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................................... What is De Quervain's stenosing tenosynovitis? ....................................What causes it? ....................................Who gets it? ....................................What are the signs and symptoms? ....................................Conservative management ....................................If surgery is necessary ....................................Post-operative management
What is De Quervain's stenosing tenosynovitis? Once called Washer Woman's Sprain, this painful inflammation of the thumb side of the wrist now bears the name of the Swiss surgeon, Fritz de Quervain, who wrote about it in 1895. Passing over the back (or dorsal surface) of the wrist are the tendons for the muscles that extend or straighten the fingers and thumb and lift the hand at the wrist. These tendons run through six lubricated tunnels (compartments) under a thick fibrous layer called the extensor retinaculum or dorsal carpal ligament.
The six extensor compartments.
The first dorsal compartment lies over the bony prominence on the thumb side of the wrist. Through it pass the tendons for the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) muscles. Both of these muscles help spread and extend the thumb away from the rest of the hand. They are necessary for a powerful grasp and also help to move the wrist.
The first dorsal compartment.
De Quervain's stenosing tenosynovitis is a painful inflammation of the tendons in the first dorsal compartment of the wrist. The lubricating synovial sheath lining this compartment thickens and swells giving the enclosed tendons less room to move. The tendons in turn may swell beyond this constriction. Fine fibres of scar (adhesions) may form between the sheaths and tendons.
The inflammation may be caused by anything that changes the shape of the compartment or causes swelling or thickening of the tendons. Repetitive trauma, overuse, or an inflammatory process are likely causes, but frequently, the cause of the disease is unknown.
De Quervain's stenosing tenosynovitis occurs most often in individuals between the ages of 30 and 50. Women are afflicted with it 8 to 10 times more often than men. People who engage in repetitive activities requiring sideways motion of the wrist while gripping the thumb, as in hammering, skiing, some assembly line jobs etc, may predispose to developing this disorder.
What are the signs and symptoms? Pain over the thumb side of the wrist is the primary symptom. It may occur "overnight" or gradually, and it may radiate into the thumb and up into the forearm. It is worse with the use of the hand and thumb, especially with any forceful grasping, pinching or twisting. Swelling over the thumb side of the wrist may be present, as well as some "snapping" when the thumb is moved. Due to the pain and swelling , there may be some decreased thumb motion. Besides pain and swelling over the first dorsal compartment, having a positive Finkelstein's test is a good indication that the patient has the problem. In this test, the patient makes a fist with the thumb placed under the little finger and bends the wrist. The test is mildly painful to many of us, but to someone with De Quervain's stenosing tenosynovitis, it is very painful.
The Finkelstein test.
Your doctor may first try to reverse the course of the disease with a 3 to 6 week trial of anti-inflammatory medication while the thumb and wrist are rested by wearing a splint which immobilises the wrist and thumb. The area may also be injected with a steroid to help reduce the inflammation. This usually takes 3 to 4 weeks to be effective.
If the symptoms of De Quervain's stenosing tenosynovitis are longstanding or unresponsive to conservative management, surgery is indicated. This is usually performed as day surgery. An incision is made over the first dorsal compartment and the dorsal carpal ligament is cut to expose the tendons. The tendons from APL and EPB are identified and motion is checked. The wound is then closed and a compressive dressing with a plaster splint is applied.
Splint used for conservative treatment (left) & bandage used following surgery (right).
The wrist will be painful particularly for the first three days. You will be given pain medication. The bulky dressing is removed approximately 10-14 days after surgery and an exercise programme will be started. It is important to do the exercises as instructed. Recurrence of the symptoms is very rare. Possible problems after the surgery can include irritation of the small nerves which give feeling to this area of the wrist and back of the hand and subluxation (abnormal movement) of the released tendons. Stiffness of the wrist is avoided by following therapy as directed.
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