|3475 Torrance Blvd., Ste F
Torrance, CA 90503
Office hours: M-F, 9am
– 5 pm
Worker’s compensation, Medicare
and most insurance plans accepted.
In September 2008, we will be moving to a beautiful new 4,400 sq ft,
state of the art dedicated hand center located at 2808 Columbia Ave
in Torrance, CA., which will feature onsite nerve conduction studies,
occupational hand therapy and digital x-ray.
This is a common tenosynovitis that affects the tendons moving the thumb.
The extensor tendons on the back of the thumb and the wrist are arranged
in 6 separate fibrous compartments. The long thumb abductor (abductor
pollicus longus) which inserts on to the base of the thumb metacarpal,
and the short thumb extensor (extensor pollicus brevis) which inserts
on to the neck of the thumb metacarpal , run in the first sheath. The
two radial sided wrist extensors (extensor carpi radialis brevis and longus)
run in the second sheath; the long thumb extensor (extensor pollicus longus)
runs in the third sheath. All of the finger extensor tendons and the ulnar
wrist extensor (extensor carpi ulnaris) run in separate compartments for
a total of six dorsal extensor compartments. These sheaths serve to orient
the line of pull of the extensor tendons and also serve to lubricate the
tendons to decrease the amount of friction. In certain instances the sheaths
can become inflamed giving rise to a tenosynovitis. Any one of the sheaths
can become involved but DeQuervain’s tenosynovitis, which involves
the first extensor compartment is the most common of these.
History / Exam:
Typically patients will give a history of repetitive pinching, repetitive
use of scissors or repetitive lifting with the wrist in radial deviation
such as placing an object into a deep cardboard box. The syndrome is a
common affliction of new mothers who develop this in part by continually
lifting their newborn infant up by their arms. The etiology also appears
to be related to breast-feeding, since it may not completely resolve while
the mother still nurses. The eventual endpoint is that of inflammation
of the first extensor compartment. This generates friction and heat with
any thumb motion and gives rise to pain and swelling. Once the inflammation
occurs, the patient complains of pain radiating from the base of their
thumb along the radial aspect of their wrist. The clinical exam reveals
a swollen extensor compartment, tenderness over the first extensor compartment
and occasionally crepitation (“crackling or creaking”) with
active thumb motion.
Finklestein’s test is a clinical test
for inflammation of the 1st extensor compartment. It is performed by asking
the patient to grasp their flexed thumb with their fingers, while the
examiner places the wrist in ulnar deviation. This test stretches the
tendons in the first extensor compartment and elicits immediate sharp
pain radiating down the thumb and wrist if the sheath is inflamed. It
is necessary to differentiate pain emanating from the trapeziometacarpal
joint or pain arising from disorders of the scaphoid / scapholunate ligament
since these structures are close to the 1st extensor compartment. The
grind test consists of compression of the base of the thumb
metacarpal against the trapezium, which gives rise to crepitation and
pain in the presence of trapeziometacarpal arthritis. When a disorder
of the scapholunate joint gives rise to radial sided wrist pain, there
is usually some tenderness over the scaphoid in addition to the reproduction
of the wrist pain while dorsally stressing the scaphoid and simultaneously
radially deviating the wrist i.e. the Watson test.
A hallmark of treatment is activity modification. The patient is instructed
in the avoidance of lifting with the wrist in radial or ulnar deviation,
as well as a restriction of pinching activities, using scissors and repetitive
thumb motion with computer use. A forearm or palmar based thumb spica
splint is applied to prevent thumb and wrist motion. Thumb stiffness is
minimized by frequent removal of the splint for range of motion exercises.
Anti-inflammatory medication provide symptomatic relief. Cortisone injections
may be necessary if the initial measures do not bring about pain relief
within 3-4 weeks. The cortisone is injected directly into the first extensor
compartment and acts to reduce the swelling of the tenosynovium, reversing
the cycle of entrapment. Up to three cortisone injections, no more frequent
than every 4-6 weeks are considered safe. Multiple injections however
may lead to skin hypopigmentation or atrophy and even tendon rupture.
In longstanding cases, the sheath becomes chronically scarred and fibrotic,
which results in a failure of response following cortisone injections.
At this stage of the disease, surgical treatment must be considered. The
surgery consists of a division of the roof of the sheath through a 1-2
cm incision near the wrist. The abductor pollicus longus and the extensor
pollicus brevis often run in separate compartments within the sheath and
may consist of 3 or more tendon slips. Each individual tendon slip must
be decompressed or else the symptoms may persist. This brings about a
resolution of the pain in many cases.
The superficial radial nerve, which supplies sensation to the dorsum of
the thumb and the first web space, crosses over the thumb extensor tendons
at the base of the thumb . Injury to or irritation of this nerve can mimic
the signs of DeQuervains and often coexists Superficial radial nerve entrapment
must hence be ruled out before proceeding with a release of the first
extensor compartment. This nerve is also at risk of injury during the
surgical procedure and can give rise to formation of a neuroma, which
may be more difficult to treat than the initial condition. Systemic disorders
such as endocrinopathies, gout, inflammatory arthritis and infectious
diseases such as tuberculosis are uncommon causes of DeQuervains but must
be kept in mind in resistant cases.
Most people can perform one-handed work activity by the 2nd week followed by light duty including clerical work at 6-8 weeks. Heavy manual labor can often be resumed by 8 -12 weeks.