DE QUERVAIN'S STENOSING TENOSYNOVITIS

De Quervain's stenosing tenosynovitis is a common cause of pain in the region of the wrist. Patients present with a complaint of pain during use of the hand. The pain is located on the thumb side of the wrist, near the base of the thumb and just above the so-called anatomical "snuff box".

The condition usually starts spontaneous and insidiously; now and again the onset may be associated with strenuous and repetitive use of the hand. The condition is more commonly seen in the middle aged and older group of patients, but can also occur in younger patients, especially females, in the first few weeks after the birth of their baby. The dominant or the non-dominant hand may be affected.

In older patients, the tendons develop short "cracks" or degenerative tears in the length of the tendon, which leads to a localised inflammatory response, with resultant swelling and pain. This localised swelling interferes with the smooth gliding motion of the tendons in question. In females, shortly after delivery, overuse and fluid retention play a significant role.

Treatment Options

Non-surgical Treatment

Local treatment - The application of ice early in the development of the condition may help, as would the application of an anti-inflammatory ointment or patch. Physical therapy may also be of some benefit.

Rest and the use of a brace - a temporary measure that may be of benefit early in the development of the condition but, it limits the use of the hand (the thumb is essential in more than 60% of hand function)

Infiltrating the tendon sheath - Injecting the soft tissue around the tendon sheath with cortisone and a local anaesthetic may temporary manage some of the swelling and pain. Attempting to inject the mixture into the tendon sheath is tricky and may cause harm, if done incorrectly.

If conservative (non-surgical) treatment fails, and the condition interferes with normal daily activities, surgery may be considered.

Surgical Treatment

The Procedure

Surgery to release a De Quervain's is done as a day procedure; i.e., you will be admitted to a hospital or day clinic and discharged the same day.

The surgery performed in an operating theatre and should never be attempted in a consulting room.

It is preferable to perform the procedure under a form of local anaesthetic, called regional anaesthetic. This aims to numb either the whole or at least part of the forearm. In addition to the local anaesthetic, you will also be given a sedative. A general anaesthetic may be used in patients that cannot tolerate a local anaesthetic.

"Cutting time" (from the first incision, to complete wound closure), is normally some 20-30 minutes.

The skin incision is short (approximately 2 - 3cm) and is located over the thumb-side of the wrist, just before the "anatomical snuff box". The surgical incision is normally closed with self-dissolvable stitches. A soft bandage is used to cover the wound, leaving the thumb and fingers free, allowing you to do most essential everyday activities. No plasters or splints that may limit movement of the wrist or fingers, are required.

Instructions after the Procedure

General Instructions

You may leave the hospital when:

  • All the paperwork is done
  • When you are totally awake
  • When your wound is not bleeding
  • When your pain is under control
  • When you have received your take-home medication
  • When you have received your follow-up appointment card

The do's & the don'ts until your 1st follow-up visit

The bandage:

  • Keep it dry and clean; don't remove it. If for some unforeseen reason it needs replacement, contact us or your general practitioner or visit you nearest clinic.
  • Do not stick anything in underneath the bandage, not even your finger(s).

Your hand:

  • Your hand: Keep your operated hand elevated by placing your elbow on a sturdy surface, with your fingers pointing upwards. Doing the opposite, by allowing the hand to hang or point downwards for long periods, will promote swelling, which can slow down wound healing, cause pain and even bleeding from the wound

The do's:

  • Frequently lightly make a fist and completely open your fingers, including your thumb; this promotes circulation, reduces swelling and prevent stiffness of the fingers.
  • Use your fingers to do light, every day activities, such as putting on clothing and buttoning up a shirt, holding a knife and fork, brushing your teeth, and holding a book or a phone, etc.
  • Typing on a keyboard is also encouraged.

The don't:

  • Do not forcefully make a fist or grip something tightly; this may cause pain and could open your wound. Gently opening and closing the fingers will not cause any harm, despite the pain you may experience
  • Do not press down too hard on the palm of your hand. This will also cause you pain and could open your wound.
  • Do not drive for the first 18 to 24 hours after surgery; you are under the influence of medication that may impair your ability to handle the vehicle. Apart from being sound medical advice, it is also a legal and an insurance issue.

Use of Medication following the Procedure

Painkillers

  • Unless you indicate otherwise, a mild painkiller will be prescribed and issued at the time of your discharge. This should help you manage your pain.
  • If the medication does not adequately control you pain, please contact our office or your general practitioner.
  • If the medication causes undesirable side effects or complications, please contact our office or your general practitioner, or if an emergency, go to your nearest emergency unit
  • Only take the prescribed painkillers when necessary and do not exceed the prescribed daily dosage. Also, do not add other painkillers without consulting with us or your general practitioner.

Antibiotics

  • All patients will receive one dose of an antibiotic in theatre to prevent the onset of an infection.
  • Unless there is a sound medical reason, a full course of an antibiotic will not be prescribed.

Chronic medication

  • Do not stop taking you chronic medication, not even on the morning of your surgery. Although you are instructed to take nothing by mouth for the 6 hours before your surgery, do take your necessary chronic medication with the least amount of clear water.
  • If we feel that any of your chronic medication may negatively affect the outcome of your surgery or may increase your risk for complications, you will be instructed to timeously stop taking such chronic medication, or we will replace it with something that’s more controllable.
  • If you are uncertain about taking your chronic medication, please contact us or your general practitioner.

Follow-up Appointments

1st Follow-up visit (10 to 12 days after surgery)

  • The purpose of this appointment is to check that the wound is healing.
  • The stitches are self-dissolving, they need not be removed.
  • You will receive instructions regarding:
    • Further wound care
    • Activities to initially avoid
    • We will recommend when you may resume your normal activities.
  • We will also deal with any questions you may have at this stage.
  • If applicable, how soon you may return to work.

2nd Follow-up visit (6 weeks after surgery)

  • The purpose of this appointment is to confirm wound healing.
  • Check for excessive scarring
  • Confirm that you have regained full use of the hand.

FAQ

What are the possible risks and potential complications when releasing a De Quervain's?

  • Most Serious Complications – damage to nearby tendons and a nerve responsible for sensation on the back of the hand and thumb finger is possible, but unlikely if your surgeon is well-trained, experienced and if the procedure is done in an operating theatre, with appropriate anaesthesia.
  • Most Common Complications – Theoretically sepsis should be the most common complication, but is in fact extremely rare, especially if you are healthy. Some patients, such as diabetics and other patients with suppression of their immune system, have a higher risk but this is still manageable.

Can a De Quervain's recur after surgical release?

Theoretically it could, but this is seldom seen. An alternative explanation for a so-called "recurrence" is that some patients have more than the average 2 tendons that are involved; one must specifically look for an "additional" or accessory tendon, which may follow a different path through a separate tunnel. If missed and not released, such patients may have persistent pain even after surgery.

How long is the recovery time after surgical release of a De Quervain's?

Your wound should take about 10-12 days to heal to such an extent that further wound dressings are unnecessary. After that, you should be able to gradually take on more of your everyday activities, and at 3 to 4 weeks you should be able to perform most of your normal activities. By 6 weeks you should be able to perform even strenuous activities.

How soon after surgical release of a De Quervain's can I drive?

Do not attempt to drive for the first 18 - 24 hours after surgery, as you are under the influence of the anaesthesia and painkillers; this is a medical and an insurance issue. Driving thereafter depends on your ability to effectively handle a vehicle in normal and emergency situations. If you can drive, you will not cause any harm to the operated hand.

What will happen if my De Quervain's is not released?

The pain associated with the condition usually becomes so intense and debilitating, that few patients can tolerate it, and most would agree to surgery long before any permanent harm is caused. Theoretically, if neglected, the tendon can either rupture during strenuous activities or it can become stuck down in one position, making the thumb "useless".

Can the development of a De Quervain's be prevented?

No.

Dr Pierre de Villiers

Dr Pierre de Villiers is one of a growing, world-wide group of physicians, specifically trained to manage difficult painful conditions. A multitude of painful conditions that exist, are known to be non-responsive to conventional treatment options, but new approaches and equipment make therapies safer and more effective.

Contact

Suite 4, Mediclinic Hermanus, Hospital Road, Hermanus

+27 28 313 0528