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1
Department of Radiology, University of Michigan Medical Center, 1500 E.
Medical Center Dr., TC-2910G, Ann Arbor, MI 48109-0326.
2
Consortium for Health Outcomes, Innovation, and Cost Effectiveness Studies,
University of Michigan, 300 N. Ingalls Bldg., 3A14, Ann Arbor, MI
48109-0409.
3
Present address: Georgia West Imaging, 605 Dixie St., Carrollton, GA
30117.
Received December 22, 2000;
accepted after revision June 21, 2001.
Address correspondence to J. A. Jacobson.
Abstract
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MATERIALS AND METHODS. A retrospective review of 49 radiographs from 45 patients in whom the clinical diagnosis of de Quervain tenosynovitis was confirmed (positive findings on Finkelstein's test) and 64 radiographs from 62 asymptomatic patients was carried out independently by two musculoskeletal radiologists in a blinded fashion. Findings on radiographs were assessed for focal radial styloid abnormality and assigned a diagnostic grade (1, definitely normal; 2, probably normal; 3, equivocal; 4, probably abnormal; 5, definitely abnormal). Receiver operating characteristic curves were constructed and compared. Kappa statistics for interobserver and intraobserver variability were calculated.
RESULTS. The presence of focal radial styloid abnormality correlated significantly with the presence of de Quervain tenosynovitis (p < 0.05). The areas under the receiver operating characteristic curves for each reviewer equaled 0.71 and 0.76. Kappa values for interobserver variability equaled 0.44 (moderate agreement), and intraobserver variability equaled 0.62 (substantial agreement).
CONCLUSION. Focal radial styloid abnormality is an indicator of de Quervain stenosing tenosynovitis of the wrist.
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Patients with de Quervain tenosynovitis present with pain radiating proximal or distal from the first dorsal wrist compartment. The diagnosis is confirmed with positive findings on Finkelstein's test. To perform this test, the patient places the thumb in the palm of the hand and flexes the digits around the thumb. The wrist is then ulnar deviated. The findings on Finkelstein's test are positive if tenderness is present over the first dorsal wrist compartment [1]. Although the diagnosis of de Quervain tenosynovitis can be made clinically, imaging may be requested in the presence of wrist pain to evaluate other diagnostic possibilities.
Sonographic and MR imaging findings of de Quervain tenosynovitis have been described as consisting of tendon sheath thickening and surrounding soft-tissue edema [4, 5]. Tendon thickening has also been described [5]. In our practice, we have noted several cases of focal radial styloid abnormality (cortical erosion, sclerosis, and periosteal bone apposition) visualized at radiography in the setting of de Quervain tenosynovitis. Our study determined whether these focal radial styloid abnormalities could be used as an indicator of de Quervain tenosynovitis.
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Posteroanterior radiographs that included the radial styloid were identified from the patient and control groups. Forty-nine radiographs of the symptomatic wrists from 45 patients with de Quervain tenosynovitis were collected (four patients had bilateral involvement). Sixty-four radiographs were collected from the 62 patients without de Quervain tenosynovitis (two patients had bilateral radiographs). If multiple posteroanterior radiographs visualizing the distal radial styloid existed from a single patient, the radiograph obtained nearest to the date of diagnosis was used. Objective data that were recorded included the age and sex of the patient, identification of right-versus-left extremity, presence of clinical de Quervain tenosynovitis, date of diagnosis, and date of clinical improvement.
The radiographs were displayed in random order, and patient identification was masked on each film with vinyl electric tape (3M Scotch super 33+; 3M Electrical Products Division, St. Paul, MN). Because the 62 control subjects were identified by ICD-9 codes for metacarpal fractures and their studies were supplemented by any available hand and wrist radiographs from the emergency department, many of these subjects had fractures. All signs of osseous trauma were masked with vinyl electric tape. Random masking of a metacarpal from each of the patients with de Quervain tenosynovitis and from the control subjects was carried out so that the control subjects could not be identified. Additionally, the soft tissues adjacent to the radial styloid of every radiograph were masked so that soft-tissue swelling associated with de Quervain tenosynovitis could not be identified. Two board-certified staff radiologists with musculo-skeletal expertise independently reviewed the radiographs in a random order. The radiologists had knowledge of the study and study design but were unaware of the clinical information and the number of patients with the diagnosis of de Quervain tenosynovitis. Each radiograph was assessed for the presence of any focal radial styloid abnormality at the lateral aspect of the radius, distal to the growth plate remnant. A diagnostic grade was assigned for the findings of each radiograph: 1, definitely normal (no evidence of periosteal bone apposition, erosion, or sclerosis); 2, probably normal; 3, equivocal (questionable abnormality that could not be definitively classified as periosteal bone apposition, erosion, or sclerosis); 4, probably abnormal; and 5, definitely abnormal (definitive periosteal bone apposition, erosion, or sclerosis) (Figs. 1,2,3A,3B,4). One observer reviewed the radiographs twice in the same order, approximately 1 month apart. Kappa values for interobserver and intraobserver variability were calculated (0.21-0.40, fair agreement; 0.41-0.60, moderate agreement; 0.61-0.80, substantial agreement; 0.81-1.0, almost perfect agreement) [7]. Receiver operating characteristic curves were plotted for each observer. Areas under each curve for each observer were calculated and compared to determine if the areas were significantly different from each other or from chance.
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The association between focal radial styloid abnormality and de Quervain tenosynovitis was significant for both observers (p < 0.05) (Figs. 1,2,3A,3B). Of the findings of 11 radiographs graded as 4 or 5 by the first observer, five (46%) showed cortical erosions, two (18%) showed periosteal bone apposition, and four (36%) showed both cortical erosions and periosteal bone apposition. Of the findings in 22 radiographs graded as 4 or 5 by the second observer, three (14%) showed cortical erosions, eight (36%) showed periosteal bone apposition, five (23%) showed sclerosis, four (18%) showed cortical erosions with periosteal bone apposition, and two (9%) showed sclerosis with periosteal bone apposition. The data regarding duration of symptoms and type of distal radius abnormality were not of sufficient size to allow statistical analysis.
Of the findings of 64 radiographs from the control subjects, the first observer graded one as definitely abnormal, whereas the second observer graded six as probably abnormal. These seven false-positive findings occurred in six control subjects imaged for trauma. This result may be explained by interpretation errors by the second observer. Of the six abnormal grades given to control cases by the second observer, the first observer graded four as "normal" and one as "probably normal."
The areas under the receiver operating characteristic curves equaled 0.71 (95% confidence interval [CI], 0.62-0.79%) and 0.76 (95% CI, 0.67-0.84%) for the two observers (Fig. 5). These areas beneath the receiver operating characteristic curves were significantly different from chance (p < 0.05) and were not significantly different from each other (p = 0.3). Kappa statistics for interobserver and intraobserver variability were 0.44 (moderate agreement) and 0.62 (substantial agreement), respectively.
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The etiology of focal radial styloid abnormality is unknown. However, periostitis of the distal tibia has been seen on CT and radiography in association with posterior tibial tendon tears [10, 11]. The proposed mechanism was that of a reactive periostitis from adjacent inflammation [10]. In rheumatoid arthritis, erosions and periosteal bone apposition have involved the metacarpal shaft, likely from adjacent inflammatory tenosynovitis [12]. In de Quervain tenosynovitis, the synovium surrounding the tendons of the first dorsal wrist compartment is thickened. This finding supports the theory of inflammation as a cause; however, acute inflammatory cells are typically lacking [3].
One cause of cortical irregularity of the distal radius is a normal cortical contour bulge or peak at the level of the distal radius epiphyseal plate remnant (Fig. 4). This normal finding has a characteristic location and contour and should not be confused with periosteal new bone apposition. The radial styloid abnormalities of de Quervain tenosynovitis occur distal to the epiphyseal remnant. Radial periostitis may also occur with infection; however, clinical history would differentiate this from de Quervain tenosynovitis. A septation in the first dorsal wrist compartment associated with a prominent osseous ridge has been noted in some patients with de Quervain tenosynovitis [13]. However, to our knowledge, no radiographic correlate has been described. It has been proposed that the presence of a septation producing separate compartments may predispose patients to de Quervain tenosynovitis and to a failure of response to injection of steroid and anesthetic agents [1].
A limitation to this study was selection bias because the more symptomatic patients with de Quervain tenosynovitis likely will present for medical care. There was also a significant difference in age and sex between the patients with de Quervain tenosynovitis and the control subjects. Additionally, a negative finding on Finkelstein's test could not be confirmed in the control wrists because of the retrospective nature of this study. A more extensive radiologic search would also be required to identify other causes of radial styloid erosion or periosteal bone apposition to compare with the findings in our cases of de Quervain tenosynovitis. Further experience may show that there are other causes of such focal erosions or bone apposition of the radial styloid. Although bone erosion was not evaluated in our study, one of the authors has observed it at precisely this site in rheumatoid arthritis associated with adjacent soft-tissue swelling, presumably due to rheumatoid tenosynovitis. Last, it is assumed that the prevalence of de Quervain tenosynovitis in our retrospective study is greater than that in the general population. Application of our receiver operating curves to all wrist radiographs in the general population with a lower prevalence of de Quervain tenosynovitis could decrease the positive predictive value of the distal radial styloid abnormality. However, in the appropriate clinical setting of nontraumatic radial styloid pain, the positive predictive value of the radial styloid abnormality would likely be higher.
In summary, we have observed focal radial styloid abnormality in association with de Quervain tenosynovitis. In the appropriate clinical setting, radiographic visualization of focal cortical erosion, sclerosis, or periosteal bone apposition of the radial styloid should suggest the diagnosis of de Quervain tenosynovitis.
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= observer 1, 
=
observer 2, dashed line = no discrimination.