dequervainspptxfisioteraoi-170303141009.pptx

ppt fisioterapi

1. De Quervain’s Tenosynovitis Dr. Akshita (PT) B.P.T D.C.PT Yoga Instructor Nutritionist

2. INTRODUCTION It is named after Swiss surgeon, FRITZ DE QUERVAIN who first described the condition in 1895.  It is a stenosing tenosynovitis which affects the tendon sheaths of the 1st dorsal compartment of the wrist .  It is characterised by degeneration and fibrosis of the tendon sheath.

3. Incidence Occurs most often in individuals age between 30 and 50 years It affects women up to six times more often than men Is commonly associated with dominant hand

4. Anantomy The dorsal aspect of the wrist contains six compartments that transmit the tendons to the hand . 1-Abd. Pollicis longus Ext. pollicis brevis 2- Ext.carpi radialis longus Ext. carpi radialis brevis 3- Ext. pollicis longus 4-Ext. digitorum Ext. indicis 5- Ext. digiti minimi 6- Ext. carpi ulnaris

5. First Dorsal Compartment The first dorsal compartment is approximately 2 cm long and is located over the radial styloid proximal to the radio- carpal joint  .

6. Abductor pollicis longus Originates from-posterior shaft of ulna and radius Inserts at-base of 1 st meta carpal Supplied by-radial nerve Action- abduction +extension of thumb Extensor pollicis bevis Originates from-posterior shaft of radius Inserts at-base of proximal phalanx Supplied by-radial nerve Action- extension of thhumb .

7. Predisposing Factors Overuse injury Repetitive tasks that involve overexertion of thumb, radial and ulnar deviation of the wrist Arthritis pregnancy

8. Activities such as Wringing out wet clothes. Long use of computer mouse. Use of scissors, surgical tongs. Texting Hammering. Knitting. Lifting heavy objects such as a jug of milk, taking a frying pan off of the stove, or mother lifting a baby out of a crib ( babywrist ).

9. Etiology The tendons of the abductor pollicis longus and the extensor pollicis brevis are tightly secured against the radial styloid by the overlying extensor retinaculum .  Acute or repetitive trauma restrains gliding of the tendons results in inflammation of synovial sheath Increases friction

10. Reactive fibrosis and thickening of the sheath. Degeneration.

11. Clinical Features Patient may complain pain on the radial side of the wrist that is worsened by moving the wrist or thumb. Sometimes there is a visible swelling over the radial styloid .

12. The tendon sheath may feels thick and hard. Tenderness is mostly acute at the tip of the radial styloid . Pain aggravates on grasping and raising objects with the wrist Wet leather sign The Finkelstein test is positive.

13. Finkelstein test It is a provocative test used in diagnostic for de Quervain's tenosynovitis . Makes a fist with the thumb inside. Now ask the patient to bend the wrist toward little finger

14. Differential Diagnosis CMC arthritis of the thumb : pain and crepitus present with the thumb "crank and grind test . Scaphoid fracture : in this tenderness will be in the anatomic snuff box. Chauffeur's fracture Intersection syndrome - tenosynovitis of the second dorsalcompartment involving the tendons of extensor carpi radialis brevis (ECRB) and extensor carpi radialis longus (more proximal pain)

15. Extensor pollicis longus (EPL) tendonitis of the third dorsal compartment: common in patients with rheumatoid arthritis or with direct injury and distal radius fracture .

16. TREATMENT GOALS I. Restoration of normal,painless use of the involved hand. II. Resolution of the inflammatory process. III. Prevention of recurrence of the through education. IV. Restoration of pain-free movements and strength .

17. CONSERVATIVE MANAGEMENT Medical management Corticosteroid injection : can be given to patient with morderate to marked pain with symptoms lasting for more than 3 weeks. NSAIDS : it is precribed initially for 6 to 8 weeks to reduce pain and inflammation.

18. PHYSIOTHERAPY MANAGEMENT Immoblisation : A thumb spica splint is used to restrict thumb movement so that the first dorsal compartment tendons are at rest. Cold compression : for 10 to 12 minutes over the inflammed area.

19. Ultrasonic therapy: pulsed mode, 3 mhz , time-5min. Phonophorersis :with 10% hydrocortisone. Gentle active and passive motion of thumb and wrist encouraged for 5 minutes every hour to prevent joint contractures and adhesions. Strenghtening and stretching exercises after the initial pain subsides.

20. Indication for decompression surgery Unsatisfactory symptom reduction Persistence of symptoms after conservative interventions. Limitations in A.D.Ls due to pain.

21. After Decompression Surgery 0-2 Days Immobilization within cast Active movement of IP joint: Flexion and Extension. After 48 hours of surgery dressings are removed. After this begin with gentle active motion of the wrist and thumb.

22. 2-14 Days Presurgical splint is worn for comfort and active exercises are continued for Ipjoint , elbow and shoulder joint . By 10- 14 days: sutures are removed. 2-6 Weeks Grip and pinch strengthening exercises may begin at approximately 3 weeks and can be progressed gradually. By the end of 6 week the patient usually is able to resume full activities.

23. Ergonomics 1) Ergonomic mouse: It feature a molded thumb rest support will help reduce the amount of gripping force your thumb needs to apply to hold the mouse.

24. 2) Use the power grip (all fingers in a loose grip) instead of using a pinch. 3) Minimize repetition and rest arm occasionally during a repetitive activity or slow down activity. 4) Use a light grip on tools, pens, the mouse. 5) Alternate hands during activities if possible

25. Case Study Name - Hemlata Age - 45 Gender- female Occupation – housewife Dominance-right Chief complaint-pain at left thumb and area below thumb from 20 days which has increased from last few days.

26. Pain history Mechanism of injury- can’t be recalled by pateint . Duration of pain-20 days Vas score-6 Type-sharp pain with movement Aggravating factor –doing house hold work like washing clothes , brooming etc. Relieving factor – pain relieving ointment( balm,painkiller given by physician) Severity-level 4 i.e pain during and after specific activity that does affect performance

27. Past history-The patient reported no past history of elbow, forearm or wrist pain. No history of systemic disease. No family history of major systemic diseases

28. On examination Swelling –minimal swelling seen on comparing right wrist ( non pitting). Tenderness-present grade :2 i.e patient allows to touch but it gives pain. RIM Wrist extensor and flexor –strong and painless Radial deviation ulnar deviation –strong and painfull

29. THUMB Flexion Extension STRONG PAINFULL Abduction Adduction Roms shown no variations.

30. TREATMENT Ultrasonic therapy 3mhz pulsed 1:4 time: 5 minutes Intensity:8 Cold compression/ Ice massage- for 10 to 12 minutes. Advice for rest.