De Quervain's Tendonitis
Click Here to include surgical photos.
De Quervain's tendonitis shows up as discomfort on the thumb side of the wrist. It occurs due to tightening of the band overlying two tendons that lift the thumb away from the fingers. Pain can be localized at the base of the thumb; it may radiate up into the top of the forearm. There may be visible swelling depending on the duration of the problem, and one may feel grating (crepitation) over the tendon. There is a high female to male ratio (9:1). De Quervain's tends to occur more frequently in the same person who develops carpal tunnel syndrome and trigger finger. This suggests a genetic predisposition for the problem.
Once a diagnosis of de Quervain's tendonitis has been made, early treatment may consist of a "cortisone" injection into the tendon sheath. The injections often work very well, much akin to pouring water on a fire, with complete symptom resolution occurring within a few days to weeks. In the case of advanced or long standing de Quervain's, especially where there is obvious swelling and grating of the tendon, weakness of pinch, etc., a thumb splint to hold the thumb at rest may be useful along with analgesics while waiting for the cortisone to work. Splinting by itself does not solve the problem. If injection fails to fully resolve the problem, definitive surgical release is recommended.
About one third to one half of cases go on to require surgery, this is performed as an outpatient under local anesthesia. Surgical success for operative treatment of de Quervain's is achieved more than 9 out of 10 times. Response to surgery is so prompt that surgery has been advocated as the only treatment. Surgery actually hurts less than cortisone injection! The pinched tendon sheath is completely cut, freeing up the tendon. Note that it is slightly compressed from the pressure of the tendon sheath. This resolves after the tendons are given space to glide.
Risks of Surgery
The predominant risks are: 1 in 200 risk of infection, some temporary numbness in the local superficial radial nerve distribution because the nerve has to be gently pulled to the side in order to perform the 1st extensor compartment release for de Quervain's, and possible new or persistent local tenderness at the surgical site.
Fallacy of Work-Relatedness
Studies on development, natural history, and the treatment of de Quervain's do not tie into workplace or heavy use of one's hand in repetitious activity as causative. In fact, in one series of 55 patients, 50 of the 55 patients with de Quervain's were not involved in occupations involving repetitive use of the hands or wrist (33% were retired, 29% were clerical workers, 13% were doing assembly/light work, 7% were doing heavy labor, 18% had just delivered children).
A Word about Corticosteroids: ("Cortisone")
Discoloration that could be permanent
Corticosteroid preparations used in a medical setting are manufactured by pharmaceutical companies. These are based on cortisol, a hormone naturally produced by the adrenal glands. Increased duration of action and strength of the drug are achieved by making a slight change to the molecule. The drugs commonly used are: dexamethasone, beclomethasone, prednisolone, and triamcinolone. They are about 25-30 times stronger than cortisol. These drugs have been used for injection since about 1951 with rare complications occurring. Non-operative "conservative" treatment of trigger digit and de Quervain's with cortisone injections may result in side effects. These include: temporary pain increase ("flare"), fat atrophy, skin depigmentation, hot flashes (in women), plus local injection pain.
Frequently Asked Question
Question: Is de Quervain’s tendinosis caused by work? I have heard that that is not likely.
Answer: There probably is some relationship of certain tasks to the development of de Quervain’s but they haven’t been identified. Unhappy workers blaming it on their keyboard activities need to look in another direction. The thumb only strikes the space bar during typing maneuvers. That is not an activity that would be anticipated to cause any problem with the thumb let alone de Quervain’s.