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De Quervain’s tenosynovitis

De Quervain’s tenosynovitis is inflammation of the extensor pollicis brevis and the abductor pollicis longus. Two tendons go over the radius styloid and help to abduct and extend the thumb. You’ve got to be able to move your thumb to be able to do almost anything De Quervain's tenosynovitis. This is very painful. Patients will complain of pain in the area of the radial styloid. It may radiate to the base of the thumb and up into the forearm, the distal forearm where the muscle bellies are located. The tendon sheath does course for several inches. It occurs more commonly in people with osteo and rheumatoid arthritis who may have disease at the radial styloid or the base of their thumb, depending on the type of arthritis. I have seen occasionally women who have just delivered a baby and then they are responsible for doing all this work at home, diapers, carrying. Although they may be only eight or ten pounds this lifting, cradling the infant in one hand, feeding with another. I’ve seen it not uncommonly in that situation. I’ve seen it in a couple of postal office workers from sorting mail. Again, this repetitive motion tenosynovitis.

The physical examination - this is one of my medical student who offered to pose for me - and what you can see is the two tendons. If you extend your thumb out the tendons kind of pop out and sometimes you can actually see them separately, but often it’s difficult. But the two tendon sheaths are right over the radial styloid going to the base of the thumb and then extending into the forma more proximally. If you examine a patient you will find that it’s very tender right over those tendon sheaths from the base of the thumb all the way back, probably a couple of inches above the radial styloid. The most useful test is called the Finklestein’s test where you have the patient make a fist with their thumb inside the fingers and then you just gently stretch those tendons. If a patient has this they will let you know. This is a very very painful maneuver and they will just say, "Yes, that’s it. You’ve got it. You know what it is. You don’t have to hurt me anymore." Again, there may be some tenderness extending up, or pain radiating up into the forearm.

The treatment is rest, splinting. If you are going to truly splint these tendons you have to have a special splint made that extends up to the thumb, but it’s very hard to use your hand with this type of splint. Often what I do is I just order like a Futuria splint, which is more for the wrist, but that sometimes helps enough.

Again, injection can be useful. I don’t always do it right away. It depends on the patient. If someone is really really in a lot of pain and they can’t function I’ll want to do something that works quickly. If they are getting by and I get the sense that they are not needle-happy then I’ll just try a little antiinflammatories and some rest for awhile, then I’ll see them back. Again, you are injecting in the tendon sheath and you do run the risk of tendon rupture, although there is not a tremendous amount of stress on this tendon like there is in Achilles tendon.

Occasionally surgery is required. I’ve seen a couple of patients in which nothing else worked and what the surgeons do is either strip the tendon sheath or transpose the tendon so it’s not going over the radial styloid, which again has a tendency to cause irritation. Sometimes they even shave that down.

I’m sure you’ve all seen this and some of you may even have it. I guess they got the name from people who used to shoot a lot of guns, maybe in the old west. I don’t know. That’s never been a reason why a person has come to me with trigger finger. Generally it is due to stenosing tenosynovitis of the flexor tendons. Often what happens is a nodule develops on the tendon due to an inflammatory process and the nodule gets stuck. There are little retaining ligaments that help to keep the tendons from bowing, they keep the tendons in position. These nodules, as they course back and forth through these ligaments, get stuck. So usually the patient complains that, "… especially when I get up in the morning I bend my hand and then I have to use my other hand to literally pop my fingers open." It’s usually the third or fourth finger that is most commonly involved on the dominant hand.

When you examine the patient you may feel some crepitus in the tendon. You may also feel this nodule coursing through and if you ask the patient to bend their fingers you may have to assist them in opening them, extending their fingers back up.