What is the treatment for Dequervain's tenosynovitis?

Treatment of De Quervain's Tenosynovitis

The treatment for De Quervain's tenosynovitis should follow a stepwise approach, beginning with conservative measures including rest, ice application, NSAIDs, and splinting, progressing to corticosteroid injections if initial measures fail, and ultimately surgical release for refractory cases. 1

Initial Conservative Management

1. Rest and Activity Modification

   • Reduce activities that cause pain and overload the affected tendon
   • Avoid painful movements, particularly those involving thumb and wrist
   • Evaluate pain and function every 2-4 weeks

2. Physical Modalities

   • Apply ice through a wet towel for 10-minute periods 1
   • Use orthotic devices (thumb spica splint) to immobilize and protect the first dorsal compartment

3. Medications

   • NSAIDs for pain relief and potential anti-inflammatory benefits
   • Topical NSAIDs may be used to avoid gastrointestinal side effects 1

Secondary Interventions

1. Corticosteroid Injections

   • Highly effective first-line treatment for persistent symptoms
   • Approximately 90% of patients can be effectively managed with either a single injection (58%) or multiple injections (33%) 2
   • Methylprednisolone acetate has been shown to rapidly control signs and symptoms with minimal adverse reactions 2
   • Injection should be peritendinous (around the tendon) rather than into the tendon substance to avoid potential tendon weakening 1

2. Physical/Occupational Therapy

   • Stretching and exercises to improve range of motion
   • Gradual strengthening exercises
   • Manual therapy techniques including carpometacarpal manipulation may be beneficial 3
   • Grip proprioception training

Surgical Management

1. Indications for Surgery

   • Failure of conservative treatment (typically after 3-6 months)
   • Persistent pain despite appropriate injections and splinting
   • Patients requiring quick recovery

2. Surgical Procedure

   • Release of the first dorsal compartment tendons (abductor pollicis longus and extensor pollicis brevis) 4
   • Usually performed under local anesthesia
   • Care must be taken to protect the radial sensory nerve and identify all accessory compartments 5
   • Excellent results with 96% of patients experiencing complete symptom relief 4

Special Considerations

• Rheumatoid Arthritis Patients

  • May require early tenosynovectomy instead of sole release of the compartment 6
  • May benefit from early surgical intervention to prevent tendon rupture

• Diabetic Patients

  • Tend to respond less to conservative measures and may require a different treatment strategy 6

• Multiple Symptomatic Tendons

  • Should prompt evaluation for possible rheumatic disease 6

Common Pitfalls and Caveats

1. Injection Technique

   • Avoid injecting directly into the tendon, which can lead to tendon weakening or rupture
   • Ensure proper identification of the first dorsal compartment

2. Diagnostic Challenges

   • Ensure proper diagnosis through physical examination (positive Finkelstein test)
   • Consider radiographs to rule out bony pathology 5

3. Surgical Complications

   • Damage to the radial sensory nerve is a potential complication of surgical release
   • Failure to identify and release accessory compartments can lead to persistent symptoms

4. Post-Surgical Care

   • Appropriate splinting after surgery
   • Early mobilization to prevent stiffness
   • Scar management and desensitization techniques 7

The evidence strongly supports a progressive approach to treatment, with most patients responding to conservative measures or corticosteroid injections. Surgical intervention should be reserved for cases that fail to respond to these initial treatments but has excellent outcomes when indicated.