De Quervain's Tenosynovitis (Guide to the diagnosis of work-related musculoskeletal disorders, 2)

Work-related musculoskeletal injuries are one of the most common occupational health problems for which physicians are consulted. There is solid scientific evidence that these injuries may be occupational in origin.

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GUIDE TO THE DIAGNOSIS OF WORK-RELATED MUSCULOSKELETAL DISORDERS

This guide was designed to help physicians interpret the results of a medical examination. By combining the standard clinical assessment procedure with guidelines concerning the identification of etiological factors, it helps physicians identify the cause of injury.

AUTHORS Louis Patry holds a degree in medicine from Laval University and a diploma in ergonomics from the Conservatoire National des Arts et Metiers de Paris (CNAM). He is a specialist in occupational medicine, an associate member of the Royal College of Physicians and Surgeons of Canada, a professor in McGill University’s Department of Epidemiology and Biostatistics and Occupational Health, and consulting physician to the Direction de la santé publique (Public Health Department), first in Québec City and currently at the MontréalCentre board.

Michel Rossignol holds degrees in biochemistry and medicine from the University of Sherbrooke, in epidemiology and community health from McGill University, and in occupational medicine from John Hopkins University. He is a professor in McGill University’s Department of Epidemiology and Biostatistics and Occupational Health, co-director of the Centre for Clinical Epidemiology of the Jewish General Hospital of Montréal, and physician-epidemiologist at the Montréal-Centre board of the Direction de la santé publique (Public Health Department).

Marie-Jeanne Costa holds a nursing degree from the Institut d’études paramédicales de Liège and a degree in ergonomics from the École Pratique des Hautes Études de Paris. She is an ergonomics consultant and has collaborated on several studies of CTDs. She is particularly interested in the development of participatory ergonomics, specifically in the problem-resolution and diagnostic processes.

Martine Baillargeon holds a degree in medicine from the Université de Montréal. She is a plastic surgeon and associate member of the Royal College of Physicians and Surgeons of Canada. After years of practising surgery she is now consulting physician, mainly in the field of musculoskeletal injuries affecting the upper limb, at the Montréal-Centre board of the Direction de la santé publique (Public Health Board).

De Quervain’s Tenosynovitis Louis PATRY, Occupational Medecine Physician, Ergonomist Michel ROSSIGNOL, Occupational Medecine Physician, Epidemiologist Marie-Jeanne COSTA, Nurse, Ergonomist Martine BAILLARGEON, Plastic Surgeon

GUIDE TO THE DIAGNOSIS OF WORK-RELATED MUSCULOSKELETAL DISORDERS

De Quervain’s Tenosynovitis Louis PATRY, Occupational Medecine Physician, Ergonomist Michel ROSSIGNOL, Occupational Medecine Physician, Epidemiologist Marie-Jeanne COSTA, Nurse, Ergonomist Martine BAILLARGEON, Plastic Surgeon

Canadian Cataloguing in Publication Data Main entry under title: Guide to the diagnosis of work-related musculoskeletal injuries Translation of: Guide pour le diagnostic des lésions musculo-squelettiques attribuables au travail répétitif. Includes bibliographical references. Contents: 1. Carpal tunnel syndrome – 2. De Quervain’s tenosynovitis – 3. Shoulder tendinitis. Co-published by: Institut de recherche en santé et en sécurité du travail du Québec. ISBN 2-921146-70-3 (v. 1) – ISBN 2-921146-71-1 (v. 2) – ISBN 2-921146-72-X (v. 3) 1. Musculoskeletal system – Wounds and injuries – Diagnosis. 2. Overuse injuries – Diagnosis. 3. Carpal tunnel syndrome – Diagnosis. 4. Tenosynovitis – Diagnosis. 5. Tendinitis – Diagnosis. 6. Occupational diseases – Diagnosis. I. Patry, Louis. II. IRSST (Quebec). III. Workplace Safety & Insurance Board. RC925.7.G8413 1998 616.7’075 C98-940950-3

Translation:

Les Services Organon, Steven Sacks

Graphic design:

Gérard Beaudry

Illustrations:

Marjolaine Rondeau, Medical Illustration Department of the Laval University Hospital Centre (CHUL) Max Stiebel, Instructional Communications Centre (ICC), McGill University

Rear-cover photographs: Gil Jacques Legal deposit – Bibliothèque nationale du Québec, 1998 Legal deposit – National Library of Canada, 1998 ISBN 2-921146-71-1 Éditions MultiMondes (Original edition: ISBN 2-921146-38-X) © Éditions MultiMondes, 1998 Éditions MultiMondes 930, rue Pouliot Sainte-Foy (Québec) Canada G1V 3N9 Tel.: (418) 651-3885 Fax: (418) 651-6822

Institut de recherche en santé et en sécurité du travail 505, boul. de Maisonneuve Ouest Montréal (Québec) Canada H3A 3C2 Tel: (514) 288-1551 Fax: (514) 288-7636

Régie régionale de la santé et des services sociaux – Montréal-Centre Direction de la santé publique 1301, rue Sherbrooke Est Montréal (Québec) Canada H2L 1M3 Tel.: (514) 528-2400 Fax: (514) 528-2459

PREFACE

The diagnosis of cumulative trauma disorders (CTDs) presents many unique problems, especially for physicians. The absence of precise criteria upon which to establish a clinical diagnosis of CTD or decide whether a musculoskeletal injury is related to occupational factors was noted by several members of the advisory committee supporting an international expert group mandated by the IRSST to review the literature on CTDs*. To remedy this situation, in 1992 the IRSST asked a group of researchers to develop diagnostic guides for carpal tunnel syndrome, De Quervain’s tenosynovitis, and tendinitis of the shoulder. The project team was initially composed of Louis Patry, occupational medecine physician and ergonomist, and Michel Rossignol, occupational medecine physician and epidemiologist, but quickly grew and increased the scope of its expertise through the addition of Marie-Jeanne Costa, a nurse with ergonomics training, and Martine Baillargeon, a plastic surgeon. All four team members participated in the drafting of the guides. These guides were designed to help physicians arrive at a clinical diagnosis and identify the most probable etiological agents. It should be noted that these guides were not designed for administrative or legal purposes and that their reliability has not been evaluated by the researchers. The publication of these guides designed specifically for physicians is one more advance in the IRSST’s efforts to shed light on the phenomenon of cumulative trauma disorders and provide specialists with appropriate tools with which to prevent these injuries and reduce related risk factors.

Jean Yves Savoie Director general Institut de recherche en santé et en sécurité du travail du Québec

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* Hagberg, M., Silverstein, B., Wells, R., Smith, M.J., Hendrick, H.W., Carayon, P., Pérusse, M. (1995), Work related musculoskeletal disorders (WMSDs): a reference book for prevention, scientific editors: Kuorinka, I., Forcier, L., publishers Taylor and Francis, London, 421 pages.

INTRODUCTION

This guide is the second in a series of practical summaries of current medical knowledge on musculoskeletal injuries with well-documented occupational etiology, namely: – carpal tunnel syndrome (CTS) – De Quervain’s tenosynovitis – tendinitis of the shoulder When occupational in origin, these injuries are often referred to as “CTDs”, a term applicable to “problems and diseases of the musculoskeletal system that include, among their causes, some factor related to work” (Hagberg et al., 1995). Whatever term is used to designate them—occupational overuse syndrome (OOS), repetitive strain injuries (RSI) or cumulative trauma disorders (CTDs) in English, troubles musculo-squelettiques (TMS), lésions musculo-squelettiques (LMS), lésions musculo-tendineuses (LMS), lésions musculo-tendineuses liées aux tâches répétitives, or pathologies d’hyper-sollicitation in French—their defining characteristic is the presence of an injury caused by biomechanical strain due to tension, pressure, or friction which is excessively forceful, repetitive, or prolonged. This guide is designed for physicians who are called upon in the course of their practice to diagnose musculoskeletal injuries and establish the extent to which these injuries are caused by their patient’s work. Its goal is to help physicians arrive at clinical and etiological diagnoses. To this end, the guide first reviews the anatomical, physiopathological, and etiological knowledge upon which diagnosis depends. This is followed by guidelines for the evaluation of symptoms, the conduct of the clinical examination, and the control of potential risk factors related to the development of the injury. Musculoskeletal injuries may have many causes. For carpal tunnel syndrome (CTS), De Quervain’s tenosynovitis, and tendinitis of the shoulder, these include not only occupational, sports-related, recreational, and household activities, but also specific health problems and conditions. This guide was prepared in response to requests from physicians, increasingly preoccupied by CTDs, for information and support on this subject. Although the approach taken emphasizes the documentation of potential occupational risk factors—a subject little discussed in formal medical training—it does not neglect the evaluation of other potential causes of De Quervain’s tenosynovitis. This guide is meant to be used in a clinical setting. To help physicians collect the information they need to diagnosis the injury and establish its causes, it therefore includes a series of questions, presented in readily identifiable text boxes, for them to ask their patients. These questions were derived from psycho-physical scales used by ergonomists to subjectively evaluate workload (Sinclair, 1992) and medical questionnaires developed for the diagnosis of CTS and the evaluation of functional capacity (Katz et al., 1994; Levine et al., 1993; Rossignol et al., 1995).

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Should however a physician remain unable to come to a definitive conclusion about the work-relatedness of an injury after consulting this guide, she or he should continue to seek information which will enable her or him to better evaluate the occupational musculoskeletal load to which her or his patient is subjected. Finally, it should be noted that this guide does not address the issues of multiple injuries and the psychosocial aspects of musculoskeletal injuries, important as they may be for the global evaluation of the patient.

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TABLE OF CONTENTS

Chapter 1 – General Considerations Introduction and Terminology ..................................................................................... 1 Epidemiology................................................................................................................. 1 Anatomical Review........................................................................................................ 1 Pathophysiology ............................................................................................................ 1 Chapter 2 – Etiology General Considerations................................................................................................. 3 Work-relatedness of Musculoskeletal Strain ................................................................ 3 Chapter 3 – Differential Diagnosis Thumb carpometacarpal osteoarthrosis ....................................................................... 5 Intersection Syndrome .................................................................................................. 6 Wartenberg’s Syndrome ................................................................................................ 6 Brachioradialis Insertion Tendinitis (Insertion of the Brachioradialis)....................... 7 Tendinitis of the Extensor Digitorum Communis........................................................ 7 Chapter 4 – Clinical Considerations Symptoms ...................................................................................................................... 9 Location of Symptoms (Where?)............................................................................ 9 Onset of Symptoms (When?) ................................................................................. 9 Characteristics of Onset (How?)............................................................................. 9 Impact on Activities of Daily Living........................................................................... 10 Chapter 5 – Recording of Information on Exposure Factors Occupational History .................................................................................................. 11 Previous Work....................................................................................................... 11 Current Work......................................................................................................... 12 Current Work and Organisational Factors ........................................................... 14 Sports-related, Recreational, And Household Activities............................................ 15 Chapter 6 – Clinical Examination Physical Examination .................................................................................................. 17 Observation........................................................................................................... 17 Palpation................................................................................................................ 17 Assessment of Range of Movement..................................................................... 17

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Dynamic Movements against Resistance ............................................................. 17 Diagnostic Tests .................................................................................................... 18 Chapter 7 – Summary of the Evaluation .................................................................... 19 Chapter 8 – Guidelines for Therapeutic and Preventive Interventions Therapeutic Guidelines ............................................................................................... 21 Prevention Guidelines................................................................................................. 22 Conclusion........................................................................................................................ 23 Bibliography .................................................................................................................... 25 List of Figures Figure 1.1 Insertion and Action of the Tendons of the Extensor Pollicis Brevis and Abductor Pollicis Longus.......................................................................... 2 Figure 3.1 Test for Carpometacarpal Osteoarthrosis of the Thumb ............................... 5 Figure 3.2 Test for the Intersection Syndrome................................................................. 6 Figure 3.3 Test for Wartenberg’s Syndrome ..................................................................... 6 Figure 3.4 Test of the Brachioradialis............................................................................... 7 Figure 3.5 Test of the Extensor Digitorum Communis .................................................... 7 Figure 6.1 Groove of the Radial Styloid Process, First Dorsal Compartment of the Wrist ..................................................................................................... 17 Figure 6.2 Test of the Abductor Pollicis Longus ............................................................ 18 Figure 6.3 Test of the Extensor Pollicis Brevis............................................................... 18 Figure 6.4 Finkelstein’s Test ............................................................................................ 18 Figure 8.1 Therapeutic Intervention Flow-chart ............................................................ 21 List of Table Table 8.1

Preventive Approach...................................................................................... 22

List of Boxes

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Box 2.1

Most Common Stressful Movements of the Abductor Pollicis Longus and Extensor Pollicis Brevis ............................................................................ 4

Box 4.1

Symptoms Reported by the Patient................................................................. 9

Box 4.2

Presentation and Clinical Severity of Symptoms.......................................... 10

Box 4.3

Questions about Activities of Daily Living ................................................... 10

Box 5.1

Questions about Previous Work.................................................................... 11

Box 5.2

General Questions on Occupational Activity and Associated Symptoms.... 12

Box 5.3

Questions about Activities that Cause Pain in the Hands or Wrist ............. 13

Box 5.4

Questions about Organisational Factors at Work......................................... 14

Box 5.5

Questions about Sports, Recreational, and Household Activities Involving the Hands or Wrist ........................................................ 15

Box 7.1

Clinical Aspects .............................................................................................. 19

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General Considerations

INTRODUCTION AND TERMINOLOGY

ANATOMICAL REVIEW

De Quervain’s tenosynovitis or tendinitis was first described in 1895 by Fritz De Quervain, a Swiss surgeon. Prior to this, the first use of the terms “tenosynovitis” and “crepitating peritendinitis” to describe injuries to the tendons and surrounding tissues was by Velpeau in 1825. This condition is a wrist tendinitis with inflammation of the tendon sheaths of the abductor pollicis longus and extensor pollicis brevis.

The tendons of the forearm are relatively long, extending beyond the wrist to cover the dorsal aspect of the hand and thumb. The tendons of the abductor pollicis longus and extensor pollicis brevis both run through the groove of the radial styloid process in the first of the six dorsal compartments of the wrist and have their insertion at the base of the first metacarpal and the proximal phalanx of the thumb (Figure 1.1).

EPIDEMIOLOGY De Quervain’s tenosynovitis is the most common tenosynovitis affecting the dorsal tendons of the wrist. It is usually diagnosed in individuals between 30 and 50 years of age and is ten times more prevalent among women than men (Dupuis, 1986). American and Scandinavian studies examining the relation between work activities and De Quervain’s tenosynovitis have rarely distinguished between this condition and other type of tendinitis of the wrist and hands. Epidemiological studies have demonstrated that workers in the meat processing and manufacturing industries run a higher risk of developing tendinitis of the hand and wrist: performing highly repetitive work increases the relative risk of developing De Quervain’s tenosynovitis to 3.3, while performing work requiring the exertion of great force increases it to 6.1. Among individuals performing work that is both highly repetitive and forceful, the relative risk is 29 (Hagberg et al., 1995).

These muscles, individually and jointly, extend and abduct the trapezometacarpal joint and extend the metacarpophalangeal joint. They are also active during radial deviation and, to a lesser extent, flexion of the wrist (Kendall et al., 1988). Both are innervated by the posterior interosseous branch of the radial nerve, which originates mostly in the C6, C7, and C8 roots. PATHOPHYSIOLOGY De Quervain’s tenosynovitis is a stenosing tenosynovitis involving inflammation of the tendon sheath of the extensor pollicis brevis and abductor pollicis longus (Dupuis, 1986; Hagberg et al., 1995). The rigidity of the structures and limited space within the wrist compartment favour the development of tenosynovitis. 1

Guide to the Diagnosis of Work-Related Muskuloskeletal Disorders

Figure 1.1

Insertion and Action of the Tendons of the Extensor Pollicis Brevis and Abductor Pollicis Longus

Extensor pollicis brevis

Tenosynovitis may result from trauma or from excessive friction between the tendon and surrounding tissues during movements of the thumb and wrist. The thickness of the synovial membranes is an indication of the stage of the tendinitis. As the inflammation progresses, the tendon tends to thin

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Abductor pollicis longus

out and become more friable, and stenosis increases. In the final stages, the sheath of the first dorsal compartment thickens, becomes fibrous, and impinges on the space of the fibro-osseous groove. This may result in “trigger finger”, a chronic form of De Quervain’s tenosynovitis.

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Etiology

GENERAL CONSIDERATIONS Tendinitis and tenosynovitis may occur when muscle and tendon structures are subjected to: – regular biomechanical strain which, over the long term, exceeds the limits of the tendons and synovial membranes – intense or unusual biomechanical strain (resumption of working activities after an absence, increase in production rates, modification of tasks, intense practice of a sport or musical instrument) – local trauma Tendinitis and tenosynovitis of the upper limb may also be related to: – metabolic diseases (diabetes mellitus, hypothyroidism, gout, ankylosing spondylitis, various collagenoses) – infection such tuberculosis or a bacterial infection – specific conditions such as pregnancy De Quervain’s tenosynovitis may coexist with carpal tunnel syndrome and “trigger finger”. Tenosynovitis affecting the dorsal tendons of the wrist may be of two types: – Tenosynovitisis with effusion is of infectious or rheumatoid origin. In the latter case, it is indicative of rheumatoid arthritis and may presage polyarthritis (Dupuis, 1986). – De Quervain’s tenosynovitis is one of the most common forms of the stenosing tenosynovitises, inflammatory conditions whose most common cause is microtrauma. The palmar aspect of the flexor digitorum profundus tendons may be in-

volved, and the condition may be congenital or secondary to rheumatoid arthritis (Dupuis, 1986). WORK-RELATEDNESS OF MUSCULOSKELETAL STRAIN Excluding accidents, the primary pathophysiological cause of De Quervain’s tenosynovitis is biomechanical strain on the tendons of the abductor pollicis longus and extensor pollicis brevis in the groove of the radial styloid process as a result of physical activity. As noted in the section on epidemiology, musculoskeletal strain associated with actions that are highly repetitive or forceful or both is an important cause of hand and wrist tendinitises, including De Quervain’s tenosynovitis (Hagberg et al., 1995). De Quervain’s tenosynovitis is also associated with grasping objects with the fingers spread, rotation of the wrist, and pronation-supination of the forearm (Kuorinka and Koskinen, 1979; Kurppa et al., 1991; Kroemer, 1989). Wrist movements requiring a pinch grip and frequent hand movements with the wrist flexed and thumb abducted generate great strain on the tendons of the abductor pollicis longus and extensor pollicis brevis. Finally, factors such as the use of gloves and exposure to cold or vibration increase the risk of developing this condition. Box 2.1 illustrates the movements frequently associated with De Quervain’s tenosynovitis. The symptoms of De Quervain’s tenosynovitis may

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Guide to the Diagnosis of Work-Related Muskuloskeletal Disorders

Box 2.1

Most Common Stressful Movements of the Abductor Pollicis Longus and Extensor Pollicis Brevis

Repeated application of pressure while flexing the distal phalanx of the thumb

Loaded abduction or extension of the thumb

Wrist movements during normal or pinch prehension

Loaded flexion-extension of the wrist

Application of thumb pressure with the wrist deviated Cofactors – Strain on the thumb: • during wrist movements • while maintaining pressure on the palm or the hand • use of gloves 4

• exposure to cold or vibration

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Differential Diagnosis

be confused with those of several other pathological conditions, including: – – – – –

carpometacarpal osteoarthrosis of the thumb intersection syndrome Wartenberg’s syndrome brachioradialis insertion tendinitis tenosynovitis of the extensor digitorum communis

Figure 3.1

Test for Carpometacarpal Osteoarthrosis of the Thumb

THUMB CARPOMETACARPAL OSTEOARTHROSIS Clinical Presentation Osteoarthrosis of the trapezometacarpal joint and usually affects women aged 50-70 years (Figure 3.1). It is accompanied by local deformity, crepitation, and pain of variable intensity that is unrelated to radiological changes (Dupuis, 1986). Probable causes – trauma – age- and sex-related factors Diagnostic Test Simultaneous axial compression and rotation of the thumb will elicit pain at the trapezometacarpal joint. INTERSECTION SYNDROME

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Guide to the Diagnosis of Work-Related Muskuloskeletal Disorders

Figure 3.2

Test for the Intersection Syndrome

Clinical Presentation This syndrome is caused by inflammation at the point where the tendons of the extensor carporadialis longus and brevis muscles of the second compartment of the extensors intersect the sheaths of the abductor pollicis longus and extensor pollicis brevis (Figure 3.2). Probable Causes – repetitive finger-pinch prehension while flexing and extending the wrist or supinating the forearm – direct trauma Diagnostic Test Palpation will reveal a painful area and crepitation with swelling on the radial side approximately three finger-widths above the wrist (Pujol, 1993). WARTENBERG’S SYNDROME

Figure 3.3

Test for Wartenberg’s Syndrome

This syndrome is caused by compression of the distal sensory branch of the radial nerve (Figure 3.3). Clinical Presentation – pain or numbness over the distal third of the forearm, increased by ulnar deviation – discomfort while writing – discomfort while grasping objects or using a pinch grip Possible Causes of Compression – – – –

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external trauma, falls, twisting of the forearm repetitive or forceful pronation compression by a bracelet or watch compression by soft-tissue disorders (synovial cyst, tumour, subcutaneous haematoma)

Diagnostic Tests Symptoms may be elicited by applying pressure over an area two finger-widths wide proximal to the radial styloid process while the patient maintains the forearm pronated and the wrist in ulnar deviation (Figure 3.3). The test is considered positive if symptoms occur in less than one minute. Finkelstein’s test may also be positive (See Figure 6.4, page 18). BRACHIORADIALIS INSERTION TENDINITIS

(INSERTION OF THE BRACHIORADIALIS) Clinical Presentation

Figure 3.4

Test of the Brachioradialis

Resisted elbow flexion* and application of pressure on the radial styloid process both elicit pain over the radial styloid process. Probable Causes – Performing repeated finger-pinch prehensions with the wrist supinated or extended Diagnostic Test Resisted movement of the brachioradialis elicits pain at its insertion on the radial styloid process (Figure 3.4). TENDINITIS OF THE EXTENSOR DIGITORUM COMMUNIS Clinical Presentation Pain is present on the radial side of the dorsal aspect of the wrist, and may be accompanied by swelling. Probable Causes

Figure 3.5

Test of the Extensor Digitorum Communis

– Extension movements – Sustained static pronation associated with grasping of objects Diagnostic Test Resisted extension elicits the symptoms and indicates the presence of tendinitis of the extensor digitorum communis (Figure 3.5).

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* The term “resisted movement” refers to a movement made while force is applied in the opposite direction.

DE QUERVAIN’S TENOSYNOVITIS

4

Clinical Considerations

SYMPTOMS The following questions are essential in establishing the medical history of patient presenting with symptoms suggestive of De Quervain’s tenosynovitis: – Where do you feel pain? – When did the pain start? – What did the pain first feel like and what does it feel like now? Location of Symptoms (Where?) De Quervain’s tenosynovitis presents as pain in the region of the apophysis of the radial styloid process. Swelling, antalgic radial deviation of the hand, and local inflammation (erythema and warm skin) may be present in long-standing cases. Onset of Symptoms (When?) Physicians should determine the time elapsed between the onset of symptoms and the current consultation. Patients should be asked the precise reason for their consultation. Symptoms are usually pre-

ceded by a prepathogenic period during which environmental or other pathophysiological factors are assumed to trigger a pathological condition (Hagberg et al., 1995). Characteristics of Onset (How?) The onset of symptoms may be sudden or progressive, and may be caused by accidents or activities involving the hand or wrist. To facilitate identification of the underlying causal factors, patients should be asked to describe in detail the circumstances surrounding the appearance of their symptoms. Symptoms which intensify during a given activity and disappear at rest or when the patient is away from work strongly suggest an extrinsic cause (musculoskeletal strain) (Porter et al., 1992). A staging scale for evaluating the severity of the symptoms associated with hand and wrist activities is proposed in Box 4.2.

Box 4.1

Symptoms Reported by the Patient – Pain near the apophysis of the radial styloid radiating to the thumb or forearm – Increased pain upon mobilisation of the thumb with the wrist flexed and in ulnar deviation – Weakness and pain during grasping

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Guide to the Diagnosis of Work-Related Muskuloskeletal Disorders

Box 4.2

Presentation and Clinical Severity of Symptoms Clinical presentation

Severity

Symptoms caused by forceful or repetitive movements of the wrist and the thumb

Symptoms

0

None during these activities

1

slight

Only after intense and repetitive activities

2

moderate

Only after light or occasional activities

3

severe

Present even at rest

Source: Adapted from Mahoney et al., 1992

IMPACT ON ACTIVITIES OF DAILY LIVING In addition to pain, patients may suffers a diminished ability to perform pinching activities with the thumb, which hinders them from performing certain

tasks of daily living. Box 4.3 lists a series of questions which will help patients pinpoint the extent of their disability.

Box 4.3

Questions about Activities of Daily Living Which hand is your dominant hand?

Right ❐ Never

Do you experience difficulty: – writing with a pencil or pen – buttoning a shirt – turning a key in a lock – picking up and holding objects with your hand – opening a car door – unscrewing the cover of a jar – performing twisting motions (e.g. wringing) 10

Sometimes

Left ❐ Often

Always

Recording of Information on Exposure Factors

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Tendinitis of the hand and wrist—such as De Quervain’s tenosynovitis—has been reported to be associated with forceful or repetitive occupational activities, with the risk of developing tendinitis significantly increased when exposure is to activities that are both forceful and repetitive (Hagberg et al., 1995). Information on environmental cofactors such as exposure to cold and vibration should also be gathered.

necessary to characterise the occupational, sportsrelated, and household activities that may have contributed to the development of tendinitis or tenosynovitis. Previous Work The patient’s occupational history provides information on the extent of previous exposure to workrelated musculoskeletal strain of the upper limb.

OCCUPATIONAL HISTORY To establish that a case of De Quervain’s tenosynovitis is caused by biomechanical requirements it is

Box 5.1

Questions about Previous Occupations Work performed

Starting date and duration in months or years

Hours per day

Risk factors or cofactors*

* See Box 2.1

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Guide to the Diagnosis of Work-Related Muskuloskeletal Disorders

Current Work The description of current work should allow the physician to form a good idea of the patient’s work and the conditions under which it is performed. As it is generally difficult for physicians to visit the workplace, this guide presents series of questions designed to help them: – obtain accurate information on the general nature of the work (Box 5.2) – determine the presence of specific biomechanical requirements which favour the development of De Quervain’s tenosynovitis (Boxes 5.3 and

5.5) – evaluate the contribution of organisational factors (Box 5.4) There is a wide range of repetitive occupational activities. Box 5.3 lists common activities which are related to the development of De Quervain’s tenosynovitis. If there is little or no correspondence between the patient’s activities and those listed, a useful strategy may be to ask her or him to describe working activities or movements and evaluate their biomechanical characteristics (duration, frequency

Box 5.2

General Questions on Occupational Activity and Associated Symptoms – Is your current job full- or part-time? – Which hand do you use the most at work? – Did your pain result from an accident or an abrupt, sudden or unusual movement? – Did your pain appear progressively? • If so, how long did it take to appear and what did it feel like? – Which activities and movements aggravate your symptoms?

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Box 5.3

Questions about Activities that Cause Pain in the Hands or Wrist Activity

Hours per day

Frequency of movements low medium high

Force exerted low medium high

– Applying pressure with the thumb – Maintaining grasping positions – Wrist flexion, extension, or rotation – Manipulation of small objects with the fingers or hand – Exerting force to hold or grasp objects – Use of hand tools (screwdrivers, knives, etc.) – Use of vibrating or percussion tools (drills, drill presses, sanders, etc.) Other (describe)

Comments

Cofactors with musculoskeletal load

Never

Occasionnally

Regularly

– Wearing gloves at work – Exposure to cold

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DE QUERVAIN’S TENOSYNOVITIS

Guide to the Diagnosis of Work-Related Muskuloskeletal Disorders

and force). CURRENT WORK AND ORGANISATIONAL FACTORS Certain factors related to the nature and organisa-

Box 5.4

Questions about Organisational Factors at Work During your work: –

Do you feed a machine at a constant rhythm?

– Do you feel time or production pressure? – Does your work need uninterrupted attention? – Do you find your work monotonous? – Can you vary your work rhythm? – Do you always work at the same workstation? Comments

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Never

Occasionnally

Regularly

tion of work may favour the development of musculoskeletal disorders (Box 5.4). SPORTS-RELATED, RECREATIONAL, AND HOUSEHOLD ACTIVITIES

Sports-related, recreational, and household activities may contribute to the development of De Quervain’s tenosynovitis. It is therefore important to establish the intensity with which these activities are practised and whether the onset of pain in the Box 5.5

Questions about Sports, Recreational, and Household Activities Involving the Hands or Wrist Activity

Hours per week

Risk factors or cofactors*

* See Box 2.1

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DE QUERVAIN’S TENOSYNOVITIS

6

Clinical Examination

hand or wrist has caused the patient to reduce their practise.

Figure 6.1

Groove of the Radial Styloid Process, First Dorsal Compartment of the Wrist

PHYSICAL EXAMINATION The clinical examination should allow the physician to confirm a diagnosis of De Quervain’s tenosynovitis and eliminate other disorders that cause symptoms affecting the radial side of the wrist. The physical examination is made up of the following stages: observation, palpation, assessment of the joint’s range of movement, evaluation of resisted movements, and diagnostic tests. Observation Appearance of the upper limb: – deviation, deformity, antalgic posture or position – comparison of the two limbs State of the tissues of the wrist and hand: – tissue trophicity – tissue integrity (thickening of the sheath, swelling, and ulcerations may indicate the existence of occupational strain) Palpation Depending on the severity of the condition, palpation may reveal: – painful swelling of the wrist-hand region – thickening of the tendons – formation of cysts or tendinous nodules

– crepitus (sound of wet leather) in the first dorsal compartment, audible with or without a stethoscope upon mobilisation of the wrist Assessment of Range of Movement The joint’s mobility is assessed through measurement of the amplitude of the following movements: – extension and abduction of the thumb – extension of the thumb with the distal phalanx flexed – flexion and extension of the wrist – radial and ulnar deviation of the wrist – pronation and supination of the wrist Dynamic Movements against Resistance Tenosynovitis-related pain is most evident during iso17

Guide to the Diagnosis of Work-Related Muskuloskeletal Disorders

Figure 6.2

Figure 6.3

Test of the Abductor Pollicis Longus

Test of the Extensor Pollicis Brevis

metric efforts against resistance. This can be elicited by exerting an opposing force while the patient abducts or extends the thumb (Figures 6.2 and 6.3). Diagnostic Tests Finkelstein’s test (Figure 6.4) is performed with the

hand in a fist, the thumb tucked under the fingers, and the hand in passive ulnar deviation. Intense pain in the area of the radial styloid process constitutes a positive result. A positive result may also be obtained in cases of carpometacarpal osteoarthrosis of

Figure 6.4

Finkelstein’s Test

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7

Summary of the Evaluation

Box 7.1

Clinical Aspects YES ❏

Are the symptoms located over the radial styloid process? SEVERITY OF COMPLAINTS

None

Slight

NO ❏ Moderate Severe

Reported Symptoms – Frequency and intensity of symptoms (p. 9) – Disruption of the activities of daily living (p. 10) Physical Examination – Reduction of joint’s range of movement (p. 17) – Reduction of strength (p. 17-18) – Positive results on Finkelstein’s test (p. 18) Medical History and Specific Conditions

– Specific pathologies or conditions (p. 3)

Yes

No

❏

❏

❏

❏

Differential Diagnosis – Arthrosis or other tendinitis (p. 5) Musculoskeletal Load

None

Slight

Moderate Severe

– Previous work (p. 11) – Current work (p. 12-13-14) – Sports-related, recreational, or household activities (p. 15) DIAGNOSIS AND EVALUATION OF THE RELATION TO WORK

19

Guidelines for Therapeutic and Preventive Intervention

8

the thumb, Wartenberg’s syndrome, and intersection syndrome.

sures.

Diagnostic guides can also help guide case management and the implementation of preventive mea-

THERAPEUTIC GUIDELINES The algorithm presented in Figure 8.1 illustrates the

Figure 8.1

Therapeutic Intervention Flow-chart Rehabilitation – Progressive mobilisation – Muscle strengthening – Functional reeducation Improvement

Preventives measures

Treatment – Modification of activities – NSAIDs* – Rest for 3-6 weeks

No improvement

Improvement

Ergonomic interventions to modify risk factors

– Hydrocortisone injection – Modification of activities

No improvement

– Consider surgery * NSAID: non-steroid anti-inflammatory drugs

21

Guide to the Diagnosis of Work-Related Muskuloskeletal Disorders

stages to be followed in treating De Quervain’s tenosynovitis. PREVENTION GUIDELINES In cases where it is possible to identify the sources

of musculoskeletal strain underlying De Quervain’s tenosynovitis, it may prove useful to propose preventive measures affecting high-risk activities. Table 8.1 presents general guidelines for preventive measures which take into account the diagnosis and extent of musculoskeletal strain. The ap-

Table 8.1

Preventive Approach Diagnosis

Evidence of De Quervain’s tenosynovitis

No evidence of De Quervain’s tenosynovitis

22

Musculoskeletal Strain Significant

Not significant

+

–

+

– Modification of activities – Reduction of musculoskeletal load – Corrective ergonomic interventions

– Treatment of causal factors – Modification of activities

–

– Reduction of musculoskeletal load – Corrective ergonomic interventions

– Information of risk factors

CONCLUSION

plication of these measures is essential to prevent deterioration or recurrence of the injury, or aggravation of the symptoms upon return to work. This guide was designed to help physicians, who in recent years have been faced with an increase in the number of consultations for musculoskeletal problems of possible occupational etiology. More specifically, its goals were to facilitate and improve the clinical and etiological diagnosis of musculoskeletal problems. Its approach emphasizes the usefulness of patient-provided information in understanding the circumstances surrounding the onset of symptoms. Physicians have a key role to play in the implementation of measures designed to reduce musculoskeletal injuries, especially those due to extrinsic factors. Through their

23

BIBLIOGRAPHY

diagnoses and the preventive measures they propose, they can help reduce the morbidity associated with inflammatory injuries associated with repetitive work.

CHIPMAN, J.R., KASDAN, L.M., CAMACHO, D., 1991, “Tendinitis of the upper extremity”, in KASDAN, Morton L. (dir.), Occupational Hand and Upper Extremity Injuries and Diseases, Philadelphie (PA), Hanley & Belfus, p. 403-421. DUPUIS, M., 1986, “Le poignet”, in DUPUIS, M. and LECLAIRE, R., Pathologie médicale de l’appareil locomoteur, Saint-Hyacinthe, Édisem, p. 542. HAGBERG, M., SILVERSTEIN, B., WELLS, R., SMITH, M.J., HENDRICK, H.W., CARAYON, P., PÉRUSSE, M. (1995), Work related musculoskeletal disorders (WMSDs): a reference book for prevention, scientific editors: Kuorinka, I., Forcier, L., publishers Taylor and Francis, London, 421 pages. HARTER, B.T., 1989, “Indications for surgery in work related compression neuropathies of the upper extremity”, Occupational Medecine: State of the Art Reviews, 4 (3): 485-495. KATZ, J.N., GELBERMAN, R.H., WRIGHT, E., et al., 1994, “Responsiveness of self-reported and objective measures of diasease severity in carpal tunnel syndrome”, Medical Care, 32: 1127-1133. KENDALL PETERSON, F., KENDALL MCCREARY, E. (1988). Les muscles: Bilan et études fonctionnelles, 3th Edition, Paris, Maloine, 325 pages (translation of Muscles testing and Function, ed. by Williams and Wilkins company, Baltimore). KROEMER, K.H.E., 1989, “Cumulative trauma disorders: their recognition and ergonomics measures to avoid them”, Applied Ergonomics, 20 (4): 274-280. KUORINKA, I., KOSKINEN, P., 1979, “Occupational rheumatic diseases and upper limb strain in manual jobs in a light mechanical industry”, Scand J Work Environ Health, suppl. 3: 39-47. KURPPA, K., VIIKARI-JUNTURA E., KUOSMA, E., HUUSKONEN, M.,

25

Guide to the Diagnosis of Work-Related Muskuloskeletal Disorders

KIVI, P., 1991, “Incidence of tenosynovitis or peritendinitis and epicondylitis in a meat processing factory”, Scand J Work Environ Health, 17: 32-37. LEVINE, D.W., SIMMONS, B.P., KORIS, M.J., et al., 1993, “A self-administered questionnaire for the assessment of severity of symptoms and fuctional status in carpal tunnel syndrome”, J Bone and Joint Surg, 75-A: 1585-1592. MAHONEY, J.L., LOFCHY, N.M., CHOW, I.J.S., HUDSON, A., 1992, “Carpal tunnel syndrome: a quality assurance

26

evaluation of surgical treatement”, Annales CRMCC, 25 (1): 20-32. MOSELY, L.H., KALAFUT, R.M., LEVINSON, P.D., MORKIS, S.A., 1991, “Cumulative trauma disorders and compression neuropathies of the upper extremities” in KASDAN, Morton L. (dir.), Occupational Hand and Upper Extremity Injuries and Diseases, chap. 27, Philadelphie (PA), Hanley and Belfus, p. 353-402. PETERSON-KENDALL, F., KENDALL-MCCREARY, E., MCCREARY, B.A.I., 1988, Les muscles, bilan et études fonctionnelles, 3rd Edition, Paris, Maloine, 325 p.

PORTER, J.M., BUCKLE, P., ROBERTSON, J.C., 1992, “Occupational causes of disorders in the upper limbs [letter comment]”, SO-BMJ, 28 304 (6830): 842-843. PUJOL, M., 1993, Pathologie professionnelle d’hypersollicitation, atteinte périarticulaire du membre supérieur, Collection de monographies de Médecine du travail, Paris, Masson, 168 p. RANNEY, D., 1991, “Work related chronic injuries of the forearm and hand: their specific diagnosis and management”, in 24e congrès de l’Association canadienne d’ergonomie, Vancouver, ACE, p. 11-20. ROSSIGNOL, M., SACKS, S., AMSTRONG, B., PATRY, L., 1996, Incidence du syndrome du canal carpien selon la profession sur l’île de Montréal et distribution des facteurs de risque, rapport de recherche, Montréal, Institut de recherche en santé et sécurité au travail, 37 p. ROSSIGNOL, M., PATRY, L., BAILLARGEON, M., COSTA, M.J., CENTOMO, P., DAVID, M.U., HAJIAN TILAKI, K.O., HANLEY, J., SACKS, S., 1995, Bilan des connaissances sur le diagnostic des lésions attribuables au travail répétitif (LATR), Montréal, Institut de recherche en santé et sécurité au travail, 151 p. SAMPSON, S.P., WISCH, D., BADALANUNK, M.A., 1994, “Complications of conservative and surgical treatment of De Quervain’s disease and trigger fingers”, Hand Clinics, 10 (1): 73-82. SINCLAIR, M.A., 1992, “Subjective assessment”, in WILSON, J.R., et CORLETT, E.N. (dir.), Evaluation of Human Work: A Pratical Ergonomics Methodology, Washington (DC), Taylor and Francis, p. 58-88. THORSON, E.P., SZABO, R.M., 1984, “Tendonitis of the wrist and elbow”, Occupational Medicine, State of the Art review, 4 (3), 419-431. YOUNGHUSBAND, O.Z., BLACK, J.D., 1963, “De Quervain’s Disease: stenosing tenovaginitis at the radial styloïd process”, Canad Med Ass J, 89: 508-512. 29

DE QUERVAIN’S TENOSYNOVITIS