Tenosynovitis: An inflammation of a tendon sheath.
DeQuervain’s tenosynovitis is inflammation of the first dorsal compartment of the wrist, i.e. thumb side of the wrist. The tendons of the extensor pollicis brevis and the abductor pollicis longus are held within this compartment. This condition is related to excessive mechanical stresses, and is often attributed to a work related or vocational related task.
Pain, swelling, and decreased ROM of the thumb are characteristics of this condition. Patients usually complain of pain in the thumb and wrist, sometimes radiating into the forearm. Other common complaints include weakness of grip and pinch, and pain on motion of the thumb, wrist, and forearm. Clinical signs include localized swelling in the area of the radial styloid (thumb side of wrist), decreased grip and pinch strength and pain or tenderness on palpation of the first compartment.
Treatment of DeQuervain’s tenosynovitis can be conservative or surgical in nature. In most cases, conservative treatment is recommended. Immobilization of the thumb and wrist and non-steroidal anti-inflammatory agents are initially prescribed. If symptoms persist after 3-4 weeks a local steroid injection is usually given. Immobilization should continue for an additional 2-4 weeks. A second injection may be given should the symptoms persist for an additional 4-6 weeks. A third injection is not highly recommended because of the effects of steroids on tendons and tendon sheaths.
Surgical intervention is indicated in cases of persistent symptoms. During surgery, the compartment is opened and decompressed and a tenosynovectomy is performed. When there is significant involvement of the tendon sheath, the sheath may be excised.
Post-operative treatment includes immobilization of the thumb and wrist for 3-5 days. AROM exercises are then initiated. Because adherence can be a post-operative complication, scar management is important. Desensitization is also begun after wound closure since neuromas and sensitivity of the dorsal radial sensory nerve may be caused by adherence. Gentle resistive exercise can begin during the 4th to 5th week. A gradual return to unrestricted activity supplements the strengthening program.
Carpal tunnel syndrome, the most commonly treated compression neuropathy, involves compression of the median nerve at the level of the wrist. As they approach the hand, the median nerve and 9 flexor tendons, pass through a confined space, the carpal tunnel. Irritation, inflammation, and swelling of the long flexor tendons from repetitive wrist motion, wrist joint swelling from trauma (such as falling on an outstretched hand), post fracture, arthritis, and sometimes swelling from pregnancy result in compromised upper confined space in the carpal tunnel, leading to compression of the median nerve and resulting neurologic symptoms distal to that site.
Symptoms of carpal tunnel syndrome include numbness and tingling (initially at night), pain, clumsiness, and weakness. As the syndrome progresses, night symptoms become more severe and remain throughout the day, and radiating or referred pain at the shoulder may be experienced. Inability to perform fine motor, sustained, or repetitive wrist motion, such as cashier/check out scanning, assembly line work, fine tool manipulation, or typing may also be experienced. Clinical signs include diminished sensation of the media nerve distribution (palmar surface of the thumb, index finger, middle finger and radial _ of the ring finger), changes of the skin, and atrophy of the thenar muscles surrounding the thumb.
Regardless of the severity of this compression neuropathy, the first line of management is to decrease the inciting and aggravating factors. Intervention may also include splinting to support the wrist or rest from the provoking activity, biomechanical analysis done through a physical therapy consultation to identify faulty wrist or upper extremity motions, and to adapt the environment if possible, and mobilization of the carpals (wrist bones) for increased carpal tunnel space. In more severe cases, surgical release of the transverse carpal ligament is frequently performed to relieve the compressive forces on the media nerve. Physical therapy may be initiated post surgery if there are restrictions or muscle weakness.
