De Quervain Tenosynovitis

Painful Wrist

This is a condition that causes pain at the base of the thumb around the wrist. The pain arises from the inflamed and thickened tendons of the thumb.

The tendons that straighten the thumb arise from the forearm, pass through a tunnel at the back of the wrist and attached to the thumb. The floor of the tunnel is formed by the radius bone and a thick fibrous tissue called extensor retinaculum forms the roof. The tendons are lined with a slippery coating called tenosynovium that allows the two tendons to glide easily within the tunnel. In de Quervain tenosynovitis, the tenosynovium is inflamed and thickened resulting in constriction of the two tendons within the tunnel.

Inflamed tenosynovium of the thumb tendons as they pass through the tunnel in the wrist.

What causes de Quervain tenosynovitis?

Majority may be due to repetitive thumb and wrist motion over a long period of time leading to chronic inflammation and thickening of the tenosynovium. These repetitive motion of grasping with the thumb can occur from activity such as carrying baby/child, manual scrubbing and wringing cloths, frequent and prolonged phone texting and console gaming.Some may present after an episode of acute trauma such as a fall or a knock on the wrist. This condition is also commonly seen in pregnancy and breastfeeding mother and is associated with the hormonal changes.

Who gets de Quervain tenosynovitis?

Anyone can get this condition. But it is commonly seen in women between the ages of 40-60. Pregnant women and breastfeeding mother have an increased risk of getting this tenosynovitis. Certain conditions such as rheumatoid arthritis predispose the patients to this condition.

What are the symptoms?

Commonly patient will have pain over wrist just below the base of the thumb. The pain is aggravated by thumb or wrist movement. Sometimes, a ‘click’ can be felt during thumb movement. Activities such as wringing, stirring, opening a tight jar cover, shaking hand and carrying baby/child can be painful.

How does the doctor make the diagnosis?

Diagnosis is usually made based on patient’s symptoms and physical examination. Imaging is usually not needed. Occasionally X-ray of the wrist is taken to exclude any arthritis of the wrist or base of thumb which may mimic the pain of de Quervain tenosynovitis. Occasionally a cystic swelling develops over the tunnel and this can be visualized with an ultrasound.

Treatment

Non-operative treatment is commonly the initial treatment. It includes resting the wrist and thumb in a splint to allow the inflammation of the tendons to resolve. Avoidance of any activities of the thumb and wrist that causes pain helps. Some anti-inflammatory medication can help to control the inflammation and swelling of the tenosynovium and also ease the pain.

Steroid injection into the tight tunnel will effectively reduces the swelling and inflammation of the tenosynovium and relieves the symptoms. However, following full recovery, recurrence may occur after months later. Steroid injection may also result in transient whitening of the skin at the site of injection which can resolve after few months.

If all non-operative treatments fail or the symptoms are severe, surgery is indicated. In this surgery, the roof of the tunnel is divided to relieve the constriction. Thickened tenosynovium of the tendons may need to be excised. Relieve of pain after the surgery occurs early. Complications of surgery are uncommon. Infection is rare. Injury to the nearby superficial radial nerve is uncommon and can be avoided with careful dissection under loupe magnifications. Tendon subluxation may occur after surgery.