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December 27, 2011

Hand Surgery #4: De Quervain's Stenosing Tenosynovitis

While trigger fingers involve inflamed flexor tendons (which bring the fingers into the fist) in their digital sheaths, de Quervain's stenosing tenosynovitis refers to inflamed extensor tendons of the thumb (which help you to hitch hike) as they traverse the back of the wrist.

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 this condition in 1895.  Stenosing refers to the narrowing of an opening or passageway in the body. Tenosynovitis refers to inflammation of the outer covering of the tendons that bend and extend any finger or thumb.

 

Anatomy

Passing over the back (or dorsal surface) of the wrist are the tendons for muscles that extend and straighten the fingers and thumb, and lift the hand at the wrist. These tendons run through 6 lubricated tunnels (compartments) under a thick fibrous layer called the extensor retinaculum.

The 1st dorsal compartment lies over the bony bump at the base of the thumb. Through it, pass the tendons for the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB) muscles. Both of these muscles help spread and extend the thumb away from the rest of the hand.

 

Pathology - De Quervain's Stenosing Tenosynovitis

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, and produces extra synovial fluid. A painful cyst may also form.

 

Causes

This inflammation may be caused by anything that changes the shape of the compartment or causes swelling or thickening of the tendons.  De Quervain's occurs most often in individuals between the ages of 30 and 50. Women are afflicted with this condition 8-10 times more often than men. People who engage in activities requiring sideways motion of the wrist while gripping with the thumb--as in hammering, skiing, and some assembly line jobs--may be predisposed to developing this disorder.

 

Signs and Symptoms

Pain over the thumb side of the wrist is the primary symptom. This condition may occur "overnight" or very gradually, and it may radiate pain into the thumb and up 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. Because of 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 the patient has this problem. In this test, the patient makes a fist with his or her thumb placed under the fingers. Then, the patient bends the wrist away from the thumb and towards the little finger side of the hand. This test is mildly painful to many of us, but to someone with de Quervain's stenosing tenosynovitis, it is very painful.

 

Treatment

  • Conservative treatment:
    • avoidance of activities that may provoke further symptoms
    • wearing a thumb spica splint to restrict movement of the wrist and thumb
    • a cortisone injection into the 1st dorsal compartment to decrease swelling
  • When conservative treatment fails, or when symptoms are severe and/or longstanding, I usually recommend surgery....
    • outpatient
    • small incision over the back of the wrist, at the base of the thumb
    • cut (release) the ligaments forming the roof and interior walls of the 1st dorsal compartment
    • The pressure on the APL and EPB tendons is relieved.
    • The whole surgery takes less than 30 minutes.

 

Recovery

A bulky post-operative dressing is worn for 1-2 weeks.  Then, an exercise program for the thumb and wrist is started. It usually takes several weeks for a full recovery.

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