2. Mohsen Mardani-Kivi M.D. Assistant Prof. Orthopaedic Dept. Guilan University of Medical Sciences

3. * Fritz de Quervain A Swiss surgeon First physician In 1895

5. The lesion occurs secondary to overuse and repeated activities of wrist in ulnar deviation position while the thumb is in abduction and extension.

6. * Adults * Especially women aged 30-50 years

7. micro-tears collagen disorientation mucoid changes thickening of the extensor retinaculum of the wrist

9. Conventional treatments such as: rest and reducing daily activities massage therapy diathermy oral analgesics local steroid injection biomechanical correction such as: Orthosis cast or brace immobilization strengthening protocols other modalities such as cryotherapy iontophoresis)

10. Cochrane review of corticosteroid injection for the treatment of de Quervain’s tenosynovitis, demonstrates that methylprednisolone injection relieves the signs and symptoms of the condition faster than other palliative treatments Peters-Veluthamaningal C, van der Windt DA, Winters JC, Meyboom-de Jong B. Corticosteroid injection for de Quervain's tenosynovitis. Cochrane Database Syst Rev. 2009(3):CD005616.

11. Light Thumb Spica Orthosis (TS) has been reported to have favorable results, with the mechanism of decreasing ulnar deviation and thumb flexion and relieving involved tendons Huang TH, Feng CK, Gung YW, Tsai MW, Chen CS, Liu CL. Optimization design of thumb spica splint using finite element method. Medical & biological engineering & computing. Dec 2006;44(12):1105-1111.

12. * If conservative treatments fail, surgical methods are recommended that are expensive and invasive

13. * Very few studies compare the efficacy of the TS+CSI and CSI (Avci et al., Richie et al., Weiss et al.) * Purpose: The present study was conducted to examine and compare the efficacy of TS+ CSI versus CSI alone in the treatment of de Quervain’s tenosynovitis. Avci S, Yilmaz C, Sayli U. Comparison of nonsurgical treatment measures for de Quervain's disease of pregnancy and lactation. J hand surg. 2002;27(2):322-324. Richie CA, 3rd, Briner WW, Jr. Corticosteroid injection for treatment of de Quervain's tenosynovitis: a pooled quantitative literature evaluation. J Am Board Fam Pract. 2003;16(2):102-106. Weiss AP, Akelman E, Tabatabai M. Treatment of de Quervain's disease. J hand surg. 1994;19(4):595-598.

14. Exclusion: Hx. of CSI during the previous six months, previous surgery, wrist fracture. Pregnancy, rheumatoid arthritis, radiculopathy and carpal tunnel syndrome, patients with skin infection or other dermatologic lesions at the injection site Inclusion criteria: pain in the radial wrist, tenderness at the first compartment of dorsal flexion of the wrist, positive Finkelstein test and pain scale more than 6 according to VAS (Visual Analogue Scale). Design: Randomized clinical trial

15. Patient referral, Clinical Examination Enrolment: 93 patients Baseline assessments Randomization: 67 CSI group: 34 patients Patients with completed questionnaire: 29 Lost to followup and/or taking analgesics: 5 CSI+TS group: 33 patients Patients with completed questionnaire: 30 Lost to followup and/or taking analgesics: 3 Excluded or refused to participate: 26 cases

16. CSI group: 40 mg of Methylprednisolone Acetate with 1cc lidocaine 2% were injected in the compartment sheath at the Maximal point tenderness CSI+TS group: The patients in CSI+TS group fiberglass thumb Spica orthosis were applied after CSI for 3 weeks. No specific analgesics were prescribed

17. Variables: Primary outcome: (treatment success rate) was assessed according to the presence or absence of: pain in the radial wrist, tenderness at the first compartment of dorsal flexion of the wrist, and Finkelstein test results. secondary outcome: (Functional outcome)  Quick DASH and VAS. Visits: pre-treatment, 3 weeks and 6-months post-treatment

19. CSI+TSCSIBoth groups Statistics No.333467 - Mean age±SD41.77±13.2945.48±1243.59±12.71 N.S ¥ Gender (Male/Female)7 / 235 / 2412 / 47 N.S  Dominant hand (Right/Left)23 / 725 / 448 / 11 N.S  affected hand (Right/Left)22 / 721 / 943 / 16 N.S  VAS pre-treatment (mean±SD) 8.77±0.858.55±1.058.66±0.96 N.S ¥ Quick-DASH pre-treatment (mean±SD) 83.7±10.482.66±10.683.7±10.4N.S ¥ SD: Standard Deviation,  : Chi-square test,¥ : Independent Sample T Test

20. 6 months post-treatment Again CSI+TS was Superior. CSI+TS group (93%) CSI group (69%) (P<0.05) 3 weeks post-treatment Success rate was significantly better in CSI+TS group. CSI+TS group (97%), CSI group (76%) (P<0.05).

21. In both groups, VAS and Quick-DASH scores were reduced in post-treatment visits (P<0.0001), suggesting that both groups were successful in reducing pain. However CSI+TS was significantly more effective in reducing pain (p<0.0001). The VAS scales were reduced 95.7% in CSI+TS and 79.5% in CSI groups.

22. Briefly, the repeated measure ANOVA test indicated that the VAS and Quick-DASH scores significantly changed pre and postoperatively in both follow ups. The differences between the two groups were also statistically significant (p<0.0001). In general, the pain relief trend was in favor of the CSI+TS group than CSI group.

23. * Richie et al.: meta-analysis study * reviewed all the studies on de Quervain’s tenosynovitis In 2003 * reported that CSI, CSI+TS, and Orthosis are successful in 83%, 61%, and 14% of patients respectively. * However, the number of reviewed studies was inadequate for a literature review * none of the reviewed studies were randomized clinical trial Richie CA, 3rd, Briner WW, Jr. Corticosteroid injection for treatment of de Quervain's tenosynovitis: a pooled quantitative literature evaluation. The Journal of the American Board of Family Practice / American Board of Family Practice. Mar-Apr 2003;16(2):102-106.

24. * Peters-Veluthamaningal et al. : Cochrane review study In 2009, databases for relative RCTs Among 563 related titles  only five studies evaluated  only one study with eligible criteria. The 18 patients (not randomized, not blinded)  results: the superiority of CSI over TS method. Peters-Veluthamaningal C, van der Windt DA, Winters JC, Meyboom-de Jong B. Corticosteroid injection for de Quervain's tenosynovitis. Cochrane Database Syst Rev. 2009(3):CD005616. Avci S, Yilmaz C, Sayli U. Comparison of nonsurgical treatment measures for de Quervain's disease of pregnancy and lactation. The Journal of hand surgery. Mar 2002;27(2):322-324.

25. * Weiss et al.: prospective study * Evaluation of efficacy of the CSI+TS, TS and CSI methods in 93 patients in 1994 * treatment success rate: 57, 19 and 67 in CSI+TS, TS and CSI respectively. * Conclusion: the CSI method produced more desired outcomes Weiss AP, Akelman E, Tabatabai M. Treatment of de Quervain's disease. The Journal of hand surgery. Jul 1994;19(4):595-598.

26. * In Literature, they argue that it is not possible to judge over efficacy of CSI method over the other methods due to limited number of studies

27. * The pressure on the wrist and hand, time exposed to pressure and the factors defined as laborious occupation in general may be much more severe in developing countries. Thus, immobilization after CSI may lead to a better therapeutic outcome in such countries. * On the other hand the patients in CSI group may not follow all the physician's advices regarding not using the wrist during the recovery period

28. * Functional outcome in CSI+TS group may increase due to inevitable immobilization of the tendons. * reduce the ulnar deviation and thumb flexion * rest the involved tendon. * Explanation: the patient is obliged not to move the APL (abductor pollicis longus) and EPB (Extensor Pollicis Brevis) tendons.

29. * Strengths of our study: * excluding patients with concurrent medical conditions. * both groups similarity with regards to demographic characteristics (age, gender, occupation) * Limitations: * Non-blinding * Lack of Control group