De Quervains Tenosynovitis + Ganglion cysts

Question 1

What is DQT?

Answer 1

• Inflammation of tendons within first extensor compartment of the wrist
• = wrist pain and swelling
• Women 30-50, repetitive movements of the wrist in job/hobbies

Question 2

Extensor compartment of the wrist contents

Answer 2

• 6 compartments - lateral to medial
• 1 = extensor pollucis brevis and abductor pollucis longus
• 2 = extensor carpis radialis longus and brevis
• 3 = extensor pollucis longus
• 4 = extensor indicis and extensor digitorum
• 5 = extensor digiti minimi
• 6 = extensor carpis ulnaris

Question 3

Which tendons does DQT involve?

Answer 3

• Extensor pollucis brevis
• Abductor pollucis longus

Question 4

RF for DQT

Answer 4

• Age - 30-50
• Female
• Pregnancy
• Occuptations/hobbies that involve repetitive movements of wrist

Question 5

Clinical features of DQT

Answer 5

• Pain near base of thumb
• Associated swelling - due to thickening of tendon sheath
• Grasping + pinching are difficult

Question 6

Examination of DQT

Answer 6

• Swelling
• Palpable thickening over tendon group fibrous sheath
• Finkelsteins test +ve

Question 7

What is Finkelsteins test?

Answer 7

• Longitudinal traction and ulnar devitation of thumb
• Pain at radial styloid process and along length of EPB and APL tendons = +ve

Question 8

Differentials for base of thumb pain/wrist swelling

Answer 8

• Arthiritis of CMC joint - more gradual, negative finkelstein but +ve grind test
• Intersection syndrome - tendons of 1st compartment cross over with those of 2nd, = pain over second compartment
• Wartenbergs syndrome - neuritis of superficial radial nerve, wearing tight jewellery

Question 9

Investigations DQT

Answer 9

• Clinical
• Plain radiographs to exclude other diagnosis?

Question 10

Management - conservative DQT

Answer 10

• Lifestyle advice - avoid repetitive actions
• Wrist splint
• Steroid injections

Question 11

Surgical management DQT

Answer 11

• Failure to respond to conservative
• Surgical decompression under LA or GA
• Transverse or longitudinal incision in tendon sheath roof
• Allows to heal and form roof again but will be wider with more space

Question 12

Complications of surgery DQT

Answer 12

• Failure to resolve
• Reduced ROM in wrist/hand
• Neuroma formation
• Nerve impingement

Question 13

What is a ganglion cyst?

Answer 13

• Non-cancerous
• Soft tissue lumps
• Occur along any joint or tendon
• Arise from degeneration within the joint capsule or tendon sheath of joint
• Then become filled with synovial fluid

Question 14

Most common location for ganglion cyst

Answer 14

• Hands and feet
• Dorsal wrist most common

Question 15

RF for gangion cyst

Answer 15

• Female
• OA - increase fluid in joint, leakage through sheath into cyst
• Previous joint/tendon injury

Question 16

Clinical features of ganglion cyst

Answer 16

• Painless
• Smooth spherical lump
• Appear suddenly or grow over time
• Sometimes can subside then reappear

Question 17

Examination of ganglion cyst

Answer 17

• Transilluminate
• May mechanically restrict ROM
• If cyst exerts pressure on adjacent nerves can have localised parasthesia, pain or motor weakness

Question 18

Differentials for ganglion cyst

Answer 18

• Giant cell tumour of tendon sheath - solid, does not transilluminate, fixed to sheath so less mobile
• Tenosynovitis - no discrete mass, swelling along tendon
• Lipoma - no transillumination
• OA
• Sarcoma - not well circumscribed, immobile

Question 19

Investigations ganglion cyst

Answer 19

• Clinically
• X-ray to rule out OA or bone malignancies - ganglions not apparent on x-ray
• If uncertain, can USS or MRI
• Aspiration - temporary relief and send fluid for microscopy +/- cytology

Question 20

Management ganglion cysts

Answer 20

• Monitor usually - as painless
• If pain or limits ROM then intervene

Question 21

Interventions for ganglion cyst if painful or limits ROM

Answer 21

• Aspiration +/- steroid injection - BUT infection risk and high rate recurrence
• Cyst excision - remove cyst capsule with portion of tendon sheath