Keywords
de Quervain's disease - Eichhoff's test - false-positive result - Finkelstein's test
Introduction
de Quervain's tenosynovitis is a common pathologic condition affecting the first extensor
compartment of the wrist, with an incidence of 0.94 per 1,000 person-years.[1] The disease has been linked to people who perform manual work, owing to the unique
mobility of the human thumb,[2] with women four times as likely to be affected than men, and increased incidence
in nonwhite individuals and those older than 40 years of age.[1] Patients with this condition typically present with radial sided wrist pain and
may have difficulty with lifting, grasping, and twisting activities involving the
thumb. Other features in the diagnosis include signs of local swelling, tendon sheath
thickening, and tenderness over the radial styloid.
Finkelstein's test has long been considered to be a pathognomonic sign of this diagnosis.[3] However, most clinicians and instructional manuals describe what is in fact the
Eichhoff's test.[4]
[5]
[6] Errors in correctly describing Finkelstein's test can be traced to Leao (1958) who
quoted Eichhoff's maneuver as Finkelstein's test.[2] Eliott pointed out the mistake in 1992 and explained the difference between Finkelstein's
test and its incorrectly described variant, which is thought to produce false-positive
results by tendon stretching in normal individuals.[5]
[7]
Several other authors have also criticized the Eichhoff's test for producing positive
results within normal individuals.[5]
[6]
[7] However, to date, there are no published studies comparing the outcomes of the originally
described Finkelstein's test with Eichhoff's variant. The intention of a clinical
test is to guide investigation and management. If a clinical test has a high false-positive
rate, it may lead to excessive investigation and treatment with the consequent costs
and risks. This study aims to investigate whether Finkelstein's test is more accurate
than Eichhoff's test.
Materials and Methods
A prospective controlled study was performed at the local university hospital. Over
a 3-month period, asymptomatic individuals were invited to participate. Informed written
consent was obtained from all participants. Patients were excluded if they suffered
from a history of wrist pain, had a previous diagnosis of de Quervain's tenosynovitis,
had ever sustained a fracture of the distal radius, suffered from inflammatory arthropathy,
or were diagnosed with intersection syndrome.
All patients underwent Finkelstein's and Eichhoff's tests as described in literature
in both dominant and nondominant wrists.[5] The tests were performed by the main author (F.W.) under supervision from A.R.,
both of whom worked in the upper limb unit. Each measurement was performed twice and
the mean was recorded.
All participants underwent ultrasonography of both wrists prior to examination. No
participants demonstrated radiographic evidence of tenosynovitis. There was a minimum
interval of 24 hours between tests on the same wrist. Finkelstein's test was performed
by placing the patient's wrist on the edge of a table. The examiner subsequently asked
the patient to actively ulnarly deviate the wrist before grasping the patient's thumb
and passively flexing it into the palm ([Fig. 1]).[5] Eichhoff's test was performed by asking the participant to place the thumb within
the hand and clench tightly with the other fingers. The hand was then passively abducted
ulnarward by the examiner ([Fig. 2]).[5] In both the tests, the examiner can also perform these maneuvers while palpating
the abductor pollicis longus and extensor pollicis brevis tendons over the lateral
radius and feeling for moving nodularity, tendon rub, or popping directly over the
tendon. Participants were asked to grade the degree of pain they experienced on a
linear visual analogue scale (VAS) from 0 to 100, with 0 being no pain and 100 being
maximal pain. Findings of moderate or severe pain (44–100) was considered to be false
positive.[8]
Fig. 1 Finkelstein's test on the patient.
Fig. 2 Eichhoff's test on the patient.
Results are given as the mean (standard deviation [SD]) or the median (range) as indicated
by tests for normality. Comparisons between the two tests were made using the Wilcoxon
signed-rank test. Statistical significance is defined as 0.05.
Results
In total, 36 eligible patients (72 wrists) participated in the study. The mean age
of the participants was 43 years (range: 24–66, SD: 12.7 years). Sixteen participants
were males and 34 were right-hand dominant.
There were a total of eight false-positive results (five patients), all of which occurred
from the Eichhoff's test. (p = 0.003, chi-square test). More false positives were encountered in the dominant
hand (five dominant, three nondominant). Eichhoff's test also produced a significantly
greater degree of discomfort than Finkelstein's test (Finkelstein's test: mean VAS
2.6, range: 0–41; Eichhoff's test: mean VAS 12.7, range: 0–87; p < 0.01 Wilcoxon signed rank test) ([Table 1]).
Table 1
Test results
|
Finkelstein's test
|
Eichhoff's test
|
|
Abbreviation: VAS, visual analogue scale.
|
|
False positives
|
0
|
8
|
|
Mean VAS
|
2.6
|
12.7
|
|
Range
|
0–41
|
0–87
|
|
Specificity
|
100%
|
89%
|
The specificity of a test defines how good the test is at correctly excluding patients
who do not have the condition under test.[9] Finkelstein's test was more specific than Eichhoff's test, with a specificity of
100%, compared with 89% for Eichhoff's test.
Discussion
This study confirmed that the hypothesis that Finkelstein's test is more accurate
than Eichhoff's test and produced fewer false-positive results. Apart from being less
specific, Eichhoff's test also produced a greater degree of discomfort than the Finkelstein
test in patients.
The first description of the test to evaluate de Quervain's tenosynovitis was by Finkelstein
in 1930, which stated that pain was elicited on traction of the thumb, which was worsened
with ulnar deviation of the hand.[3] Eichhoff's variant of this manoeuver involved the thumb gripped in the palm by the
other fingers followed by passive ulnar deviation of the wrist with, which caused
severe discomfort.[4] Eichhoff used this maneuver to illustrate his understanding of the pathomechanics
of the disease process, namely stretching the tendons and sheath of the first dorsal
compartment as the cause for pain in de Quervain's tenosynovitis. This was to confirm
his theory that repetitive tendon stretching by ulnar abduction of the hand could
cause the condition. There is no evidence that Eichhoff meant this to be a test to
diagnose de Quervain's tenosynovitis, yet Eichhoff's maneuver has been taught as Finkelstein's
test in texts of hand surgery.[10] The first time this is described incorrectly appears to the in the paper by Leao.[2]
Since the initial description of Finkelstein's test and Eichhoff's variant, there
has been controversy regarding the accuracy of the tests and the generation of false-positive
results in normal wrists.[5]
[6]
[7] The mechanism for both the tests involves generation of a passive distension and
shear stress between the tendons of the first dorsal compartment and the radius on
its blunt styloid edge. Eichhoff's maneuver produces a greater degree of ulnar deviation
of the wrist, because the patient's entire hand is abducted ulnarward by the examiner
rather than just the thumb in Finkelstein's test. This would naturally create a greater
level of distension and shear stress at the radial styloid, thereby causing pain in
a normal wrist. Brunelli postulated that distension of the joints in Eichhoff's test
can also create pain in other articular areas that is unrelated to true de Quervain's
disease, owing to the tensioning of the radial collateral carpal ligament, the scaphotrapezial
ligament, and the carpometacarpal ligament.[7]
This is the first study to demonstrate that in a normal population Finkelstein's test
is more specific and produces significantly fewer false-positive results than Eichhoff's
test. The authors recognize the limitations of the study. They do not have a group
of patients with de Quervain's tenosynovitis to compare the sensitivity of the two
tests. However, it is clear that Finkelstein's test produces fewer false-positive
results and less patient discomfort, and therefore it should be the clinical test
of choice when examining a patient suspected of having de Quervain's tenosynovitis,
rather than the erroneous Eichhoff's variant. This will help reduce unnecessary further
investigation or treatment.
