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 extended (cocked back). The space inside the tunnel is lubricated but limited. If inflammation occurs in the tunnel then the tendons may become irritated and friction between the tendon and tunnel roof may occur. This would cause pain and swelling inside tunnel. DeQuervain's disease is inflammation of the tendons in the first extensor compartment. This compartment is on the back of the wrist (not palm side) at the base of the thumb.

Symptoms

Patients with De Quervain's have localised pain and swelling on the back of the wrist at the base of the thumb. The pain tends to run up and down in line with the thumb at the level of the wrist. The pain is made worse on moving the thumb backwards or forwards. Trying to cock the thumb back will be sore. This may be accompanied with a palpable and sometimes audible "creaking" sensation.

Clinical Examination

Bending the thumb over into the palm and clasping the thumb with the fingers reproduces the pain particular if the wrist is then bent forwards in line with the thumb. This test is often called the Finklestein's test.

Investigations

The diagnosis of De Quervain's is often very clear from the history and clinical examination. In such cases no special tests are required.

However an ultrasound scan can visualise the tendons and look for abnormal fluid, thickening and inflammation.

Non-operative treatment

A resting splint and physiotherapy can often help early cases of De Quervain's.

A low dose corticosteroid injection into the sheath may lubricate and also damp down the inflammation. Steroid injections are not often repeated. Further attempts may damage the skin and dissolve fat leaving the tendons very prominent and the skin pigmentation altered. 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 not often used, as adrenaline ( a vasoconstrictor) is mixed with the local anaesthetic to reduce bleeding.

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

Local anaesthetic (with adrenaline) is infiltrated under the skin in line with the incision at the thumb side of the wrist. Once numb the skin is incised and 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 with absorbable stitches under the skin ( no need to be removed) 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 covered and 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 and be able to control the vehicle in an emergency. It is probable advisable to delay returning to driving for a few days if the hand is tender. However everyone is different and some people feel able to drive straight away after the operation.

Return to work:

Everyone has different work environments.

Light desk based activities can be performed immediately.
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.

 

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