David J. Slutsky


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3475 Torrance Blvd., Ste F
Torrance, CA 90503


Appointments: 310.792.1809
Fax: 310.792.1811

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.
 


PROCEDURES

DEQUERVAIN'S TENOSYNOVITIS

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.

Treatment:
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.

Complications:
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.

Work Considerations
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.