Diagnosis
The diagnosis of Tendovaginitis de Quervain is usually very easy to make. The positive Finkelstein sign is a clear indication. In addition, the questioning of the patients by their typical complaints and the clinical examination results usually already provide sufficient clues for the correct diagnosis.
Further diagnostic measures are usually not necessary. If the findings are unclear, an ultrasound can be performed, as the tendons can be well visualized. In order to exclude changes in the joints, e.g. arthrosis of the thumb saddle joint (rhizarthrosis), an X-ray may be helpful in individual cases.
Conservative therapy
Tendovaginitis de Quervain is usually treated conservatively at first, i.e. surgical intervention is avoided as far as possible. In many cases, the immobilization of thumb and wrist is sufficient to reduce the symptoms. For this purpose, 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 and anti-inflammatory medication. A local application of ice can also help to reduce the pain.
If these measures do not bring the desired success, an anti-inflammatory preparation (cortisone) in combination with a local anaesthetic can also be injected directly into the extensor tendon compartment. This way, the active ingredients reach their target directly, resulting in a higher concentration of active ingredients, which can very effectively alleviate the pain. However, the injections should not be given more than three times in half a year, otherwise the tendons can be permanently damaged. Alternatively, anti-inflammatory preparations in ointment form can be applied directly to the painful area.
Surgical therapy
In addition to the conservative treatment of tendovaginitis de Quervain there is also the possibility of surgery. This is usually only performed if the conservative treatment options do not bring about an improvement or the patient suffers from too much pain.Surgery may also be indicated in severe tendovaginitis de Quervain. Usually the operation is performed on an outpatient basis by means of anesthesia of the brachial plexus.
With this method, patients can go home after the operation. However, there are several options for anesthesia, such as local or general anesthesia, which can be discussed separately with the anesthesiologist. Before the actual operation, the affected arm is first wrapped with a bandage for protection above the area of intervention and then a cuff similar to that used to measure blood pressure is applied.
The cuff is inflated and the blood flow into the surgical area is stopped. The operation is then performed in a so-called “bloodless” condition. Due to the reduced blood flow, the anatomical structures can be better separated from each other.
This significantly reduces the risk of injuring nerves, tendons or blood vessels during the operation. Only then, after thorough disinfection and sterile covering, the actual skin incision of approx. 3-5 cm length is made on the inside of the wrist, below the thumb.
During the operation, the surgeon usually wears magnifying glasses. This further improves the visualization of the conductive pathways of the hand and thus protects important tissue structures. After the skin has been opened, the superficial, sensitive branches of the radial nerve (N. radialis) are exposed in order to avoid damaging them in the following steps.
Only after securing these structures can the surgeon prepare the 1st extensor tendon compartment freely. The extensor tendon compartment is then split and its lateral boundaries removed. In some cases, the boundary between the long thumb spreader (abductor pollicis longus) and the short thumb extensor (extensor pollicis brevis) is then cut through.
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 again in their slide bearing, which is checked during the operation.
Finally, the small nerve branches on the surface are checked once again to ensure that they are intact. Only then can the wound be closed after opening the upper arm cuff and covered with a sterile, compressive bandage. After the operation, the patient can carefully move the fingers, including the thumb, but full loading should not be applied at first.
The dressing on the surgical wound should be left in place for about 5 days and then changed. As a rule, this does not have to be done at the operating physician’s office, but can be done by the family doctor or the referring physician. The removal of the stitches, which should take place after approx.
10-14 days, can also be carried out at GP level. After the stitches have been removed, the wound should be covered with a plaster for another day, after which a wound dressing is no longer needed. During this period, physiotherapy exercises should also be started.
The exercises can initially be performed in cold water, as this reduces swelling and pain, and should be performed several times a day. You will receive instructions from a physiotherapist. The scar can be rubbed with a high-fat ointment about 5 days after the stitches are removed.
This promotes a resilience of the scar, as it becomes softer and therefore more flexible. After the operation, the wound pain is usually mild. Nevertheless, the patient is usually given painkillers for safety reasons.
The local pain that was still present before the operation should have completely disappeared and even if the pain symptoms radiating into the arm are still present, improvement usually occurs after several days. Complaints about the operation scar are possible, but usually disappear after a few weeks to half a year. 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 incapacity to work is usually 2-3 weeks. The typical symptoms usually disappear immediately after the operation. The affected hand may be moved, but should not be loaded at first.
After one week the first dressing is changed, after two weeks the stitches are removed. From then on, no bandage needs to be worn. Patients should now perform regular exercises to improve mobility in the wrist and thumb again.These can optionally be carried out under cold water, which has an additional decongestant and pain-relieving effect.
Physiotherapy is usually not necessary and is only prescribed in case of significant movement restrictions after the operation. One week after the stitches are removed, the scar should be regularly rubbed with fatty ointments to make it softer and more elastic. It can take several months until the scar also no longer causes any discomfort, but the pain symptoms caused by tendovaginitis de Quervain have completely disappeared at the latest eight weeks after the operation.
In rare cases, the surgical treatment of tendovaginitis de Quervain may be accompanied by complications. Possible are bleeding and infections in the area of operation, sensory disturbances due to nerve injury, tendon injuries and swelling in the soft tissues. In the worst case, Sudeck’s disease (also known as algodystrophy or Sudeck’s disease) may develop, the exact cause of which is unknown. This is a pain syndrome that can ultimately lead to stiffening of the joints and shrinking of muscles, skin and tendons.
