ORIGINAL RESEARCH |
https://doi.org/10.5005/jojs-10079-1114 |
Correlation between EPB Entrapment Test and Ultrasound Wrist Findings in Patients with De Quervain’s Disease
1,3,4Department of Orthopaedics, Velammal Medical College Hospital and Research Institute, Madurai, Tamil Nadu, India
2Department of Hand Surgery, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
Corresponding Author: Vijayaraja Elangovan, Department of Orthopaedics, Velammal Medical College Hospital and Research Institute, Madurai, Tamil Nadu, India, Phone: +91 9659997500, e-mail: drvijayevr@gmail.com
Received on: 23 March 2023; Accepted on: 18 April 2023; Published on: 07 July 2023
ABSTRACT
Introduction: The reliability of clinical tests in diagnosing de Quervain’s disease has been established, but the presence of subcompartmentalization is difficult to identify, which gave the origin of the extensor pollicis brevis (EPB) entrapment test. Diagnosis of several other anatomical variations like a bony crest, multiple abductor pollicis longus (APL), and EPB slips are necessary. However, surgical inspection is the gold standard method for diagnosing anatomical variation, but the improvement in diagnostic efficacy for better prognosis by combining clinical and ultrasound examination is to be assessed.
Aim: To determine the correlation between EPB entrapment test and ultrasound wrist findings in patients with de Quervain’s tenosynovitis in the detection of anatomical variations of the first extensor compartment.
Materials and methods: A total of 40 Finkelstein’s test-positive wrists underwent EPB entrapment test and ultrasonography (USG) examination by a surgeon and a radiologist, respectively. Radiological evidence of sub-compartmentalization and other anatomical variations were recorded. Both the surgeon and radiologist were blinded to each other’s results. Surgery was done as a reference standard.
Results: The sensitivity of the EPB entrapment test in identifying the sub-compartmentalization is 73.6%, and that of the ultrasound examination is 97.4%, with a majority of the distal incomplete septum (75%). The mean number of APL slips was three, and one wrist had multiple EPB slips.3 Ultrasound also showed a bony crest in the radial styloid of 39 wrists (97.5%)
Conclusion: The extensor pollicis brevis (EPB) entrapment test, a reliable and simple clinical test for identifying sub-compartmentalization of the first extensor compartment but in combination with ultrasound examination, which identifies anatomical variations, could be vital in deciding appropriate treatment and effective surgical release, thereby preventing treatment failures.
How to cite this article: Elangovan V, Rajappa S, Jeganathan GK, et al. Correlation between EPB Entrapment Test and Ultrasound Wrist Findings in Patients with De Quervain’s Disease. J Orth Joint Surg 2023;5(2):45-49.
Source of support: Nil
Conflict of interest: None
Keywords: Anatomical variations, Bony crest, De Quervain’s disease, Extensor pollicis brevis entrapment test, Intracompartmental septa, Sub-compartmentalization.
INTRODUCTION
De Quervain’s disease is the most common cause of radial side wrist pain. It is a stenosing tenosynovitis of the first extensor compartment of the wrist, which contains the tendons of the APL and EPB. Anatomical variations within the first extensor compartment have been identified and studied. The first extensor compartment is found to present as two different compartments containing the two tendons, and each of the tendons was also found to present as multiple slips. There is also a fibrous septum separating these two compartments, which arises from a bony ridge over the dorsal aspect of the radial styloid. These anatomical variations are observed to increase the incidence of the disease, most commonly in women, affecting the activities of daily living. De Quervain’s disease is being managed initially by nonsurgical methods like analgesics, splinting, and steroid injections, while surgical management is done for chronic and refractive cases. However, there was documented evidence of the failure of nonsurgical and surgical treatment methods due to the nonidentification of anatomical variation. These anatomical variations were initially identified by cadaveric studies, but in recent times better diagnostic methods have been developed, and ultrasound examination was suggested to be a better diagnostic tool. Preoperative (pre-op) identification of these anatomical variations is essential for planning complete surgical release. However, prior clinical diagnosis is mandatory, which has led to the development of the EPB entrapment test. These diagnostic tests help in proper planning for surgical management. These anatomical variations may be suspected as the cause for the failure rates in steroid injections in the first extensor compartment due to the noninclusion of the sub-compartment. Therefore ultrasound-guided injection practices are followed. However, the identification of anatomical variation by any proper diagnostic tool is to be studied.
AIMS AND OBJECTIVES
To determine the correlation between EPB entrapment test and ultrasound wrist findings in patients with de Quervain’s tenosynovitis in the detection of anatomical variations of the first extensor compartment.
MATERIALS AND METHODS
This is a prospective observational study approved by the Institutional Ethics Committee. Informed consent was obtained from all patients. A total of 40 wrists with de Quervain’s disease were observed between November 2020 to October 2022. Patients with de Quervain’s disease having radial wrist pain with age >18 years with clinically positive Finkelstein’s test, who presented with failure of nonsurgical treatment, were included in the study. Patients who underwent previous first extensor compartment release were excluded. Patients who are not consenting to the study were excluded.
A total of 39 patients who met the inclusion criteria were enrolled in the study. There were three males and 36 females. All selected patients underwent an EPB entrapment test by a surgeon, followed by an ultrasound examination of the wrist by a radiologist. All the USG tests are done by a single radiologist who was blinded to clinical findings. The surgeon was blinded to the radiological findings.
EPB Entrapment Test
All the patients with positive Finkelstein’s test were subjected to the EPB entrapment test by a surgeon, and the results were recorded. The pain elicited during resisted thumb metacarpophalangeal (MCP) abduction and resisted thumb MCP extension were compared, and the comparative increase in pain during the thumb MCP extension is considered a positive test (Fig. 1).
Figs 1A and B: Extensor pollicis brevis (EPB) entrapment test—resisted thumb MCP extension and resisted thumb MCP abduction
Ultrasound Assessment
All the patients with positive Finkelstein’s test were subjected to ultrasound examination by a radiologist who is blinded to the results of the EPB entrapment test. The presence of sub-compartment, intracompartmental septa, nature of septa, number of APL and EPB tendon slips, and bony crest over radial styloid were recorded (Fig. 2).
Fig. 2: Multiple APL tendon slips and single EPB tendon, each within two separate sub-compartments, with a hypoechoic septa-like structure in between, arising from a deep bony crest over dorsal cortex of radial styloid, marked by a white arrow
Surgical Release
The surgical release of the first extensor compartment was done as a reference standard. All the patients underwent surgical release under local anesthesia by a surgeon who was blinded to the results of the ultrasound assessment. The surgery was done by the wide-awake local anesthesia no tourniquet (WALANT) technique with injection protocol as described by Lalonde et al. The presence of sub-compartment, intracompartmental septa, nature of septa, number of APL and EPB tendon slips, and bony crest over radial styloid were recorded (Fig. 3).
Figs 3A to D: (A) Extensor pollicis brevis (EPB) tendon in a complete sub-compartment; (B) EPB tendon in a distal incomplete sub-compartment; (C) Multiple tendon slips of APL; (D) Bony crest over the surface of radial styloid; visualized after retracting the tendons away
Statistical Analysis
The collected data were analyzed with IBM Statistical Package for the Social Sciences statistics. To find the significance in categorical data Chi-squared test and Fischer’s exact test was used. The probability value of <0.05 is considered as significant.
RESULTS
Patient Characteristics
A total of 40 wrists from 39 patients, 37 females and three males, were studied, with a mean age of 43.6 years (range 24–65 years). Right-side (dominant) involvement was seen in 29 patients. Most of the females are homemakers, and all the males are farmers (Table 1).
| Age (years) | 43.65 (24–65) |
| Age distribution (years) | >50 (32.5%) |
| Sex (M/F) | 3/37 (7.5%/92.5%) |
None of the participants had a previous history of hand traumas.
Outcomes
On comparing the ultrasound examination and EPB entrapment test, the ultrasound examination identified intracompartmental septum in 28 patients in whom the EPB entrapment test was positive and in 10 patients in whom the EPB entrapment test was negative (p-value of 0.46). Similarly, ultrasound examination has identified the presence of bony crest in all 29 patients in whom the EPB entrapment test was positive (p-value of 0.1) (Table 2).
| EPB entrapment test | Ultrasound intracompartmental septum | Total | p-value | |
|---|---|---|---|---|
| Present | Absent | |||
| Negative | 10 | 1 | 11 | 0.465 |
| Positive | 28 | 1 | 29 | |
| Total | 38 | 2 | 40 | |
Extensor pollicis brevis (EPB) entrapment test was positive in 29 wrists (72.5%) and negative in 11 wrists (27.5%).
Ultrasound examination showed intracompartmental septum in 38 wrists (95%), of which 30 wrists had distal incomplete septations and eight wrists had complete septations. Ultrasound couldn’t see any form of the intracompartmental septum in only two patients. Of these two cases, ultrasound has failed to identify a thin septum in one of the wrists, and another one is a true negative value. However, ultrasound falsely identified an intracompartmental septum, and there was no actual septum found between the two tendons. Ultrasound examination has identified a bony crest in 39 wrists, but all 40 wrists had shown a bony crest during surgery. Of the 40 surgically identified bony crests, 24 bony crests were shallow, 14 were deep, and one was double grooved. Ultrasound had missed one shallow bony crest (Figs 4 and 5).
Fig. 4: Nature of septum
Fig. 5: Nature of bony crest
The number of APL tendon slips varied from one to eight. The majority of the patients had triple tendon slips rather than single and double tendon slips. Single APL tendon slip was seen in only 4 patients. Only one wrist had triple EPB tendon slips, and the same wrist had double APL slips. The rest others had a single EPB tendon slip. However, the insertions of these multiple tendon slips were not traced.
The sensitivity of the EPB entrapment test is 76.3%, and the specificity is 100%. The positive and negative predictive values of the EPB entrapment test are 100 and 18.2%, respectively. However, the correlation between the EPB entrapment test and surgical findings is not statistically significant (p = 0.071) (Table 3). The sensitivity of ultrasound in detecting intracompartmental septum is 97.4%, and the specificity is 50%. The positive and negative predictive values of ultrasound examination are 97.4 and 50%, respectively. However, the correlation between ultrasound findings and surgical findings is not statistically significant (p-value of 0.099) (Table 4). Ultrasound has missed the bony crest in one wrist, so the sensitivity of detecting a bony crest by ultrasound is 97.4%.
| EPB entrapment test | Surgical intracompartmental septum | Total | p-value | |
|---|---|---|---|---|
| Present | Absent | |||
| Positive | 29 | 0 | 29 | 0.071 |
| Negative | 9 | 2 | 11 | |
| Total | 38 | 2 | 40 | |
| Ultrasound examination | Surgical intracompartmental septum | p-value | ||
|---|---|---|---|---|
| Present | Absent | Total | ||
| Positive | 37 | 1 | 38 | 0.099 |
| Negative | 1 | 1 | 2 | |
| Total | 38 | 2 | 40 | |
DISCUSSION
De Quervains disease is a common musculoskeletal pathology of the upper limb in the adult population, with a prevalence of 0.5% in men and 1.3% in women. Many surgeons have started to give the anatomical variations of the first extensor compartment the due attention it needs. This is due to the increasing trends in failure and recurrence rates following conservative and surgical management. Our study was unique in the following aspects. Although many studies have documented anatomical variations by cadaveric samples,1 the correlation between ultrasound examination and clinical findings hasn’t been explored.
Finkelstein’s test2 and Eichhoff’s test3 are the two most significant and commonly misperformed tests for clinical diagnosis of de Quervain’s disease. Finkelstein’s test being more sensitive,4 couldn’t identify the anatomical variations within the compartment, which gave origin to the EPB entrapment test. Alexander5 compared the pain elicited during resisted thumb MCP joint palmar abduction and resisted thumb MCP joint extension, and if the patient had more painful thumb extension, the likelihood of having the tendon of EPB in a separate compartment is high.
The earliest evidence of anatomic variations like accessory tendons and fibrous septum and their possible misinterpretation during surgery was first described by Giles in 1960.6 The involved tendon compartment and its contents are regarded as phylogenetically young structures, and hence the occurrence of anatomical variations is thought to be more common.
Despite being a topic of great interest among surgeons, its etiopathology hasn’t been clearly identified. The most acceptable etiopathology is that de Quervains disease is due to myxoid degeneration and not due to an inflammatory reaction.7
The relation between multiple EPB and APL tendon slips, and the pathology of de Quervain’s disease is yet to be established, but it is suspected that the pathogenesis of de Quervain’s disease may not be related to the number of APL slips but the site of attachment of these slips.8-11 Apart from the most common insertion site, which is the base of the first metacarpal multiple slips are found to have been inserted in various sites like the trapezium, muscle belly of abductor pollicis brevis, tendon of opponens pollicis, and the first carpo metacarpal joint capsule. Similarly, the tendon of EPB is also found to have multiple tendon slips which attach to the thumb metacarpal bone, trapezium, and extensor apparatus, and some even blend with tendons of APL.12 This results in overcrowding and increased inter tendinous friction and hence the pathology.
The usefulness of ultrasound examination in detecting anatomical variations, mainly the intracompartmental septum and its nature, has been established in recent literature with reasonable diagnostic accuracy.13,14
De Quervain’s disease is usually managed by nonoperative methods like corticosteroid injection or splinting, or a combination of both. Since the failure rates are almost 50%, ultrasound-guided injections have been practiced.15-18 Surgical release of the first extensor compartment is regarded as the gold standard management of de Quervains disease. However, in general practice, surgical release is done when all other conservative measures fail. Even yet, dissatisfaction rates following surgical release have been documented in the literature, which is suspected to be due to a lack of awareness about the anatomical variations causing the incomplete release.19
An osseous ridge was defined as an elevation from the cortex of the dorsal radial surface within the first extensor compartment. This osseous ridge was found to give rise to the infamous intracompartmental septum.13 The presence of this osseous ridge can be considered an indirect sign of sub-compartmentalization.
Although many studies have documented anatomical variations by cadaveric samples, the correlation between ultrasound examination and surgical findings hasn’t been explored. Testing this correlation and pre-op identification of the anatomical variation was our aim.
The correlation is, however, statistically insignificant, but ultrasound examination can identify anatomical variations with good sensitivity and positive predictive value. This help in pre-op identification of anatomical variations, which guides the surgeon in performing complete surgical release and thus reducing treatment failure.
Among the anatomical variations, distal incomplete septa prove to be the reason for the majority of incomplete surgical releases. In our study, most of the patients had distal incomplete septa between the sub-compartments. In our study, prior identification helped in the complete release of these distal incomplete septa. All the surgical release was done by the WALANT technique as per Lalonde et al.20
Clinically EPB entrapment test can identify the presence of EPB tendon in a subsheath but with sensitivity lower than that of ultrasound examination. In our study, ultrasound falsely identified one distal incomplete septa. Due to this false-positive value, the specificity of ultrasound examination in detecting intracompartmental septum has dropped to 50%, which is much lower as compared to what has been observed in previous studies. It was also noted that the EPB entrapment test is found to have a better correlation with the osseous ridge than the presence of intracompartmental fibrous septum. The ultrasound identification of this osseous ridge can be considered an indirect sign of sub-compartmentalization. We feel that the diagnostic accuracy of ultrasound examination should have been checked by establishing proper inter and intraobserver reliability analysis.
Since the combined results of clinical and ultrasound examinations were included in the diagnosis, it helps in improving better diagnostic accuracy and helps in better surgical release, thereby giving better postoperative outcomes. All the patients were followed up, and no major postoperative complications were noticed. One patient had scar tenderness which was managed by scar massage and ultrasound therapy.
The study has a few drawbacks, the ultrasound examination is not affordable for all the patients in our setup, and some of them have denied surgical release. This is a nonrandomized study with a small sample size. So further randomized studies with comparison groups can be done for further evaluation. Further long-term follow-up studies regarding the functional outcome of these patients are being carried out.
CONCLUSION
Since anatomical variations increase the incidence of de Quervain’s disease and are the reason for treatment failures, prior identification of these anatomical variations is mandatory for complete surgical release. EPB entrapment test can identify the sub-compartment with reliable sensitivity. Ultrasound examination can identify several other anatomical variations. The combined results can be vital before and during surgery, mainly for nonhand surgeons, aiding in complete surgical release and thereby preventing treatment relapse.
ORCID
Vijayaraja Elangovan https://orcid.org/0000-0002-1854-6496
Gokul K Jeganathan https://orcid.org/0000-0002-3731-0323
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