De Quervain Tenosynovitis: MRI
34 yrs male with chronic right thumb pain /
no trauma / X ray unremarkable for MRI right hand, shows -Diffuse subcutaneous edema on
radial aspect of lower third of forearm
/ wrist /proximal hand regions with significant free fluid along the tendons of
first extensor compartment ( Abductor pollicis longus – APL & Extensor
pollicis brevis – EPB) with relative more involvement of APL than EPB with ill
definition & enlargement of tendons including insertional sites ( APL sips
to trapezium/base of 1st metacarpal & EPB to base of proximal phalanx of thumb) with no
significant radial styloid abnormality – possibly suggesting De Quervain
tenosynovitis. Subtle edema /tiny cyst in
lunate (contour & intercarpal articulations maintained) with subtle
heterogeneity of the triangular fibrocartilage complex ligament with rest grossly
normal – possibly represent stress related change. Case Report submitted by Dr GA Prasad & Dr MGK Murthy
Discussion –
Clinically – h/o of
repetitive overuse and sustained thumb abduction and extension in combination
with radial and ulnar wrist movements in the dominant hand as usually seen in
workplace activities / carrying babies/ sports related with associated soft tissue swelling in the
radial side of wrist.
Classic de Quervain’s
tenosynovitis includes chronic inflammation scar formation with stenosis of the
approximately 1-cm-long fibroosseous tunnel of the first dorsal compartment
(the groove along the radial styloid process covered by the overlying extensor
retinaculum through which the abductor pollicis longus and extensor pollicis
brevis tendons run). Histological examination of the disease reveals myxoid
degeneration within the tendon sheath wall with degeneration as the primary
process rather than inflammation within the tendon sheath.
Typical MRI findings de Quervain’s tenosynovitis are
soft-tissue enlargement in the region of the first compartment of the wrist,
thickening of the tendon sheath with decreased signal intensity on both T1- and
T2-weighting, bone spurring at the site of attachment of the overlying extensor
retinaculum .
MRI can help in
prognostication & guiding management by providing information about –
-
Number of slips of each tendon,
-
Presence of any intervening septum
&
-
Relative severity of
involvement of each tendon separately.
These findings may be
predisposing conditions for the disease & may cause surgical or
percutaneous treatment to fail.
Multiple tendon slips have
variable insertions and cause increased friction, predisposing to tenosynovitis
with “lotus root” appearance on ultrasound with tendon slips appearing as holes
in the sliced lotus root.
Multiple slips are more
common in APL than EPB tendons. Information about multiple APL tendons is also
relevant for surgical procedures in patients with degenerative joint disease
and chronic subluxation of the first carpometacarpal joint. Presence of a
septum may split the first extensor compartment into subcompartments partially
or completely. This anatomic variation is common in de Quervain tenosynovitis
with poor response to both medical and operative management . Failure to inject
steroid into or surgically decompress both the subcompartments may lead to persistent
symptoms. In the presence of an intervening septum, the EPB tendon is usually
more severely affected than the APL tendon. The septum is much easier to
visualize on ultrasound & MRI may suggest its presence indirectly by
involvement of only one of the tendons. Other indirect indicators of
subcompartmentalization include a bony ridge and double groove on the surface
of the radial floor.
Radiologic
differentials - include atypical infections, scaphoid
fracture or nonunions or radioscaphoid arthritis, and trapeziometacarpal joint
arthritis where bony findings help in diagnosis. Rheumatoid arthritis can be
another cause of stenosing tenosynovitis of the wrist.
Clinically, flexor carpi
radialis tenosynovitis entrapment of the branches of the superficial radial
nerve can mimic de Quervain’s disease.
Another rare differential
diagnosis, both clinically and radiologically, is the intersection syndrome .
Pain and swelling of the muscle bellies of abductor pollicis longus and extensor
pollicis brevis 4 cm proximal to the wrist joint and the disorder location are
probably caused by tenosynovitis of the second dorsal compartment of the wrist.
De Quervain Tenosynovitis: MRI
Reviewed by Sumer Sethi
on
Thursday, April 11, 2019
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