Q & A: DE QUERVAIN'S TENOSYNOVITIS

by Lorenzo G. Walker, M.D.

Surgery of the Hand and Upper Extremity

QUESTION: I have two young children at home, one aged 8 months and one 2 years. Over the past two months, I have noticed a severe pain on the thumb side of my wrist when lifting my children. This has become increasingly aggravated and sore despite my efforts to lift them in a different fashion. I have tried icing this area of my wrist, but cannot take aspirin due to the fact that I am still breastfeeding. What should I do?

ANSWER: Pain about the thumb is very common in young women who have recently undergone childbirth. De Quervain's tenosynovitis is common in this population and is due to an inflammation of the tendons which extend the thumb within their protective sheath. It must be differentiated from arthritis of the carpometacarpal joint which is found in an older population and presents with a grinding and burning pain when the thumb is used for fine motor activities.

De Quervain's tenosynovitis can also be found in individuals who perform repetitive pinching type occupational activities such as assembly line work, strawberry picking, or even playing the drums. On examination, the diagnosis is confirmed by a positive Finkelstein's test. If pain is reproduced (as pictured) when the patient's thumb is placed inside the other clasped fingers and the wrist moved downward as if striking something with a hammer, de Quervain's tenosynovitis is the most likely diagnosis.

Initial treatment consists of splinting the thumb and taking aspirin or anti-inflammatory medications. At times this is impossible as nursing mothers are wary of transmitting these medications to their infants. Steroid injections have a controversial role in this disorder, although some physicians claim to provide relief in up to 50% of the patients using this treatment modality. If conservative therapy fails to alleviate this problem, surgery provides an excellent relief of symptoms, and is advocated by some clinicians at the patient's initial presentation.

Many patients question the use of steroids as part of their treatment plan. This is understandable. Steroids have become a tremendously controversial topic in the field of sports medicine due to their misuse by high-performance athletes. It should be emphasized that steroids injected into joints or tendon sheaths as described above only act locally, and are not absorbed into the bloodstream. The main complications associated with these injections are nerve irritation secondary to the injection and the possibility of lightening of skin color over the area of injection. Both of these problems occur infrequently. These steroid compounds are usually injected in combination with an anesthetic, which may provide initial relief for a few hours. The real effect of the steroids may take up to 48 hours to begin, and the patient should be aware of this delay.