What is the treatment for De Quervain's Tenosynovitis?

Treatment for De Quervain's Tenosynovitis

The most effective treatment for De Quervain's tenosynovitis is a multimodal conservative approach, with corticosteroid injections being the mainstay of treatment, providing excellent symptom relief in up to 98.75% of patients within 12 weeks. 1, 2

Conservative Management

First-line Treatment Options:

• Rest and Activity Modification

  • Avoid repetitive wrist and thumb movements that exacerbate symptoms
  • Use of thumb spica splinting to immobilize the affected area 3

• Medications

  • NSAIDs are strongly recommended as first-line treatment for tendon pain 4
  • Ibuprofen at 1.2g daily (safest option), which can be increased to 2.4g daily if needed
  • Can be combined with paracetamol (up to 4g daily) for inadequate relief

• Corticosteroid Injections

  • Most effective conservative treatment option 2
  • Typically a mixture of methylprednisolone acetate (40mg) and 2% lignocaine hydrochloride 1
  • Success rates:
    • 65% symptom-free after first injection at two weeks
    • 80% symptom-free at four weeks
    • 95% symptom-free at six weeks
    • 98.75% symptom-free at 12 weeks 1
  • Limited to 2-3 injections with 4-6 weeks between injections 4
  • Ultrasound guidance may improve accuracy and help identify separate subcompartments 2
  • Safe during third trimester of pregnancy and breastfeeding 2

Physical/Occupational Therapy:

• Splinting with thumb spica splint 5, 3
• Manual therapy techniques 4
• Progressive strengthening exercises following a phased approach:

  Phase	Focus	Duration
  Initial	Pain control and protected range of motion	0-4 weeks
  Intermediate	Progressive strengthening exercises	4-8 weeks
  Advanced	Occupation-specific training	8-12 weeks

• Neural therapy has shown effectiveness in reducing pain and improving hand function 3

Surgical Management

Surgical intervention should be considered when:

• Conservative treatment fails after 3-6 months 4, 5
• Symptoms persist despite appropriate conservative management 2

Surgical Options:

• Open Release of First Dorsal Compartment

  • Preferred approach using longitudinal incision for better visualization
  • Lower incidence of hypertrophic scarring compared to transverse incision 2

• Endoscopic Release

  • Quicker symptom improvement
  • Superior scar cosmesis
  • Lower incidence of radial sensory nerve injury
  • Appropriate for surgeons comfortable with endoscopic techniques 2

• WALANT Technique

  • Wide-awake local anesthesia with no tourniquet
  • Cost-effective without compromising quality or patient comfort 2

Treatment Algorithm

1. Initial Presentation:

   • Start with NSAIDs and thumb spica splinting
   • Advise activity modification and rest

2. After 2-4 weeks if symptoms persist:

   • Administer first corticosteroid injection
   • Continue splinting and activity modification

3. At 4-6 weeks if symptoms persist:

   • Consider second corticosteroid injection
   • Initiate physical/occupational therapy with progressive strengthening

4. At 8-12 weeks if symptoms persist:

   • Consider third corticosteroid injection (if not already administered)
   • Evaluate response to conservative treatment

5. At 3-6 months if symptoms persist:

   • Consider surgical consultation for release of first dorsal compartment

Common Pitfalls and Caveats

• Failure to identify and inject separate subcompartments can lead to treatment failure
• Adverse reactions to corticosteroid injections occur in approximately 25% of patients but typically subside within 20 weeks 1
• Early recognition is crucial as De Quervain's tenosynovitis is highly treatable, especially in the acute phase 6
• Ensure proper diagnosis using the Finkelstein test (pain provoked with wrist ulnar deviation) to differentiate from other wrist pathologies 3
• Surgical release should be considered only after adequate trial of conservative measures