Treatment of de Quervain disease
Prevention and education
De Quervain disease was originally described by a French doctor, Fritz de Quervain, in 1895. It is caused by stenosing tenosynovitis of the first extensor compartment of the wrist. Patients usually complain of pain at the dorsolateral aspect of the wrist with radiation towards the thumb or lateral forearm.
The tendons at the base of the thumb are protected by a retinaculum sheath. When the sheath becomes narrow or when the tendons inside becomes swollen because of different pathologies, pressure may build up inside the sheath and cause pain.
The exact cause for de Quervain disease is still unknown. People who use their hands and thumbs in a repetitive and unaccustomed fashion can develop the disease. It may also occur after an isolated episode of acute trauma to the region. It appears to be more common in women. Many women suffer from de Quervain disease at postpartum period because of the repeated lifting or carrying of their newborn baby.
You may have pain or swelling in your thumb or the wrist below the affected thumb. The pain usually occurs when you move the wrist up and down, or while grasping an object. The swelling may be a fluid-filled cyst at the site of pain. You may also experience weakness and difficulties in putting up the thumb and wrist.
De Quervain disease is usually diagnosed clinically. The most classic finding in de Quervain disease is a positive Finkelstein test. The test is positive if dorso-lateral wrist pain is reproduced when resisting passive ulnar deviation of the wrist with the thumb inside the fingers. X-ray may sometimes be needed to exclude other pathology including fracture, osteoarthritis of the basal joint of the thumb. Magnetic Resonance is rarely needed for diagnosis. It may show the inflammation surrounding the affected tendons.
In the acute stage, the physiotherapist may use cryotherapy (eg, cold packs, ice massage) or other modalities to reduce the inflammation and edema around the region. Local inflammation also can be treated with non-steroidal anti-inflammatory medication. An occupational therapist will assess and identify possible precipitating factors and suggest activity modifications. A custom-made thumb splint can be fabricated to rest the wrist. Local steroid injection may help to relieve pain and inflammation if the above measures failed. However, repetitive injection is not recommended as it may weaken the tendons.
Surgery is indicated for resistant cases in which injections, splinting, and modification of activities have failed. An incision was made over the radial aspect of wrist, protecting the cutaneous nerves in it is neighbourhood, opening up the extensor retinaculum and relieving the compression of the tendons underneath.
Post-operatively, early wrist mobilization is encouraged to decrease adhesion and pain.
Occasional complications of surgery may include scar pain, incomplete release of all compartments resulting in residual pain, injury to radial superficial branch of radial nerve. Recurrence after surgery is uncommon.
The patient needs to avoid certain repetitive activities of the wrist or thumb that reproduce pain.
Dr. CHAN, Wai-lam