De Quervain's tenosynovitis, ultrasound-assisted treatment

Definition of de Quervain's tenosynovitis  :

De Quervain's tenosynivitis, whose medical name is stenosing tenosynivitis of extensors at the wrist's first compartment is one of the most frequent tendinous pathologies in hand surgery along with trigger fingers. De Quervain's tenosynovitis corresponds to a conflict between the tendons of the extensors' first compartment and the extensor retinaculumThe retinaculum constitutes a pulley in which two tendons pass in the first compartment : the abductor longus and the extensor brevis of the thumb.

Friction results in inflammation of the synovial sheath around the tendon and significant thickening of the retinaculum at this location. This thickening of the synovial sheath is called synovitis (stenosing) and it causes both pain in the thumb and loss of fluidity in flexion-extension of the thumb. A membrane called septum is often found between the abductor longus and extensor brevis tendons of the thumb, and can also contribute to inflammation.

Video of ultrasound-assisted release surgery for de Quervain’s syndrome  :

Video of ultrasound-assisted hand surgery showing an ultrasound-guided release operation for a de Quervain tenosynovitis / Toulouse specialist

 

Diagnosis of de Quervain's tenosynovitis  :

 De Quervain's tenosynovitis is a form of tendonitis of the thumb's extensors with pain centered around the radial styloid favoured by repetitive mechanical activities and/or movements with a constrained tilt.

De Quervain's tenosynovitis is more frequent in people with diabetes. De Quervain's tenosynovitis corresponds to acute pain above the base of the thumb, which is reproduced when palpating the radial styloid process. Flexing the thumb whilst ulnar deviating the wrist triggers the pain: the Finkelstein test is said to be positive.

Further examination is rarely necessary to establish the diagnosis. However an ultrasound of the wrist and thumb base which the hand surgeon can perform at his office will confirm any thickening of the first compartment's retinaculum, or even of the synovial membrane, intratendinous oedema (hypoechogenic area) possibly associated with localized hypervascularization.

Surface anatomic marking for ultrasound-assisted de Quervain surgeryUltrasound-assisted surgery for de Quervain

 

Ultrasound-assisted surgery for de Quervain: Release surgery for de Quervain’s syndrome under ultrasound monitoring nbsp;:

In the absence of diabetes and if the de Quervain's tenosynovitis has been evolving for less than 3 months, the first-line treatment is a nocturnal splint associated with a slow-release corticosteroid injection in the digital sheath, which in many cases cures this tenosynovitis of the wrist.

When the injection, ideally performed under ultrasound monitoring (to target each tendon) is not sufficient, a simple operation on the wrist can be performed. The release technique for de Quervain's tenosynovitis that I am discussing here is an ultrasound-assisted surgical procedure. This ultrasound-assisted release technique makes it possible to operate a de Quervain's tenosynovitis through a single 2-mm incision at the radial styloid process, at the base of the thumb.

This ultrasound-assisted procedure is performed with the base of the thumb under local anaesthesia, in approximately 7-8 minutes. The thumb can move and be used immediately after the hand surgery, the initial dressing can be removed after 2 days. The pain will take some weeks to subside after the procedure.

The patient is placed in the dorsal decubitus, the first stage of the hand surgery consists in positioning the ultrasound probe over the radial styloid process and then locate the proximal and distal limit of the first compartment. Ultrasound diagnosis thus becomes systematic before this finger tendonitis surgery allowing possible – rare – differential diagnoses to be made: a synovial cyst, a giant cell tumor, or fluid in the radiocarpal joint that contributes to tendon impingement.

A surgical incision is then carried out using an 18G (1-mm) needle at the anatomical snuffbox. The second stage of the surgical procedure consists in introducing a 1.8-mm blade specifically designed for this ultrasound-assisted de Quervain tenosynovitis release procedure.

ultrasound-assisted evaluation before sectioning the retinaculumUltrasound-assisted de Quervain surgery, In-plane section

Ultrasound-assisted de Quervain surgery, In-plane section the blade and the sectioning of the pulley will be under constant sonographic monitoring. Indeed, for this ultrasound-assisted procedure, a continuous In-Plane instrumental approach is used, with the blunt tip of the blade inserted under the retinaculum and the sectioning carried out from distal to proximal down to the proximal edge of the first extensor compartment. In addition to the sonographic feedback, a distinctive squeaking noise can be heard when the extensor retinaculum is sectioned.

Once the retinaculum is sectioned, an ultrasound guided injection is performed proximally so as to limit inflammation induced by healing.

Recovery after ultrasound-assisted de Quervain surgery

A dressing is applied to the wrist and will be kept for 2 days. The hand can be used immediately after surgery for all daily gestures, including driving.

The dressing on the wrist will be removed after 2 days and the patient can use his/her thumb normally for all gentle activities, including self-care. A few weeks will be needed for full range of motion to be restored. For several months, constrained and end-of-ROM movements will cause pain in the thumb. The hand is restored to its full strength 3 to 4 months after surgery.

Scar at 1 month post ultrasound-assisted de Quervain surgery, Toulouse

 

In some cases, this ultrasound-assisted de Quervain surgery can be associated with carpal tunnel surgery .

Find out more about complications after ultrasound-assisted surgery on De Quervain's tenosynovitis