The Hand PatientA Select ion of Gase Studies for Ouick Reference

Having had the pleasure to teach and train students for many years,and the privilege ofhaving patients referred tome by ex-student General Practitioners, one realizes that medical school training can only impart but a generaloverview of knowledge. lt is impossible and unfair to expect of any medical student to "know it all".

For this reason continuing medical education, or Continuing Professional Development (CPD) as it is now knownin South Africa, is imperative.

This post-graduate training should however, be presented in such a way that the busy practitioner readily hasaccess to the relevant information in a succinct form and in an understandable jargon.

Communication between the referring doctor and the specialist should not only include information regardingthat particular patient, but should also contain some informative detail on the pathology and management.

This continuing education is part of the responsibilities of a consultant specialist.

It is sincerely hoped that this edited collection of selected case reports will promote a well-informed communicationbetween the practitioner and his/her "hand patient".

Mennen, U.MBChB, FRCS (Glasg), FRCS (Edin), FCS (SA) Orth., MMed (Orth), MD (Ort) Pret

Head: Department Hand- and Microsurgery, MEDUNSA

De Ouervain Stenosing Tenosynovit is

Dear Colleague

RE:YOUR PATIENT WITH PAIN lNTHETHUMBAND HARD NODULEONTHE RADIAL SIDE OFTHEWRIST

Thank you for the referral of Ms D Q,24 year old right handed data processorwho has been complaining of a painfulright thumb, inabil ity to extend thethumb and a hard nodule on the radialside of her right wrist for the last 6m o n t h s . T h i s c o n d i t i o n s t a r t e dspon taneous l y w i t h no h i s to ry o fin jury or overuse. l t impinges on herwork when she uses the keyboardand has d i f f i cu l t y i n l i f t i ng heavyobjects such as f i les. Things tend tofa l l out of her hand.

On examinat ion Ms Q shows noneurovascular abnormalit ies in bothhands. On local inspection, she has adefinite tender hard swelling of about

+ cm by * cm on the radial styloid. Withpercussion she has local tenderness aswel l as p ins and needles in the radia lnerve distribution over the thumb andthe first web space. This is the type ofpain which she experiences during herdai ly act iv i t ies. The pain is fur therenhanced bygently pressing on the hardnodule and requesting the patient toflex and extend her thumb. One couldc lear ly feel crepi tus of the tendonswhich run through the l itt le nodule, i.e.the abductor pol l ic is longus and theextensor pollicis brevis. One could alsofeel the unevenness ofthe tendon as itmoves i n and ou t o f t he t unne l .Clutching the thumb in the palm by theother fingers and gently forcing thewrist in ulnar deviation causes acutepain. (Finkelstein test).

S ince the d iagnos i s i s qu i t e c l ea rs p e c i a l i n v e s t i g a t i o n s a r e n o tnecessary.

The d iagnosis is a De Quervain 'ss tenos ing tenosynov i t i s o f t hea b d u c t o r p o l l i c i s l o n g u s a n d t h eextensor poll icis brevis tendons.

T h e m a n a g e m e n t s h o u l d b econservative init ially. Since Ms Q hasa clear synovitis in the tunnel, a localinjection with a steroid preparationsuch as Celestone/Soluspan and a longacting local anaesthetic such as Macainin jec ted i n to t he tunne l w i t hou tinfi ltration of the tendons,would oftenclear the problem. One should alsosupport the thumb with a firm crepebandage for about a week. Additionalnon-steroidal anti-infl ammatory drugsfor 5 to 7 days may augment theconservative management. Should thein ject ion be unsuccessfu l , one maycons ide r a second i n j ec t i on . Th i sshould however, be done very carefullylest the cortisone is injected into thetendon.This may cause a future rup-

ture of the tendon. lf conservativemanagement is not successful a surgicalre lease is ind icated. A 2cm obl iqueincision is made carefully through theskin only , tak ing great care not todamage the delicate superficial branchesofthe radial nerve. Should one ofthesebranches be injured, neuroma formationi s i n e v i t a b l e w i t h v e r y p a i n f u lconsequences. These branches arecarefully pushed aside unti l the noduleand the APL and EPB tendons a reidentif ied. The nodule is excised andthe tunnel released. Invariably one findsmany more than the two tendons.These tendons may often run in at leasttwo tunnels. The var iat ion shouldcarefully be explored and noted. Theskin is carefully closed again,taking greatcare not to involve the superficial radialnerve branches. A volar splint is applied

supporting the thumb in abduction forfive days only. The patient is encouragedto use the thumb after removal of thespl in t . A scar massage is s t ronglyadvised to prevent adhesions.

DISCUSSION:

De Quervain stenosing tenosynovitisusual ly occurs in the young female.However, one f inds i t as an acuteoccurring condition in people who arenot accustomed to a DIY job, such ast i l i n g t h e k i t c h e n f l o o r o v e r t h eweekend. The over extended andoverused thumb presents with acutet e n o - s y n o v i t i s w i t h o u t t h echaracteristic nodule at the entranceof the tunnel. These patients usuallyr e s p o n d v e r y w e l l t o c o r t i s o n e

injections with or without additionalnon-steroidal anti-infl ammatory drugsand spl in t ing for a few days. Oneoccas iona l l y sees a young nu rs ingmother with the same condition. Thisc lass ical ly descr ibed a cause for De

Querva in ' s d i sease i s due to t heabducted position of the thumb whilethe mother supports the head of thenu rs ing baby . Aga in conse rva t i vemanagement should usually suffice inthe situation. The deferential diagnosisshould exclude scaphoid pathology,scapho-radial osteo-arthritis, scaphoid-t rapezium-trapezoid (STT) osteo-arthrosis, osteo-arthrosis of the firstcarpo-metacarpal jo ints , and evenscapho-lunate and lunate pathology.Should these conditions be susDected,plain radiographs of both hands shouldreveal the diagnosis.

De Quervain Stenosing Tenosynovitis

The tender and hard nodule on the radial side of the radius styloid process is usually indicative of a cartilaginoustunnel entrance. Surgical excision as well as a synovectomy of the tendons is indicated. Always explore formore than one tunnel.