A Preliminary Survey of Bilateral Wrist First Compartments Variations by High Resolution Ultrasonography

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1 DOI / Original Research Article A Preliminary Survey of Bilateral Wrist First Compartments Variations by High Resolution Ultrasonography Wei-Ting Wu 1, Shao-Li Han 1,* ABSTRACT Back ground and purpose: The existence of the septum within the first compartment of wrists may be a risk factor of developing de Quervain s disorder. In order to figure out the relationship between the variations in the first compartment and de Quervain s disease, the prime question is the prevalence of normal variations in normal population. Previous studies of the prevalence were mostly based on the studies of cadava anatomy. Furthermore, few studies have been conducted to compare bilateral wrist variations. This study aims to investigate the anatomic variations and bilateral wrist first compartments variation by ultrasonography. Methods: A cross-sectional study was conducted by using the ultrasound to identify the existence of the septum within the first extensor compartment in the wrists. To ensure all kinds of wrist anatomic variations, 24 participants (12 male, 12 female) with and without DQ was recruited. We used the criteria of Kwon s research to detect the presence of a septum in the first extensor compartment. Results: Among the 24 participants, the prevalence of the septum within the first extensor compartment was 70.8% and the prevalence of bilateral septum was 54.2%. There was a discrepancy in the first extensor compartment between the bilateral wrists in 4 participants; the prevalence rate was 16.7%. Conclusions: Ultrasonographic examination is a good way to detect the existence of septum between APL and EPB. The prevalence rate of septum was high in this study. Compared with previous research, the existence of septum was the risk factor of de Duervain s disease and further evaluating the anatomic variations was warranted among those patients due to the variation of bilateral wrists. Furthermore, due to the high prevalence of bilateral septum, home education of reducing the work loading of affected wrist with subsequently increasing the burden of the unaffected wrist might be a risk factor of subsequent DQ attack in the unaffected wrists. Therefore we suggested that bilateral wrists ultrasonographic examination of DQ patients should be taken subsequent DQ attack of the unaffected wrists. Keywords: ultrasound, stenosing tenosynovitis, wrist pain, wrist extensor compartment 1 Department of Physical Medicine and Rehabilitation, Sijhih Cathay General Hospital, New Taipei City, Taiwan Submitted December, 02, 2015; final version accepted February, 04, * Corresponding author: Shao-Li Han (s811087@gmail.com) 輔仁醫學期刊第 15 卷第 1 期

2 Wei-Ting Wu Shao-Li Han INTRODUCTION Ultrasound has been growing importance on evaluation of musculoskeletal disorders[1-5]. High resolution ultrasonography can depict the normal anatomic structures, the anatomic variations and pathological changes. Some rare structure variation might also be seen and guided the therapy strategy[6]. Superficial masses can also be evaluated by soft tissue ultrasound due to the advance of sonographic instruments with high resolution, color image and Doppler image technique. Besides, ultrasonography serves a highly available, cost-effective and reliable image tool for further guidance of therapy or following the response after therapy. Recent research about sono-guided injection therapy has also revealed its expanding applications in clinical practice[6]. The de Quervain s disease(dq) has been viewed as a stenosing extensor tendonitis of extensor pollicis brevis(epb) and abductor pollicis long(apl). The causes of de Quervain s disease include overuse and anatomic variations may also a causative factor. [7] The diagnosis is usually through clinical history and physical diagnosis. Image study may be helpful depict wrist extensor structures and good to exclude other causes, such as tumor compression or anatomic variations. Ultrasound provides an easy and rapid tool to evaluate the wrist conditions. In addition, the application of high frequent sonographic examination is expanding. While approaching a patient with wrist pain, sonographic examination for DQ provides only the diagnosis of tendonitis, but the guidance of accurate injection of drugs to the first compartment. Accurate injection of drugs was known as the key to treat DQ, and sonographic guidance provides good intervention help[8, 9]. The etiology of de Quervain tendinopathy is not well-understood. Repetitive wrists activities involving postures that maintain the thumb in extension and abduction were always considered as one of the important factor. Some study also found that rapid repetitive activities involving pinching, grasping, pulling or pushing have been considered a risk factor of DQ[10]. However a systematic review of potential risk factors discussed in the literature did not find any evidence of a causal relationship with occupational factors[11]. According to previous studies, the presence of the septum in the first extensor compartment is a causative factor for DQ[12].. Several studies have proven that ultrasound is a good tool to evaluate de Quervain s disease and even to identify the anatomic variations in the first extensors compartment[13]. This anatomic variations may lead the failure of injection or surgical therapy[13, 14]. To identify this variation in patients with suspecting de Quervain s disease may be the crucial for therapy. Previous studies of the prevalence were mostly based on the studies of cadaver anatomy and large-scale anatomic studies showed that the anatomic variation of first compartment was 40% to 63%. Anatomic variations in the first extensor compartment of the wrist are common and the existence of the septum between the extensor pollicis brevis and abductor pollicis longus may be the risk of developing de Quervain s disease. [14] In our experience, most patients suffered from de Quervain s disease at their dominant hands, some patients in their non-dominant hands and very few patients suffering bilateral de Quervain s tendonitis at the same time. Anatomic variations between two wrists in the patients might be the reason but little research focused on the bilateral wrist variations. 12 Fu-Jen Journal of Medicine Vol.15 No

3 Comparison of first compartments variation of bilateral wrist by ultrasonography This study focused on the anatomic variations and bilateral wrists variations in general population by using high-resolution ultrasongraphy. As the best of our knowledge, this is the first research discussing bilateral wrists variation by ultrasonography. MATERIALS AND METHODS was used to depict the wrist first extensor compartment. Septum could be identified by transverse scan technique. Kwon et al. pointed the presence of vertical or oblique septumlike structure within first compartment was a good way to detect the existence of the septum with good surgical correlation[13].figure 1 illustrated the presence and absence of septum in the same participant. Research design This was a cross-section study by using the ultrasound to identify the exits of the septum within the first extensor compartment in the wrists. All participants received ultrasonographic evaluation for wrist first extensor compartment by using a 3-9 MHz linear array transducer.(phillips IE 33) Subjects/Materials To ensure all kinds of wrist anatomic variations, we enrolled the patients who received musculoskeletal ultrasound examination for any conditions, such as chronic shoulder pain, recurrent ankle sprain, wrist pain and so on. Exclusion criteria included any wrist deformities, skin infection around wrist area, any wrist surgical history and those who refused to participate in this study. Subjects received the sonographic examination after getting their agreement and written informed consents. APL and EPB were identified by anatomic location and dynamic wrist movement test. The detection of subcompartmentation in wrist extensor compartment was based on Kwon s research[13]. Kwon s research constituted a easy and useful way to identify the presence of a septum between APL and EPB. Longitudinal scan was used to detect the presence of anatomy variation and transverse scan Figure 1. One participant has different extensor compartment variation in his right and left wrist. The two arrows pointed the cephalic vein, asterisks pointed out the EPB and the two black arrowheads showed the APL. There was a septum causing subcompartmentation in left wrist, illustrated between the two while arrowheads. Data collection procedure All sonographic images were obtained by the same qualified rehabilitation doctor. All participants were examined while seated with good support for the intended forearm and wrist by placing a pillow. Ultrasonographic examination was done from the insertion to origin area of APL and EPB and focused on the wrist extensor compartments. Both wrists were inspected. Along with the existence of septum, the age, sex, dominant hand and weather the presence of ongoing DQ were also recorded for further analysis. Ethics issue This study was approved by the IRB of Cathy General Hospital (CGH-CS100116). All data were collected after getting participants' informed contents. 輔仁醫學期刊第 15 卷第 1 期

4 Wei-Ting Wu Shao-Li Han RESULTS Table 1. Summary of the subcompartmentation in the extensor first compartment. 24 participants were recruited in this study. There were 12 males and 12 females, with an average age of 48.6 years. They were 20 right-handed and 4 left-handed. 48 wrists were inspected. There were six participants with ongoing wrists pain and DQ was made according to their clinical presentation and physical examination. However, 3 of them suffered DQ at their non-dominant hands and 4 wrists pain at their subcompartementation wrists. One DQ patient didn t have subcompartment at her bilateral wrists. The overall prevalence of septum among 48 wrists was 70.8%. Besides, the existence rate of septum within first compartment in right and left wrists was equally 62.5%. The rate of bilateral septum within first extensor compartment was 54.2%. Most of the participants have the same condition, presence or absence of septum, in bilateral wrists. There was a discrepancy in the first extensor compartment between the bilateral wrists in 4 participants and the prevalence of discrepancy was 16.7%. Other data was showed as Table 1. DISCUSSION The prevalence of bilateral discrepancy in this study was 16.6%. Little research was conducted to compare bilateral wrist first extensor compartment and this was,to the best of our knowledge, the first research to find out the prevalence of bilateral wrist discrepancy[15, 16].Chang and Hung also pointed out this discrepancy[8]. Their patient suffered DQ at the wrist with subcompartmentation but the relationship between anatomic variations and clinical pathogenesis still needs further invitation. There were six participants with ongoing DQ. However, not all of them suffered DQ at their dominant hands and even one DQ patient didn t have wrist subcompartmentation at her bilateral wrists. Owing to the very small sample size, further statistic analysis was not suitable, but anatomic variations, including the existences of septum should not be the only factor contributing to DQ[16].According to this study, most participants had the same extensor compartment structures and most the patients suffered DQ at their dominant hands. This finding, however, failed to be consistent with clinical observation well because only very few patients suffered bilateral DQ[17]. The reason was that the existence of septum was not the only causative factor. Dominant hand takes the major efforts in daily activities and overuse in dominant hand is obviously reasonable. 14 Fu-Jen Journal of Medicine Vol.15 No

5 Comparison of first compartments variation of bilateral wrist by ultrasonography High prevalence of septum within first compartment was noted in this study. The prevalence was 70.8%. According to Choi and Ahn, the prevalence was also very high in patients with intractable wrists pain.[12] The prevalence rate from their research was 73.3%. However, the estimated prevalence of septum in surgical patients in previous research ranged from 28.9%, 67.5% 15 to 73.3%[12, 18]. Participants who has ongoing wrist pain were also recruited and this may be the cause of high estimated prevalence. However, this finding implied the accuracy of sonongraphy to detect the existence of septum in wrists. In this study, bilateral wrist discrepancy did exist and this phenomenon should also be taken into consideration while educating patients to reduce the work loading of affected wrist and to adopt other compensatory technique[7]. These procedure would increase the burden of the unaffected wrist. The presence of septum in both wrists may be a risk factor of subsequent DQ attack in the other wrists and should take into consideration adapting of intervention strategy. According to this study, sonographic examination should be viewed as a part of complete evaluation of de Quervain s disease due to its high prevalence of septum and the existence of bilateral wrist anatomic variation. Further research to explore the relationship of bilateral wrists variations and DQ is warranted. The limitation of study is its small sample sizes and participants were recruited for those who would receive soft tissue ultrasonographic examination for any reason. The prevalence of septum cannot stand the prevalence among population well. Further research may be warranted. All authors declared that there was not conflict of interest in this study. REFERENCES [1]. Ahmed R, Nazarian LN. Overview of musculoskeletal sonography. Ultrasound Q 2010;26: [2]. Allen GM, Drakonaki EE, Tan MLH, Dhillon M, et al. High-resolution ultrasound in the diagnosis of upper limb disorders: a tertiary referral centre experience. Ann Plast Surg 2008;61: [3]. Azócar P. Sonography of the hand: tendon pathology, vascular disease, and soft tissue neoplasms. J Clin Ultrasound 2004;32: [4]. Bianchi S, Martinoli C, Abdelwahab IF. Highfrequency ultrasound examination of the wrist and hand. Skelet radiol 1999;28: [5]. Chen H-S, Chen M-Y, Lee C-Y, et al. Ultrasonographic examination on patients with chronic wrist pain: a retrospective study. Am J Phys Med Rehabil 2007;86: [6]. Sofka CM, Adler RS, Saboeiro GR, et al. Sonographic Evaluation and Sonographic- Guided Therapeutic Options of Lateral Ankle Pain: Peroneal Tendon Pathology Associated with the Presence of an Os Peroneum. HSS J 2010;6(2): [7]. Goel R, Abzug JM. de Quervain s tenosynovitis: a review of the rehabilitative options. Hand 2015;10(1):1-5. [8]. Chang K-V, Hung C-Y, Özçakar L. Ultrasound Imaging for Precise Diagnosis and Injection of Isolated Extensor Pollicis Brevis Tenosynovitis. Am J Phys Med Rehabil 2015;94(3):255. [9]. Zingas C, Failla JM, Van Holsbeeck M. Injection accuracy and clinical relief of de 輔仁醫學期刊第 15 卷第 1 期

6 Wei-Ting Wu Shao-Li Han Quervain s tendinitis. J Hand Surg Am 1998;23(1): [10]. Steven J. De Quervain s Tenosynovitis: Stenosing Tenosynovitis of the First Dorsal Compartment. J Occup Environ Med 1997;39(10): [11]. Stahl S, Vida D, Meisner C, et al. Systematic review and meta-analysis on the work-related etiology of de Quervain s tenosynovitis. Plast Reconstr Surg 2013:1. [12]. Choi S, Ahn J, Lee Y, et al. de Quervain Disease: US Identifi cation of Anatomic Variations in the First Extensor Compartment with an Emphasis on Subcompartmentalization. Radiology 2011;260: [13]. Kwon BC, Choi S-J, Koh SH, et al. Sonographic Identification of the intracompartmental septum in de Quervain s disease. Clin Orthop Relat Res 2010;468(8): [14]. Gousheh J, Yavari M, Arasteh E. Division of the first dorsal compartment of the hand into two separated canals: rule or exception? Arch Iran Med 2009;12(1): [15]. Jackson W, Viegas S, Coon T. Anatomical variations in the First Extensor Compartment of the Wrist. J Bone Jt Surg Am 1986;68: [16]. Gurses IA, Coskun O, Gayretli O, et al. The anatomy of the fibrous and osseous components of the first extensor compartment of the wrist: a cadaveric study. Surg Radiol Anat 2015;37(7): [17]. Scheller A, Schuh R, Hönle W, Schuh A. Long-term results of surgical release of de Quervain s stenosing tenosynovitis. Int Orthop 2009;33(5): [18]. Kamath HBJ, Kumar KRKA, Praveen MS. Preoperative ultrasound in de Quervain s disease: an investigation worth doing. Int Orthop 2009;1(May 2005): Fu-Jen Journal of Medicine Vol.15 No

7 Comparison of first compartments variation of bilateral wrist by ultrasonography 以高頻超音波檢查比較兩側手腕第一間隔區的變異情形 : 先遣研究 吳韋廷 1, 韓紹禮 1,* 中文摘要 根據文獻, 手腕伸肌處第一間隔區隔膜的存在是造成狄魁文氏症候群的危險因子之一 若要進一步研究第一間隔區縱隔的解剖變異以及狄魁文氏症候群的關係, 首先應該需要知道一般人手腕伸肌第一區間的變異盛行率 過去盛行率的研究多使用屍體解剖的研究, 並且過去文獻很少比較同一個體兩側手腕伸肌第一區間的變異情形 本研究邀請任何原因需要接受超音波檢查的病患, 額外接受兩側超音波檢查, 並依 Kwon 學者研究的超音波檢測標準, 進行第一間隔區隔膜解剖變異的超音波研究 結果共有 24 位個案 48 個手腕, 第一間隔區隔膜存在的盛行率為 70.8%, 而兩側手腕同時存在隔膜的盛行率為 54.2%, 並且有 4 位個案左右手腕第一間隔區的縱隔存在是不對稱的 根據本研究, 手腕伸肌第一間隔區的變異率頗高 並且因兩側手腕同時存在隔膜的高盛行率, 我們建議任何狄魁文氏症候都應該評估是否有這種變異存在並作正確的衛教, 以避免狄魁文氏症候患者的患側手因休息而加重非患側手的負擔, 而導致續發非患側手的狄魁文氏症候 關鍵詞 : 超音波, 狹窄性肌腱滑囊炎 手腕疼痛 手腕伸肌區間 1 新北市汐止區汐止國泰醫院復健科投稿日期 :2015 年 12 月 02 日接受日期 :2016 年 01 月 04 日 * 通訊作者 : 韓紹禮電子信箱 :s811087@gmail.com 輔仁醫學期刊第 15 卷第 1 期

8 Wei-Ting Wu Shao-Li Han 18 Fu-Jen Journal of Medicine Vol.15 No