|Year : 2018 | Volume
| Issue : 1 | Page : 38-42
De quervain’s disease: A case presentation
Angeline Jeya Rani
Lecturer, College of Nursing, CMC, Vellore, India
|Date of Web Publication||11-Jun-2020|
Source of Support: None, Conflict of Interest: None
Occupational health is a growing concern in hospitals. Health care professionals are highly prone to develop occupational health disorders that include musculoskeletal disorders. De Quervain disease is one of the musculoskeletal disorder prevailing among health care providers. The cause is inflammation of a tendon that involves disruption of normal flexor tendon function in the hand. Factors contributing to this disorder are overuse like straining while writing, and long computer use and other repetitive tasks which involve the use of fingers and wrists. Breast feeding mothers and patients with history of arthritis and diabetes are at high risk for De Quervain disease. The outcome of the disorder depends on early diagnosis and treatment.
Keywords: Occupational health, nursing, musculoskeletal disorder, De Quervain disease
|How to cite this article:|
Rani AJ. De quervain’s disease: A case presentation. Indian J Cont Nsg Edn 2018;19:38-42
| ntroduction|| |
Being healthy is the desire of all humans and the ultimate aim for many. One of the hindrances to a healthy lifestyle is the development of musculoskeletal disorders. This is especially true for health care professionals who need to be physically fit to render good care to patients. The tasks involved in rendering care to patients, however, sometimes predispose health care professionals to injuries and disorders that are predominantly musculoskeletal in nature.
Work-related musculoskeletal pain and injuries seem to be common among health care professionals, especially nurses all over the world. A systematic review in Brazil exploring 17 studies on work related disorders among nursing professionals revealed that work related musculoskeletal disorders commonly affected nursing professionals and were related to contributory conditions at the workplace, and is also influenced by organizational factors as well as structure of work (Lelis et.al, 2012).
In a study in Iran, 89% of nurses reported musculoskeletal pain, mainly in lower back (74%) and knees (48.5%) (Madani, Alavi, & Taghizadeh, 2014). A study in the Netherlands showed that 57% of nurses had musculoskeletal pain in at least one region. In a study done in Brazil, 80.7% of nurses complained of musculoskeletal pain. Upper extremity, shoulder, and neck injuries were common areas of pain among nurses. Most of these pain and injuries were due to lifting and moving patients manually (Alavi, 2014).
One such occupational health disorder to which nurses are susceptible is a relatively rare condition known as De Quervain disease. On an average 1.3% of working women suffer from De Quervain tenosynovitis (Stahl, et.al., 2015). Though it is rare, it is significant due to the serious complication of wrist deformity which affects occupational efficiency as well as effectiveness and decreases the quality of life in individuals affected with the disease. A qualitative research showed that painful physical manifestations and limitations generated a multiplicity of feelings among twelve women suffering from De Quervain disease (Leite, Merighi, Silva, 2007). Findings from a systematic review report that soft tissue disorder needs early identification and diagnosis to minimize pain and disability (Hubbard et.al, 2018).
| Background|| |
De Quervain tenosynovitis is otherwise called as texting thumb, gamer’s thumb or washer woman’s thumb. It is the inflammation of the sheath or synovium that surrounds the two tendons (extensor pollicis brevis and abductor pollicis longus) that run between the wrist and the thumb (see [Figure 1]).
|Figure 1: Anatomy of De Quervain’s Disease (Source: Medical Conspectus, 2015)|
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This condition was first described in 1895 by Fritz De Quervain, a Swiss surgeon who published five case reports of patients presenting with tender, thickened first dorsal compartment at the wrist and hence the condition was named after him.
| Etiology|| |
De Quervain tenosynovitis is believed to result from repetitive, forceful, ergonomically stressful work, trauma, drugs, hormonal influences, pregnancy, and rheumatoid disease. It is also reported by breast feeding mothers, probably due to the stress on wrist while holding the baby (Virzi, 2010). Activities like playing golf, playing piano, typing, carpentry, and carrying a child are closely linked to this disorder.
Pain, swelling, and tenderness along the radial aspect of the wrist, feeling or hearing creaking as the tendons slide through the sheath, and reduced grip strength are common signs and symptoms of De Quervain disease. It is aggravated by movements such as pinching, grasping or wringing and repetitive movements of wrist flexion, ulnar deviation, and thumb extension.
A simple method to diagnose the De Quervain disease is to do the following steps recommended by Kaizer Foundation Health Plan (2018).
Finkelstein stretch test
De Quervain disease is clinically diagnosed if the patient is positive for a simple test known as Finkelestein stretch test. This test can be performed while patient is seated comfortably on a chair or while lying down in bed or even while standing in relaxed posture. The examiner positions self in front of the patient and moves the thumb in ulnar deviation applying longitudinal traction. If patient experiences pain in the radial styloid process and along length of extensor pollicis brevis and abductor pollicis longus tendons, then test is positive for De Quervain’s tenosynovitis. Radiography studies are not an option as De Quervain disease cannot be ruled out. [Fiure 2]
|Figure 2: Demonstration of Finkelstein Test (Source: Medical Conspectus, 2015)|
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De Quervain disease can be treated by providing adequate rest to the wrist, avoiding straining of wrist, taking small breaks at work, ergonomics, hot or cold applications, anti inflammatory medications and splinting. The best therapy is exercises which can be performed easily (see [Figure 3] [Figure 4]).
|Figure 4: Exerises for De Quervain disease (Source: Summit Medical Foundation, 2018)|
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The following exercises are taught to patients:
Teach the technique of placing the hand on a flat surface while palm is facing up, slowly lifting the thumb away from palm, holding this position for 6 seconds.
Another technique is moving metapharyngeal joint passively. The hands are placed in ‘hand shaking position’ using unaffected hand is used to bend affected thumb, thus pointing thumb downward(see Figure 3). This position is held for 30 seconds and repeated 2 to 4 times a day (Hall & Brody, 2005).
|Figure 3: Thumb Lifting (Source: Harvard Health Publishing School, 2018)|
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In this exercise, the patient should rest the hand on a table with palm facing upwards. Then he should bring the tip of the thumb towards the tip of the little finger and touch it. The patient is advised to hold this position for 6 seconds and then release. This exercise is to be repeated ten times.
The patient should push the back of an injured side using the unaffected hand and then bend the wrist slowly. He/She is advised to hold for 15-30 seconds and then stretch the hand back.
The patient is advised to hold a can or hammer handle in hand with palm facing up and then bend the wrist upward. He/She should slowly lower the weight and return to the starting position and gradually increase the weight of the object.
Wrist radial deviation strengthening
The patient needs to put wrist in the sideways position with thumb up, hold a hammer handle and gently bend the wrist up, with the thumb reaching toward the ceiling. He/She /She is to then slowly lower to the starting position. He is advised not to move forearm throughout this exercise.
Here the patient is advised to hold a hammer handle in hand with palm facing down and slowly bend the wrist up and then slowly lower the weight down into the starting position, gradually increasing the weight of the object.
The patient should place a large rubber band around the outside of thumb and fingers, then stretch the fingers outward by allowing the rubber band to expand as much as possible.
The patient is advised to place a large rubber band around the outside of thumb and fingers. The patient is to squeeze a soft rubber ball and hold the squeeze for 5 seconds and then open fingers to stretch the rubber band.
Exercise alone may not be beneficial when there is severe inflammation. Injection of corticosteroid is considered to reduce inflammation and prevent scarring. A dose of 0.5ml of 1% Lidocaine and 0.5ml of long acting corticosteroid injection are administered into the sheath of the first dorsal compartment in a sequential manner to reduce the inflammation and tendon thickening. Drug administration need to be cautiously performed as it can cause atrophy of skin. If therapy fails, the physician would opt for surgical release of the first dorsal compartment. The person can resume light activities and use of hand for self-care and then progress to full activities. Complications after surgery include volar tendon subluxation.
The following case study highlights the symptoms, treatment, preventive measures for De Quervain disease.
A 23 year old young nurse presented to the Outpatient Department with swelling over the right thumb and pain over the right wrist for more than 3 months which affected her self- care and her functioning at work. She was unable to perform her routine patient care as her pain interrupted her work. She was referred to an orthopedician and a detailed history and physical examination was performed. She demonstrated a positive Finkelstein’s test on her right wrist that confirmed the diagnosis of De Quervain tenosynovitis. She was advised to perform simple stretching exercises throughout the day. She was also treated with Non Steroidal Anti Inflammatory Drugs namely Tab. Calpol T (combination of Paracetamol and Tramadol). With these simple interventions, she experienced relief from pain and swelling and was able to perform her tasks at work and at home demonstrating good recovery in a short span of time.
Nursing care of the patient involves assessment of patient, identification of symptoms and complications, provision of appropriate therapeutic interventions and health education.
1. Nursing Diagnosis: Acute pain related to musculoskeletal disorder as evidenced by pain score of 6 and above
Expected Outcome: Pain is minimized as evidenced by a pain score of less than 2
- Assessed the characteristics of pain such as location, intensity, frequency, duration of pain, aggravating factor, relieving factor
- Monitored the pain score 4 hourly
- Started each stretching exercise slowly.
- Stopped the exercise when it starts being painful
- Administered analgesics as ordered
- Consulted physician if pain aggravates
Evaluation: Patients’s pain reduced considerably by one week with the exercises and pain medication. She had no pain by the end oftwo weeks.
2. Nursing Diagnosis: Impaired physical mobility related to muscle and joint stiffness secondary to limited range of motion
Expected Outcome: Mobility improved as evidenced by ability to resume self-care and activities at work
- Taught simple exercises such as thumb lifting and opposition stretch
- Started with one exercise and gradually increased to more to improve range of motion in the wrist
- Encouraged to gradually increase self-care activities and other work
- Advised to monitor pain and take rest when needed
Evaluation: Mobility improved and she was able to join work and continue her activities as before by about two weeks.
3. Nursing Diagnosis: Activity intolerance related to pain, imposed activity restriction
Expected Outcome: Activity tolerance is improved as evidenced by resuming regular work
- Assessed the physical activity level and mobility
- Determined the patients daily routine
- Advised patient to perform the activity more slowly in a longer time with more rest or pauses or with assistance if necessary
- Gradually increased activity with active exercises
- Suggested to use assistive devices for work at kitchen
- Provided emotional support
Evaluation: Tolerance to activity increased with exercises and drug therapy. She was able to resume normal activity within two weeks.
4. Nursing Diagnosis: Anxiety related to pain, prognosis, threat to occupation and productivity
Expected Outcome: Anxiety is reduced as evidenced by verbal expression of relief of pain
- Helped the patient to identify factors that have contributed to need for treatment
- Supported the patient in adhering to treatment and gave positive feedback
- Maintained good interpersonal relationship
- Encouraged to express her feelings
Evaluation: With the relief in pain and her ability to resume work normally, she expressed reduced state of anxiety.
De Quervain hinders the ability of healthcare professionals, especially nurses to carry out their tasks effectively. As nurses report high levels of job related injury or illness and majority experience persistent job related pain, it is essential for nurses to be aware of the risk of developing De Quervain’s disease. Nurses also need to be familiar with the various exercises for De Quervain disease to improve mobility and reduce pain, thus improving productivity and efficiency at work. The recommended exercises can also be performed by those who are at high risk for developing De Quervain disease.
Conflicts of Interest: The author has declared no conflicts of interest.
| References|| |
Alavi, N. M. (2014). Occupational hazards in nursing. Nursing andMidwifery Studies
, 3(3), e22357.
Hall, C. M., & Brody, L. T. (2005). Therapeutic exercise: Moving toward function
. Philadelphia: Lippincott Williams & Wilkins.
Hubbard, M. J., Hildebrand, B. A., Battafarano, M. M., & Battafarano, D. F. (2018). Common Soft Tissue Musculoskeletal Pain Disorders. Primary Care: Clinics in Office Practice
, 45(2), 289-303.
Leite, P. C., Merighi, M. A. B., & Silva, A. (2007). The experience of a woman working in nursing suffering from De Quervain’s disease. Revista Latino-Americana de enfermagem
, 15(2), 253-258.
Lelis, C. M., Battaus, M. R. B., Freitas, F. C. T. D., Rocha, F. L. R., Marziale, M. H. P., & Robazzi, M. L. D. C. C. (2012). Work-related musculoskeletal disorders in nursing professionals: An integrative literature review. Acta Paulista de Enfermagem
, 25(3), 477-482. doi.org/10.1590/S0103-21002012000300025
Madani, M., Alavi, N. M., & Taghizadeh, M. (2014). Nonspecific musculoskeletal pain and vitamin D deficiency in female nurses in Kashan, Iran. Journal of Musculoskeletal Pain
, 22(3), 268-274.
Stahl, S., Vida, D., Meisner, C., Stahl, A. S., Schaller, H. E., & Held, M. (2015). Work related etiology of de Quervain’s tenosynovitis: a case-control study with prospectively collected data. BMC Musculoskeletal Disorders
, 16(1), 126.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]