DeQuervains Tenosynovitis

De Quervain’s is an inflammation of the tendons that straighten the thumb as they pass through a tunnel on the thumb side of the wrist resulting in localized pain in that area.

The tendons that straighten the thumb are held in place on the bone by a series of ligaments called pulleys. These ligaments form an arch on the surface of the bone that creates a tunnel for the tendon to run in along. To keep the tendons moving smoothly under the ligaments, the tendons are wrapped in a slippery coating called tenosynovium. The tenosynovium reduces the friction and allows the tendons to glide through the tunnel as the hand is used to grasp objects. The constant irritation from the tendon repeatedly sliding through the pulley causes the tendon to swell in this area. 

 

The cause for this is unknown however individuals who perform rapid repetitive activities involving pinching, grasping, pulling or pushing are possibly more likely to develop it. It is more common in women and with pregnancy. Inflammatory arthritis e.g. Rheumatoid patients may also develop it. It is named after the Swiss surgeon Fritz de Quervain who first identified it in 1895

SYMPTOMS

The symptoms of De Quervain’s include pain and tenderness usually occurs over the area of the thickening. There may be some redness and swelling in that area.

NON SURGICAL TREATMENT

You may be referred to have a splint.  These may be off the shelf with a metal bar that extends down the thumb or alternatively a custom made splint by the occupational therapist. Treatments provided by an occupational therapist may be effective when symptoms have been present for less than a few months. Therapists build a splint that immobilizes the thumb and wrist in a straight neutral position, holding and resting the inflamed area. Therapy sessions sometimes include iontophoresis, which uses a mild electrical current to push anti-inflammatory medicine to the sore area. This treatment is especially helpful for patients who can't tolerate injections.

A cortisone injection into the tendon sheath acts to decrease the inflammation and reduce the swelling. This combined with a splint will relieve the symptoms in 70-80% of patients. In most patients there is a permanent cure, whilst in about 20% some recurrence of the symptoms may develop a few months later. Side effects from the injection are usually minimal. Patients may notice some mild aching in the area for 1-2 days, on occasion requiring a Panadol. Diabetic patients may have some elevation of their blood sugars for 1-2 days and must therefore monitor their blood sugar levels and contact their physician if they become significantly raised.  Other local reactions are uncommon and include infection, abscess formation, increase or decrease in skin pigmentation, skin or fat atrophy, tendon or nerve damage. More serious generalized complications are rare and include fluid retention, heart irregularities, hip bone necrosis, muscle weakness, peptic ulceration or convulsions.  A maximum of 2 injections is given as the cortisone may weaken the tendon and cause it to snap if repeated treatments are given.

SURGERY

The surgical solution for treating De Quervain’s is to split open the roof of pulley so that the tendon may slide smoothly. This surgery can usually be done as a daycase procedure. The surgery can be done using a general anesthetic or a local anesthetic with some sedation. A 2 cm incision will be made in the skin along the natural wrist crease line on the thumb. The skin and deeper tissues are separated so the tendon pulley is identified. Special care is taken not to damage the nearby radial nerve branches which gives feeling to the skin over the back of the hand on the thumb side. The tendon pulley is then divided longitudinally along its roof and movement checked to make sure it is moving freely. The skin is sewn together with dissolving stitches beneath the skin. The cure rate for this type of surgery is approximately 98%.

After Surgery

After the surgery you will probably have a large padded bandage on your hand, which will need to be kept dry. This is to provide gentle compression and reduce the bleeding and swelling that occurs immediately after surgery. We will change this dressing after a week to a small dressing pad that you can shower with. You will begin a gentle range-of-motion exercises, straight after surgery. It is essential that you keep your fingers moving post operatively so that they do not swell and stiffen. i.e. make a fist and then straighten out the fingers several times every half hour during the day.

Most patients won't need to participate in a formal rehabilitation program unless you develop a lot of swelling or stiffness.  An occupational therapist may apply a special brace to rest the area if significant discomfort still.  The therapist may also apply ultrasound, soft-tissue massage, and hands-on stretching to help with the range of motion. The scar may be slightly thick, lumpy, and tender for 2-3 months after surgery. If it is a problem then the occupational therapist can treat the area and help the scar tissue to resolve. This may involve ultrasound, soft-tissue massage, silicone gel sheeting or iontophoresis with dexamethasone.

 

Possible Complications of Surgery

  1. Bleeding and haematoma (bleeding into the tissues).  This rarely requires return to the operating theatre.  Aspirin and other non-steroidal anti-inflammatory agents taken up to two weeks prior to surgery, even as a single small dose, can increase the risk of bleeding.  Patients on anti-coagulants may need to cease them prior to surgery to minimize risk of bleeding. (Please check with Miss Terrills’ rooms).
  2. Wound dehiscence (i.e. wound opening up) and delayed healing.
  3. Inflammation and infection.
  4. Pain – the severity and duration of post-operative pain varies though is usually mild especially after the first 24hours requiring simple analgesia such as Panadol / panadeine.
  5. Anaesthetic complications e.g. Sore throat when a tube is used to administer general anaesthetic, painful or infected intravenous site, nausea and vomiting, stroke, heart attacks, cardiac arrhythmias, deep venous thrombosis (DVT) leading to pulmonary embolism, allergic reaction.
  6. Sensitivity to dressings and tape.
  7. Thick, lumpy and tender scars.
  8. Damage to other structures – Nerves, blood vessels, bone and soft tissues may be damaged during surgery.  The main structure at risk is the superficial branch of the radial nerve.  This may lead to numbness or uncomfortable tingling over the back of the thumb and part of the back of the hand.
  9. Chronic Regional Pain Syndrome - Chronic pain, swelling and limited movement in the hand.  This may take months to years to resolve.