What is De Quervain's (De Quervain's tenosynovitis) tenosynovitis?

De Quervain's Tenosynovitis

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.

Pathophysiology and Clinical Features

De Quervain's tenosynovitis involves:

• Non-inflammatory thickening of the tendinous sheath in the first dorsal compartment of the wrist 1
• Entrapment of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons 2, 1
• Increased friction between tendons and their sheath, leading to pain and restricted movement 1

Key clinical features include:

• Insidious onset of load-related localized pain on the radial (thumb) side of the wrist 3
• Pain that worsens with thumb and wrist movements, especially with ulnar deviation of the wrist with thumb abduction and extension 4
• Well-localized tenderness over the first dorsal compartment 3
• Positive Finkelstein test (pain elicited when the thumb is flexed across the palm and the wrist is ulnarly deviated) 4
• Possible swelling or thickening over the affected area 3

Epidemiology

De Quervain's tenosynovitis is:

• More common in women, particularly between 30-50 years of age 1
• Often seen 4-6 weeks postpartum 1
• Associated with repetitive wrist and thumb movements 4
• Can be work-related, especially with occupations requiring repetitive hand use 5

Diagnosis

Diagnosis is primarily clinical, based on:

1. Radial-sided wrist pain 4
2. First dorsal compartment tenderness 4
3. Positive Finkelstein test 4

Imaging studies may be used in selected cases:

• Ultrasound is the first-line imaging modality for detecting tenosynovitis 2

  • Can identify synovial thickening, fluid in tendon sheath, and increased vascularity
  • 2.48-4.69 times better detection rate than clinical examination alone

• MRI without contrast may be appropriate in selected circumstances but is not routinely needed 2

  • Superior for detecting tenosynovitis compared to clinical examination
  • Particularly sensitive for detecting extracapsular inflammation

Treatment

Conservative Management

1. Relative rest and activity modification

   • Avoid repetitive thumb and wrist movements 2
   • Reduce activity to decrease repetitive loading of the damaged tendon 3

2. Splinting

   • Thumb spica splinting is effective when worn consistently, especially at night 2
   • Avoid continuous splinting during the day to prevent muscle deconditioning 2

3. Cryotherapy

   • Ice application for 10-minute periods through a wet towel 3, 2
   • Provides acute pain relief 3

4. NSAIDs

   • Recommended for short-term pain relief (typically 1-2 weeks) 3, 2
   • Topical NSAIDs may have fewer systemic side effects 3, 2
   • No effect on long-term outcomes 3

5. Corticosteroid Injections

   • Highly effective first-line treatment with 65-98.75% success rate after 1-3 injections 6
   • A mixture of corticosteroid (e.g., methylprednisolone acetate) and local anesthetic injected into the first dorsal compartment 6
   • More effective than NSAIDs for acute pain relief 3
   • Should be performed with ultrasound guidance when possible 2
   • Potential adverse effects may occur in about 25% of patients but typically subside within 20 weeks 6

6. Physical or Occupational Therapy

   • Eccentric strengthening exercises 2
   • Tendon gliding exercises 2
   • Ergonomic education 2

Surgical Management

Surgical release of the first dorsal compartment is indicated when:

• Symptoms persist beyond 4-6 months of conservative therapy 2
• Failed response to at least 2-3 corticosteroid injections 6
• Severe symptoms or functional limitations continue 2

Monitoring and Prognosis

• Regular monitoring of symptoms and range of motion is crucial to prevent long-term complications 2
• Early detection and treatment are essential to prevent progression 2
• Most cases respond well to conservative management, with 98.75% of patients becoming symptom-free after appropriate corticosteroid injections 6
• Ultrasound can help assess treatment response and disease progression 2

Common Pitfalls and Caveats

1. Failing to recognize anatomical variations in the first dorsal compartment, such as subcompartmentalization, which may affect treatment outcomes 3

2. Overuse of splinting during the day, which can lead to muscle deconditioning 2

3. Inadequate corticosteroid injection technique or failure to use ultrasound guidance, potentially reducing treatment efficacy 2

4. Delaying surgical referral when conservative measures fail after 4-6 months 2

5. Overlooking the need for activity modification and ergonomic adjustments to prevent recurrence 2