Wednesday, July 22, 2009

De Quervain Tenosynovitis

I love this problem though I’m sure I wouldn’t if I ever had it. It is one of those hand problems diagnosed by history and physical exam. The name can be a mouthful and is tricky to spell, but it is one that is treatable. Most often with a good outcome.

De Quervain tenosynovitis was first described in 1895 by a Swiss surgeon, Fritz de Quervain. He reported 5 cases of patients who had the now “classic” physical finding -- a tender, thickened first dorsal wrist compartment. Now this condition bears his name – De Quervain tenosynovitis.

De Quervain tenosynovitis is an entrapment tendinitis of the first dorsal compartment of the wrist. Even a small amount of swelling or inflammation of the tendons (abductor pollicis longus and extensor pollicis brevis) trying to slide through the non-elastic tunnel creates more irritation and inflammation (photo credit). The involved tendons are used to move the thumb, so pain occurs with thumb motion.

De Quervain tenosynovitis is the second most common entrapment tendinitis of the hand/wrist. The most common is trigger finger (trigger digit) which is about 20 times more common. Frequently patients are mothers of infants aged 6-12 months who will have symptoms in both wrists.

Anyone with De Quervain tenosynovitis will note pain with thumb and wrist motion. These patients will also note tenderness and thickening at the radial styloid. Crepitation or actual triggering is rarely noted. Repetitive lifting/use is responsible for friction tendinitis. De Quervain tenosynovitis can also develop in individuals who have sustained a direct blow to the area of the first dorsal compartment.

Physical findings on examination will include local tenderness and swelling of the extensor retinaculum of the wrist over the first compartment. A positive Finkelstein sign confirms the diagnosis.

"Finkelstein sign” is done by tucking the thumb into the palm where it is held by the patient’s fingers. The examiner then gently deviates the wrist ulnarly. This creates a sharp increase in pain along the first dorsal compartment in any patient with De Quervain tenosynovitis. (photo credit

The goal in treating de Quervain's tendinitis is to relieve the pain caused by irritation and swelling. Nonsurgical treatment should be tried first. If the tenosynovitis is associated with pregnancy, then the nonoperative treatment should be prolonged (4-6 months).

  • Splints. Splints may be used to rest the thumb and wrist.
  • Anti-inflammatory medication (NSAIDs). These medications can be taken by mouth or injected into that tendon compartment. They may help reduce the swelling and relieve the pain.
  • Avoiding activities that cause pain and swelling. This may allow the symptoms to go away on their own.
  • Corticosteroids. Injection of corticosteroids into the tendon sheath may help reduce swelling and pain.
  • Surgery -- recommended if symptoms are severe or do not improve. The goal of surgery is to open the compartment (covering) to make more room for the irritated tendons. (photo credit)

    The procedure is usually done on an out-patient basis. The surgery typically involves identification and cutting of the tendon sheath segment under local anesthesia. Care must be taken to avoid cutting the sensory branch of the radial nerve. Patients commonly return to their normal activities within 2-3 weeks. The procedure has been reported to be successful in about 90% of the cases.

REFERENCES

De Quervain Tenosynovitis; eMedicine Article, Feb 17, 2009; Roy A Meals, MD

De Quervain's Tendinitis (De Quervain's Tendinosis) -- AAOS

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6 comments:

StitchinByTheLake said...

Thanks so much for posting this - it explains a lot for me. The splints are a frustration but hopefully they'll make a difference in the pain. blessings, marlene

Vijay said...

My mother had this when I was a first year medical student. The orthopedic surgeon who treated her asked me about the anatomical snuff box as he was examining my mother! I was thrilled because I knew the answer. He tried oral NSAIDs for 2 weeks, but my mom didn't have much relief. And it was limiting her activities. A steroid injection cured her.

rlbates said...

Marlene, I hope they help too.

Good for you, Vijay!

ER's Mom said...

I had this when I was a SAHM with my first child. Stupid first ortho told me not to do the activity that made my left wrist hurt. That activity was lifting DD out from her crib. I fired him and went to someone else.

Second ortho steroided and splinted me. The pain relief was within a few hours.

The pain from DeQuervains was incredible!

siddharth said...

Hi. It was nice to read your posting. I am a computer science student, and have been having this tenosynovities for almost an year now. I have tried all the conservative approaches, but they havent worked at all. Ice Therapy (normal application of ice), massage ( which i do with my other hand), just about everything. The swelling, which is mainly caused due to unstability of fluids/tenosynovium dosent go at all. I feel most worried, since i also a percussion instrument calledl Tabla..i am so scared that i might loose it for ever. I dont want to go for Coristone injections,since i have done so much research which suggests that an injection is nothing but a way to reduce the inflammation and not really helping to cure the tendon. I am now using an ergonomic work station, but even doing that the pain is consistent. I am also worried that with too much pain lasting for about an year now...i dont land into Tendonosis (a condition which leads to the brain and the nervous system just ignoring the pain, and stopping the recovery process, and turning that region dead).
Please suggest me if your research suggests some another conservative approach which can be better.

rlbates said...

Siddharth, it sounds like you have failed conservative therapy and need to see a surgeon. Best wishes