De Quervain's Tendonitis
Pain that occurs on the inside of your wrist (thumb side) may indicate a condition known as de Quervain's tendonitis. This is especially true for individuals who have carpal tunnel syndrome and/or trigger finger. De Quervain's tendonitis is frequently treated with cortisone shots, however the shots themselves are often painful. At Nebraska Hand & Shoulder Institute, patients can also find relief from this condition through surgery, which is often less painful than cortisone shots. You can learn more about de Quervain's tendonitis below, or contact us today to schedule an appointment.
Introduction to de Quervain's Tendonitis
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. This condition occurs much more frequently in women than men with a 9:1 female to male ratio. 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 basis 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.
WARNING: MAY CONTAIN GRAPHIC IMAGES
Risks of Surgery
The predominant risks are: infection (1 in 200), 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).
Discoloration that could be permanent from a cortisone injection.
A Word about Corticosteroids: ("Cortisone")
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 finger 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 it is unlikely.
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.
Anderson, Bruce Carl, et al, “Treatment of de Quervain’s tenosynovitis with corticosteroids.” Arthritis and Rheumatism, Vol. 34, No. 7, July 1991, pp. 793-798.
Badalamente, M.A., “Pathobiology of the Human A1 Pulley in Trigger Finger.” The Journal of Hand Surery, Vol. 16A, 1991, pp. 714-721.
Bishop, A.T., “Extensor Triggering in de Quervain’s Stenosing Tenosynovitis.” The Journal of Hand Surgery. Vol. 24A, 1999, pp. 1311-1314.
Dinham, J.M., Meggitt, B.F., “Trigger thumbs in children: a review of the natural history and indications for treatment in 105 patients.” Journal of Bone and Joint Surgery, Vol. 56B, No 1, 1974, pp. 153-155.
Doyle, J.R., Blythe, W.F., “The finger flexor tendon sheath and pulley: anatomy and reconstruction.” AAOS Symposium on Tendon Surgery in the Hand, St. Louis, 1975. The C.B. Mosby Company, pp. 81-87.
Doyle, J.R., “Anatomy of the Flexor Tendon Sheath and Pulleys of the Thumb.”, The Journal of Hand Surgery, Vol. 2, 1977, pp. 149-151.
Eastwood, D.M., Gupta, K.J., Johnson, D.P., “Percutaneous Release of Trigger Finger: An Office Prodedure.” Journal of Hand Surgery, Vol. 17A, 1992, pp. 114-117.
Ezaki, M., “Trigger Finger in Children.”, The Journal of Hand Surgery, Vol. 24A, 1999, pp. 1156-1161.
Fulcher SM, Hill, J.J.; “An Analysis of Patients with Multiple Trigger Digits.” [Poster] 56th Annual Meeting of the American Society for Surgery of the Hand Oct. 4, 2001, Seattle, WA.
Gray, R.G. and Gottlieb, N.L., “Hand flexor tenosynovitis in rheumatoid arthritis: prevalence, distribution, and associated rheumatic features.” Arthritis and Rheumatism, Vol. 20, No. 4, 1970, pp. 103-108.
Griggs, S.M., “Treatment of Trigger Finger in Patients with Diabetes Mellitus.” The Journal of Hand Surgery, Vol. 20, 1995, pp. 787-789.
Harvey, Francis J., et al, “deQuervain’s disease: surgical and non-surgical treatment.” Journal of Hand Surgery, Vol. 15A, No. 1, January 1990, pp. 83-87. (Diagram 4).
Hoffmann, R., “Open Versus Percutaneous Release of the A1-Pulley for Stenosing Tendovaginitis: A Prospective Randomized Trial.”, Techniques in Hand & Upper Extremity Surgery, Vol. 12, 2008, pp. 183-187.
Hollander, J.L., et al, “Hydrocortisone and cortisone injected into arthritic joints, comparative effects of and use of the hydrocortisone as a local anti-arthritic.” JAMA, Vol. 147, 1951, pp. 1629-1635.
Jackson, W.T., et al, “Anatomical variations of the first extensor compartment of the wrist: a clinical and anatomical study.” Journal of Bone and Joint Surgery, Vol. 68A, No. 6, July 1986, pp. 923-926.
Lane, L.B., “Commentary: Percutaneous Release of the First Annular Pulley.” The Journal of Hand Surgery, Vol. 20, 1995, pp. 785-786.
Lapidus, P.W., “Stenosing tenovaginitis.” Surgical Clinics of North America, Vol. 33, 1953, pp. 1317*1347.
Lubahn, J., “Complications of Open Trigger Finger Release.”, The Journal of Hand Surgery, Vol. 35A, 2010, pp. 594-596.
Medl, W.T., “Tendonitis, tenosynovitis, trigger fingers, and deQuervain’s disease.” Orthopaedic Clinic of North America, Vol. 1, No. 2, 1970, pp. 375-382.
Otto, N., Wehby, M., et al, “Steroid injections for tenosynovitis in the hand.” Orthopaedic Review, Vol. 15, No. 5, May 1986.
Patel, M.R., Bassini, L., “Trigger fingers and thumb: when to splint, inject or operate” Journal of Hand Surgery Vol. 17A, No. 1, Jan. 1992, pp. 110-113.
Patel, M.R., “Percutaneous Release of Trigger Digit With and Without Cortisone Injection.” The Journal of Hand Surgery, Vol. 22A, 1997, 150-155.
Peimer, C.A., “Release of the Sixth Dorsal Compartment.” The Journal of Hand Surgery, Vol. 19A, 1994, pp. 599-601.
Pratt, H.L., Bunnell, S., “Use of compound F (hydrocortisone in op) in operative and non-operative conditions of the hand.” Journal of Bone and Joint Surgery, Vol. 35, 1953, pp. 94-102.
Roth, J.H., “Percutaneous A1 Pulley Release: A Cadaveric Study.” The Journal of Hand Surgery, Vol. 20A, 1995, 781-784.
Sampson, S.P., et al, “Pathobiology of human A-1 pulley in trigger finger.” Journal of Hand Surgery, Vol. 16A, 1991, pp. 714-721.
Tanaka, J., “Percutaneous Trigger Finger Release.”, Techniques in Hand and Upper Extremity Surgery, Vol. 3, 1999, pp. 52-57.
Weilby, A., “Trigger finger: incidence in children and adults and the possibility of a predisposition in certain age groups.” Acta Orthopaedics Scandinavia, Vol. 41, 1970, pp. 419-427.
Weiss, A.C., “Treatment of De Quervain’s Disease.” The Journal of Hand Surgery, Vol. 19A, 1994, pp. 595-598.
Witczak, J.W., “Triggering of the Thumb with de Quervain’s Stenosing Tendovaginitis.” The Journal of Hand Surgery, Vol. 15, 1990, pp. 265-268.
Witt,J. “Treatment of de Quervain Tenosynovitis: A Prospective Study of the Results of Injection of Steroids and Immobilization in a Splint.” Journal of Bone & Joint Surgery, Vol. 73, 1991, pp. 219-222
Woods, T.H.E., “deQuervain’s disease: a plea for early operation: a report on 40 cases.” British Journal of Surgery, Vol. 51, No. 5, May 1964, pp. 358-359.