Preferred First Treatment for de Quervain's
A common problem affecting the wrist called de Quervain's tenosynovitis causes pain on the inside of the wrist and forearm just above the thumb. Dr. A.M. Ilyas from the Temple Hand Center in Philadelphia uses this case report to bring us up-to-date on the evidence on how to treat this problem.
The patient in question was a 33-year-old woman with functional left wrist pain. Functional means it hurt whenever she tried to use the hand and wrist to accomplish daily tasks. She couldn't lift her children, open jars, turn doorknobs, or twist off bottle tops. The first step in treating this problem is always conservative (nonoperative) care. But which to choose: steroid injection, splinting, or antiinflammatory drugs?
De Quervain's tenosynovitis affects two thumb tendons. These tendons are called the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB). On their way to the thumb, the APL and EPB tendons travel side by side along the inside edge of the wrist. They pass through a tunnel near the end of the radius bone of the forearm. The tunnel helps hold the tendons in place, like the guide on a fishing pole.
This tunnel is lined with tenosynovium. The tenosynovium is a slippery covering that allows the two tendons to glide easily back and forth as they move the thumb. Inflammation of the tenosynovium and tendon is called tenosynovitis.
In de Quervain's tenosynovitis, the inflammation constricts the movement of the tendons within the tunnel. But more recent data shows that in some cases, there isn't any active inflammation. This is considered a tendinosis, not a tendinitis.
Instead of finding cells that show an inflammatory process, scientists have discovered that the collagen fibers making up the tendons and tenosynovium are laid down in a haphazard fashion (every which way). Changes in the mucous cause these normally slippery structures to dry out. The tendons can no longer slide and glide smoothly. The dryness causes a painful catching of the tendon over the bone.
If there's no inflammation, then should we be using antiinflammatory drugs to treat this problem? Maybe not but we need some research into this question to know for sure. Studies already done using nonsteroidal antiinflammatory drugs (NSAIDs) haven't compared the use of NSAIDs with a placebo (pretend) drug. And more often than not, when NSAIDs are used, they are combined with some other treatment, so we don't know if the results are based on the effects of the NSAIDs or both treatments given together.
What about a steroid injection? Will that help? The results of several studies suggest that with careful application, steroid injection can be very helpful. But the surgeon must advance the needle administering the drug through the soft tissues into the first dorsal compartment. The medication must be delivered inside the tendon sheath to be effective. The steroid drug must reach inside the sheath of both the abductor pollicis longus and the extensor pollicis brevis tendons.
In the case of the patient treated in this study, her primary care physician put her on antiinflammatory drugs and gave her a wrist splint. When the symptoms did not go away, she was referred to the Temple Hand Center where Dr. A. M. Ilyas evaluated her.
A review of the literature showed that use of a splint alone can be helpful. More patients get pain relief when splinting is combined with NSAIDs. But these folks have minimal pain. Anyone with more moderate or severe symptoms will only have a one in three chance of getting relief with splinting and NSAIDs. Still, it may be worth it to prescribe a trial of this type before considering a steroid injection.
Dr. Ilyas prefers to start with a steroid injection. Anyone with moderate-to-severe pain may want to use a splint for a few weeks until the pain settles down. Splinting and NSAID-use appears to give comfort and improve the patient's quality of life. If it helps them get through the initial phase of de Quervain's then it has some limited value.
There's no evidence that it is the splinting and drug-use that's really making a difference in the disease process. Most people with de Quervain's just get better on their own over time. Surgery may be recommended if symptoms remain extremely painful even after six months of conservative care.
Asif M. Ilyas, MD. Nonsurgical Treatment for de Quervain's Tenosynovitis. In The Journal of Hand Surgery. May/June 2009. Vol. 34A. No. 5. Pp. 928-929.
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