De Quervain’s Tenosynovitis
This condition causes pain on the inner side of the wrist and forearm, just above the thumb. It is a common problem, probably one of the most painful in the wrist, but easy to diagnose and treat successfully. Again, earlier the better.
De Quervain’s tenosynovitis affects two thumb tendons: the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB). These tendons connect the muscles at the back of the forearm to thumb bones facilitating thumb movements away and above the plane of hand. On their way to the thumb, the APL and EPB tendons travel together along the inside side of the wrist where they pass through a tight tunnel which holds tendon in place i.e. stabilise them over the forearm bone (the first extensor compartment, picture 1).
The tunnel and tendons are lined with a slippery coating called tenosynovium which allows two tendons to glide easily back and forth as they move the thumb. Inflammation of the tenosynovium is called tenosynovitis. In de Quervain’s tenosynovitis, the inflammation constricts the movement of the tendons within the tunnel hence it is also known as stenosing tenosynovitis.
DeQuervain’s tenosynovitis appears without obvious cause in many cases. Repeated thumb motions such as grasping, pinching, squeezing, or wringing (work, sports, DIY) may lead to tenosynovitis. This inflammation produces swelling, which hampers the smooth gliding action of the tendons within the tunnel. Pregnancy and breast feeding seem to trigger symptoms often, probably due to hormonal changes. In other cases, an injury leads to the tendon swelling and/or scarring within the tunnel compromising tendon gliding and eliciting symptoms. Whatever the cause, there is always a discrepancy between the size of the tunnel and volume of its content: either the tunnel is too narrow (scarring, degenerative changes) or more commonly, tendons and their tenosynovium are enlarged (inflammation, tendon swelling after strenuous work, injury, swelling due to fluid retention – pregnancy/breast feeding) etc.
Symptoms usually start slowly and gradually. Sudden onsets are associated with ‘sprain’ like accidents of the thumb and wrist.
Patients complain of soreness, swelling and pain above the thumb. Symptoms are aggravated by thumb movement and stretching. If the problem is not recognised and treated, symptoms continue and often deteriorate, vicious circle continues making condition truly uncomfortable.
Diagnosis of de Quervain’s tenosynovitis is usually very straightforward. Patient’s history and careful physical examination are unambiguous in vast majority of cases so no special tests are required. The condition however should be distinguished from other problems.
The first line ‘treatment’ is to rest and stop all activities that cause the symptoms i.e. avoid repetitive hand motions such as heavy grasping, wringing, or turning and twisting movements of the wrist.
Many patients find it easier to achieve this whilst wearing wrist/thumb splints, sometimes even casts. Both, wrist and thumb should be immobilized. This would allow APL and EPB tendons to rest and swelling of the tendons and its lining to subside. This will invariably reduce irritation within the tunnel.
Anti-inflammatory medications (ibuprofen, neurofen, diclofenac, voltarol etc.) may also help control the swelling of the tenosynovium and ease symptoms.
If these simple measures fail to control the symptoms, an injection of steroid into the irritated tunnel is usually the second treatment step. Injections are administered in the consulting rooms. Steroids relieve symptoms by reducing the swelling of the tenosynovium. It relieves pain in 70% of patients, but seems to have more curative and longer lasting effect in patients with early stages of the disease. Risks of injection are very small, but steroid might cause skin thinning and discoloration at the site of injection very occasionally.
Occupational therapists can sometimes help by modifying your workstation and the way you do your work tasks. Suggestions may be given about the use of healthy body alignment and wrist positions, helpful exercises, and tips on how to prevent future problems.
If nonsurgical treatment is successful, improvement is likely to be noticed in 4-6 weeks. If symptoms start to recur, repeated steroid injections should be contemplated against surgical treatment.
The goal of surgery is to give the tendons more space so they no longer rub inside of the tunnel. It predictably provides almost instant and lasting relief. In my experience, partial improvement is only rarely seen. This is in patients in whom considerable constriction of tendons was present for a long time inducing chronic tendon changes resistant to tunnel decompression.
The surgery takes 15-20 minutes and is done under the local anaesthesia on a day care basis. Local anaesthetic is injected around the area of incision. Injection itself is uncomfortable for just few seconds, but bearable by everybody. It is a reliable method of analgesia and works very quickly. General or regional anaesthesia (anaesthetic is injected into the armpit to numb the entire arm) are very rarely required and are, in my practice, offered to patients who have strong feelings against local anaesthesia and feel very anxious about being awake during the procedure.
Once tissues are completely numb, a small, 1-2cm incision is made over the troubled tendons. The top (roof) of the tunnel is incised (opened) allowing the tunnel to open up and creating more space for the tendons. The tunnel will eventually reform, but it will be larger than before. Nerve branches that overlie affected tendons need to be carefully pulled away during surgery, which can result in transient numbness on the back of the hand and thumb. The skin is then stitched together, and the hand is wrapped in a bulky dressing (picture 2). The scar is hardly noticeable and colourless after several months, but in the first few weeks it fades from dark to pale pink (picture 3).
Risks and side effects of surgery are: scar, infection, hypertrophic or sensitive scar, partial improvement, temporary numbness on the back of the hand or thumb, neuroma (painful lump within the nerve), recurrent pain, complex regional pain syndrome (CRPS).
Rehabilitation after surgery
The hand should be elevated in the first few days so that wrist is above elbow level. This prevents swelling and associated pain. Fingers and wrist should be moved gently straight after surgery (whilst bandage is on) in order to prevent stiffness. Pain and symptoms generally begin to improve straight after surgery, but you may have tenderness in the area of the incision for several weeks.
The sutures are removed 10 to 14 days after surgery. I personally prefer to use a single, non-dissolving stitch which causes no skin reaction and which is pulled out easily without any discomfort. It is possible to use absorbable (dissolving) stitches instead if patient has such preference. Wound can get wet from day 7, but in most cases patients manage to maintain operated area dry with ‘shower proof’ dressing.
When the stitches are removed, you may start carefully strengthening hand and thumb by squeezing and stretching a sponge or putty. Hand therapists use a series of gentle stretches to encourage the thumb tendons to glide easily within tunnel, but sometimes it is possible to conduct exercises without supervision.
If you have any concerns following your surgery please contact:
|Hospital stay||Day care|
|Anaesthetic||Local (no starving required)|
|Surgery time||10-15 minutes|
|Wound healing||2 weeks|
|Splintage||wrist bandage for 1 week; wound dressing for 2 weeks|
|Hand therapy||not always required, but can be implemented for 2 weeks|
|Washing||from week 1|
|Time off work||1-2 weeks for office based work; 3-4 weeks for manual work|
|Sports and exercise||from week 2|
|Driving||straight away, no restrictions|
|Full recovery||2-3 weeks|
Picture 1: First extensor compartement and its thumb tendons
Picture 2: Bandage for the first week
Picture 3: Scar on the wrist at 4 weeks; it fades further and becomes almost inconspicuous after few months.