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

Treatment for De Quervain's Tenosynovitis

De Quervain's tenosynovitis should be treated with a multimodal conservative approach first, including splinting, NSAIDs, and corticosteroid injections, with surgery reserved for cases that fail to respond to conservative management. 1, 2

Diagnosis

• Pain on the radial side of the wrist due to inflammation of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons in the first dorsal compartment
• Positive Finkelstein test: pain provoked with wrist ulnar deviation 3
• Radiographs may be helpful to rule out bony pathology 4

Treatment Algorithm

First-Line Treatment (Conservative Management)

1. Rest and Activity Modification

   • Avoid repetitive wrist and thumb movements that exacerbate symptoms 1

2. Thumb Spica Splinting

   • Immobilizes the thumb and wrist to reduce tendon irritation
   • Should be worn consistently for 4-6 weeks 4, 5

3. Medications

   • NSAIDs are recommended as first-line treatment for pain and inflammation 6
   • Ibuprofen 1.2g daily (can be increased to 2.4g daily if needed)
   • Can be combined with acetaminophen (up to 4g daily) for inadequate relief 6

4. Corticosteroid Injection

   • Mainstay of treatment with high success rates 2
   • Ultrasound guidance may improve accuracy and help identify separate subcompartments 2
   • Safe during third trimester of pregnancy and breastfeeding 2
   • Limited to 2-3 injections with 4-6 weeks between injections 6

Physical Therapy Interventions

• Manual therapy techniques
• Therapeutic exercises focusing on:
  • Gentle stretching
  • Progressive strengthening
  • Proprioception training 5
• Modalities such as ice, heat, or ultrasound may provide symptomatic relief 5

Alternative Treatments

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

Second-Line Treatment (Surgical Management)

Indicated when conservative measures fail after 2-3 months of appropriate treatment:

1. Surgical Release of First Dorsal Compartment

   • Open release through a longitudinal incision provides better visualization of anatomy
   • Lower incidence of hypertrophic scarring compared to transverse incision 2
   • Endoscopic release may result in:
     • Quicker symptom improvement
     • Superior scar cosmesis
     • Lower incidence of radial sensory nerve injury 2
   • WALANT (wide-awake local anesthesia no tourniquet) technique is safe and effective 2

2. Post-Surgical Rehabilitation

   • Splinting
   • Edema management
   • Scar management
   • Therapeutic exercise
   • Desensitization techniques 5

Important Considerations

• Early recognition and treatment leads to better outcomes, especially in the acute phase 1
• When performing surgical release, care must be taken to protect the radial sensory nerve and identify all accessory compartments 4
• Most patients respond well to conservative treatment, making surgery unnecessary in many cases 1
• Return to activity should be gradual and based on resolution of pain, restoration of range of motion, and functional improvement 6

Common Pitfalls to Avoid

• Failing to identify and treat separate subcompartments during injection or surgery
• Not providing adequate duration of splinting (minimum 4-6 weeks)
• Overlooking the radial sensory nerve during surgical intervention
• Performing more than 2-3 corticosteroid injections, which may lead to tendon deterioration 6
• Neglecting post-treatment rehabilitation, which is essential for optimal recovery