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De Quervain’s Disease

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Finkelstein’s test

What is it?
Tendons pass to the thumb via a tight tunnel (sheath) as they cross the wrist joint. De Quervain’s tenosynovitis is due to thickening of a localised segment of the sheath, which narrows the tunnel and pinches the tendons.
Its symptoms are pain and tenderness on the thumb side of the wrist, which are particularly aggravated by use or movement of the thumb. Physical signs include swelling, tenderness and a grating sensation when the thumb is moved. Downward deviation of the wrist, with the thumb held clasped in the palm, typically causes discomfort (Finkelstein’s test). This is shown opposite in the diagram.

What can be done?

  • Rest – It is important to limit aggravating activities as much as possible to allow the problem to settle whatever other treatment is provided.
  • NSAID – Anti-inflammatory tablets and topical gels can relieve the symptoms but there is no evidence that they speed recovery.
  • Physiotherapy – Treatments such as massage, ultrasound, and heat can help symptoms but may not contribute to the speed of recovery.
  • Splints can be helpful in reducing pain and swelling
  • Steroid injection –  Injection of the sheath is very effective in relieving the problem with 70% of patients responding. It has no general side-effects but it can cause thinning and/or discolouration of the skin on the wrist. Therefore two injections are the maximum over a year.
  • Surgery – If pain persists, despite non-surgical management, the problem can be solved by surgical release of the sheath.

The operation is performed under local or general anaesthetic. Post surgery the hand will be dressed with a supportive dressing that permits finger movement and light hand use. Occasionally a Plaster of Paris will be used. It is important to keep the hand elevated for the first few days. Stitches are often dissolvable, if not then they will be removed two weeks after your operation. You will be reviewed in the clinic at 2 – 6 weeks. Timing of your return to work is variable according to your occupation.

There are a number of potential complications.

Infection
Any operation can be followed by infection and this would be treated with antibiotics.

Scar
You will have a scar on the wrist (2cm). This will be somewhat firm to touch and tender for 6-8 weeks. This can be helped by massaging the area firmly with moisturizing cream.

Neuroma
Small nerves running in the region can be damaged during the surgery and form a painful spot in the scar (neuroma). This complication is unusual but may require a further operation to correct.

Stiffness
About 5% of people are sensitive to hand surgery and their hand may become swollen, painful and stiff after an operation (Complex regional pain syndrome). This problem cannot be predicted but will be watched for afterwards and treated with physiotherapy.

Tendon
The operation can sometimes cause the thumb tendons to move from side to side when the wrist is bent. This is usually no more than irritating and does not affect their function.