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

De Quervain's Tenosynovitis Treatment

Initial treatment for De Quervain's tenosynovitis should consist of thumb spica splinting combined with NSAIDs, followed by corticosteroid injection into the first dorsal compartment if conservative measures fail after 4-6 weeks. 1, 2

Initial Conservative Management (First-Line)

• Thumb spica splinting to immobilize the affected tendons and prevent ongoing damage 1, 2
• NSAIDs (oral or topical) for pain relief and potential anti-inflammatory benefit 1
• Relative rest by avoiding activities that worsen pain, while preventing complete immobilization to avoid muscular atrophy 1
• Cryotherapy applied through a wet towel for 10-minute periods provides effective short-term pain relief 1

Duration of conservative treatment: Continue for 4-6 weeks before escalating therapy 1, 2

Corticosteroid Injection (Second-Line)

If conservative measures fail after 4-6 weeks, corticosteroid injection is the preferred next step and should be the initial treatment before considering surgery. 3, 2

Injection Protocol

• Mixture: 1 mL (40mg) methylprednisolone acetate combined with 1 mL of 2% lidocaine injected into the first dorsal compartment 4
• Success rates: Approximately 58% respond to a single injection, with an additional 33% responding to multiple injections (total 90% success rate) 3
• Timing: If first injection fails, repeat injection can be given 2 weeks later 4

Critical Technical Consideration

Ultrasound-guided injection is superior to blind injection because 52% of patients have multiple subcompartments (septations) within the first dorsal compartment that must all be injected for treatment success. 5 Failure to inject all subcompartments is a common cause of treatment failure and explains the variable response rates reported with blind injections 5.

Expected Outcomes with Injection

• 65% symptom-free at 2 weeks after first injection 4
• 95% symptom-free at 6 weeks 4
• 97% have at least partial symptom resolution at 6 weeks 5
• Mean recurrence time if symptoms return: 11.9 months 3

Adverse Effects

• Minor and self-limited in 25% of patients, resolving by 20 weeks 4
• No tendon ruptures or local infections reported in prospective studies 3

Surgical Release (Third-Line)

Surgery is reserved for the 10% of patients who fail to respond to 2-3 corticosteroid injections over 3-6 months of conservative management. 3, 6, 2

Surgical Technique

• Longitudinal incision is superior to transverse incision with significantly better outcomes (p=0.03) and fewer postoperative complications 6
• Critical intraoperative step: Identify and release all accessory compartments/septations to prevent treatment failure 2
• Protect the radial sensory nerve during dissection 2

Common Pitfalls to Avoid

• Failing to identify subcompartments: This is the most common cause of both injection and surgical failure 5, 2
• Injecting corticosteroid into the tendon substance rather than the tendon sheath may cause deleterious effects and predispose to rupture 1
• Complete immobilization should be avoided as it leads to muscular atrophy and deconditioning 1
• Premature surgery before adequate trial of conservative therapy and injections 3, 2