What is DeQuervain's tenosynovitis?

De Quervain's Tenosynovitis: Clinical Features and Management

De Quervain's tenosynovitis is a stenosing tenosynovitis of the first dorsal compartment of the wrist, characterized by pain and tenderness over the radial side of the wrist due to thickening of the tendon sheath surrounding the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons. 1, 2

Anatomy and Pathophysiology

• Affects the first extensor compartment of the wrist containing:
  • Abductor pollicis longus (APL) tendon
  • Extensor pollicis brevis (EPB) tendon
• Pathology involves non-inflammatory thickening of the tendinous sheath leading to:
  • Entrapment of the tendons
  • Increased friction during tendon movement
  • Pain with thumb and wrist movements 1

Epidemiology

• More common in women, particularly those aged 30-50 years
• Frequently seen in women 4-6 weeks postpartum
• Associated with repetitive hand and wrist movements 1
• Can be related to occupational activities requiring repetitive thumb movements 3

Clinical Presentation

Patients typically present with:

• Pain on the radial (thumb) side of the wrist
• Tenderness over the first dorsal compartment
• Pain exacerbated by thumb and wrist movements
• Possible swelling over the affected area
• Impaired thumb function 3

Diagnostic Approach

Physical Examination

• Finkelstein test: The most specific test where the thumb is folded across the palm and the wrist is ulnarly deviated, reproducing pain
• Direct palpation over the first dorsal compartment elicits tenderness
• Possible crepitus with thumb movement 2, 3

Imaging

• Radiographs are primarily used to rule out other bony pathologies
• Ultrasound can identify:
  • Thickened tendon sheath
  • Presence of anatomical variations such as accessory APL tendons or subcompartmentalization
  • Tenosynovial fluid 4, 5
• MRI may show tenosynovitis but is rarely necessary for diagnosis 6

Management

Conservative Treatment

1. Activity modification to reduce movements that exacerbate pain

   • Avoid repetitive thumb movements and pinching activities
   • Relative rest of the affected wrist and thumb

2. Immobilization

   • Thumb spica splinting to restrict movement of the first metacarpal and thumb
   • Typically worn for 4-6 weeks

3. Medications

   • NSAIDs as first-line medication for pain and inflammation
   • Acetaminophen if NSAIDs are contraindicated

4. Corticosteroid Injection

   • Highly effective for pain relief
   • Limited to 2-3 injections with 4-6 weeks between injections
   • Success rates of 60-95% reported 4, 7

Surgical Management

Indicated when conservative measures fail after 3-6 months:

• Surgical release of the first dorsal compartment
• Important to identify and release any accessory compartments
• Care must be taken to protect the radial sensory nerve
• Recovery period typically 3-6 months 4, 7

Special Considerations

Anatomical Variations

• Presence of a septum or subcompartmentalization within the first dorsal compartment can affect treatment success
• Accessory APL tendons are common (found in up to 70% of cases) and may complicate management 4, 5

Associated Conditions

• May coexist with Wartenberg's syndrome (compression of the superficial radial nerve), causing tingling and dysesthesia 5

Prognosis

• Over 90% of cases respond well to appropriate conservative management
• Even with optimal treatment, resolution typically requires 3-6 months
• Surgical intervention has high success rates for refractory cases 4

Common Pitfalls

1. Failure to identify anatomical variations like accessory tendons or subcompartmentalization
2. Inadequate duration of conservative treatment before considering surgery
3. Overlooking associated conditions like Wartenberg's syndrome
4. Improper technique during corticosteroid injection
5. Inadequate protection of the radial sensory nerve during surgical release

De Quervain's tenosynovitis is generally a self-limiting condition with appropriate management, though treatment is often required for symptom relief and to prevent chronic disability.