Tendovaginitis (stenosans) de Quervain
- De Quervain's stenoscopic tendovaginitis
- Quervain Disease
- Tendon obstruction syndrome
Tendovaginitis de Quervain is tendinitis of the extensor tendons of the thumb, which run in the first tendon compartment on the wrist. These tendons are the attachment points of the muscles that are responsible for stretching and splaying the thumb. The disease is characterized by severe pain with certain movements in the wrist and thumb. The name was given after the Swiss surgeon de Quervain, who first described the disease in 1896.
The tendons of the stretching forearm muscles run in tendon sheaths up to their attachment points on the fingers, which in turn are covered by a connective tissue plate (Extensor retinaculum) can be fixed on the hand.
Basically, it must be stated that stenoscopic tendovaginitis usually results from overloading the flexor muscles of the hand. On the one hand, this can happen due to excessive stress at work, here tendovaginitis stenosans would then be seen as an occupational disease (e.g. in athletes, craftsmen, pianists, etc.). Often, however, e.g. During sporting activities such as climbing or with craftsmen in the private sector, the fingers are exposed to mechanical overload, so that the aforementioned inflammation then occurs in the area of the tendon sheaths.Appointment with a hand specialist?
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Those affected usually complain of severe shooting pain when certain movements of the hand occur on the side of the thumb. In addition, the so-called Finkelstein sign can be triggered. This sign describes a strong, electrifying pain in patients with tendovaginitis de Quervain when they jerk the wrist in the direction of the little finger with a closed fist and a folded thumb. In addition, the thumb region is often swollen and tender. The pain can radiate into the forearm. Sometimes creaking or cracking can be heard when moving the wrist (crepitatio).
De Quervain's tendovaginitis mostly occurs in patients between the ages of 30 and 50. Women are about eight times more likely to be affected than men.
The diagnosis of de Quervain's tendovaginitis is usually very easy to make. The positive Finkelstein sign is a clear indication. In addition, the questioning of the patient's typical complaints and the clinical examination findings usually provide sufficient clues for the correct diagnosis. Further diagnostic measures are usually not necessary. If the findings are unclear, a Ultrasonic as the tendons can be easily visualized. To changes in the joints, for example a arthrosis of the thumb saddle joint (Rhizarthrosis) can be excluded in individual cases X-ray image be helpful.
De Quervain's tendovaginitis is usually treated conservatively at first, i.e. surgery is avoided as far as possible. In many cases, immobilizing the thumb and wrist is sufficient to alleviate the symptoms. For this, either a firm tape bandage or a special splint can be applied. The movements that trigger the pain should be consistently avoided. At the same time, it is recommended to take pain reliever and anti-inflammatory drugs. Applying ice locally can also help reduce pain. If these measures do not have the desired effect, an anti-inflammatory preparation (cortisone) in combination with a local anesthetic can be injected directly into the extensor tendon compartment.
The fact that the active ingredients reach their destination directly in this way means that a higher active ingredient concentration is achieved there, which can very effectively alleviate the symptoms. However, the injections should not be given more than three times in six months, as otherwise the tendons could be permanently damaged. Alternatively, anti-inflammatory preparations in the form of ointments can be applied directly to the painful area.
In addition to conservative treatment for de Quervain's tendovaginitis, there is also the option of surgery. This is usually only carried out if the conservative therapy options do not bring about any improvement or the patient is suffering from excessive pain. Surgery may also be indicated for severe de Quervain's tendovaginitis. The operation is usually carried out on an outpatient basis by numbing the arm nerve plexus. With this method, patients can go home after the procedure. But there are several options for anesthesia, e.g. Local or general anesthesia, which can be discussed separately with the anesthetist. Before the actual operation, the affected arm is wrapped with a bandage for protection above the surgical area and then a cuff, similar to the one used to measure blood pressure, is put on. The cuff is inflated, thus stopping the flow of blood to the operating area. The operation is then carried out in a so-called "blood void". Due to the reduced blood flow, the anatomical structures can be better separated from one another. This significantly reduces the risk of injuring nerves, tendons or blood vessels during the procedure. Only then, after thorough disinfection and sterile covering, is the actual skin incision approx. 3-5 cm long on the inside of the wrist, below the thumb.
During the operation, the surgeon usually wears magnifying glasses. This again improves the representation of the conduction pathways of the hand and thus protects important tissue structures. After the skin has been opened, the superficial, sensitive branches of the radial nerve are exposed so that they are not injured in the following work steps. Only after securing these structures can the surgeon dissect the 1st extensor tendon compartment. Then the extensor tendon compartment is split and its lateral borders removed. In some cases, the border between the long thumb spreader (abductor pollicis longus) and the short thumb extensor (extensor pollicis brevis) is also severed. Inflammatory tissue can also be removed directly. Following these steps, the two tendons can now be pulled forward and existing adhesions can be released directly. The tendons should then be able to slide freely in their sliding bearings again, which is checked during the operation. Finally, the small nerve branches on the surface are checked again to ensure that they are intact. Only then, after opening the upper arm cuff, can the wound be closed and covered with a sterile, compressive bandage.
After the operation, the patient can move their fingers, including the thumb, carefully, but they should not be fully loaded at first. The bandage on the surgical wound should be left for about 5 days and then changed. As a rule, this does not have to be carried out by the operating doctor, but can be done by the family doctor or the referring doctor. The pulling of the threads, which should take place after approx. 10-14 days, can also take place at the level of a general practitioner. After pulling the threads, the wound should be covered with a plaster for a day, after which a wound dressing is no longer needed. Physiotherapy exercises should also be started during this period. The exercises can initially be done in cold water as this reduces swelling and pain and should be done several times a day. You can get instructions from a physiotherapist. The scar can be rubbed with a high-fat ointment about 5 days after the threads have been pulled. This increases the resilience of the scar, as it becomes softer and therefore more mobile.
After the operation, the wound pain is usually mild. Nevertheless, the patient is usually given pain medication to be on the safe side. The local pain that was still present before the operation should have completely disappeared, and the pain symptoms radiating into the arm will usually improve after several days. Discomfort on the operation scar is possible, but usually disappears after a few weeks to six months. The scar reaches its final state, in which it no longer changes, after about a year. Depending on the stress during work, the duration of the inability to work is usually 2-3 weeks.
The typical symptoms usually disappeared immediately after the operation. The affected hand can be moved, but should not be strained at first. The first dressing change takes place after a week and the stitches are pulled after two weeks. From then on there is no longer any need to wear a bandage. Patients should now exercise regularly to improve wrist and thumb mobility again. These can optionally be carried out under cold water, which also has a decongestant and pain-relieving effect.
Physiotherapy is usually not required and is only prescribed after the operation if there are significant mobility restrictions. One week after pulling the stitches, the scar should be rubbed regularly with ointments containing fat to make it softer and more elastic. It can take several months for the scar to stop causing symptoms, but the pain symptoms caused by de Quervain's tendovaginitis have completely disappeared eight weeks after the operation at the latest.
Surgical treatment of de Quervain's tendovaginitis can in rare cases also be associated with complications. Bleeding and infections in the operating area, sensory disturbances due to damage to nerves, tendon injuries and swelling in the soft tissues are possible. In the worst case, Sudeck's disease (also algodystrophy or Sudeck’s disease) can develop, the exact cause of which is unknown. This is a pain syndrome that can ultimately lead to stiffening of the joints and shrinkage of muscles, skin and tendons.
Overall, the prognosis for de Quervain's tendovaginitis is good as long as no other disease is the cause (e.g. rheumatic disease). Following the operation, the typical electrifying pain caused by flexing the wrist usually disappears immediately. The radiating pain will improve over the course of the days. After about a year, the scar has finally reached its final state.