What is the step-wise management of De Quervain's (De Quervain's tenosynovitis) tenosynovitis?

Step-wise Management of De Quervain's Tenosynovitis

The management of De Quervain's tenosynovitis should follow a step-wise approach, beginning with conservative measures and progressing to more invasive interventions only when necessary, with corticosteroid injection being the mainstay of treatment for most cases. 1

Initial Assessment

• Look for 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
• Perform Finkelstein test (pain with ulnar deviation of the wrist with the thumb flexed across the palm)
• Consider radiographs to rule out bony pathology 2

Step 1: Conservative Management

1. Activity Modification and Rest

   • Avoid repetitive movements that exacerbate symptoms
   • Recommend protective padding for athletes or workers with repetitive wrist movements

2. Immobilization

   • Thumb spica splinting to restrict thumb and wrist movement
   • Typically worn for 2-4 weeks

3. NSAIDs

   • First-line medication for pain and inflammation
   • Ibuprofen 1.2-2.4g daily or other NSAIDs as tolerated 3
   • Can be combined with acetaminophen (up to 4g daily) if inadequate relief

Step 2: Intermediate Interventions

1. Corticosteroid Injection

   • Mainstay of treatment with high success rate 1
   • Consider ultrasound guidance to improve accuracy, especially with anatomical variations
   • Limit to 2-3 injections with 4-6 weeks between injections 3
   • Safe during third trimester of pregnancy and while breastfeeding 1

2. Physical Therapy

   • Progressive strengthening exercises
   • Stretching of the affected tendons
   • Follow a phased rehabilitation approach:
     • Initial (0-4 weeks): Pain control and protected range of motion
     • Intermediate (4-8 weeks): Progressive strengthening
     • Advanced (8-12 weeks): Occupation-specific training 3

Step 3: Advanced Interventions

1. Surgical Release

   • Indicated when conservative treatment fails after 3-6 months 1
   • Open surgical techniques:
     • Longitudinal incision preferred for better visualization and lower risk of hypertrophic scarring
     • Complete release of the first dorsal compartment
     • Careful identification and protection of the superficial branch of the radial nerve
     • Identification of any accessory compartments 4, 2

2. Alternative Surgical Approaches

   • Endoscopic release may provide quicker symptom improvement and better cosmesis 1
   • WALANT (wide-awake local anesthesia no tourniquet) technique is safe and cost-effective 1

Follow-up and Monitoring

• Evaluate response to treatment at 2,6, and 12 weeks
• Assess for complete resolution of pain, full range of motion, and strength recovery
• Return to full activity when:
  • Pain-free during and after activity
  • Full range of motion compared to uninjured side
  • Strength symmetry >90% compared to uninjured side 3

Important Considerations

• Early recognition and treatment leads to better outcomes 5
• Multiple anatomical variations exist in the first dorsal compartment, including separate subcompartments for APL and EPB tendons
• Surgical complications may include injury to the superficial branch of the radial nerve, incomplete release, and hypertrophic scarring 4
• Most cases can be successfully managed without surgery 5, 1