How to treat mommy's wrist (De Quervain's tenosynovitis)?

Treatment of De Quervain's Tenosynovitis (Mommy's Wrist)

Ultrasound-guided corticosteroid injection into the first dorsal compartment is the most effective first-line treatment for De Quervain's tenosynovitis, with surgical release reserved for cases that fail conservative management. 1, 2

Diagnosis

• Pain and tenderness over the radial side of the wrist at the first extensor compartment (containing abductor pollicis longus and extensor pollicis brevis tendons)
• Positive Finkelstein test (pain with ulnar deviation of the wrist while the thumb is flexed across the palm)
• Ultrasound can identify septation or subcompartmentalization within the first dorsal compartment, which may affect treatment decisions 1

Treatment Algorithm

First-Line Treatment

1. Conservative Management (Multimodal Approach)

   • Thumb spica splinting to immobilize the wrist and thumb
   • NSAIDs at the lowest effective dose for the shortest duration 3
   • Activity modification to avoid repetitive thumb and wrist movements
   • Ice application for pain control 3

2. Corticosteroid Injection

   • Most effective non-surgical intervention 2
   • Ultrasound guidance improves accuracy and helps identify separate subcompartments 2
   • Safe during third trimester of pregnancy and while breastfeeding 2
   • May require repeat injection if symptoms persist

Second-Line Treatment (for persistent symptoms)

Surgical Release of First Dorsal Compartment

• Indicated when:
  • Conservative treatment fails after 2-3 months
  • Symptoms are severe or recurrent
  • Tendon tears >50% of thickness 3
• Surgical options:
  • Open release through longitudinal incision (better visualization, fewer complications) 2
  • Endoscopic release (quicker recovery, better cosmesis, lower risk of radial sensory nerve injury) 2
  • Can be performed using WALANT technique (wide-awake local anesthesia no tourniquet) 2

Special Considerations

• Pregnant/Postpartum Women: Condition is more common 4-6 weeks postpartum 4
• Diabetic Patients: May respond less to conservative measures 3
• Anatomical Variations: Presence of septum or subcompartmentalization (identified by ultrasound) may affect treatment success 1

Post-Treatment Rehabilitation

• Gentle passive and active-assisted range of motion exercises 3
• Progressive strengthening exercises, particularly eccentric strengthening 3
• Activity-specific exercises for return to normal function 3
• Post-surgical rehabilitation should include edema management, scar management, and desensitization 5

Treatment Efficacy

• Most cases can be successfully managed with conservative treatment 6
• Corticosteroid injection success rates are high, especially when ultrasound-guided 2
• Surgical release provides excellent symptom relief when conservative measures fail 2

Pitfalls to Avoid

• Failing to identify and inject separate subcompartments when present
• Using transverse incision for surgical release (higher risk of hypertrophic scarring) 2
• Injuring the radial sensory nerve during surgical release
• Delaying treatment, which may lead to chronic symptoms and tendon damage
• Returning to aggravating activities too soon after symptom improvement

Early recognition and appropriate treatment of De Quervain's tenosynovitis is crucial for optimal outcomes and preventing progression to chronic symptoms.