Changes In The Radial Styloid Bone: Can They Affect
The Choice Of Treatment Method In De-Quervaın Tenosynovitis?
Radial
Stiloid Kemikte Değişiklikler: De-Quervain Tenosinoviti Hastalığında Tedavi
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ABSTRACT
Introduction: De Quervain tenosynovitis is a stenosing
tenosynovitis of the Abductor Pollicis Longus (APL) and M. Extensor Pollicis
Brevis (EPB) tendons located in the 1st dorsal compartment of the wrist, un=
der
the dorsal carpal ligament and radial tunnel. This research aimed to define=
and
investigate the radial styloid bone changes and to evaluate which treatment
option was applied to patients with bone changes.
Method: A total of 55 patients with De Quervain
tenosynovitis were included in this study. Two separate radiologists analyz=
ed
the anterior-posterior wrist radiographs of patients at different times to
investigate and define the radial styloid bone changes and evaluate which
treatment option was applied to patients with radial styloid bone changes. =
The
impact of treatment was assessed to determine the extent to which the
appropriate treatment option can be decided for patients via X-ray.
Results: According to radiological imaging findings,
changes were detected in the radial styloid bone in 72.2% of the patients,
while no such changes were observed in 27.8%. The analyses show no signific=
ant
relationship between X-ray findings and pre-FTR status, conservative or
surgical treatment (p>0.05). The age variable was statistically signific=
ant
in predicting X-ray changes (p =3D 0.049). The probability of X-ray changes
increases with age (p =3D 0.049), which shows that age is an essential fact=
or in
X-ray changes.
Keywords: De Quervain =
Tenosynovitis,
Conservative Treatment, Physical Therapy and Rehabilitation, X-ray, Age.
ÖZET
Amaç: De Quervain tenosinoviti, bileğin 1. dorsal
kompartımanında, dorsal karpal ligament ve radyal tünel altında bulunan
Abductor Pollicis Longus (APL) ve M. Extensor Pollicis Brevis (EPB)
tendonlarının stenozan tenosinovitidir. Bu araştırmanın amacı, radyal stilo=
id
kemik değişikliklerini tanımlamak ve incelemek ve kemik değişiklikleri olan
hastalara hangi tedavi seçeneğinin uygulandığını değerlendirmektir.
Yöntem: Bu çalışmaya De Quervain tenosinoviti olan to=
plam
55 hasta dahil edildi. İki ayrı radyolog, radyal stiloid kemik değişiklikle=
rini
araştırmak ve tanımlamak ve radyal stiloid kemik değişiklikleri olan hastal=
ara
hangi tedavi seçeneğinin uygulandığını değerlendirmek için hastaların farklı
zamanlarda çekilen ön-arka bilek radyografilerini analiz etti. Tedavinin
etkisi, hastalar için uygun tedavi seçeneğinin direk grafi yoluyla ne ölçüde
kararlaştırılabileceğini belirlemek için değerlendirildi.
Bulgular: Radyolojik görüntüleme bulgularına göre
hastaların %72.2'sinde radyal stiloid kemiğinde değişiklikler tespit edilir=
ken,
%27.8'inde böyle bir değişiklik gözlenmedi. Analizler, direk grafi bulguları
ile FTR öncesi durum, konservatif veya cerrahi tedavi arasında anlamlı bir
ilişki olmadığını göstermektedir (p>0.05). Yaş değişkeni, direk grafi
değişikliklerini tahmin etmede istatistiksel olarak anlamlıydı (p =3D 0.049=
).
X-ışını değişikliklerinin olasılığı yaşla birlikte artmaktadır (p =3D 0.049=
), bu
da yaşın direk grafi değişikliklerinde önemli bir faktör olduğunu
göstermektedir.
Anahtar Kelimeler: De Quervain =
Tenosinoviti,
Konservatif Tedavi, Fizik Tedavi Ve Rehabilitasyon, Direk Grafi, Yaş.
INTRODUCTION
De Quervain tenosynovitis is a
stenosing tenosynovitis of the Abductor Pollicis Longus (APL) and M. Extens=
or
Pollicis Brevis (EPB) tendons located in the 1st dorsal compartment of the
wrist, under the dorsal carpal ligament and radial tunnel. There are many f=
actors
in the etiology of De Quervain tenosynovitis. Excessive and repetitive
movements of the thumb and wrist cause increased frictional force and
microtrauma, causing De Quervain tenosynovitis. De Quervain tenosynovitis is
more likely to be seen between the ages of 30-60 and is 6-10 times more com=
mon
in women than men (1).
Although the etiology of De
Quervain tenosynovitis is not fully understood, many factors play a role in=
the
etiology. In pathology, rather than acute inflammation of the synovial tiss=
ue,
fibrous tissue accumulations and increased vascularity, together with myxoid
degeneration, play a role. These accumulations cause thickening of the tend=
on
sheath and painful effects on the APL and EPB tendons (2). In occupational
groups that force the thumb into abduction and extension (knitting, prolong=
ed
keyboard use, prolonged phone-tablet use, use of musical instruments such as
piano and guitar, continuous straining of the finger during excessive
cleaning), microtraumas may cause De Quervain tenosynovitis (3). It is thou=
ght
that repetitive movements performed during baby care in pregnant and
breastfeeding women predispose to De Quervain disease. In challenging and
repetitive situations, such as breastfeeding, grasping the baby's head, and
carrying it in the same position, the position of the mother's hand causes
tendon compression. In prolonged complaints, treatment may go as far as
surgical intervention (4).
De Quervain's tenosynovitis m=
ay
present symptoms such as pain caused by using the hand and thumb, localized
tenderness in the radial styloid area, edema, Finkelstein's sign in positive
extension of the thumb, and limitation and weakness in abduction. The pain =
and
restriction resulting from De Quervain's tenosynovitis limit people's abili=
ty
to use their hands functionally in daily life activities. De Quervain, among
the occupational diseases, causes loss of work power (5). Conservative and
surgical methods are utilized to treat De Quervain's tenosynovitis. Orthoses
have an essential place in conservative treatment. When we look at the
literature, we see that the thumb Spica orthosis is used more frequently in
treating De Quervain's tenosynovitis. The thumb Spica orthosis prevents the
patient from using his hand functionally because it covers the thumb and wr=
ist.
The short opponens splint does not restrict the hand's functionality becaus=
e it
only stabilizes the carpometacarpal (CMC) joint (6).
This research aimed to define=
and
investigate the radial styloid bone changes (bone localization, periosteal =
reaction,
sclerosis, osteopenia, erosion, and contour finding in the remaining epiphy=
sis)
and to evaluate which treatment option was applied to patients with bone
changes.
METHOD
A total of 55 patients with De
Quervain tenosynovitis were included in this study. All procedures followed
were in accordance with the ethical standards of the responsible committee =
on
human experimentation (institutional and national) and with the Helsinki
Declaration of 1975, as revised in 2008. Ethics committee approval was gran=
ted
from our institution on 31/07/2024 with protocol number 1707/1687, and info=
rmed
consent was obtained from all participants.
Among 190 patients who applie=
d to
our institution's Department of Orthopedics and Traumatology Department bet=
ween
2019 and 2024 with de-Quervain tenosynovitis (n=3D55) were enrolled in this
research. Two separate radiologists analyzed the anterior-posterior wrist
radiographs of patients at different times to investigate and define the ra=
dial
styloid bone changes and evaluate which treatment option was applied to
patients with radial styloid bone changes. The impact of treatment was asse=
ssed
to determine the extent to which the appropriate treatment option can be
decided for patients via X-ray.
Statistical Analysis
The data obtained in this stu=
dy
were analyzed using SPSS 24.0 (Statistical Package for the Social Sciences)
software. Descriptive statistics of the data (number, percentage, mean,
standard deviation, minimum and maximum values) were calculated, and patient
characteristics were summarized. The chi-square test was applied to evaluate
the relationships between categorical variables. Logistic regression analys=
is
was used to determine the factors predicting X-ray changes. X-ray changes (=
0:
No, 1: Yes) were considered dependent variables, and age, gender, pre-FTR
treatment status, conservative treatment, surgical treatment, and affected =
side
were used as independent variables. The logistic regression analysis evalua=
ted
model fit with -2 Log-likelihood, Cox & Snell R², and Nagelkerke R² val=
ues.
Results with a P value below 0.05 were considered statistically significant=
.
RESULTS
According to gender distribut=
ion,
of the 55 patients with De Quervain tenosynovitis included in the study, 68=
.5%
were female, and 31.5% were male. The patients' ages ranged from 24 to 85, =
and
the mean age was 48.04 ± 15.59 years. This distribution shows that the study
covered a broad age group; the mean age was concentrated in the middle age
group. Additionally, 96.3% of these patients did not receive physical thera=
py
rehabilitation (PTR) and preoperative treatment. While the conservative
treatment option was applied to 85.2% of the patients, this treatment was n=
ot
used for 14.8%. The rate of patients receiving surgical treatment was 25.9%,
and 74.1% did not undergo surgical intervention (Table 1).
Table
1. Baseline Demographic and Treatment of Study
Population
|
|
n |
% |
|
|
Gender |
Female |
37 |
68,5 |
|
Male |
17 |
31,5 |
|
|
Pre-operative PTR |
No |
52 |
96,3 |
|
Yes |
2 |
3,7 |
|
|
Conservative treatment |
No |
8 |
14,8 |
|
Yes |
46 |
85,2 |
|
|
Surgery |
No |
40 |
74,1 |
|
Yes |
14 |
25,9 |
|
|
Dominant hand |
Right |
52 |
96,3 |
|
Left |
0 |
0,0 |
|
|
Bilateral |
2 |
3,7 |
|
|
Affected side |
Right |
25 |
46,3 |
|
Left |
27 |
50,0 |
|
|
Bilateral |
2 |
3,7 |
|
|
Change in X-ray |
No |
15 |
27,8 |
|
Yes |
39 |
72,2 |
PTR: physical therapy rehabilitation.
In the dominant hand distribu=
tion,
96.3% of the patients used their right hand as the dominant hand, while 3.7%
had bilaterally affected hands. There were no patients who used their left =
hand
as the dominant hand. Regarding the affected side, 50% of the patients had =
left
wrist effects, 46.3% had right wrist effects, and 3.7% were affected
bilaterally.
According to radiological ima=
ging
findings, changes were detected in the radial styloid bone in 72.2% of the
patients, while no such changes were observed in 27.8%.
<=
span
style=3D'font-size:9.0pt;line-height:107%;font-family:"Times New Roman",ser=
if'>Table
2. Relationships Between X-ray Changes and Treatme=
nt
Options
|
|
Change in X-ray |
Chi-Square Test |
||||
|
|
No |
Yes |
|
|||
|
n |
% |
n |
% |
p-value |
||
|
Pre-operative PTR |
No |
15 |
28,8 |
37 |
71,2 |
0,518 |
|
Yes |
0 |
0,0 |
2 |
100,0 |
||
|
Conservative treatment |
No |
2 |
25,0 |
6 |
75,0 |
0,610 |
|
Yes |
13 |
28,3 |
33 |
71,7 |
||
|
Surgery |
No |
11 |
27,5 |
29 |
72,5 |
0,596 |
|
Yes |
4 |
28,6 |
10 |
71,4 |
PTR: physical therapy rehabilitation.
The difference between pre-PTR
treatment status and X-ray changes was insignificant (p =3D 0.518). X-ray c=
hanges
were observed in 71.2% of patients who did not undergo PTR. While all patie=
nts
who underwent PTR (100%) had X-ray changes, only two patients in the sample
received treatment before FTR. X-ray changes were observed in 71.7% of pati=
ents
who received conservative treatment, while this rate was 75.0% in patients =
who
did not. This difference was also not statistically significant (p =3D 0.61=
0).
Relationship Between Surgical Treatment and X-ray Changes: X-ray changes we=
re
detected in 71.4% of patients who received surgical treatment, while this r=
ate
was 72.5% in patients who did not receive surgical treatment. This differen=
ce
was not statistically significant (p =3D 0.596). The analyses show no signi=
ficant
relationship between X-ray findings and pre-FTR status, conservative or
surgical treatment (p>0.05) (Table 2).
Table
3. Relationships Between X-ray Changes and Gender,
Dominant Hand, and Affected Side
|
|
Change in X-ray |
Chi-square Test |
||||
|
|
No |
Yes |
|
|||
|
n |
% |
n |
% |
p-value |
||
|
Gender |
Female |
10 |
27,0 |
27 |
73,0 |
0,550 |
|
Male |
5 |
29,4 |
12 |
70,6 |
||
|
Dominant hand |
Right |
14 |
26,9 |
38 |
73,1 |
0,482 |
|
Left |
0 |
0,0 |
0 |
0,0 |
||
|
Bilateral |
1 |
50,0 |
1 |
50,0 |
||
|
Affected side |
Right |
8 |
32,0 |
17 |
68,0 |
0,480 |
|
Left |
6 |
22,2 |
21 |
77,8 |
||
|
Bilateral |
1 |
50,0 |
1 |
50,0 |
X-ray changes were detected in
73.0% of female and 70.6% of male patients. No statistically significant
difference was found between gender and X-ray changes (p =3D 0.550). X-ray
changes were observed in 73.1% of patients using the right hand as the domi=
nant
hand. This rate was found to be 50.0% in bilateral hand use. Although no
patient used the left hand as the dominant hand, no statistically significa=
nt
difference was found between dominant hand preference and X-ray changes (p =
=3D
0.482). X-ray changes were seen in 68.0% of patients with the right side af=
fected
and in 77.8% of patients with the left side affected. This rate was 50.0% in
bilaterally affected patients. No significant relationship was found between
the affected side and X-ray changes (p =3D 0.480). As a result, no statisti=
cally
significant relationship was found between gender, dominant hand, and affec=
ted
side and X-ray changes in the analyses performed (p > 0.05) (Table 3).
Table
4. The results of Lojistik Regresyon Sonuçları
|
|
Coefficient |
sh |
Wald |
sd |
p-value |
|
Age |
0,049 |
0,025 |
3,869 |
1 |
0,049 |
|
Female |
0,101 |
0,715 |
0,020 |
1 |
0,887 |
|
Pre-operative PTR (yes) |
20,250 |
26645,449 |
0,000 |
1 |
0,999 |
|
Conservative (yes) |
-0,354 |
1,206 |
0,086 |
1 |
0,769 |
|
Surgery (yes) |
-0,642 |
1,087 |
0,348 |
1 |
0,555 |
|
Affected Side |
|
|
0,764 |
2 |
0,682 |
|
Right |
0,521 |
1,989 |
0,069 |
1 |
0,793 |
|
Left |
1,044 |
1,981 |
0,277 |
1 |
0,598 |
|
Constant |
-1,668 |
2,930 |
0,324 |
1 |
0,569 |
PTR: physical therapy rehabilitation.
![](3D"5.EuroAnArticle.HTML_dosyalar/image004.png")
Figure 1. Relationship between X-ray findings and beforephysical therapy
rehabilitation R status, conservative treatment and surgical treatment
The age variable was statisti=
cally
significant in predicting X-ray changes (p =3D 0.049). The probability of X=
-ray
changes increases with age (p =3D 0.049), which shows that age is an essent=
ial
factor in X-ray changes. The gender (female) variable did not significantly
correlate with X-ray changes (p =3D 0.887). This result shows that the fema=
le
gender does not have a determining effect on X-ray changes. The Pre-PTR
Treatment variable was insignificant despite showing a very high coefficient
value in the analysis (p =3D 0.999). This situation reveals that receiving
treatment before PTR does not affect X-ray changes. The Conservative Treatm=
ent
and Surgical Treatment variables were also insignificant in predicting X-ray
changes (p =3D 0.769 and p =3D 0.555). This finding shows that these treatm=
ent
options do not have a substantial relationship with X-ray changes (Table 4)=
.
As a result, age was a signif=
icant
factor in predicting X-ray changes in this logistic regression model, while
other variables were not significant.
DISCUSSION
The first dorsal compartment =
is a
fibroosseous tunnel located on the radial styloid. It contains the long
abductor of the thumb, abductor pollicis longus (APL), and the short extens=
or,
extensor pollicis breg. The pelvic muscle is located inside. The tunnel is
approximately 1 cm long. It occurs due to nodular thickening of the abductor
pollicis longus and pelvic muscle tendons and their compression within the
canal (7)]. The studies observed that the compartment was frequently divided
into two by vertical septa extending from the radius to the extensor
retinaculum. The APL was generally located on the palmar side, and the pelv=
ic
muscle on the dorsal side. Previous studies stated that these two tendons w=
ere
located in two separate channels in 17-40% of the cases. Often, the APL ten=
don
was present in more than one case. Two channels are frequently seen in De
Quervain patients (8). Two separate channels were reported in 17-40% of the
cases in clinical studies. The channel on one side contains the pelvic musc=
le,
and the channel on the other contains the APL tendons. Some studies have al=
so
mentioned a third channel (9).
Studies on De Quervain's
tenosynovitis suggest that De Quervain's tenosynovitis is caused by a
mechanically narrowed fibro-osseous canal, resulting in a mechanical
compression of the tendons and the narrowed fibro-osseous canal. This
compression causes increased tension on the abnormal retinaculum, stimulati=
ng
nociceptors and resulting in pain. This pathophysiological model explains w=
hy
splinting is an effective way to manage symptoms. It prevents the tendon fr=
om
sliding within the abnormal fibro-osseous canal and compresses the tendon
retinaculum. Patients usually feel pain over the radial styloid, and this p=
ain
increases particularly with thumb movements. They feel pain when lifting and
grasping objects with the wrist in a neutral position. There are provocativ=
e tests
to make the diagnosis (10). The first is the Finkelstein test. In this test,
when the patient grasps the thumb and abducts the wrist to the ulnar side, =
the
increase in pain indicates that the test is positive. EPB is a test that sh=
ows
tendon pathologies more than APL. The pain increases when the patient grasps
the thumb, which causes ulnar deviation, and the pain is relieved when the
patient opens the thumb in this position. This is also known as the Eichhoff
maneuver, another test that helps make a diagnosis (11). De Quervain's
tenosynovitis is often a self-limiting disease. Most patients are relieved =
with
non-surgical methods. These methods include rest, non-steroidal
anti-inflammatory drugs, splinting, physical therapy modalities, and steroid
injections into the tendon sheath. Relaxation of the first extensor compart=
ment
is recommended in resistant cases that do not respond to non-surgical
treatments (12).
Conservative treatment method=
s are
quite effective in relieving pain and increasing joint movements in De
Quervain's disease, especially in acute cases. In our study, 96.3% of these
patients did not receive physical therapy rehabilitation (PTR) and preopera=
tive
treatment. Current non-surgical me=
thods
commonly include hand physical therapy, thumb spica splints to immobilize t=
he
irritated tendons, anti-inflammatory non-steroidal anti-inflammatory drug
(NSAID) prescriptions, and corticosteroid injections to reduce the inflamma=
tory
swelling and irritation of the APL/EPB tendons (13). Surgical methods are a=
pplied
in symptomatic cases with conservative treatment. Surgery can be performed =
with
open or endoscopic techniques. In our study, the conservative treatment opt=
ion
was applied to 85.2% of the patients. This treatment was not used for 14.8%.
The rate of patients receiving surgical treatment was 25.9%, and 74.1% did =
not
undergo surgical intervention. Various complications can also be seen due to
surgical procedures. These are cephalic vein injury, radial nerve sensory
branch injury, tendon subluxations, painful wound scar tissue, and wound
problems (14) Iatrogenic radial nerve sensory branch injury is among the mo=
st
common complications. Endoscopic release surgery reduces these complication=
s,
which are more common in open surgery. After surgery with the endoscopic
method, there is less pain in the early period and more patient satisfaction
due to the small wound area. In addition, Poublon et al. stated that there =
are
many variations of the radial nerve sensory branch; therefore, it is not a =
safe
area (15).
In the cadaver study of Jacks=
on et
al. (16), EPB was absent in 2% of the cases, and Brunelli's study (17) in 4=
%.
In the study of Witt et al. (18), it was determined that the pelvic muscle =
was
in separate channels during surgical treatment in 73% of the cases treated
conservatively and with unsuccessful results. In the instances showing
recurrence, it was observed that there were two separate channels in four
patients during the second surgery. Eidelmann et al. (19) found that patient
dissatisfaction is significantly associated with disease recurrence or
long-term complications. Consequently, reintervention in these cases is
sometimes inevitable. Although different studies have shown multiple
predisposing risk factors for Quervain’s syndrome, there are almost no stud=
ies
focusing on possible risk factors that influence patient-reported outcomes
following de Quervain’s release. Eidelmann et al. reported that 80% of
dissatisfied patients in their cohort had recurrent disease or postoperative
complications and a clear explanation for persistent pain. The remaining 20=
% in
that study did not have an apparent reason for their persistent pain. Still,
the authors reported all were either workman’s compensation patients or bei=
ng
treated for psychiatric diseases (19).
Although diagnosis is apparen=
t,
standard posteroanterior (PA) wrist radiography is essential to prevent the
misdiagnosis of arthritic changes, a fracture, or a tumor by considering the
similar localization of pain. At the same time, most patients describe repe=
titive
trauma (20). Chien et al. (21) reported that some radiographic findings of =
the
radial styloid, such as focal cortical erosion, sclerosis, or periosteal bo=
ne
resorption, should suggest de Quervain’s tenosynovitis. After almost 9 year=
s,
Suresh et al. (22) found that radial styloid abnormalities did not affect
management. Recently, Henry et al. (23) published no significant difference=
s in
surgery rates with positive X-ray findings. However, there is still
insufficient data about the radiographic findings of de Quervain’s
tenosynovitis patients and their contribution to patient management. Chien =
et
al. (21) showed that the focal radial styloid abnormality at the first dors=
al
wrist compartment was significantly associated with de Quervain’s tenosynov=
itis.
Additionally, Suresh et al. (22) reported that radial styloid abnormality w=
as
not statistically significant in patients with de Quervain’s tenosynovitis =
and
did not affect the management outcome. In addition, Henry et al. (23) publi=
shed
no significant differences in surgery rates with positive X-ray findings.
According to the radiological imaging findings of our study, changes were
detected in the radial styloid bone in 72.2% of the patients, while no such
changes were observed in 27.8%. Previous research states that surgery for
nontraumatic upper extremity conditions is mostly discretionary and
preference-sensitive (24).
CONCLUSION
Regarding the outcomes of this
research, one can say that age variable was statistically significant in
predicting X-ray changes. The probability of X-ray changes increases with a=
ge,
which shows that age is an essential factor in X-ray changes.
DESCRIPTIONS
No financial support.
No conflict of interest.
AI Statement: The authors used AI and AI-assisted
Technologies (Grammarly and MS Word Editor) in the writing process. These
technologies improved the readability and language of the work. Still, they=
did
not replace key authoring tasks such as producing scientific or medical
insights, drawing scientific conclusions, or providing clinical recommendat=
ions.
The authors are ultimately responsible and accountable for the contents of =
the
whole work.
Consent for Publication: The original article is n=
ot
under consideration by another publication, and its substance, tables, or
figures have not been published previously and will only be published
elsewhere.
Data Availability: The data supporting this study's
findings are available on request from the corresponding author. The data a=
re
not publicly available due to privacy or ethical restrictions.
Ethical Declaration: All procedures followed were =
in
accordance with the ethical standards of the responsible committee on human
experimentation (institutional and national) and with the Helsinki Declarat=
ion
of 1975, as revised in 2008. Our institution has granted ethics committee
approval. As this was retrospective research, no informed consent was obtai=
ned
from participants.
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