What is the treatment for Dequervain's (De Quervain's tenosynovitis)?

Treatment for De Quervain's Tenosynovitis

The treatment of De Quervain's tenosynovitis should begin with conservative management including rest, NSAIDs, splinting, and if needed, corticosteroid injections, with surgery reserved for cases that fail to respond after 3-6 months of well-managed conservative treatment. 1, 2

Initial Conservative Management

First-Line Approaches

1. Relative Rest and Activity Modification

   • Reduce activities that exacerbate wrist pain
   • Avoid repetitive thumb and wrist movements that stress the affected tendons 1

2. Thumb Spica Splinting

   • Immobilizes the thumb and wrist to reduce tendon irritation
   • Should be worn during activities that aggravate symptoms 2, 3

3. Pharmacological Management

   • NSAIDs: First-line medication for pain and inflammation 1
     • Both oral and topical NSAIDs are effective for pain relief
     • Topical NSAIDs eliminate the risk of gastrointestinal complications 1
   • Acetaminophen: Alternative if NSAIDs are contraindicated

Second-Line Approaches

1. Corticosteroid Injections

   • Highly effective treatment with approximately 90% success rate 4
   • 58% of patients respond to a single injection, while 33% require multiple injections 4
   • Technique:
     • Injection directed to the site of inflammation
     • Limited to 2-3 injections with 4-6 weeks between injections 1
     • Ultrasound guidance may improve accuracy, especially when separate subcompartments exist 5
   • Safe during third trimester of pregnancy and breastfeeding 5
   • Caution: Corticosteroids may inhibit healing and reduce tendon tensile strength if injected into the tendon substance 1

2. Physical Therapy

   • Eccentric strengthening exercises
   • Deep transverse friction massage to reduce pain 1
   • Stretching exercises are generally beneficial 1

3. Cryotherapy (Ice)

   • Effective for short-term pain relief
   • Apply ice through a wet towel for 10-minute periods 1

4. Neural Therapy

   • Local anesthetic injections have shown effectiveness in reducing pain and improving hand function 3

Advanced Treatment Options

For Persistent Cases (after 3-6 months of conservative treatment)

1. Extracorporeal Shock Wave Therapy (ESWT)

   • Safe and potentially effective option before considering surgery 1
   • Promotes tendon healing through acoustic shock waves 1

2. Surgical Management

   • Indicated when conservative measures fail after 3-6 months 1, 6
   • Surgical options:
     • Open Release: Performed through a longitudinal incision for better visualization of anatomy 5
     • Endoscopic Release: May result in quicker symptom improvement, better cosmesis, and lower incidence of radial sensory nerve injury 5
     • WALANT technique (Wide-Awake Local Anesthesia No Tourniquet) can be safely used 5
   • Key surgical considerations:
     • Protection of the radial sensory nerve
     • Identification of all accessory compartments 6
     • Post-surgical recovery period of 3-6 months 1

Prognosis and Follow-up

• Over 90% of cases respond well to appropriate conservative management 2
• Even with optimal management, resolution typically requires 3-6 months 1
• Pain and function should be reassessed every 4-6 weeks
• Treatment plan should be adjusted if no improvement after 8-12 weeks of consistent therapy

Common Pitfalls and Caveats

1. Diagnostic Accuracy: Ensure proper diagnosis with Finkelstein test (pain with wrist ulnar deviation) 3
2. Injection Technique: Avoid intratendinous injections which may weaken the tendon 1
3. Anatomical Variations: Be aware of possible separate subcompartments that may require specific targeting during injection or surgery 5
4. Surgical Complications: Risk of radial sensory nerve injury during surgical release 5, 6
5. Patient Expectations: Inform patients that even with optimal treatment, resolution typically takes 3-6 months 1