What is De Quervain Tenosynovitis?
De Quervain tenosynovitis, named after Swiss surgeon Fritz de Quervain, is a condition that affects some of the tendons in the wrist. In this condition, the protective covering around the two tendons that help move the thumb, thickens and softens at a point where they pass through a tunnel near the wrist bone. This typically leads to pain that worsens with thumb movement or when the wrist is twisted from side to side. This condition mostly occurs among pregnant women or those who have recently given birth.
The treatment for this condition usually starts with non-surgical measures like immobilizing the thumb and wrist, along with using steroids to reduce inflammation in the affected area. The majority of patients get better with this approach. However, if these measures don’t bring relief, a minor surgical procedure to release the affected area might be needed.
What Causes De Quervain Tenosynovitis?
De Quervain tenosynovitis, a painful condition of the wrist, doesn’t have a clear known cause. However, it’s believed to be linked to a process called myxoid degeneration where fibrous tissue builds up, and the blood supply increases. These changes result in a thickening of the protective covering of the tendons, causing pain as it restricts two specific tendons in the thumb.
This condition is often associated with repetitive movements of the wrist, particularly those that involve moving the thumb away from the palm, extending it, and deviating the wrist towards the thumb side. It’s commonly seen in new mothers who repeatedly lift their babies using a specific grip with their thumbs widely spread and their wrists flexing from the pinky side to the thumb side.
Several possible causes have been suggested for this disease. These include a sudden injury to the wrist, increased friction due to forceful wrist and thumb movements, germs causing disease, inflammatory conditions, and variations in the anatomical structure of a specific area of the wrist called the first dorsal compartment.
Risk Factors and Frequency for De Quervain Tenosynovitis
De Quervain tenosynovitis is a condition that affects a small portion of men and women, primarily in their forties and fifties. While estimates vary, some studies suggest that about 0.5% of men and 1.3% of women have this disease, while others suggest slightly lower numbers. It seems to occur more often in those who have had either medial or lateral epicondylitis. Its presence is often observed in new mothers or those who care for children, with many cases naturally resolving as the child grows and needs less physical lifting. Pregnancy and manual labor are two significant factors that can increase the risk of developing this condition.
- De Quervain tenosynovitis happens more often in women and men in their forties and fifties.
- About 0.5% of men and 1.3% of women are affected by the condition.
- People who experienced medial or lateral epicondylitis are more likely to get it.
- New mothers or those who provide child care often report the condition, which often resolves on its own as less lifting is required.
- Pregnancy and manual labor significantly increase one’s risk of developing De Quervain tenosynovitis.
Signs and Symptoms of De Quervain Tenosynovitis
De Quervain tenosynovitis is a condition that causes a wrist pain primarily on the side of the thumb, typically worsened by thumb and wrist movement. It can be so severe that it might be difficult to perform simple tasks such as opening a jar lid. The pain tends to be focused around the bony bump on the inner side of your wrist. Swelling might also occur in the same area. This condition is typically found in pregnant women in their third trimester or those who are breastfeeding, due to the repetitive action of carrying their child.
To diagnose de Quervain tenosynovitis, doctors typically use various tests. These include:
- The Finkelstein test: the patient’s thumb is bent inwards while the wrist is angled towards the little finger. Sharp pain along the inner side of the wrist may indicate a positive test.
- The Eichhoff test: the patient clenches their thumb with their other fingers and bends their wrist towards the little finger. A sharp pain over the inner side of the wrist can signify a positive test.
- The WHAT test: This involves extreme bending of the wrist and the lifting of the thumb. This test is specific for diagnosing this condition.
Testing for De Quervain Tenosynovitis
If you have pain on the thumb side of your wrist, your doctor might suspect that you have de Quervain tenosynovitis. Your symptoms and an exam can typically confirm this diagnosis. However, your doctor may order an X-ray to rule out other conditions that can cause similar wrist pain, such as arthritis of the thumb.
The use of ultrasound can be quite helpful in this case. It can reveal if there is a dividing wall (or septum) in the inflamed canal that houses the irritated tendons. Knowing this can increase the chances of successful treatment with corticosteroid injections, which are used to alleviate the inflammation and pain.
In case surgery is needed, knowing about the septum beforehand is beneficial. This is because both compartments of the affected area need to be treated for successful pain relief. So, an ultrasound can support the surgical planning by identifying this septum ahead of time.
Treatment Options for De Quervain Tenosynovitis
De Quervain tenosynovitis, a type of hand pain, can sometimes get better on its own without treatment. However, if symptoms persist, non-surgical treatments like splinting, taking anti-inflammatories, and getting steroid injections can help.
A thumb spica brace, which is a type of splint, can provide short-term relief. However, it might not work for everyone, and symptoms can often come back. Also, patients may find it uncomfortable and stop wearing it. This splinting method is often a temporary solution for those who do not wish to try other treatments. It’s important to note that using a hard splint or cast may actually worsen the condition, leading to damage in the tendons affected by De Quervain tenosynovitis. A semi-rigid splint that can be removed might be a better option.
Steroid injections can provide almost complete relief for many patients. During this procedure, a doctor injects the steroid directly into the area where the tendons are inflamed, which is located near the wrist. The doctor may use ultrasound imaging to guide the needle and improve the effectiveness of the injection. The first injection helps about half of the patients, and a second injection helps an additional 40% to 45%. However, too many injections could weaken the tendons or cause changes in skin color or texture.
Other treatments like laser therapy, ultrasound therapy, and acupuncture have been suggested, but there isn’t strong evidence to recommend these methods as highly effective.
If two rounds of steroid injections don’t relieve symptoms, surgery may be recommended. The procedure, usually done in an outpatient setting, involves cutting a small incision on the back of the wrist, exposing and cutting the ligament that covers the inflamed tendons. Once the operation is complete, the patient can begin moving their wrist again shortly after. Post-operation care is typically minimal, consisting of a simple dressing or wrap and light activities. Full normal activities can usually be resumed two weeks after the surgery, once the stitches are removed.
Complications from surgery are rare but can occur. These can include infection, wound opening, damage to a sensory nerve, and the tendons slipping out of place with movement. Such issues can typically be managed with non-invasive treatments like antibiotics and wound care. Rarely, further surgical intervention may be required. There is also a chance for the formation of hypertrophic scars, which are thick and raised, following operation.
What else can De Quervain Tenosynovitis be?
The conditions that can appear similar to this one include:
- Arthritis in the joint at the base of the thumb
- A broken bone in the wrist known as a scaphoid fracture
- A fracture in the lower part of the thumb known as a radial styloid fracture
- An inflammation of the sensory nerves in the thumb, also called Wartenberg’s syndrome
- A condition in which the tendons in the wrist become inflamed, known as intersection syndrome
- A condition where the thumb gets stuck in a bent position, known as trigger thumb
These conditions can seem like the one being examined, so they should also be considered when trying to figure out the correct diagnosis.
What to expect with De Quervain Tenosynovitis
Most patients can be treated successfully without resorting to surgery. A method called corticosteroid injection, often combined with immobilization, proves effective for many individuals. Even when this non-surgical approach doesn’t work, surgery to release the first dorsal compartment usually relieves the pain, so the outlook for these patients is generally quite good.
However, there are some risk factors which might make non-surgical treatment less successful. These include being female, suffering from an underactive thyroid (hypothyroidism), having a dividing wall (septum) in the first compartment, and dealing with mental health disorders.
Possible Complications When Diagnosed with De Quervain Tenosynovitis
Possible side effects from the surgery may include:
- Damage to the superficial radial nerve
- Trapping of the abductor pollicis longus and extensor pollicis brevis muscles
- Partial dislocation of the tendons
Preventing De Quervain Tenosynovitis
It’s vital to inform patients about the disease’s risk factors, treatment choices, and possible complications. If a patient’s treatment involves multiple steroid injections, these should be administered with several weeks in between each round. This spacing can help prevent any complications that might arise from the injections.