De Quervain’s disease
What is De Quervain’s disease?
De Quervain’s disease is a painful wrist condition due to inflammation and compression of the tendon in a tunnel on the thumb side of the wrist. Tendons are cord like structures that join the muscle to the bone. This disease is also known as De Quervain’s tendinosis, or Dequervain’s tenosynovitis or gamer’s thumb or mother’s thumb. It is caused by the inflammation and thickening of the sheath that contains the tendon and the tunnel leading to pain and swelling in wrist and thumb movements. The main cause behind this is overuse or overstraining of these tendons, in work or sports (racquet sports) that involves repetitive wrist and thumb movement and also happens sometimes after injury.
De Quervain’s disease is often associated with rheumatoid disease and pregnancy. It is more common in women than men in age of 30-50 years. It usually affects the dominant wrist. Its prevalence is estimated to be 0.5% in men and 1.3% in women. New mothers often develop this disease in both the hands when they repeatedly lift the new born. However, it resolves when lifting of the baby is less frequent.
What are the symptoms of De Quervain’s disease?
Pain and presence of a nodule (bump) at the thumb side of the wrist are the most common symptoms of De Quervain’s disease. You will feel the pain over the thumb side of the wrist that may extend to the forearm. It gets worse when you use the hand and thumb especially to grasp or grip something or twist the wrist. You may feel a creak, catching or snapping sensation in the thumb side of the wrist with certain movements. You will feel stiffness in the wrist and thumb in the morning especially after a long period of inactivity.
How is it diagnosed?
Your surgeon will diagnose De Quervain’s disease by evaluation of your symptoms, complete medical history and examination of your affected side. He will perform a simple test called Finkelstein test. He will place your thumb against the palm your hand, making a fist and closing all the fingers over your thumb. After this, he will bend your wrist toward your little finger. If you have De Quervain’s disease you will feel a lot of pain on the thumb side of the wrist. He will also assess tenderness, thickening, and swelling of the sheath and most cases your surgeon will ask for ultrasound scan.
What happens if nothing is done?
If De Quervain’s disease is left untreated, it could lead to progressive narrowing and inflammation of the tendon in the tunnel that limits the thumb movement. The tendon could get permanently damaged and you could struggle to perform day-to-day activities.
How is it treated?
The treatment depends on the severity of the symptoms and around 70% of them could be treated without surgery. If the disease begins in pregnancy, it usually settles down with the end of pregnancy or breast feeding. Non-operative symptoms include rest, splint, anti-inflammatory medicines, steroid injections and hand therapy.
Surgery is indicated in
- Failure of the conservative treatment
- Severe symptoms
- Associated pathology of bone, wrist joint
- Contraindication to steroid injection
What are the non-operative treatments?
Most cases of De Quervain’s disease resolve through conservative treatment. It involves the following-
- Rest /activity modification – you should rest your hand and avoid those activities that provoke pain.
- Splint- your therapist will give you a splint, which is to be worn at night to hold the thumb and wrist straight while sleeping.
- Cold application- Application of ice packs helps to reduce pain and swelling of the wrist.
- Medicines– anti-inflammatory drugs such as aspirin and ibuprofen can be taken to control inflammation and pain.
- Steroid injections– cortisone (an inflammatory agent) is directly injected into the tendon sheath/A1Pulley at the base of the involved finger. It is usually performed under ultrasound guidance, as there are lot of anatomic variations that are reported in these tendons. Some cases require two steroid injections to resolve the problem. If the problem is persistent after two injections, then surgery may be considered.
- Hand therapy– gentle exercises including massage of the nodule could help with the symptoms in early stages. It helps to improve the range of motion in the affected finger.
What does the operation involve?
- The operation is conducted as a day case with local anaesthetic/general anaesthetic and with a small 2cm cut is made in the thumb side of the wrist.
- The tight tunnel and tendon sheath is released, to allow free movement of tendons again.
- The skin is then closed with absorbable stitches and is kept covered with a light bandage for 48hrs. The operation ends in 30-45 minutes and most patients are discharged on the same day.
What happens after surgery?
- The local anaesthetic wears off in 4 to 12 hours after surgery. Patients are given painkillers before the pain starts i.e. on return to home. It is continued for at least 48 hours after the first dose. Thus, most of our patients report little or any pain.
- You will have a bulky bandage when you wake up, that usually needs to be reduced in 24-48 hrs. You will have spare dressings to take home and have to keep the wound dry and clean for 2 weeks
- You have to keep your hand and wrist elevated (above the level of your heart) and keep moving your fingers, elbow and shoulder to maintain the flexibility and prevent stiffness of its joints.
- You are reviewed again after the period of two weeks to check the wound and hand therapy is advised for rehabilitation.
- The wound should be massaged (typically after 2 weeks) using moisturising cream by the patient 3 times a day for 3 months once the wound is well healed. This reduces the scar sensitivity and scar-related complications (tenderness; helps scar to mature).
- Hand therapy is needed in most patients to restore the range of motion, normal function and strength of the hand.
Are there any risks?
- Injury to sensory branch of radial nerve leading to patch of numbness
- Neuroma formation
- Stiffness of the thumb
- Scar tenderness
- Inadequate release
- Tendon instability/snapping
- Complex regional pain syndrome
What are the results of the operation?
The results of the operation are excellent with a success rate of > 97% and few complications. The results are more predictable under the author’s experiences.
When can I return to driving and work?
You can get back to work in few days if you have a desk job, however might take 2-4 weeks if your job involves physical work. You should be able to resume driving in 2 weeks. The above time line could vary based on the severity of problem and the treatment modality. Your surgeon can give you the correct estimation for this.
Dequervains disease is the inflammation of tendon sheath (two tendons – yellow arrow) and the tunnel (red arrow) through which the tendon glides.