de Quervain's tenosynovitis (tendinitis)

De Quervain's tenosynovitis (or tendinitis) is a painful irritation of the thumb tendons at the wrist (Image: HandDecide). It was first described by the Swiss surgeon Fritz de Quervain in 1895. The tendons become inflamed, swollen and thickened. It may be due to repetitive movements, overuse or an inflammatory process. Often there is no clear reason for the condition to have developed. 

De Quervain's tenosynovitis is 10 times more common in women than men, and it most commonly affects individuals aged 30-50. It is common in new mothers, but whether this is due to repetitive movements or hormonal changes, or a combination of these factors (or other factors!) is unknown. The pain may develop suddenly or gradually, and may limit thumb movement. It is worst with forceful movement and twisting.

Non surgical treatment

Non surgical treatment under the care of a hand therapist is recommended as first line treatment. This involves wearing a splint that immobilises the wrist and thumb (photo credit). The splint is worn at all times except when bathing. A corticosteroid injection to the inflamed area will also help reduce the swelling and pain. Your surgeon may refer you to have this injection performed under ultrasound, as there is evidence that ultrasound-guided delivery is more effective than blind delivery in patients whose tendons run in multiple sheaths (type II dDQ), and it is not possible to tell by examining you whether this situation applies to you. Oral anti-inflammatory medications (such as ibuprofen) may also be recommended to reduce the inflammation and pain. After 4 weeks of rest stretching exercises will be commenced, with the aim of eventually resuming full movement without the recurrence of pain.

The following educational video that shows a corticosteroid injection for de Quervain's tenosynovitis was created by NSW Hand Surgeon Dr Stuart Myers for general practitioners. It discusses the anatomy of de Quervain's and what will happen when you have a corticosteroid injection for this condition. Please note: this video contains a medical procedure (injection of the 1st dorsal compartment of the wrist).

Surgery

Surgery is indicated if persistent attempts at non-surgical treatment fail or if conservative treatment is deemed unlikely to succeed. The surgery is done as day case surgery. It can be done as wide awake hand surgery, or with sedation anaesthesia, or with general anaesthesia). A 2cm skin incision is made and through this the tough retinaculum that lies on top of the swollen tendons is divided. The tendons are freed from adhesions and inflamed tissue is removed. Local anaesthetic will numb the area for approximately 6-8 hours. You will receive pain medications to take. It is advisable to keep the area of surgery still for a few days to minimise your pain. However, it is also important that you commence exercises relatively early after surgery (within a week) so that you do not develop adhesions or stiffness at the site of surgery. A hand therapist will assist you with your post operative recovery, just as with the initial non-surgical treatment. It is important that you follow the recommended post operative regimen in order to minimise complications and speed your recovery.

It is advisable not to drive for 2 weeks after the surgery. You should be able to do most things relatively normally after 3-4 weeks, but it commonly takes 2-3 months before you will feel that the wrist has fully recovered.

Complications

When performing this surgery your surgeon will be aware of the presence of a sensory nerve that travels in the area and will do her (or his) utmost to treat this nerve with respect. This nerve (the superficial radial nerve) provides sensation to an area of skin on the back of the hand, over the fleshy muscle between the base of the thumb and index finger. This nerve objects to being treated roughly (more so than most other nerves in the body) and is easily irritated. If the nerve becomes irritated by the surgery it may give a sensation of persisting pain, burning, or numbness on the area of skin on the back of the hand. If this problem occurs the symptoms usually resolve over several weeks but in some cases it is more persistent.

Sometimes after surgery patients develop a sensation of the tendons flicking, snapping or clicking at the wrist during certain movements. This occurs if the released tendons move out of their usual position during these movements. This complication is minimised by the surgeon dividing the tough retinaculum at a site that permits the greatest amount of covering of your tendons, so that after a short period of healing there is no gap for the tendon to flick or snap through.

It is rare for de Quervain's tenosynovitis to recur after surgery.

Video

This short video explains a little about de Quervain's tenosynovitis, which is sometimes referred to in the US as "Mommy's thumb".

 

Reference

In Dequervain's with a separate EPB compartment, ultrasound-guided steroid injection is more effective than a clinical injection technique: a prospective open-label study. K. Kume, K. Amano, S. Yamada, K. Amano, N. Kuwaba, H. Ohta. J Hand Surg Eur Vol 2012 37: 523