DeQuervain’s Disease

Mr Mike Hayton
FRCS(Trauma and Orth) FFSEM (UK)
Consultant Orthopaedic Hand Surgeon

Other common names

 - DeQuervain's tenosynovitis
 - First Extensor compartment tenosynovitis

Who does it affect?

Usually adults, slightly more common in females.

Why does it occur?

The tendons on the back of the wrist travel through separate tunnels at the wrist joint level. These tunnels are to ensure that the tendons do not bowstring when the wrist is cocked back. The space inside the tunnel is limited and lubricated. If inflammation occurs in the tunnel then the tendons become irritated and cause pain and swelling inside the tunnel. DeQuervain's disease is inflammation of the tendons in the first compartment. This compartment is on the back of the wrist on the thumb side.

Symptoms

Localised pain and swelling on the back of the wrist on the thumb side. This may be accompanied with a palpable and sometimes audible "creaking" sensation.

Clinical Examination

Bending the thumb over into a flexed position reproduces the pain. This test can be positive in other conditions. This test is often called the Finklestein's test.

Investigations

Usually none, however an ultrasound scan can visualise the inflammation.

Non-operative treatment

A steroid injection into the sheath may lubricate and also damp down the inflammation. Steroid injections can be repeated only once. Further attempts may damage the skin and dissolve fat and therefore surgery would be advised after one or two failed injections.

Operative treatment

The surgery is a day case procedure usually under local anaesthetic and takes about 10 minutes. A tourniquet is used; which is like a blood pressure cuff around the upper arm that prevents blood from obscuring the surgeons view. It is quite tight, but well tolerated for up to 20 minutes.

The surgery is performed through a 2cm transverse skin crease incision

Local anaesthetic is infiltrated under the skin in line with the incision at the thumb side of the wrist. Once numb the skin is incised and then the underlying fat is retracted. Care is taken not to injure sensitive nerves and blood vessels. At the base of the wound is the extensor compartment sheath. This structure needs to be released to allow the tendon and its nodule to glide in and out without catching. Occasionally multiple small sub compartments need to be released. The skin is sutured and a bulky dressing is applied.

Post-operative rehabilitation

The patient is fit to go home soon after the operation. The anaesthetic will wear off after approximately 6 hours. Simple analgesia usually controls the pain and should be started before the anaesthetic has worn off. The hand should be elevated as much as possible for the first 5 days to prevent the hand and fingers swelling. Gently bend and straighten the fingers from day 1. My preference is to remove the dressing at 2 days. The wound is cleaned and redressed with a simple dressing. Avoid forced gripping or lifting heavy objects for 2-3 weeks. The sutures dissolve at about 2-3 weeks. You should notice an improvement in symptoms within a few days but the final result may be realised at about 3 months.

Return to activities of daily living

It is my advice to keep the wound dry until the wound has healed at 7-10 days.

Return to driving:

The hand needs to have full control of the steering wheel and left hand the gear stick. It is probable advisable to delay returning to driving for at least 7 days or even once the sutures are removed.

Return to work:

Everyone has different work environments.
Returning to heavy manual labour should be prevented for approximately 4 - 6 weeks. Early return to heavy work may cause the tendons and nerve to scar into the released ligament. Please ask your surgeon for advice on this.

Complications

Overall greater than 95% are happy with the result. However complications can occur.

There are complications specific to DeQuervain's disease and also general complications associated with hand surgery.

General complications:

 - Infection (Less than 1%)
 - Neuroma (Less than 1% , a coiled painful nerve bundle)
 - Numbness

Chronic regional pain syndrome (1-2% rare reaction to surgery with painful stiff hands - this can occur with any hand surgery from a minor procedure to a complex reconstruction.)

Specific complications:

Failure to completely resolve the symptoms (approximately 1% - this may be due to failure to completely release all the tendon sub sheaths. This should be rare but may be released again).
The nerves just under the skin are notoriously sensitive, if damaged a painful neuroma can develop. Extra care is taken with these nerves to keep this risk to a minimum.