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De Quervain’s Tenosynovitis

Introduction


  • De Quervain’s tenosynovitis (also called De Quervain’s tendinosis) is a painful condition of two tendons at the level of the wrist on the side of the thumb
  • It’s a repetitive strain injury due to overuse of two tendons used to move the thumb away from the other fingers


Anatomy


  • Tendons are strong fibres of collagen that attach muscles to bones and therefore enable muscles to produce movement
  • Tendons slide within a tissue that forms a tunnel called a sheath
  • The sheath helps keep the tendons close to the bones
  • Extensor tendons run on the back side of the wrist:
  • Their function is to straighten the fingers and extend the wrist
  • The extensor tendons are organised into 6 compartments at the level of the wrist
  • The 1st compartment is on the side of the thumb and the 6th on the side of the little finger
  • De Quervain’s tenosynovitis affects the 1st compartment which contains two tendons:
  • Abductors pollicis longus:
  • Its function is to tilt the wrist towards the thumb and abduct the thumb (moving the thumb vertically away from the palm)
  • Extensor pollicis brevis:
  • Its function is to tilt the wrist towards the thumb and extend the thumb (moving the thumb sideways away from the palm)


Pathophysiology


  • It occurs due to thickening and/or swelling of the tendon or its covering sheath
  • This causes friction and pain as the tendon struggles to slide through the sheath


How often does it occur?


  • It is seen more commonly in patient who have tennis elbow or golfer’s elbow
  • Often seen on both wrists in new mothers or those who look after children and resolves on its own once lifting the child is less frequent


Symptoms


  • Pain occurs on the side of the wrist at the base of the thumb
  • Pain is made worse when gripping
  • The symptoms come on gradually
  • Pain on moving the thumb especially when gripping objects
  • Swelling at the base of the thumb has also been noted


Risk factors


  • It is more common in women than men: 
  • Especially mothers of newborns who repeatedly lift the newborn with the thumbs away from the rest of the fingers
  • Typically affects 30-50 year olds
  • Most commonly affects the dominant wrist
  • It is an overuse injury of the thumb particularly from repetitive grasping
  • Can also be caused by a direct blow to the thumb or arthritis
  • Provocative movement in particular is the sideways wrist motion whilst gripping such as:
  • Lifting young children
  • Gardening
  • Racquet sports
  • Skiing
  • Using a hammer
  • Long hours pressing playing computer games that involve pressing a button repeatedly with the thumb


Diagnosis


  • The classic test for De Quervain’s tenosynovitis is the Finkelstein test
  • The patient is asked to make a fist by wrapping their fingers over the thumb (as opposed to the more conventional thumb over fingers)
  • Whilst keeping their fist in this position the doctor then moves the wrist sideways away from the thumb
  • If this causes pain then it is a positive test for De Quervain’s tenosynovitis as the irritated tendons are forced down the narrowed overlying sheath


Treatment


  • Most cases will settle with conservative management
  • High rate of recurrence i.e. can come back once the symptoms settle
  • First line treatment should be:
  • Rest
  • Avoiding repetitive thumb movements as much as possible
  • Anti-inflammatory medications
  • Thumb immobilisation splint
  • Ice
  • Physiotherapy to strengthen muscles used to move the thumb
  • Steroid injection into the affected tendon compartment of the wrist to help reduce
  • Studies have shown that 20% of patients using thumb immobilisation splint alone for 6 weeks had improvement in symptoms and this increased to 60% when combined with anti-inflammatory medications
  • The splint should allow some movement of the thumb as opposed to completely immobilising it
  • Surgical treatment is considered for cases when conservative management has failed:
  • It has a high success rate
  • A small cut is made on the wrist over the painful side and the sheath is released over the irritated tendons
  • This removes the pressure on the tendons and allows them to heal
  • The operation can be performed under local or regional anaesthesia
  • There is a nerve (superficial radial nerve) around the surgical incision site which provides sensation to the area so it is important to avoid this potential complication


Prevention


  • Avoiding provocative movements that cause pain
  • Taking breaks when having to carry out a repeated wrist motion
  • Keeping your hand and forearm muscles strong

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