How is De Quervain's tenosynovitis managed?

Management of De Quervain's Tenosynovitis

The optimal management of De Quervain's tenosynovitis should begin with conservative measures including splinting, NSAIDs, and physical therapy, followed by corticosteroid injections if initial treatment fails, with surgery reserved for refractory cases. This approach is supported by evidence showing high success rates with conservative management and corticosteroid injections.

Initial Conservative Management

• Thumb spica splinting to immobilize the first dorsal compartment and rest the affected tendons should be implemented as first-line treatment 1
• Local application of heat (e.g., paraffin wax, hot packs) before exercise may provide symptomatic relief 1
• Nonsteroidal anti-inflammatory drugs (NSAIDs) can be used for pain relief, with topical NSAIDs being an effective alternative that avoids gastrointestinal side effects 1
• Physical therapy modalities including therapeutic ultrasound may help decrease pain and increase collagen synthesis, though evidence for consistent benefit is limited 1, 2
• Low-level laser therapy has shown effectiveness in reducing pain and improving hand function in De Quervain's tenosynovitis 2

Corticosteroid Injections

• Corticosteroid injection into the first dorsal compartment is highly effective and should be considered when initial conservative measures fail after 4-6 weeks 3, 4
• Studies show approximately 58% of patients respond to a single injection, while another 33% respond to multiple injections, for a total success rate of about 90% 4
• A mixture of methylprednisolone acetate (40mg) and local anesthetic (e.g., 1ml of 2% lidocaine) is commonly used 3
• Ultrasound guidance may improve injection accuracy, especially when anatomical variations like separate subcompartments for the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons are present 5, 6
• Corticosteroid injections are safe during the third trimester of pregnancy and while breastfeeding 6
• Potential adverse effects include skin depigmentation, fat atrophy, and temporary pain at the injection site, but these are typically self-limited 3, 4

Surgical Management

• Surgical release of the first dorsal compartment should be considered when patients fail to respond to conservative treatment and corticosteroid injections (approximately 10% of cases) 4
• Open surgical release through a longitudinal incision provides better visualization of underlying anatomy, resulting in fewer injuries to surrounding structures 6
• Endoscopic release may result in quicker symptom improvement, better cosmetic results, and lower incidence of radial sensory nerve injury for surgeons experienced with the technique 6
• Wide-awake local anesthesia no tourniquet (WALANT) technique can be safely used for surgical release 6

Treatment Algorithm

1. First line (0-6 weeks):

   • Thumb spica splinting
   • NSAIDs (oral or topical)
   • Activity modification to reduce repetitive wrist movements
   • Physical therapy modalities (heat application, ultrasound, laser therapy)

2. Second line (if no improvement after 6 weeks):

   • Corticosteroid injection into the first dorsal compartment
   • Consider ultrasound guidance for injection accuracy
   • Continue splinting and activity modification

3. Third line (for recurrent or persistent symptoms):

   • Repeat corticosteroid injection (if first injection provided temporary relief)
   • Maximum of 2-3 injections recommended

4. Fourth line (if failed conservative management):

   • Surgical release of the first dorsal compartment
   • Choice between open or endoscopic technique based on surgeon expertise

Special Considerations

• Anatomical variations like multiple compartments or separate subcompartments for APL and EPB tendons can be detected by ultrasound and may affect treatment outcomes 5
• Differential diagnosis should include intersection syndrome, osteoarthritis of the first carpometacarpal joint, and scaphoid fracture 5
• Neural therapy (local anesthetic injections) has shown promise in reducing pain and improving hand function 7
• Extracorporeal shock wave therapy (ESWT) may be an alternative physical modality for pain control, though more research is needed 2