Its a common condition .. and myself iam suffering from it .. so i found its useful to know more about it .. and get benefit of the informations .. Caption: Picture 1. In de Quervain tendinitis, the first dorsal compartment is thickened, raising the skin and creating a prominence at the radial styloid. [align=justify]Caption: Picture 2. De Quervain tenosynovitis. Finkelstein test draws the tendons of the first dorsal compartment distally and causes sharp local pain when entrapment and inflammation are present. History of the Procedure: In 1895, a Swiss surgeon, Fritz de Quervain, published 5 case reports of patients with tender thickened first dorsal compartments at the wrist. The condition subsequently has borne his name. Problem: The disease is an entrapment tendinitis of the tendons contained within the first dorsal compartment at the wrist, resulting in pain with thumb motion. Frequency: Trigger digit is the most common entrapment tendinitis in the hand and wrist, and de Quervain tendinitis is the next most common, although it occurs approximately one twentieth as often as trigger digit. Etiology: The tendons of the abductor pollicis longus and extensor pollicis brevis are tightly secured against the radial styloid by the overlying extensor retinaculum. Any thickening of the tendons from acute or repetitive trauma restrains gliding of the tendons through the sheath. Efforts at thumb motion, especially when combined with radial or ulnar deviation of the wrist, cause pain and perpetuate the inflammation and swelling. Clinical: Patients note pain with thumb and wrist motion and tender thickening at the radial styloid. Crepitation or actual triggering rarely is noted. Patients often are mothers of infants aged 6-12 months, and symptoms often are noted in both wrists. Repetitive lifting of the baby as it grows heavier is responsible for friction tendinitis. Day care workers, and others who repetitively lift infants, also are frequently affected. Those who have sustained a direct blow to the area of the first dorsal compartment also can develop de Quervain tendinitis. Examination The first dorsal compartment over the radial styloid is thickened and feels bone hard. This thickening usually distorts the sparsely padded skin in this area sufficiently to create a visible fusiform mass (see Picture 1). The area is tender. The Finkelstein test (ie, flexion of the thumb across the palm and then ulnar deviation of the wrist) causes sharp pain at the first dorsal compartment (see Picture 2). Tenderness is absent over the muscle bellies proximal to the first dorsal compartment. Tenderness and pain on axial loading are absent at the carpometacarpal (CMC) joint unless the patient has arthritis in that joint. Relevant Anatomy: The tendons of the abductor pollicis longus and the extensor pollicis brevis pass through the first dorsal compartment. The abductor pollicis longus tendon usually is multistrand. The extensor pollicis brevis tendon typically is considerably smaller than even a single slip of the abductor pollicis longus tendon, and it may be congenitally absent. A septum separating the first dorsal compartment into distinct subcompartments for the abductor pollicis longus tendons and the extensor pollicis brevis tendon often is noted at surgery. Imaging Studies: Radiographs Although the thickened first dorsal compartment can be bony hard, the thickening is made up of fascia and tendon. Radiographs are negative and not necessary for routine diagnosis. However, it should be emphasized that radiographs should be obtained to rule out other conditions that may be responsible for the patient's pain. Radiographs may be helpful to differentiate between the patient who has de Quervain tendinitis and one who has osteoarthritis at the thumb CMC joint or who has both conditions. Medical therapy: Splinting of the thumb and wrist relieves symptoms, but most patients find the loss of the thumb for functional activities too restrictive and do not consistently wear the splints. Injection of corticosteroid into the sheath of the first dorsal compartment reduces tendon thickening and inflammation. A dose of 0.5 mL of 1% plain Xylocaine and 0.5 mL of a long-acting corticosteroid preparation can be injected either sequentially or simultaneously. One injection permanently relieves symptoms in roughly 50% of patients. A second injection given at least a month later permanently relieves symptoms in another 40-45% of patients. Exercise caution to ensure that the injection is placed in the sheath rather than subcutaneously, where corticosteroids can lead to fat and dermal atrophy. Atrophy causes a hollowing out of the skin and loss of normal pigmentation. Although these atrophic changes generally resolve over 6 months, their presence is disturbing to most patients. Surgical therapy: If injection therapy fails, surgical release of the first dorsal compartment relieves the entrapment. Preoperative details: Surgical release of de Quervain tenosynovitis is an outpatient procedure. The procedure can be performed under local or regional anesthesia, depending on surgeon preference. Use of a tourniquet precludes intraoperative bleeding and facilitates identification of structures. Intraoperative details: A 3-cm incision is placed over the prominent thickening of the first dorsal compartment. A transverse skin incision is preferred because it provides better appearance of the scar in this highly visible area. Once the skin is incised, only longitudinal blunt dissection is used until the first dorsal compartment is exposed. This minimizes risk of sharp injury to the superficial radial nerve, which runs superficial to the first dorsal compartment. Along its dorsal margin, the first dorsal compartment is sharply opened longitudinally for approximately 2 cm. The tendon(s) are inspected to ensure that both the abductor pollicis longus and the extensor pollicis brevis are released. If present, a septum separating the 2 motor units can be deceiving. Gently moving the patient's thumb distinguishes one tendon from the other. If a tendon glides with metacarpophalangeal (MCP) joint motion, it is the extensor pollicis brevis. If a septum between the abductor pollicis longus and the extensor pollicis brevis is identified, it also is released. Surgeons have personal preferences regarding management of the sheath. Some excise a portion, and others make a step-cut and then suture a strip of sheath back loosely over the exposed tendons. The author has good results without sheath excision or reconstruction by releasing just the thickened portion of the first dorsal compartment and leaving in place the transparent fascia overlying the tendons proximal and distal to the first dorsal compartment. The skin is sutured. Patients generally appreciate the diminished disfigurement from the placement of a subcuticular skin closure. A soft dry circumferential wrist dressing is placed for a week. Postoperative details: Early use of the hand for self-care and light activities is encouraged. The suture is removed approximately 10 days after surgery. Thereafter, patients rapidly may resume full activities. Some surgical site tenderness is expected for several months. complications: Although this is a simple tendon entrapment and the treatment is quick and straightforward, complications can be profound and permanent. Careful attention to surgical technique at the initial release is paramount to avoid complications. Superficial radial nerve injury is the most irksome complication. Sharp injury, traction injury, or adhesions in the scar can cause neuritis in this high-contact area and greatly limit hand and wrist function. This complication is best avoided through careful blunt dissection of the subcutaneous tissue and gentle traction. Persistent entrapment symptoms are possible if the tendon slips of the abductor pollicis longus are mistaken for the tendons of both the abductor pollicis longus and the extensor pollicis brevis. In this instance, the extensor pollicis brevis tendon may remain entrapped within the septated first dorsal compartment. Should repeat cortisone injections fail to relieve symptoms, careful surgical reexploration may allow release of a previously overlooked tendon. Subluxation of released tendons is possible. With wrist flexion and extension, the tendons of a widely released first dorsal compartment snap over the radial styloid. This complication is best avoided by carefully limiting the release to the thickest mid 2 cm of the first dorsal compartment or by reconstructing a loose roof to the released sheath. Reconstruction of the sheath with a slip of local tissue may relieve symptoms Relief is permanent following successful surgery. Some patients treated successfully with injections may have recurrent symptoms when they return to lifting infants aged 6-12 months. This author would suggest the following: "Relief is usually permanent." ======== since i hate injections very much .. i preferred the physiotherpy and i will see if the pain and welling resolve or not ..