How Do I Distinguish Between Carpal Tunnel Syndrome and De Quervain s Disease?

Transcription

1 How Do I Distinguish Between Carpal Tunnel Syndrome and De Quervain s Disease? Krista Paulson, BSc, BMR-PT, MSc Acupuncture Provider Physiotherapist Certified Hand Therapist

2 Relationships with Commercial Interests: Co-owner of EastCity Physiotherapy: A Hand to Shoulder Clinic May indirectly benefit from increased referrals to our clinic, although no specific referrals will be solicited.

3 Objectives Review anatomy, patient history, exam, diagnostic imaging findings Review evidence-based conservative and surgical management Review when / where to refer (Winnipeg)

4 Carpal Tunnel Syndrome (CTS)

5 CTS - Anatomy (Source: H P T S APB (Source: Author)

6 CTS - Anatomy (Source: gr1.jpg) (Source: 7/77/Musculusabductorpollicusbrevis.png)

7 CTS - History Most common focal neuropathy Women > Men (especially ages 40-60) Diabetes, RA, Obesity, Smoking Pregnancy, menopause, estrogen use Vibrating tools, repeated forceful gripping (Calandruccio & Thompson, 2018; D Arcy & McGee, 2000; Leblanc & Cestia, 2011)

8 CTS - Examination Variety of clinical tests with varying sensitivity and specificity Multiple positives = more compelling

9 CTS - Examination (Motor) The Abductor Pollicus Brevis (APB) Test Abductor Pollicus Brevis Wasting * (D Arcy & McGee, 2000) (Source:

10 CTS Examination - Durkan s Apply pressure over carpal tunnel for 30 seconds Positive: Numbness/tingling in median distribution Sensitivity 87% Specificity 90% (Source: Author) (Calandruccio & Thompson, 2018)

11 CTS Examination - Tinel s Percuss median nerve just distal to wrist crease Positive: Numbness/tingling in median distribution Sensitivity 62% (Source: Skirven, T. Clinical Examination of the Wrist. J Hand Ther Apr- Jun;9(2);96-107) Specificity 93% (Skirven, 1996)

12 CTS Examination - Phalen s Passive wrist flexion seconds Positive: Numbness/tingling in median distribution X (Source: Skirven, T. Clinical Examination of the Wrist. J Hand Ther Apr-Jun;9(2);96-107) Sensitivity 68-70% Specificity 73-83% (Calandruccio & Thompson, 2018; D Arcy & McGee, 2000) (Source: Author)

13 CTS - Electrodiagnostic Testing Often required by third party payers Nerve Conduction*: impaired conduction of median nerve across carpal tunnel Electromyography (EMG): usually assesses pathologic changes in Abductor Pollicus Brevis, more used if other neuropathy/radiculopathy suspected Sensitivity 49-84%, specificity 95-99% (Calandruccio & Thompson, 2018)

14 CTS - Management Mild to Moderate: consider 3-6 months of conservative management (splinting, injection) Severe: consider surgical evaluation (Leblanc & Cestia, 2011; Wiperman & Goerl, 2016)

15 CTS Management - Splinting Mild to moderate CTS 8-12 weeks of nightly splint use ~$60 ~$95 (Source: Author) Unclear if custom more effective than off-the-shelf Sweating Comfort Insurance coverage (Source: Author) (Hall et al., 2013; So, Chung, Cheung & Yip, 2018)

16 CTS - Injection Only one RCT comparing splinting vs methylprednisolone acetate premixed with lidnocaine (mild to moderate CTS) Equally effective on Boston Carpal Tunnel Questionnaire But injection yielded better hand function scores (So, Chung, Cheung & Yip, 2018)

17 CTS - Injection As effective as splinting Repeat injection after 6 months Delay surgery up to 1 year (Source: specialistphysio.com) Wiperman & Goerl, 2016)

18 CTS - Surgical Intervention Results favorable up to 9 years post-op even in severe cases Two portal endoscopic vs open release: Endoscopic: less post op pain Both equivalent for scar pain, patient satisfaction and recurrence rate at 5-yrs post op (Atroshi et al, 2009; So, Chung, Cheung & Yip, 2018; Tang, Lai & Tay, 2017)

19 De Quervain s Disease New Mom Thumb Baby Wrist Washerwoman s Syndrome? First Dorsal Compartment Tendinopathy

20 De Quervain s Disease (Source: Author) (Source: Y76uWzfJ2uQ/T2tAkZmZgPI/AAAAAAAAA4A/o0dmhmZdDhA/s1600/asb2.jpg)

21 De Quervain s History Three Groups of Patients: Anatomical Pregnancy/lactation Mechanical

22 De Quervain s History Anatomical variations: Septum between APL and EPB (30%-60%) Multiple tendon slips of APL? More prone to De Quervain s (Mirzanli et. al., 2012; Orlandi et. al., 2014 Scheller, 2009; Vuillemin et. al., 2012) (Source: )

23 De Quervain s History Pregnancy / Lactation? d/t fluid retention, hormones Mechanical stress of infant care Self limiting with cessation of lactation al., 2002; Orlandi et. al., 2014; Peters-Veluthamaningal et al., 2009; Scheller, 2009) (Avci et.

24 Degenerative: Intrinsic, degenerative mechanism rather than extrinsic inflammatory Thickened sheath Increased ground substance (Scheller, 2009)

25 De Quervain s - Examination Finkelstein s Test Eichoff s Test WHAT Test (Avci et. al., 2002; Peters-Veluthamaningal et al., 2009; Scheller, 2009)

26 Finkelstein s Test Often described incorrectly! Ulnar deviation with longitudinal traction Sensitivity:? Specificity:? (Goubau et al., 2014) (Source: Goubau et al., 2014)

27 Eichoff s Test Often mislabeled as Finkelstein s Test Passive Thumb Opposition with Ulnar Deviation Sensitivity: 89% (Source: Goubau et al., 2014) Specificity: 14% (Goubau et al., 2014)

28 WHAT Test Wrist in flexion Resist thumb palmar abduction Sensitivity: 99% Specificity: 29% (Goubau et al., 2014) (Source: Goubau et al., 2014)

29 De Quervain s - MRI De Quervain s is primarily a clinical diagnosis Fluid in tendon sheath +/- tendon sheath thickening Low-signal intensity within tendon sheath = fibrosis = poorer prognosis (Source: Jbara, Patnana, Kazmi & Beltran; 2014) (Source: Jbara, Patnana, Kazmi & Beltran; 2014)

30 De Quervain s - Splinting Best for more mild cases Short to midterm benefit demonstrated (moderate evidence) Contradictory evidence re: combining with steroid injection No studies comparing custom vs off-the-shelf splints (Huisstede, Gladdines, Randsdorp & Koes, 2017; Richie & Briner, 2003Weiss et. al.; 1994)

31 De Quervain s Management - Splinting ~$60 ~$95 (Source: dme-direct.com) ~$95 (Source: Author) (Source: Author)

32 De Quervain s Management - Injection Short to midterm benefit demonstrated (moderate evidence) Superior to splinting alone Contradictory evidence re: combining with splinting injection Not as beneficial in females, obesity Suggestion that US guided is superior, particularly if septum is present (Huisstede, Gladdines, Randsdorp & Koes, 2017; Oh, Messing, Hyrien & Hammert, 2017; Orlandi et. al., 2014; Richie & Briner, 2003; Weiss et. al.; 1994)

33 De Quervain s Management - Surgery Before considering Sx: 4-6 months of conservative tx 1-3 cortisone injections (in both APL, EPB*) Last resort treatment (Scheller et al., 2009)

34 De Quervain s Surgical Release If septum present, both APL EPB released Favorable outcomes in the long-term (16 years) High patient satisfaction Dorsal radial sensory nerve lesion more common in open procedure vs. endoscopic (Kang, Hahn, Kim & Choi, 2011; Scheller, 2009)

35 Hand Therapy

36 Hand Therapy Public (*Splinting = OT): HSC Private: EastCity Physiotherapy, Green Hand to Shoulder Physiotherapy, Foundation Rehabilitation Services, Centric Health Splinting as required on referral, please

37 Injections/Surgery Sports Medicine: Pan Am (* US guided - Dr. H. Peters) Legacy Plastic Sx (Hands) Ortho Sx (Hands)

38 Electrodiagnostic Testing Riverview Health Centre Health Sciences Centre St. Boniface Hospital Deer Lodge Private Neurologist Private Physiatrist

39 References Atroshi, I., Hofer, M., Larsson, G. U., Ornstein, E., Johnsson, R., & Ranstam, J. (2009). Open compared with 2-portal endoscopic carpal tunnel release: a 5-year follow-up of a randomized controlled trial. J Hand Surg Am, 34(2), doi: /j.jhsa Brunelli, G. (2003). [Finkelstein's versus Brunelli's test in De Quervain tenosynovitis]. Chir Main, 22(1), Calandruccio, J. H., & Thompson, N. B. (2018). Carpal Tunnel Syndrome: Making Evidence-Based Treatment Decisions. Orthop Clin North Am, 49(2), doi: /j.ocl D'Arcy, C. A., & McGee, S. (2000). The rational clinical examination. Does this patient have carpal tunnel syndrome? Jama, 283(23), Goubau, J. F., Goubau, L., Van Tongel, A., Van Hoonacker, P., Kerckhove, D., & Berghs, B. (2014). The wrist hyperflexion and abduction of the thumb (WHAT) test: a more specific and sensitive test to diagnose de Quervain tenosynovitis than the Eichhoff's Test. J Hand Surg Eur Vol, 39(3), doi: / Hall, B., Lee, H. C., Fitzgerald, H., Byrne, B., Barton, A., & Lee, A. H. (2013). Investigating the effectiveness of full-time wrist splinting and education in the treatment of carpal tunnel syndrome: a randomized controlled trial. Am J Occup Ther, 67(4), doi: /ajot Huisstede, B. M., Gladdines, S., Randsdorp, M. S., & Koes, B. W. (2017). Effectiveness of Conservative, Surgical, and Postsurgical Interventions for Trigger Finger, Dupuytren Disease, and De Quervain Disease: A Systematic Review. Arch Phys Med Rehabil. doi: /j.apmr Jbara, M., Patnana, M., Kazmi, F., & Beltran, J. (2006). MR imaging: Arthropathies and infectious conditions of the elbow, wrist, and hand. Radiol Clin North Am, 44(4), , ix. doi: / j.rcl Kang, H. J., Hahn, S. B., Kim, S. H., & Choi, Y. R. (2011). Does endoscopic release of the first extensor compartment have benefits over open release in de Quervain's disease? J Plast Reconstr Aesthet Surg, 64(10), doi: /j.bjps LeBlanc, K. E., & Cestia, W. (2011). Carpal tunnel syndrome. Am Fam Physician, 83(8),

40 References Oh, J. K., Messing, S., Hyrien, O., & Hammert, W. C. (2017). Effectiveness of Corticosteroid Injections for Treatment of de Quervain's Tenosynovitis. Hand (N Y), 12(4), doi: / Orlandi, D., Corazza, A., Silvestri, E., Serafini, G., Savarino, E. V., Garlaschi, G.,... Sconfienza, L. M. (2014). Ultrasound-guided procedures around the wrist and hand: how to do. Eur J Radiol, 83(7), doi: /j.ejrad Richie, C. A., 3rd, & Briner, W. W., Jr. (2003). Corticosteroid injection for treatment of de Quervain's tenosynovitis: a pooled quantitative literature evaluation. J Am Board Fam Pract, 16(2), Scheller, A., Schuh, R., Honle, W., & Schuh, A. (2009). Long-term results of surgical release of de Quervain's stenosing tenosynovitis. Int Orthop, 33(5), doi: / s z Skirven, T. (1996). Clinical examination of the wrist. J Hand Ther, 9(2), So, H., Chung, V. C. H., Cheng, J. C. K., & Yip, R. M. L. (2018). Local steroid injection versus wrist splinting for carpal tunnel syndrome: A randomized clinical trial. Int J Rheum Dis, 21(1), doi: / x Tang, C. Q. Y., Lai, S. W. H., & Tay, S. C. (2017). Long-term outcome of carpal tunnel release surgery in patients with severe carpal tunnel syndrome. Bone Joint J, 99-b(10), doi: / x.99b10.Bjj R2 Weiss, A. P., Akelman, E., & Tabatabai, M. (1994). Treatment of de Quervain's disease. J Hand Surg Am, 19(4), doi: / (94) Wipperman, J., & Goerl, K. (2016). Carpal Tunnel Syndrome: Diagnosis and Management. Am Fam Physician, 94(12),