Tenosynovitis is inflammation of the tendons, and a common site of occurrence are those around the wrist. De Quervain’s is a particular tenosynovitis that affects tendons on the thumb side of the wrist near the base of the thumb (1st extensor compartment). The reason the tendons become inflamed, particularly around the wrist, is that they run in sheaths or pulleys which hold the tendon down close to the bony structures to allow them to work around corners. There are individual pulleys or sheaths in the wrist, particularly on the back of the wrist (dorsum), where there are six extensor compartments, each comprising a group of tendons. The sheath that the tendons run in are quite thickened and do not allow for much expansion and as tendons degenerate (age) they become more swollen and a vicious cycle is created where inflammation around the tendon swells the tendon, which then causes it to rub inside the compartment, causing it to become more inflamed and therefore more swollen.
With painful inflammation, fluid is produced and this fluid can then produce pouchings or sacs of fluid which are then known as ganglions.
What are the symptoms of tenosynovitis?
The main symptom is pain, particularly in one area of the wrist. De Quervain’s is along the thumb side of the wrist, which is worse when flexing or deviating the wrist palmarwards or to the ulnar side (away from the base of the thumb). For each different tenosynovitis, the pain can occur in other locations. Often associated with the pain is a sensation of grinding or grating (crepitus) which can be felt as a creaking or catching sensation. Sometimes the tendons are so inflamed any particular movement causes so much pain that the person does not wish to move it.
Are there any other causes of tenosynovitis?
Anything that causes inflammation of the tendons can cause the condition to occur. As such, tendinopathies are associated with smoking and also the use of chemotherapy drugs.
How are tenosynovitises treated?
The treatment is to settle the inflammation, thus allowing the swelling of the tendon to settle and recover such that normal motion and normal use of the hand can then return. Settlement may involve resting the particular area in a splint, anti-inflammatory modalities such as hand therapy with massage, or the use of injections of cortisone around the tendon sheath. However, long term use of injections can mask the symptoms and can weaken the tendon, causing it to rupture, so it should only be used on one or two occasions.
If the tendon will not settle on its own then the sheath needs to be released to stop the continual irritation of the tendon and this known as a tendon sheath release and in the case of de Quervain’s it can be done under local anaesthetic with or without sedation. It is a small procedure and it has a high success rate with the chance of recurrence being very low. It is usually done as day surgery.
Are there any risks with a tendon sheath release surgery?
Yes, there are. There is a risk that the anaesthetic, either locally or with a sedative, can lead to chest infections or nausea. These risks are low. The surgical procedure itself leads to a scar, and there are nerves that supply sensation around the scar and these will be irritated, leaving some numbness around the scar, but also run the risk of leading to some irritation and reduced sensation further down the wrist, although this usually recovers and will not lead to loss of function. There is a risk of stiffness and the wound itself can become infected. If this occurs, it can usually be treated by the use of antibiotics, removal of sutures and regular dressings, although rarely it may require another operation.
In general, however, the risks of surgery are low and most patients do very well with surgical intervention, although the vast majority of patients will settle prior to that with just the use of a splint, therapy and steroid injections.
As such, at Glenelg Orthopaedics we try the simple measures first, progressing to surgery which we believe should always be considered as a last resort, albeit that it does have very good results. Please be aware that nothing beats the advice provided by an orthopaedic surgeon.
At Glenelg Orthopaedics we are here to provide quality orthopaedic care.