De Quervain's tenosynovitis is a painful condition highlighted by inflammation in certain tissues. Specifically, it affects the tissues surrounding two tendons that run between the wrist and the thumb.
The Anatomy of the Wrist, Thumb & Tendons
Two tendons - the Abductor Pollicis Longus (APL) and the Extensor Pollicis Brevis (EPB) – run from the thumb to the radial (thumb side) of the wrist in a small tunnel called the first dorsal compartment. These tendons work to straighten or extend the thumb and abduct the thumb (i.e. pull the thumb away from the other fingers).
In a small percentage of patients, the APL and EPB tendons are actually separated into two smaller compartments over top of the Radius. A broad sheet of fibrous tissue called the retinaculum runs overtop the two tendons at the wrist, holding them in place. The tendons are covered by a slick tissue called tenosynovium.
There is limited clearance for the tendons in this tunnel over the radius. Any condition that causes swelling or inflammation in the tunnel can produce irritation of the tenosynovium, leading to De Quervain's tenosynovitis.
Symptoms of De Quervain's tenosynovitis include:
- sharp or burning pain along the thumb or radial side of the wrist, often extending both up the thumb and up the arm.
- stiffness with motion of the thumb towards the other fingers (adduction) or away from the other fingers (abduction).
- a creaking sensation or noise with thumb motion called crepitus. This has also been called the “wet leather sign”, since it resembles the sound of stretching wet leather. There may be swelling on the thumb or radial side of the wrist.
- the area over the tendon at the wrist may be tender to touch.
- if there is significant swelling, the radial nerve – which supplies sensation to the dorsum (top) of the thumb – may be irritated, producing numbness or tingling.
All of the symptoms above may be aggravated by wearing a tight watch or bracelet.
There are many causes for De Quervain's tenosynovitis.
- Direct trauma, such as a blow to the radial side of the wrist, may cause swelling and symptoms.
- Frequently wearing of a tight wristwatch or bracelet may also lead to De Quervain's tenosynovitis.
- A fracture of the underlying radius, even if undisplaced, may also produce this condition.
- Repetitive overuse of the thumb – such as using clippers, scissors and staplers, or repetitive pinching – may also be a cause.
- Inflammatory disorders such as rheumatoid arthritis, lupus or gout may cause swelling of the tenosynovium and produce De Quervain's tenosynovitis.
Initial treatment of this issue is usually conservative.
- The first steps for patients are discontinuing all aggravating activities, and no longer wearing tight jewelry.
- Regular use of ice packs and anti-inflammatories are also helpful.
- A small injection in the tunnel or first dorsal compartment with Xylocaine and cortisone is also beneficial in approximately 80% of cases.
Surgery is recommended when these conservative treatments are no longer effective. This treatment consists of a procedure called a Dequervains Release, which is offered on an outpatient basis and uses local standby or twilight anesthesia.
- During surgery, a small longitudinal incision is made over the tendons at the radius.
- The fibrous band or retinaculum is released, allowing the tendons to move freely without friction.
- The skin is closed and a small dressing is applied.
- The patient is instructed to move their fingers freely, but to do no heavy gripping or lifting for two weeks.
- The dressing and incision must remain dry for two weeks post-op.
- At two weeks postoperatively, the sutures are removed and the patient may shower as well as massage the scar.
- Patients may begin to progressively increase their activity after that.
Possible complications are anesthesia related problems, wound healing problems or infection, irritation of the small radial nerves, or snapping of the tendons.