A Patient's Guide to de Quervain's
Tenosynovitis
Introduction
The condition called de Quervain's
tenosynovitis causes pain on the inside of the
wrist and forearm just above the thumb. It is a common
problem affecting the wrist and is usually easy to
diagnose.
This guide will help you understand
- how this condition starts
- how to recognize the symptoms
- what can be done to stop the pain
Anatomy
What part of my thumb and wrist is causing
problems?
De Quervain's tenosynovitis affects two
thumb tendons. These tendons are called the
abductor pollicis longus (APL) and the
extensor pollicis brevis (EPB).
Tendons connect muscle to bone. Muscles pull on
tendons for movement. The muscles
connected to the APL and EPB tendons are on the
back of the forearm. The muscles angle toward the
thumb.
On their way to the thumb, the APL and EPB tendons
travel side by side along the inside edge of the
wrist. They pass through a tunnel
near the end of the radiusbone of the forearm.
The tunnel helps hold the tendons in place, like the
guide on a fishing pole.
This tunnel is lined with a slippery coating called
tenosynovium. The tenosynovium is a slippery
covering that allows the two tendons to glide easily
back and forth as they move the thumb. Inflammation of
the tenosynovium and tendon is called
tenosynovitis. In de Quervain's tenosynovitis,
the inflammation constricts the movement of the
tendons within the tunnel.
Related Document: A
Patient's Guide to Wrist Anatomy
Causes
How did this condition develop?
Repeatedly performing hand and thumb motions such
as grasping, pinching, squeezing, or wringing may lead
to the inflammation of tenosynovitis. This
inflammation can lead to swelling, which hampers the
smooth gliding action of the tendons within the
tunnel. Arthritic diseases that affect the whole body,
such as rheumatoid arthritis, can also cause
tenosynovitis in the thumb. In other cases, scar
tissue from an injury can make it difficult for the
tendons to slide easily through the
tunnel.
Symptoms
What problems does this condition cause?
At first, the only sign of trouble may be soreness
on the thumb side of the forearm, near the wrist. If
the problem isn't treated, pain may spread up the
forearm or further down into the wrist and thumb.
As the friction increases, the two tendons may
actually begin to squeak as they move through the
constricted tunnel. This noise is called
crepitus. If the condition is especially bad,
there may be swelling along the tunnel near the edge
of the wrist. Grasping objects with the thumb and hand
may become increasingly painful.
Diagnosis
What tests will my doctor want to do?
Doctors usually diagnose de Quervain's
tenosynovitis easily through a physical examination.
Most of the time no special tests are required. The
major problem can be distinguishing de Quervain's
tenosynovitis from intersection syndrome, which
is a very similar condition.
Related Document: A
Patient's Guide to Intersection Syndrome
Careful attention must be paid to where the pain is
located: over the de Quervain's tunnel near the end of
the radius bone, or over the intersection point on the
wrist. The intersection point is about three inches up
the forearm.
The Finklestein test is one of the best ways
to make the diagnosis. You can do this test yourself.
Bend your thumb into the palm and grasp the thumb with
your fingers making a fist with the thumb inside. Now
bend your wrist away from your thumb. If you feel pain
over the tendons to the thumb, your problem may be de
Quervain's tenosynovitis.
Treatment
How can I make the pain go away?
Nonsurgical Treatment
If at all possible, you must change or stop all
activities that cause your symptoms. Take frequent
breaks when doing repeated hand and thumb actions.
Avoid repetitive hand motions such as heavy grasping,
wringing, or turning and twisting movements of the
wrist. Keep the wrist in a neutral alignment. In other
words, keep it in a straight line with your arm,
without bending it forward or backward.
Your doctor may want you to wear a special forearm
and thumb splint called a thumb-spica
splint. This splint keeps the wrist and lower
joints of the thumb from moving. The splint allows the
APL and EPB tendons to rest, giving them a chance to
begin to heal.
Anti-inflammatory medications may also help control
the swelling of the tenosynovium and ease symptoms.
These medications include common over-the-counter
medications such as ibuprofen and aspirin.
If these simple measures fail to control your
symptoms, your doctor may suggest an injection of
cortisone into the irritated tunnel. Cortisone
reduces the swelling of the tenosynovium and may
temporarily relieve your symptoms. Cortisone
injections will usually control the inflammation in
the early stages of the problem.
Your doctor may have you work with a physical or
occupational therapist. The main focus of therapy is
to reduce or eliminate the cause of irritation of the
thumb tendons. Your therapist may check your
workstation and the way you do your work tasks.
Suggestions may be given about the use of healthy body
alignment and wrist positions, helpful exercises, and
tips on how to prevent future problems.
Surgery
If all else fails, you may need surgery. The goal
of surgery is to give the tendons more space so they
no longer rub on the inside of the tunnel. To do this,
the surgeon performs a surgical release of the
roof of the tunnel.
This surgery can usually be done on an outpatient
basis, which means that you won't have to spend the
night in the hospital. It can be done using a
general anesthetic, which puts you to sleep, or
a regional anesthetic. A regional anesthetic
blocks the nerves going to only a certain part of the
body. Injection of medications similar to novocaine
can block the nerves for several hours.
In surgery for de Quervain's tenosynovitis, you may
get an axillary block, which puts the arm to
sleep, or a wrist block, which puts only the
hand to sleep. It is even possible to perform the
surgery by simply injecting novocaine around the area
of the incision.
Once you have anesthesia, your surgeon will make
sure the skin of your forearm and wrist is free of
infection by cleaning the skin with a germ-killing
solution. The first step in the surgical release is to
make a small
incision along the thumb side of the wrist.
The surgeon moves aside other tissues and locates
the tendons and the tunnel. An incision
is made to split the roof, or top, of the tunnel.
This allows the tunnel to open up, creating more space
for the tendons. The tunnel will eventually heal
closed, but it will be larger than before. Scar tissue
will fill the gap where the tunnel was cut.
The skin is then stitched together, and your hand
is wrapped in a bulky dressing.
Rehabilitation
What can I expect after treatment?
Nonsurgical Rehabilitation
If nonsurgical treatment is successful, you may see
improvement in four to six weeks. You may need to
continue wearing your thumb splint to control
symptoms. Try to do your activities using healthy body
and wrist alignment. Limit activities that require
repeated motions of the wrist and thumb.
After Surgery
Rehabilitation is more involved after surgery. Full
recovery could take several months. Pain and symptoms
generally begin to improve after surgery, but you may
have tenderness in the area of the incision for
several months.
Take time during the day to support your arm with
your hand elevated above the level of your heart. You
should move your fingers and thumb occasionally during
the day. Keep the dressing on your hand until you
return to the surgeon. Avoid getting the stitches wet.
Your stitches will be removed 10 to 14 days after
surgery.
You will probably need to attend occupational or
physical therapy sessions for six to eight weeks.
You'll begin doing active hand movements and
range-of-motion exercises. Therapists also use ice
packs, soft-tissue massage, and hands-on stretching to
help with the range of motion. When the stitches are
removed, you may start carefully strengthening your
hand and thumb by squeezing and stretching putty.
Therapists also use a series of gentle stretches to
encourage the thumb tendons to glide easily within
tunnel.
As you progress, your therapist will give you
exercises to help strengthen and stabilize the muscles
and joints in the hand and thumb. Other exercises are
used to improve fine motor control and dexterity. Some
of the exercises you'll do are designed to get your
hand working in ways that are similar to your work
tasks and sport activities.
Your therapist will help you find ways to do your
tasks that don't put too much stress on your thumb and
wrist. Before your therapy sessions end, your
therapist will teach you a number of ways to avoid
future problems. |