 efforts have been made to construct reliable classifications and case-definitions for soft-tissue rheumatic disorders of the upper limb, including de Quervain's tenosynovitis [5, 6, 7].

In a large community based study from the United Kingdom, the prevalence of de Quervain's tenosynovitis was 0,5% for men and 1,3% for women[8]. It was associated with considerable impact on daily activities and health seeking behaviour. The prevalence and incidence of patients with de Quervain's tenosynovitis in primary care are not known.

De Quervain's tenosynovitis can be treated by operative and non-operative treatment. Operative therapy (slitting or removing a strip of the tendon sheet) has been reported to be effective with a 91% cure rate in non-controlled studies, but is more invasive and associated with higher costs and the possibility of surgical complications[9].

The effectiveness of injection therapy is often attributed to anti-inflammatory effects of corticosteroids but the exact mechanism of action remains unclear. A recent Cochrane review found one controlled clinical trial by Avci of 18 participants (all pregnant or lactating women) that compared one steroid injection with methylprednisolone and bupivacaine to splinting with a thumb spica[10, 11]. All patients in the steroid injection group (9/9) achieved complete relief of pain whereas none of the patients in the thumb spica group (0/9) had complete relief of pain, one to six days after intervention (number needed to treat to benefit (NNTB) = 1. However, it...

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Gale Document Number: GALE|A211566902