The area of the wrist closer to the thumb is called the radial side of the wrist. Pain in this area is termed "radial-sided wrist pain". This is in contrast to the opposite side of the wrist (nearer the little finger side) called the ulnar side of the wrist. Pain in this area is called ulnar-sided wrist pain.
The common causes of radial-sided wrist pain include:
- Osteoarthritis of the 1st carpometacarpal joint (thumb basal joint osteoarthritis)
- Fractures or fracture non-union of the scaphoid bone
- Radial styloiditis or DeQuervain's tendovaginitis
- Intersection syndrome (synovitis of the tendons due to repetitive friction between the tendons of the 1st and 2nd dorsal compartments of the wrist
The most common of the above in a young person is DeQuervain's tendovaginitis. In fact, this is also extremely common in new mothers who are nursing an infant. In these cases, this condition is commonly known as "mummy's wrist".
DeQuervain's tendovaginitis is a condition where the thin synovium (covering) of the tendons at the radial side of the wrist (the abductor pollicis longus and extensor pollicis brevis tendons) become swollen and painful. These tendons run within a fitting tunnel called the 1st extensor compartment.
As these tendons become swollen and enlarged, they start causing additional friction against the walls and the edge of this tunnel. This starts a vicious cycle - the now enlarged tendon girth rubs against the tight tunnel walls and this further encourages more swelling and inflammation due to the friction and irritation of the tendon synovium.
This is why the pain always seems to worsen rather than improve with more movement and motion when one tries to "stretch" or "mobilise" the wrist to "loosen the tightness".Treatment Options for Dequervain's Tendovaginitis
Splint and NSAIDS
The first line of treatment is actually the opposite of this. Immobilisation and rest is the initial treatment for early DeQuervain's tendovaginitis. The aim of this is to:
- break the cycle of repetitive friction and
- inflammation by resting the tendon.
This allows the body to heal the inflammation naturally. A long thumb spica splint (not a common wrist brace) is the correct implementation to help with thumb and radial wrist immobilisation. A custom-moulded thumb spica splint can be obtained from a trained hand occupational therapist at a hand & wrist surgeon's clinic. Furthermore, oral non-steroidal anti-inflammatory drugs (NSAIDs) are prescribed to accelerate the resolution of inflammation and pain.
Corticosteroid Injections
The second line of treatment is corticosteroid injections, also known as H&L (Hydrocortisone & Lignocaine) injections. This injection contains a mixture of a corticosteroid (a very potent anti-inflammatory agent) and xylocaine or lignocaine (a local anaesthetic agent).
A hand & wrist surgeon will be the best person to administer this injection as accurate delivery of the medication mixture into the 1st extensor compartment (containing the inflamed tendons) is key to the success of this procedure. The proper administration of this injection will also reduce the likelihood of adverse effects of such an injection such as:
- infection,
- skin hypopigmentation,
- skin and fat atrophy.
In about 50% of patients who receive this injection, the condition is resolved and does not recur. In the other 50%, however, the condition recurs and repeat treatment is required. The recommendation is no more than 2 injections given to a specific site. If the condition recurs again after 2 injections, surgical intervention is indicated.
Surgery
Surgery for DeQuervain's tendovaginitis involves:
- releasing the 1st extensor compartment,
- removing all the inflammatory tissue and inflamed synovium surrounding the affected tendons and
- reconstruction of the extensor retinaculum by repairing the incised retinaculum with a Z-plasty closure.
This last procedure prevents subluxation, or clicking, of the tendons after release. This operation can be done under local anaesthesia or moderate sedation and is performed as a Day Surgery procedure. Post-operative discomfort usually lasts for about 1 week, after which the surgical wound, which is also usually sutured with absorbable and subcuticular sutures, would have completely healed.
Simple tasks such as typing and texting on the mobile phone can be commenced on the first day after surgery. All discomfort will resolve within a month. This condition rarely recurs after surgery.
In my professional experience, patients do very well with the above 3 options. One can consider seeking effective treatment from a hand & wrist specialist.
